Malaria Elimination Project Quarterly Report (FY19 Q3)

CAMBODIA MALARIA ELIMINATION PROJECT

Cambodia Malaria Elimination Project

Quarterly Progress Report - Year 3, Quarter 3 April - June 2019

Submission Date: , 30th July 2019

Contract Number: AID-442-C-17-00001 Contract Period: October 26, 2016 to October 25, 2021 COR: Rida Slot Alternate COR: Bunna Sok

Submitted by: Sharon Thangadurai, Chief of Party University of Research Co., LLC. #31, St 352, Sangkat Beugkengkang 1, Khan Chankamon, Email: [email protected]

This document was produced by University Research Co., LLC (URC) for review and approval by the United States Agency for International Development (USAID).

Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3)

TABLE OF CONTENTS

Acronyms ...... iv

1. Introduction ...... 1

2. Progress Toward achieving CMEP OBJECTIVES ...... 2 2.1 Objective 1: Develop a scalable, evidence-based elimination model in SPL OD and support its dissemination and replication for malaria elimination in Cambodia...... 2 2.2 Objective 2: Support scale-up of high quality malaria control and prevention interventions in five to eight ODs, where gaps in coverage or quality exist...... 7 2.3 Objective 3: Strengthen national malaria surveillance systems and M&E appropriate for malaria elimination and control activities ...... 12 2.4 Objective 4: Build capacity of Ministry of Health (MOH) to manage, intensify, and sustain malaria control and elimination efforts particularly at the OD level ...... 14

3. Project Management ...... 15 Oversight and Coordination ...... 15 Procurement ...... 18 Financial Management ...... 18 Human Resource Management ...... 19

4. RESOLVING CHALLENGES FROM FY19 Q2 ...... 20

5. CHALLENGES AND ACTIONS TAKEN OR PROPOSED ...... 20

6. PLANS FOR NEXT QUARTER AND UPCOMING EVENTS ...... 20 ANNEX 1 CSO FY19 Q3 RESULTS TABLES ...... 21 ANNEX 2 LAB QA/MICROSCOPY TRAINING TABLES ...... 24

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3)

ACRONYMS

ACT Artemisinin-based Combination Therapies AFRIMS Armed Forces Research Institute of the Medical Sciences AHEAD Action for Health Development (CSO in Cambodia) AOP Annual Operational Plan APMEN Asia Pacific Malaria Elimination Network BKN Bakan BTB Battambang CHAI Clinton Health Access Initiative CMEP Cambodia Malaria Elimination Project CBO / CSO Community Based Organization / Civil Society Organization CDC Centers for Disease Control and Prevention CM Case Management CNM Cambodia National Malaria Center COP / DCOP Chief of Party /Deputy Chief of Party COR Contracting Officer’s Representative CPIRS Commodity Procurement Information Requests CRS Catholic Relief Services DBS Dried Blood Spot EDAT Early Diagnosis and Treatment G6PD Glucose 6 Phosphate Dehydrogenase HC, HF Health Centre, Health Facility IDQA Internal Data Quality Assessment IPC Interpersonal Communication IRB Institutional Review Board ITN Insecticide-Treated Net KRK Krakor LLIN / LLIHN Long Lasting Insecticidal Net / Hammock Net M&E Monitoring and Evaluation MEAF Malaria Elimination Action Framework 2016-2020 MMP Mobile and Migrant Populations MMW Mobile Malaria Worker MoH Ministry of Health MORU Mahidol Oxford Tropical Research Unit MRS Maung Russey MSF Medecins Sans Frontieres NCA National Competency Assessment NECHR National Ethics Committee Health Research OD / ODMS Operational Health District / OD Malaria Supervisor ODTL/ODTLA Operational District Team Leader / OD Assistant TL OEC Operation Enfant Cambodge (CSO in Cambodia) PCR Polymerase Chain Reaction PHD / PMS Provincial Health Department / Provincial Malaria Supervisor PFDA Partner For Development in Action (CSO in Cambodia) PKV Phnom Kravanh PLN Pailin PMI President’s Malaria Initiative PP Private Provider PPM Private Public Mix PQ Primaquine PSI Population Services International PSM Procurement and Supply Management QA Quality Assurance

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3)

RDT Rapid Diagnostic Tests SBCC Social and Behavior Change Communication SLDPQ Single Low Dose Primaquine SOP Standard Operating Procedure SPL Sampov Loun STA Senior Technical Advisor TMK Thmar Kaul TPR Test Positivity Rate UNOPS United Nations Office for Project Services URC University Research Co., LLC USAID United States Agency for International Development VMW Village Malaria Worker WHO World Health Organization WMD World Malaria Day

