20 years of advancing health equity in Zambia

“There is no reason that the best technologies and health tools should be out of reach for people simply because of where they were born,” said Dr. Nanthalile Mugala, PATH’s Chief of the Africa Region, during her remarks at the 20th-anniversary event in Lusaka, Zambia, in June.

This clear moral fact has inspired the exceptional collaboration between PATH the government of Zambia since its beginnings in 2004. And together, we’ve been improving health outcomes for the people of Zambia ever since.

“We have been present in Zambia for two decades, with the Malaria Control and Elimination Partnership in Africa (MACEPA) project being our oldest and most well-known initiative,” said Dr. Mugala. “Most people knew us by MACEPA well before they knew us as PATH! And we had to do a lot to make people understand that MACEPA was a project managed by PATH.”

Speaking on behalf of the Zambia Minister of Health, the Permanent Secretary for Donor Coordination at the Ministry of Health (MOH) Dr. George Sinyangwe affirmed PATH's impact, stating: "PATH has played a pivotal role in this country's fight against malaria. The Ministry of Health is very proud to showcase PATH's significant contributions to our health systems.

“[PATH’s work] aligns well with our mission of providing equitable access to cost-effective, quality health care services as close as possible to where families live, work, and go to school. This aligns with our vision of creating a nation of healthy and productive people.”

Over the past two decades, PATH has been a catalyst for health equity in Zambia, evolving to align with the shifting needs of its people and government. The organization’s commitment to trust, partnership, and the realization of Zambia’s vision has been the cornerstone of our journey together. By harnessing our extensive technical expertise, fostering robust partnerships, and driving innovative health solutions, we have supported the Zambian government in pioneering and expanding groundbreaking strategies and technologies.

With 132 staff who possess robust experience collaborating with the MOH and other local stakeholders, we have been at the forefront of change. Currently, we are managing 12 active projects across eight provinces, thanks to generous support from organizations including the US Agency for International Development (USAID), the US President’s Malaria Initiative (PMI), the Bill & Melinda Gates Foundation (BMGF), the Hewlett Foundation, the Bayer Cares Foundation, and others.

These initiatives directly address Zambia’s critical health challenges, including eliminating malaria and tuberculosis (TB), enhancing digital health and data systems, reducing malnutrition, increasing immunization rates, decreasing mortality from noncommunicable diseases, expanding high-quality respiratory care, and improving public health security and outbreak response systems.

As we commemorate 20 years of meaningful progress, PATH and the Zambia MOH are taking a moment to celebrate our dedication to advancing health equity by highlighting the work and impact we have achieved together.

• Click here to read a compendium of successes shared by PATH the Ministry of Health.

• Click here to read a compendium of monitoring and evaluation accomplishments and research publications.

PATH shares the government of Zambia’s ambition to end malaria. Over the years, we led several large malaria projects in Zambia that support the National Malaria Elimination Center (NMEC) in fighting the disease from every angle—from the national level down to facilities and communities—by developing new tools and strategies for malaria control and elimination, strengthening laboratory and clinical capacity, and improving malaria prevention and case management.

Since 2005, through the Gates Foundation–funded MACEPA project, PATH has supported the Zambia MOH to improve the efficiency of current interventions, test new approaches, strengthen surveillance systems, and increase access to and use of high-quality malaria data for informed decision-making.

Speaking at the anniversary event, Philip Welkhoff, Director of Malaria at the BMGF, underscored the program's impact: "The success of the program in Zambia has been remarkable, proving it to be a model for other countries." Indeed, lessons learned through MACEPA in Zambia are now exported to other malaria-endemic geographies, helping ministries of health develop impactful, data-driven strategies and strengthened systems to drive the fight against malaria within their countries.

From the early days, MACEPA's approach caught the attention of key stakeholders. "[The late] Bill Gates Sr. then went to Zambia in 2006 and visited a location where MACEPA had been supporting the ministry with their first large-scale long-lasting insecticidal net campaign, which MACEPA helped kick-start that year. Bill Sr. was particularly impressed by how MACEPA was responsive to needs identified by the community," Philip Welkhoff recalled.

