USAID: Zambia FY 2002 Congressional Budget Justification

PROGRAM: ZAMBIA
TITLE AND NUMBER: Increased Use of Integrated Child and Reproductive Health and HIV/AIDS Interventions, 611-003
STATUS: Continuing
PLANNED FY 2001 OBLIGATION AND FUNDING SOURCE: $2,880,000 DA; $21,573,000 CSD
PROPOSED FY 2002 OBLIGATION AND FUNDING SOURCE: $3,104,000 DA; $22,817,000 CSD
INITIAL OBLIGATION: FY 1995 ESTIMATED COMPLETION DATE: FY 2002

Summary: Zambia's health needs are enormous. Approximately 20% of adults are HIV-infected. The HIV/AIDS epidemic is having a devastating impact on the people, institutions, and the country's ability to achieve sustainable development. As AIDS death rates have accelerated, a secondary epidemic of orphaned and vulnerable children has arisen. By the end of the year 2000, an estimated 1.25 million children (27.4% of children under age 15) were orphaned. Zambia also has some of the world's highest infant and under-five mortality rates. The maternal mortality ratio of 649 per 100,000 live births is one of the worst in Africa. Largely because of the AIDS crisis, life expectancy at birth is declining. Vitamin A deficiency, which increases the risk of blindness, severe illness and death in children, affects an estimated 66% of Zambian children.

With the advent of multi-party government in 1991, the Government of the Republic of Zambia (GRZ) began restructuring the health sector to improve the health status of its citizens by providing equitable access to decentralized, integrated, low-cost basic health services. USAID supports GRZ health reforms by expanding access to critical public health interventions in four integrated areas: HIV/AIDS; infectious diseases; child survival; and family planning/reproductive health. USAID's population, health, and nutrition sector activities focus on 30 districts, covering over 60% of the total Zambian population. While overall progress in the sector has been positive, the ongoing AIDS pandemic takes its toll on human and financial resources needed to implement health reforms.

USAID's FY 2001 program will use $21,573,000 in Child Survival and Disease (CSD) funding to expand access to HIV/AIDS prevention services and treatment strategies, establish sustainable community-response mechanisms for orphans and vulnerable children, expand malaria prevention and treatment programs, reduce vitamin A deficiency, further consolidate immunization services, prevent and treat diarrheal diseases, and implement other child health interventions. Funding for these elements will be comprised of $10,887,000 in HIV/AIDS funding, $1,995,000 in vulnerable children funding, $3,991,000 in infectious disease funding, $4,620,000 in child survival funding, and $80,000 in polio funding. As part of this investment, USAID will continue to fund an ongoing non-project assistance activity supporting healthcare services and activities of the District Health Management Teams at the district level and below in the amount of $2,000,000, of which $750,000 is child survival funds, $750,000 is HIV/AIDS funds, and $500,000 is infectious disease funds. USAID will use $2,880,000 in development assistance funds for population, specifically to expand access to family planning and integrated reproductive health activities through supporting social marketing of contraceptives; expanding community- and employer-based services; improving training of health workers; providing information, education and communication (IEC); and promoting key policies.

The direct beneficiaries of this program are the Zambian Ministry of Health (MOH) and district- and community-level health facilities and workers. The ultimate beneficiaries are Zambian citizens, who will receive better health care.

Agreements under this notification will incorporate clauses that implement the President's recent directive reinstating the Mexico City Policy.

Key Results: HIV/AIDS prevention programs have contributed to a decline in prevalence rates among Zambian youth aged 15 to 19 years. In Lusaka, prevalence in this age group dropped from 28% in 1993 to 15% in 1998. Additional analysis of this data shows that the decline for urban antenatal clients extends to the 20-24 years age group. Other studies echo these findings. Preliminary results from the 2000 Zambia Sexual Behavior Survey show that condom use among men and women with non-regular partners increased significantly between 1998 and 2000: from 33% to 40% (men) and 24% to 34% (women). Sales of socially marketed condoms increased by 30% from 6.6 million in FY 1999 to 8.6 million in FY 2000, exceeding targets. These data suggest that many Zambians, particularly those who are young and urban-based, are changing their sexual behavior by practicing abstinence, having fewer partners, and/or using condoms to reduce HIV transmission.