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3)

1. INTRODUCTION The USAID | PMI Cambodia Malaria Elimination Project (CMEP), 2016-2021, was launched on October 26, 2016 to support the Cambodian National Center for Malaria Control, Parasitology and Entomology (CNM) to reduce malaria morbidity and mortality and contribute towards malaria elimination goals nationwide by 2025. To reach this goal, the project has set up four strategic objectives to: 1. Develop a scalable, evidence-based elimination model in Sampov Loun OD and support its dissemination & replication for malaria elimination in Cambodia. 2. Support scale-up of high-quality malaria control and prevention interventions in five to eight ODs, where gaps in coverage or quality exist. 3. Strengthen national malaria surveillance systems and monitoring and evaluation (M&E) appropriate for malaria elimination and control activities. 4. Build capacity of malaria program to manage, intensify, and sustain malaria control and elimination efforts particularly at the OD level. Until Year 2 Quarter 2, CMEP implemented activities in four ODs in (Sampov Loun (SPL), Battambang (BTB), Maung Russey (MRS), Thmar Kaul (TMK)) and two ODs in Province (Phnom Kravanh (PKV) and Krakor (KRK)). During Year 2 Quarter 3 (April to June 2018), CMEP expanded to three additional ODs (two ODs in : Bakan and Sampov Meas, and 1 OD in : Pailin OD). Three transitional ODs graduated to elimination ODs (BTB, MRS and TMK), and Pailin initially started as an elimination OD. See Figure 1 for a summary of activity progress in FY19 Q3. CMEP conducted the following key activities in FY19 Q3: . 24,164 of suspected cases tested with 1,770 positive cases confirmed and all cases received appropriate treatment according to National Treatment Guidelines . Among the 5 elimination ODs in Battambang and Pailin province, 98% of all cases were notified within 1 day, 95% investigated within 3 days, and 93% responded to within 7 days (for SPL OD, 100% were notified within 1 day, 100% investigated within 3 days, and 92% respnded to within 7 days) . CMEP response to the increase in cases in Pursat ODs in FY19 Q3 continued and included monitoring daily/weekly cases, intensifying services at all points of care, and the continued setup and support of touchpoint/peer educator volunteers (there are now 6 touch point volunteers in KRK, 8 in PKV ODs, 5 touch point volunteers in KRK, 11 in PKV ODs) . Despite the changes due to the Private Provider ‘PRAKAS’, CMEP continued limited support to PPs in the areas of SBCC and referrals of suspected malaria patients. . In the 5 elimination ODs, CMEP deployed 14,410 ITNs as buffer stock to HFs and VMWs in Q3 (target=14,750). Through VMW outreach activities, 16,368 ITNs were distributed (target=12,950) to local recidents and 4,281 ITNs (target=775) were distributed to PPMs through MMWs at big farms and MMP locations. . In the 4 transitional ODs, 8,227 ITNs were deployed as buffer stock (target was 5,640) to HF and VMW levels. 11,322 ITNs were distributed to local residents (target=13,425) and 112 ITNs were distributed (target was 480) to MMPs at big farms and MMP locations during outreach and response activities. . Conducted systematic administration of single low dose primaquine for confirmed P. falciparum (Pf)/mixed cases (93 cases in all 9 target ODs). . Supported CNM technical units to conduct 32 planned supervision visits (target=24).

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3)

CMEPFY19Q3PITT.xls Progress against each performance indicator is presented in the file attached. x

Figure 1. CMEP Summary of Activity Progress (April-June 2019)

2. PROGRESS TOWARD ACHIEVING CMEP OBJECTIVES 2.1 Objective 1: Develop a scalable, evidence-based elimination model in SPL OD and support its dissemination and replication for malaria elimination in Cambodia. Task 1. Pre-implementation situational analysis of current malaria elimination operations in SPL: Rapid Situational Analysis and Needs Assessment Report1: Task 2. Sustain universal long-lasting insecticidal net (LLIN) coverage: Mass distribution: There was no mass distribution activity in FY19 Q3 for Objective 1. Ensure continuous distribution of LLINs: In line with the updated list of villages for ITN distribution, CMEP’s target for continuous LLIN distribution was 322 villages in the 5