The backbone of MACEPA’s work is data. In collaboration with the MOH, through the NMEC, we designed and tested a reporting system to capture the malaria cases and the number of test kits and treatments remaining on the shelf. The system, begun in 12 health facilities in Sinazongwe District in Southern Province, has now been introduced into every district in the country. Weekly reporting via mobile phone arms decision-makers with real-time and reliable malaria information, and a data visualization partnership improves access to the data through colorful and interactive dashboards.

MACEPA and the MOH also focused on Southern Province to determine the optimal package of interventions appropriate to an area’s malaria transmission and to demonstrate that malaria elimination is possible. In 2014, MACEPA-supported research in 60 health facility catchment areas bordering Lake Kariba in Zambia's Southern Province evaluated strategies to clear malaria parasites from entire communities.

Over the course of the 14-month study, which concluded in February 2016, there was a remarkable 87 percent reduction in malaria cases and a 97 percent reduction in facility-reported malaria deaths. By the end of the study, more than half of the health facility areas had zero malaria infections. The demonstrable success of this initiative prompted the Zambia MOH to incorporate mass drug administration into its arsenal of proven malaria interventions.

With support from PMI, which is led by USAID and the US Centers for Disease Control and Prevention, PATH implemented the Program for the Advancement of Malaria Outcomes (PAMO) from 2016 to 2020 to increase coverage of proven malaria interventions in alignment with the National Malaria Strategic Plan. Now through PAMO’s successor, PMI PAMO Plus, PATH continues to work to improve malaria prevention, detection, and treatment in Zambia’s Eastern, Luapula, Muchinga, and Northern provinces through strong partnerships across all levels of the health system.

Through PAMO Plus, PATH is helping to increase coverage of proven malaria interventions at provincial and district levels, improve the health management information system, and build the management capacity of health personnel to provide oversight and delivery of malaria interventions. Over 20,000 health facility staff have now been mentored by PAMO and PAMO Plus through outreach training and supportive supervision to improve the quality of care for malaria patients in health facilities.

The strength of this partnership was highlighted by Dr. Paul Psychas, PMI Zambia Resident Advisor, at the anniversary celebration in Zambia. Dr. Psychas noted, "Over the years, I have seen us learning together, collaborating, [and] planning carefully to make sure our implementation is complementary rather than duplicative. We raise our voices together when we need to. We have some healthy debates sometimes on technical issues and strategy. That's part of a partnership."

This collaborative approach has been key to the success of initiatives like PAMO Plus. A total of 8,331 community health workers have been trained through this work, equipping them with the skills needed to ensure that high-quality malaria services are available within their communities, including testing and treating malaria cases and referring those who need advanced care to higher-level facilities.

Since 2017, the BMGF’s PATH-led DMPA-SC Access Collaborative, a transformative initiative aimed at increasing the availability and use of subcutaneous depot medroxyprogesterone acetate (DMPA-SC), also known as Pfizer’s Sayana® Press self-injectable contraceptive.

The initiative has helped to ensure that women and girls in Zambia have greater access and the autonomy to self-inject as part of a comprehensive range of contraceptive options offered through informed-choice programming. Through a catalytic opportunity fund, PATH is currently supporting an initial introduction of DMPA-SC self-injection in 200 private pharmacies to inform future scale-up.

PATH is also implementing innovative approaches to integrating family planning into routine childhood immunization services in 40 health facilities in Zambia’s Southern Province to help address unmet family planning needs.

PATH also supported the Centre for Infectious Disease Research in Zambia in its work to strengthen and scale up high-quality antimicrobial resistance (AMR) and antimicrobial use (AMU) surveillance.

From 2019 to 2021, PATH developed a costed operational work plan for sustained and expanded AMR and AMU surveillance in Zambia, worked to improve microbiology laboratory capacity and capabilities for quality-assured AMR and AMU surveillance in the human health sector, strengthened the multisectoral AMR Surveillance and Research Technical Working Group, and established a national AMC and AMU surveillance strategy. This initiative was supported by the UK government’s Fleming Fund grant, managed by Mott MacDonald.

Nanopore-based sequencing platforms offer the potential for affordable malaria molecular surveillance in resource-limited settings to track and ultimately counteract emerging threats. In 2019, MACEPA staff supported the Mobile Malaria Project to show that it is possible to sequence DNA in remote settings, the success of which led to the launch of the NOMADS project.