USAID also achieved strong results in malaria prevention and vitamin A supplementation. A total of 42,770 insecticide-treated mosquito nets were distributed to prevent malaria in high-risk areas, a 254% increase over 1999 and exceeding the target for 2000. Vitamin A supplementation programs in the July/August 2000 distribution reached 86% of Zambian children, exceeding the target for the year. Sales of the home water chlorination product, Clorin, which reduces diarrheal diseases, were 569,000 bottles in 2000 versus 187,043 in 1999, almost double the target of 300,000. The percent of children under one year of age who were fully vaccinated against common childhood diseases was 76%, meeting the target for 2000.

DA funding support to family planning and reproductive health activities resulted in a 31% increase in sales of socially marketed oral contraceptives from 339,000 cycles in 1999 to 445,000 in 2000, exceeding planned sales by 11%. New family planning clients in USAID-assisted districts were 98,074, an increase over the revised 1999 figure of 97,159.

Performance and Prospects: Given the severity of the HIV/AIDS epidemic in Zambia, USAID's program to increase access to HIV prevention and support continues to expand. Ongoing activities include behavior change campaigns; social marketing of condoms; improving treatment of sexually transmitted infections (STIs); policy development; and monitoring and evaluation of the epidemic to inform policy makers. USAID worked to reduce HIV transmission among high-risk truckers and prostitutes at five border sites through expanded access to IEC, condoms and STI treatment. Young adults were targeted through a mass media campaign that was expanded to all 72 districts. USAID also supported expanded access to voluntary HIV counseling and testing (VCT) services in three districts working through non-governmental organizations. Demand for VCT is growing, as more Zambians want to know their HIV status (currently only an estimated 6% do). With USAID support, national guidelines for preventing mother-to-child transmission of HIV were developed and comprehensive services are now available for antenatal clients in six sites covering a population of 250,000.

In FY 2000, USAID also continued community-level work with orphans and vulnerable children and their caregivers in seven districts. Activities include income generation and other approaches to create an economic safety net and psychosocial support. USAID is also supporting a national multi-sectoral structure to address policy and coordination on issues related to orphans and vulnerable children.

USAID's child health activities are intended to contribute to increased coverage and quality of preventive and curative interventions. As of 1997, two-thirds of Zambian children under five were vitamin A deficient. USAID-supported research shows that vitamin A supplementation can reduce mortality in this age group by an average of 23%. With USAID as the major donor, Zambia has reached coverage rates for supplementation that are among the highest in the world. Also with USAID assistance, all of Zambia's domestic sugar has been fortified with vitamin A for three years in a row, making it the most important source of vitamin A in the diet. Malaria is the number one killer of children in Zambia and bednets have been shown to be the most cost-effective strategy to reduce malaria incidence. A recent study shows that 30% of households in the USAID-assisted target area own nets as compared to 16% of households in control districts. USAID will continue to support in the coming years: the national program of vaccination against childhood diseases; vitamin A supplementation and fortification programs; the training of health workers in integrated management of childhood illnesses; malaria prevention and treatment efforts; and distribution of Clorin home water treatment.

In family planning, USAID continues to support expanding access to reproductive health services. These include an employer-based distribution program for family planning and related information and services, which reaches 88,764 workers and their families; social marketing of oral contraceptives; and improved reproductive health training for nurses and midwives. USAID also supports a maternal health initiative to increase community awareness of pregnancy care and risks.

USAID completed the first year of an innovative sector-wide assistance program that provides resources to the district health system based on GRZ performance in expanding community-level health services. The MOH met all the performance milestones set for the first tranche of funding, including providing evidence of acceptable systems for monitoring district program and financial performance, and submission of a Health Care Financing policy to the Cabinet.