1 Activity 1,1.1. was completed in Year 1 and Year 2 is not applicable to the FY19 Q3 reporting period

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3) elimination ODs [Act 1.2.3]. Of these 5 elimination ODs, CMEP deployed 14,410 ITNs as buffer stock to HFs and VMWs in Q3 (14,750 planned). CMEP will further deploy ITNs in Q4, (using USG-purchased ITNs). CMEP distributed 16,368 ITNs (12,950 planned) to target populations during outreach and response activities [Act 1.2.5] and another 4,281 ITNs (target=775) were distributed to MMPs at big farms and MMP locations [Act 1.2.5.a]. Net top up and malaria education to households: In the 5 elimination ODs, VMWs conducted 2,771 visits (target=1,110) to households/farms for net use monitoring, net top-up and health education [Act 1.2.6]. The number of supervision visits increased significantly due to the number of VMW visits increasing visits to up to 5 per month. Visits to HH members/farm workers included health education for malaria prevention/LLIN use. There were 2 monitoring & supervision visits conducted from CNM Unit to elimination ODs in Q3 [Act 1.2.7]. Task 3. Ensure Early Diagnosis and Treatment (EDAT) and follow up: For the 5 elimination ODs, CMEP activities covered 360 points of care in Q3 (81 public health facilities and 279 VMWs/MMWs) in Q3 (this figure does not include private providers as they are now not allowed to perform malaria tests and treatment) [Act. 1.3.1]. 13,146 of 13,262 (99%) suspected malaria cases received a parasitological test. 77% of individuals were tested by VMWs and 23% by HFs. Out of all the individuals tested, 122 cases were confirmed positive. All 122 cases were enrolled in the system and 117 have travel history information. (See Figure 2 for a table of case classification and OD case distribution maps for Q3). Further analysis showed that 68 cases (58%) were imported from Pursat, 1 (1%) from Thailand and the remaining 48 cases (41%) from other provinces in Cambodia. There were no local cases for Pf/Mix identified in this quarter in the 5 elimination ODs. Figure 2. Map of case classification in table for 5 ODs and reported malaria cases by origin Apr-Jun 2019

Battambang Mong Russei Pailin Sampov Luon Thma Koul Species L1 L2 L3 L4 Imported L1 L2 L3 L4 Imported L1 L2 L3 L4 Imported L1 L2 L3 L4 Imported L1 L2 L3 L4 Imported Pf 0002 0 0004 0 0001 0 0001 0 0000 0 Pv 82025 0 10143 0 1009 0 00010 1 0017 0

Out of 122 positive cases reported in FY19 Q3, 8 (7%) were Pf/mixed and 114 (93%) were Pv.

Figure 3 provides the cases breakdown for Q3 and the cases trend since January 2017.

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3)

Figure 3. Number of confirmed malaria cases in 5 ODs per species in Jan 2017-Jun 2019 (source MIS/PMIS)

Of the total 122 cases, 8 were Pf/mixed and all cases were reached through reminder messages via the mHealth application and automatically transferred to a response team to conduct 28- day follow up. 7 patients out of 8 (87.5%) received 28-day follow-up (for the remaining case, the pateient moved to another area in Cambodia and could not be followed up) [Act. 1.3.3]. Figure 4 summarizes the implementation of DOT for PF/mixed cases in the 5 CMEP elimination ODs. Figure 4. Implementation of DOT in 5 ODs per species (*data fully Pf/Mixed)

In FY19 Q3, no patients were hospitalized for second line treatment in the 5 elimination ODs. [Act 1.3.6]. CMEP provided orientation training to government staff and continued