The NMEC-Oxford Malaria Amplicon Drug-resistance Sequencing (NOMADS) project developed a cost-effective, scalable assay to detect antimalarial drug resistance in Plasmodium falciparum using nanopore sequencing and demonstrated its feasibility in a pilot conducted in collaboration with the NMEC. The NOMADS team was able to reduce sequencing costs from approximately US$90 to US$25 per sample.

Building on the success of NOMADS, and with renewed investment from the Bill and Melinda Gates Foundation, PATH works to strengthen and expand nanopore sequencing to combat antimalarial drug resistance and diagnostic escape through the NOMADS 2 project. NOMADS 2 is continuing to strengthen and expand the use of nanopore sequencing for malaria genomic surveillance by integrating the NOMADS assay into routine malaria surveillance in Zambia, expanding nanopore sequencing to new geographies through collaboration and capacity-building, and optimizing existing and developing novel nanopore sequencing assays for malaria molecular surveillance.

PATH works with end users to co-create solutions aimed at accelerating the pace of innovation, lowering risk, and increasing the likelihood of realizing sustainable solutions. Through the Living Labs project, PATH tests user-prioritized solutions to increase immunization health worker motivation and engagement, improving their performance and subsequent immunization service delivery and population coverage.

Additionally, with support from KfW Development Bank, and as part of the health impact evaluation of cervical cancer interventions in Zambia, PATH is leading a study that seeks to investigate health system needs and opportunities for treatment delivery to women with preinvasive and invasive disease who are being treated in the cervical cancer prevention program in Zambia.

Under the Bill and Melinda Gates Foundation’s Better Immunization Data Initiative, working in partnership with the government of Zambia, PATH designed and tested interventions such as an electronic immunization registry system at the facility and community levels, text reminders, and stock management tools to address critical data-related challenges.

PATH also led a consortium of Zambian organizations in supporting the MOH through the National TB Program to eliminate TB in six provinces. Under PATH leadership, the consortium strengthened laboratory network capacity to diagnose and monitor TB patients more efficiently and effectively; increased the number of TB patients notified of TB diagnosis from 11,882 in 2018 to 26,912 in 2021; and improved the drug-resistant TB treatment success rate, which increased to 68 percent in 2021, up from 59 percent in 2019.

To help bolster COVID-19 vaccine preparedness, rollout, and surveillance, PATH supported capacity-building and change management for the COVID-19 vaccine rollout in two provinces and provided technical assistance to COVID-19 vaccine campaigns. PATH also improved laboratory surveillance of COVID-19 infections and vaccine escape through genomic sequencing, including on samples collected during wastewater surveillance using a bag-mediated filtration system designed by PATH and the University of Washington.

During the COVID-19 pandemic, PATH partnered with the University of Zambia, the only in-country institution with a Biosafety Level 3 laboratory, which is required for working with airborne infections such as SARS-CoV-2. MACEPA staff assisted with COVID-19 diagnosis, and through NOMADS funding we began SARS-CoV-2 sequencing in September 2020. In December 2020, the team became the first in Africa to identify the Beta variant outside of South Africa.

Additionally, PATH was awarded the two-year, $3.4 million Zambia Digital Community Health Project by the BMGF in 2021 to support the MOH to establish, grow, and modernize a fully functional, user-friendly digital community health system for Zambia. This digital health system is ensuring community health workers have access to the tools and data necessary to deliver high-quality care to their community.

As PATH Zambia celebrates these remarkable achievements, the country office looks to the future with renewed determination and optimism. At the 20th-anniversary event, PATH Zambia unveiled its new strategic plan, a significant milestone that charts our course for the next five years.

The new strategy reinforces PATH Zambia’s unwavering commitment to advancing health equity and improving the lives of all Zambians. It builds upon two decades of successful partnerships and innovative approaches, while also addressing emerging health challenges and leveraging new opportunities in public health.

In his closing remarks, Dr. Sinyangwe said, "The journey ahead is filled with opportunities and challenges. Together with PATH and all our partners, we are ready to embrace these opportunities and overcome the challenges we face. Our collective efforts will drive us towards a future where health equity is not just a vision, but a reality.

"The Ministry of Health looks forward to another 20 years of cooperation with PATH. Let us continue to support and implement innovative solutions, strengthening our health care systems, and empowering our communities. By doing so, we are not only enhancing the health of our nation but also paving the way for a brighter and more prosperous country for all of us."