In FY 2002, child survival activities will focus on cost-effective strategies to reduce the malaria incidence, reduce vitamin A deficiency and support the national program of vaccination against childhood diseases. USAID will also expand its support for programs addressing the HIV/AIDS pandemic. Activities will include behavior change campaigns, social marketing of condoms, improving treatment of sexually transmitted infections, policy development, and the monitoring and evaluation of the epidemic to inform policy makers. Activities designed to create an economic safety net and emotional and social support for orphans and vulnerable children will also continue. USAID will continue to support GRZ activities to expand access to reproductive health services and continue support for an innovative sector-wide assistance program to provide health services at the district level.

Possible Adjustments to Plans: The specter of HIV/AIDS threatens all USAID investments in Zambia. New initiatives are under development, including a strategic framework for multisectoral approaches to the epidemic. In addition, USAID will focus on activities to respond to the recent findings that the decline in HIV prevalence seen among urban, better-educated populations is not found among rural dwellers and the less educated.

Other Donor Programs: Support is provided to Zambia's health reform program through a multi-donor health program. USAID is the primary donor in HIV/AIDS prevention and child survival activities. The U.S./Japan Common Agenda is extremely strong and includes collaboration on ten specific areas. The United Kingdom provides the majority of condoms that are socially marketed through the USAID program. The United Kingdom, Japan, the Netherlands, Ireland, Denmark and Sweden are close partners in overall funding. USAID also works closely with the United Nations Children's Fund (UNICEF).

Principal Contractors, Grantee or Agencies: Major U.S. institutions include the Johns Hopkins University Center for Communication Programs; John Snow, Inc.; Abt Associates, Inc.; and Population Services International. These principal contractors/grantees work with a number of U.S. sub-contractors, including Pathfinder, Africare and CARE International. Other nongovernmental partners include the U.S. organizations Adventist Development and Relief Agency, Christian Children's Fund, Project Concern International, World Vision, and Family Health International; Churches Medical Association of Zambia; the International HIV/AIDS Alliance; and a number of private sector organizations. Selected MOH units also are grantees.

FY 2002 Performance Tables

U.S. Financing

(In thousands of dollars)

	Obligations		Expenditures		Unliquidated
Through September 30, 1999	13,478	DA	9,520	DA	3,958	DA
	27,346	CSD	14,120	CSD	13,226	CSD
	0	ESF	0	ESF	0	ESF
	0	SEED	0	SEED	0	SEED
	0	FSA	0	FSA	0	FSA
	29,015	DFA	28,629	DFA	386	DFA
Fiscal Year 2000	3,200	DA	4,909	DA
	15,600	CSD	16,272	CSD
	0	ESF	0	ESF
	0	SEED	0	SEED
	0	FSA	0	FSA
	500	DFA	308	DFA
Through September 30, 2000	16,678	DA	14,429	DA	2,249	DA
	42,946	CSD	30,392	CSD	12,554	CSD
	0	ESF	0	ESF	0	ESF
	0	SEED	0	SEED	0	SEED
	0	FSA	0	FSA	0	FSA
	29,515	DFA	28,937	DFA	578	DFA
Prior Year Unobligated Funds	320	DA
	0	CSD
	0	ESF
	0	SEED
	0	FSA
	0	DFA
Planned Fiscal Year 2001 NOA	2,880	DA
	21,573	CSD
	0	ESF
	0	SEED
	0	FSA
	0	DFA
Total Planned Fiscal Year 2001	3,200	DA
	21,573	CSD
	0	ESF
	0	SEED
	0	FSA
	0	DFA
			Future Obligations		Est. Total Cost
Proposed Fiscal Year 2002 NOA	3,104	DA	0	DA	22,982	DA
	22,817	CSD	0	CSD	87,336	CSD
	0	ESF	0	ESF	0	ESF
	0	SEED	0	SEED	0	SEED
	0	FSA	0	FSA	0	FSA
	0	DFA	0	DFA	29,515	DFA

ZAMBIA

Activity Data Sheet

FY 2002 Performance Tables

U.S. Financing