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3) emphasizing the use of single low dose primaquine (SLDPQ) in monthly meetings with VMWs and HF staff since FY18. All 8 Pf/mixed cases diagnosed in the 5 ODs in Q3 were eligible for SLDPQ (weight ≥ 50kg) and 100% of these received SLDPQ, and all 8 cases received 7-day follow up. No significant SLD-PQ adverse events were notified. CNM Pharmacy, Lab and Diagnosis and Treatment units completed 6 supervision visits (4 planned visits) during FY19 Q3. [Act. 1.3.10]. Task 4. Malaria case reporting, investigation, and response For 5 ODs, in Q3, 120 out of 122 cases (98 %) were notified within 1 day via the SMS Day-0 mHealth system, 116 cases (95%) were investigated within 3 days, and for 114 (93%) the response was provided within 7 days [Act.1.4.1-1.4.3]. All HFs/VMWs followed the established 1-3-7 surveillance practice. Among all 122 confirmed cases, only 2 cases (1.6%) were not notified within 24 hours. This late notification was mainly due to limitations of internet connection, tablets and smartphones (which were not functioning well) and also due to HF staff/VMWs being busy. For the investigation within 3 days, 6 cases (4.9%) were investigated later than 3 days or were not investigated due too late notification or no notification being done or due to patient movements. For response within 7 days, 8 cases out of 122 cases (6.5%) were not responded too or were responded too later than 7 days, mainly due to no notification, late notification, and HF staff being busy [Act.1.4.1-1.4.3]. Task 5. Strengthen case management, reporting, and response to all malaria cases in the private sector CMEP is in the process of proposing and submitting a contract modification which includes a component on private sector non involvement in testing and treatment. In Q3 64.9% of PPs (162/250) attended the PP meetings [Act 1.5.3]. PPs who were absent from quarterly meetings were either busy with other tasks or did not consider the meetings relevant as they realize PPs are no longer able to test and treat. (i) There is now little motivation generally for the PPs to attend the meetings as they are not testing and treating and don’t receive any drugs and test. (ii) Most of the PPs are also HC staff and as they know that PPs cannot test and treat and they are already involved with OD and CMEP activity they don’t attend these meetings. (iii) Often the PP’s have nothing to report as such because they are not much involved with any OD or HC activity, they expressed that there is no benefit for them to attend the meetings and they are busy with their own work in their clinic and their home. Those PPs who were absent received data collection visits from PHD/OD or from CMEP staff to ensure all PPs were continuing to provide health education and referrals for suspected malaria patients for all target populations. Semesterly supervision visits were also conducted to provide technical feedback on referrals and to improve SBCC initiatives. This still remains a mundane activity. Although no supervision visits were planned, 28 supervision visits to 162 PPs were accomplished in Q3 [Act 1.5.4]. During the supervision visits the findings are (i) Many of the PPs do not have the information available to complete the checklist during the supervision visit, (ii) PPs mention during the supervision visits that they are not able to refer all suspected malaria cases as they are busy with their own business and since now they see no benefit from CMEP project they hardly gets involved. Few of the non registered PPs are still testing and treating. No supervision visits (target=0) from CNM’s PPM unit were conducted in Q3 [Act 1.5.6]. Task 6: Build capacity and strengthen systems to manage elimination activities Supporting VMW monthly meetings: Monthly meetings continued in Q3 to support capacity building of VMWs. Meetings were held during the fourth week of April, May, and June. In Q3, for the 5 ODs, 1050 VMWs attended meetings versus 1,240 planned (85%) [Act 1.6.1]. The VMWs who did not attend the meeting were notified as first time absent, and CMEP along with HF staff will now monitor the VMWs for the 2nd and 3rd month, and if found consecutively not attending for 3 months, CMEP and the OD will ensure the replacement of VMWs as per

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3)

CNM guidance. CMEP OD teams made 16 visits to absent VMWs at their homes (visiting a total of 78 VMWs) to review progress and provide mentoring [Act 1.6.2]. Reasons mentioned for VMWs being absent included attending to economic activites and being away from the OD. Integrated supervision from ODs to HFs: 49 supervision visits were conducted to 76 HFs in the 5 elimination ODs using the CNM supervision checklist (target=51) [Act 1.6.3]. Data verification on total tests, total confirmed cases and total treated cases was performed during the visits. No artemisinin-based combination (ACT) stock outs or potential stock outs were detected at the time of supervision (further data verification during the visits confirmed this). Stock monitoring: CMEP continued to provide monthly RDT and ACT (ASMQ) stock status reports to CNM and all partners including UNOPS and updates from all HFs in the 9 target ODs. Overall, stocks of tests and drugs in CMEP areas was secured for the period of April- June 2019; there was no stockout and the few places that did identify any potential stockout were immediately fixed. There was no reallocation of drugs between Elimination ODs during Q3. CMEP staff also visited key HCs, reviewed/monitored the stock levels and verified the consumption against the allocation. Visit to selected VMW’s from CNM VMW Unit: There was no vists planned in Q3 [Act 1.6.6]. All Elimination ODs were visited in Q2. District Special Working Group for Malaria Elimination: 4 meetings were conducted in Q3. The meetings enabled updates of the malaria situation and knowledge sharing for participants. Provincial Special Working Group for Malaria Elimination There were no PSWGE meetings conducted in the elimination ODs during Q3. [Act 1.6.8]. Task 7. Social and Behavior Change Communication (SBCC) for malaria elimination In the 5 elimination ODs, 13,146 individuals tested for malaria received IPC for malaria education (target=5,963, was over target mainly due to VMWs/HFs increasing their number of tests and increased CSO activity) [Act 1.7.1]. In addition to malaria patients, IPC was provided to 4,034 people (137 sessions were carried out at SPL, BTB, TMK, MRS & PLN) from high-risk groups during case response activities [Act 1.7.2]. At the farms, VMWs organized small group education sessions to deliver key malaria messages. As a result, 7,726 MMPs were reached at farms with malaria outreach educational activities. CNM Health Education Unit made 2 visits to the elimination ODs in Q3 (target=0) [Act 1.7.3]. In Q3, CMEP continued to support the public service announcements (PSA’s) and radio call- in show program in BTB Province. The PSA’s continue 4 times a day in BTB. A ‘Radio-Call- In-Show’ assessment was conducted by CMEP in Q3 to assess how effective the radio call in shows have been since their inception. 160 Households in BTB OD were interviewed for the assessment. The key results are summarized as follows:  BTB HH’s listening to the radio - 32.5% (52HHs) of respondents said ‘yes’  BTB HH’s listening to malaria programs on the radio - 11.3% (18HHs) of respondents said ‘yes’  BTB HH’s saying they changed behavior due to the messaging- 10.6% (17HHs) of respondents said ‘yes’ Although the number of persons listening to the PSA’s is relatively low, it is encouraging that there were 17 households who said that they had changed behavior because of the messaging. Task 8. Support civil society organizations (CSOs/CBOs) to complement malaria elimination activities: During Q3, AHEAD continued to work collaboratively with OD/HC staff, CMEP, volunteers and local authorties to implement key activities in its target areas (in BTB, THK, SPL, PLN ODs). As the period April to June is typically a time when the planting

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3) of cassava/corn takes place, there were many MMPs moving to work in AHEAD areas and this enabled AHEAD to implement its activities well and achieve good results. Key activities included conducting 120 health education campaign sessions in 101 high transmission villages, distribution of 2,614 ITNs (1,289 LLINs and 1,325 LLIHNs), the mapping of 142 mobile/migrant settlements in 84 remote villages, and the referral of 331 (male: 199; female: 132) suspected malaria patients to VMWs/MMW/HFs (with 330 of these reaching VMWs/MMWs/HFs successfully). Also during Q3, OEC working in MRS OD, made efforts to improve its implementation. OEC was able to meet most of its activity targets including organizing 17 health education campaign sessions in high risk villages, distributing 563 ITNs to people who moved in and out to work in malaria areas, the mapping of 17 mobile/migrant locations in Sdok Pravoek and Prey Tralach Communes, Rukha Kiri District, and Battambang Province. Additionally, OEC’s staff indentified 43 malaria suspected patients and successfully referred these to VMWs/HFs (Full results for AHEAD and OEC are provided in Annex 1). Due to a tight schedule in Q3, CMEP is planning to conduct field visits to AHEAD/OEC to review field implementation and participate in the quarterly meetings during the second week of July 2019. The results of the field visit and and quarterly meeting will be shared in the Q4 report. Task 9. Conduct operational research in the context of malaria elimination CNM, CMEP, sub-contractor (Institute Pasteur in Cambodia or IPC) and relevant PHDs/ODs/HFs in Battamabang and Pailin continued the hsRDT study. By 30th June 2019, only 11 Pf cases were detected and enrolled in the study. From these, 12 index cases and 58 individuals were screened/tested with 4 tests as mentioned in the protocol (cRDT, 2 hsRDTs, and DBS for PCR). The PCR result is not available since the samples are not sufficient for analysis. None of the screened individuals tested positive for malaria. The number of Pf/Mix malaria cases in the study areas has declined considerably leading to challenges in searching for a reasonable sample size of expected cases. Therefore, with approval from CDC/PMI IRB, the CDC team along with IPC and CMEP team field visits and meetings suggested to expand the study site to Pursat province and extend the study timeframe until March 2020 to ensure completeness of 150 Pf sample index cases and 1,000 screenings from populations surrounding those index cases. The admendment for expansion and extention was submitted to the Cambodian National Ethics Committee for Health Research (NECHR) on 12 June 2019 Subsequently, it was confirmed that the amendment has been approved by NECHR and will be effective from July 2019. Task 10. Refine existing malaria elimination tools, SOPs, and guidelines The remaining tool for malaria elimination was the foci investigation form. CMEP joined with CNM, WHO and CHAI to review and develop an SOP for foci investigation and management. CMEP took the lead in entomological monitoring, mapping, house enumeration and field surveys as part of the joint activities. The foci investigation form was eventually finalized during Q3. CMEP along with partners (including WHO) will facilitate Foci Investigation training during Q4. Similarly CMEP jointly engaged with CN,WHO and CHAI to develop the PQ Radical Cure training manual, SOPs, and job aids the finalized product and sign off shall happen in Q4.

2.2 Objective 2: Support scale-up of high quality malaria control and prevention interventions in five to eight ODs, where gaps in coverage or quality exist Task 1. Rapid Situational Analysis and Needs Assessment Report - There was no activity on this task during FY19 Q3. Task 2. Ensure universal coverage with LLINs Mass distribution: There was no mass distribution activity in FY19 Q3 for Objective 2. Continuous LLIN distribution and top up monitoring: Initially, there was no plan to deploy

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3)

ITNs to VMWs/MMWs in Q3 given the mass distribution campaign. However, since CNM revised targets for ITN mass distribution for only villages with an API ≥5, CMEP deployed ITNs to villages that were not covered by the mass campaign. Therefore, 8,227 (146%) ITNs were deployed as buffer stock at the HC and VMW level (5,640 planned). During Q3, CMEP distributed 11,322 (84%) ITNs (13,425 planned) to target populations during outreach and response activities in April - June 2019. The actual result was lower than planned due to a relatively low need for ITNs after the mass distribution event [Act 2.2.5]. MMWs distributed 112 ITNs at big farms and MMP locations in Q3 (480 targeted) [2.2.6]. VMWs/MMWs conducted outreach visits to households and farms to top up ITNs using remaining nets from the previous deployment, along with providing SBCC activities and EDAT services, when required. 1,840 visits were accomplished (570 planned) by VMWs to households for ‘use monitoring’ and health education [Act 2.2.7]. 29,364 individuals received malaria education through IPC (target=5,700) [Act 2.2.8]. Task 3. Ensure EDAT and follow up Provide ongoing support in malaria diagnosis and treatment: CMEP activities covered 324 Point of Care units in Apr-June 2019 for 4 transitional ODs (43 HFs and 281 VMWs). PPs are now excluded as they are not allowed to test and treat [Act 2.3.1]. In the 4 transitional ODs, 11,018 individuals were tested, 1,648 were confirmed with malaria and 1,648 cases were treated in Q3 (see Figure 5). For confirmed cases, 159 cases (10%) were Pf/mixed and 1,489 cases (90%) were Pv. Three-day DOT was provided to 93 Pf/mixed cases by VMWs (77% of total, 121 Pf/Mix cases) [Act. 2.3.2]. 85 Pf/mix cases received SLD-PQ treatment by VMWs [Act 2.3.3]. During Q3, there were no severe malaria cases [Act. 2.3.4]. Figure 5. Confirmed malaria cases in 4 ODs (April January 2017 to June 2019)

Table 1 provides a breakdown of the confirmed malaria cases by species in the 4 transitional ODs. Overall, there has been a significant increase in Pf and Pv cases since 2017 in PKV and KRK ODs (see Figure 6), although there has been a decline in the past year. Table 1. Breakdown of confirmed malaria cases by species in 4 ODs OD Name Species Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Pf 198 179 208 321 347 418 380 242 196 157 128 67 54 77 39 33 28 29 Kravanh Pv 343 382 465 574 861 945 928 853 740 669 644 545 517 415 365 323 331 320 Mix 24 19 49 28 33 31 26 7 18 11 15 10 11 6 2 4 4 8 Pf 56 67 47 72 82 115 73 81 47 47 48 26 25 16 9 8 9 19 Krakor Pv 167 138 167 215 196 317 246 308 205 231 216 165 195 137 120 130 119 144 Mix 6 310 5 21211 7 4 3 2 2 4 1 0 0 4 3 Pf 3 61311 3 312 8 0 1 2 00 0 0 0 0 2 Bakan Pv 4 8 9 16 30 24 23 26 21 30 23 21 18 14 13 13 16 19 Mix 0002 30200100000000 Pf 7 11 0 14 7 1710 12 15 8 4 10 2 2 0 2 1 3 Sampov Meas Pv 15 9 19 37 23 55 56 45 47 40 43 34 33 26 20 21 24 29 Mix 0000 02222200000200 Figure 6. Monthly malaria cases in Kravanh and Krakor ODs

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3)

Outreach activities: Among all confirmed malaria cases, 1,080 (66%) were in PKV, and 436 (26 %) were in KRK ODs. The remaining 132 cases (8 %) were in BKN and SPM ODs. See Figure 7 for maps showing village incidence in PKV and KRK ODs. Although there were some changes in the number of cases identified in individual villages, the general areas of concern remain the same, with most representing areas near the forest. For 9 selected high incidence villages in PKV, there were 59 cases in April and 59 cases in June 2019. For 12 selected high incidence villages in KRK, there were 50 cases in April and 59 cases in June 2019. Figure 7. Map of villages with high number of malaria cases in PKV and KRK

Forest interventions: In response to the high caseload in Pursat province since 2018, CMEP continued supporting forest interventions along with an intensification plan (IP) introduced by CNM since October 2018. The interventions aim to increase malaria services coverage for forest workers, particularly in PKV and KRK ODs where population movement into the forest areas is still very high. In Q3, the interventions were managed through MMWs, which included 14 touch point volunteers (6 in KRK and 8 in PKV), and 16 peer educators (5 in KRK and 11 in PKV), together with existing VMWs/MMWs in the ODs. The MMWs (touch points/peer educator volunteers) contacted and encouraged forest goers/workers to conduct malaria testing, provided treatment for confirmed cases, provided health education via IPC, and distributed treated nets and SBCC materials (as the touch points are entry points, they come into contact with forest goers while they pass through the touch points into the forests, wheras the peer educators get into contact with the forest goers when visiting the work sites inside the forest). The MMWs regularly joined monthly meetings with VMWs (under the same catchment areas of relevant HFs). Results showed the touch point/peer volunteers conducted site visits to meet with forest workers and tested 1,984 suspected malaria patients. 171 patients (151 Pv,20 Pf/Mix) or 8.6% tested positive. 859 ITNs (162 LLINs/697 LLIHNS) were distributed (many of the forest goers already have nets from previous distribution events) and health education sessions were conducted (which reached 2,880 forest workers). Special efforts have been made in PKV OD as the number of malaria cases is the highest among all endemic ODs in the country; in April 2019, CNM, PHD, OD, and CMEP had meetings with

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3) district governors of Phnom Kravanh and Veal Veng administrative districts to get an update on malaria situation and discussed how to support a local response to prevent increasing numbers of malaria cases in the upcoming rainy/transmission period. As a result, village mapping was conducted with direct assistance from village chiefs to locate more potential hotspot areas through identification of entry/exit points to the forest so that malaria services or planned outreach interventions can be executed. In June 2019, following this exercise, 15 new MMWs were additionally selected in 23 village catchment areas. Further more, CMEP has been facilitating transportation and distribution of CNM/Global Fund procured forest packs to identified MMPs in the hotspot areas (forest govers/workers). Two lots of 600 forest packs were transported from Phnom Penh to deploy at MMWs in KRK and PKV ODs respectively. Capacity building: Technical supervisions were conducted by technical units from CNM, as well as PHDs/ODs to respective target ODs and HFs/VMWs. CNM supervision: There were 4 supervision visits from the laboratory unit of CNM to the transitional ODs against the 4 planned [Act 2.3.10]. Task 4. Strengthen case management and reporting in the private sector: Private Provider Mapping: CMEP is in the process of proposing and submitting a contract modification which includes a component on private sector non involvement in testing and treatment. However, 2 quarterly meetings (4 planned) were held in the 4 ODs (PPM tasks are no longer a priority for the Government staff and PPMs are less motivated to attend). [Act 2.4.3]. 73 PPs attended (target=122) the quarterly meeting during which the main questions were around, why PPs are being asked to stop testing/treating and when this might change. Supervision visits: During this reporting period, there were 4 supervision visits from CNM PPM unit to CMEP transitional ODs against 4 planned [Act. 2.4.5]. Task 5. Build capacity and strengthen systems to manage malaria control activities: CMEP Support to VMWs/MMWs: In total, 656 (270-KRK; 224-PKV; 65-SPM; 97-BKN) VMWs/MMWs (target 542) attended monthly meetings from April to June 2019 (121%) [Act 2.5.1]. During these meetings, VMWs reported information on malaria cases; received RDTs/ACTs from health center staff; and, received on the job training for case management, SBCC, case registration/reporting, and ITN monitoring/top-up reports. VMWs also shared challenges which included difficulties with DOT completion among MMPs and forest-related workers, poor road conditions, long distances to travel and unnecessary demands of topping up ITNs among the residents. During Q4, CMEP teams at OD level will continue to work with VMWs to encourage them to attend meetings to share experiences and build knowledge, and will work with ODMS to ensure that the attendance of VMWs in meetings increases. Integrated supervision from OD to HFs [Act 2.5.3]: 41 supervisory visits were accomplished during Q3 108% against 38 planned. Build capacity and strengthen systems to manage malaria commodities: CMEP provided support in stock monitoring and management to the nine target ODs during Q3. CMEP used the mHealth application (via laptops) [Act 2.5.4-2.5.5] which automatically geotags facilities and locations to allow close monitoring of places visited. ACT distribution:No ACT and/or RDT stock out/potential stockout were reported for 9 ODs in Q3 (see table 2). Table 2. Q3 ACT and RDT stock monitoring in all ODs Operational # of HFs ACT RDT District monitored Potential Stock Out Potential Stock Out SPL 10 0 0 0 0 BTB 28 0 0 0 0

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3)

PKV 8 0 0 0 0 KRK 8 0 0 0 0 TMK 18 0 0 0 0 MRS 15 0 0 0 0 PLN 5 0 0 0 0 BKN 11 0 0 0 0 SPM 12 0 0 0 0 Total 115 0 0 0 0 Visits to selected VMWs from CNM VMW Unit: In Q3, there were no planned visits from CNM’s VMW Unit to CMEP areas [Act. 2.5.6]. Provincial special working group for malaria elimination [Act 2.5.7]: There were no PSWGE meetings conducted in the transitional ODs in Q3. Task 6. Strengthen BCC interventions for intensified malaria control IPC to tested malaria cases and high-risk groups: From April to June 2019, 11,018 (target 13,622) suspected malaria patients were tested and received IPC through VMWs and HCs [Act 2.6.1]. For the high risk groups in KRK and PKV ODs, 16 peer educators and 14 touch points provided 1,971 health education sessions to 2,864 MMPs (target=1863 sessions) [Act 2.6.2]. Public Service announcement broadcasting: CMEP has continued to support Pursat PHD to broadcast public service announcements on the radio (broadcasting 4 times per day to alert malaria vulnerable persons using ‘radio 98.50 MHz’). The broadcasting includes a one-hour radio call-in show. An assessment of this activity was conducted by CMEP in Q3 to assess how effective the radio call in shows have been since their inception. 160 Households in PKV OD were interviewed for the assessment. The key results are summarized as follows:-  PKV HH’s listening to the radio - 38.8% (62HHs) of respondents said ‘yes’  PKV HH’s listening to malaria programs on the radio - 15% (24HHs) of respondents said ‘yes’  PKV HH’s saying that they changed behavior - 15% (24HHs) of respondents said ‘yes’ Although the number of persons listening to the PSA’s is relatively low, it is encouraging that there was 24 households who said that they had changed behavior because of the messaging. Malaria education campaigns at schools: There were no CMEP activities for this in Q3. Teachers at the schools in PKV and KRK ODs who had previously taken part in CMEP education interventions are routinely passing on and reminding students on malaria messages. Task 7. Support civil society and community-based organizations (CBOs) to implement Provide support to selected CSO partners & Implement sub-grant activities [Act 2.7.2]: During Q3, PFDA continued its project implemention in SPM, BKN, PKV and KRK ODs in Pursat province. PFDA has had good collaboration and coordination at all levels of implemention including with the local authorities. During Q3, PFDA continued implementing key activities including organizing 34 health education campaign sessions to reach 1,182 high risk persons, distribution of 2,760 ITNs to MMPs, mapping of 27 new settlers/forest workers sites, referral of 659 suspected malaria cases to VMWs/HFs and follow up on these. Overall, PFDA accomplished very good over target results in Q3 for ITN distribution and referral of suspected malaria patients. PFDA organized a meeting with ODs and PHD to update on PFDA activities and progress. PFDA also attended meetings organized by OD counterparts (see Annex 1 for the full PFDA results). Due to a tight schedule in Q3, CMEP is planning to conduct field visits to PFDA to review field implementation and participate in the quarterly meeting during the second week of July 2019 (results will be shared in the Q4 report).

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3)

Task 8. Operational research- CMEP Q3 OR activity is covered under Objective 1.

2.3 Objective 3: Strengthen national malaria surveillance systems and M&E appropriate for malaria elimination and control activities

Task 1. Refine and harmonize M&E reporting forms and support consistent use by public and private healthcare providers Work with CNM and partners to harmonize M&E reporting forms: Technical supervision procedures were continued to be revised for HF/RH/ODs in 2019. [Act 3.1.1] Support consistent use of the harmonized forms by providers: CMEP regularly ensures consistency of the forms (including recent visits/spot checks from key staff that check for this) Some inconsistent Elimination forms were identified in the ODs in Q3 by the CMEP team. OD teams were urged to always use the required correct forms [Act 3.1.2]. Overall, 93% of providers submitted surveillance data on time (100% from HFs and 92% from VMWs). See Figure 8 for provide submission percentages per OD since FY2018 Q3. Figure 8. Percentage of HFs, VMWs/MMWs, and private providers in target transitional ODs submitting surveillance data on time per national guidelines (since FY2018 Q3)

Task 2. Provide technical assistance on data management and use Conduct IDQA at OD and selected HFs by ODMS/PMS and CMEP [Act 3.2.2]: There was no activity for this during Q3 (the next IDQAs in 2 selected CMEP ODs will be in FY20 Q1. Provide TA to CNM on village-based stratification and facilitate use of stratification tools [Act 3.2.3]: CMEP has started developing the next administrative level/commune based stratification for all 9 ODs. Initial maps have been completed, and various parameters required for spatial analysis and stratification have been collected. CMEP has also analysed village wise data in PKV OD and developed initial maps and identified 22 villages that were reporting high prevelance of malaria cases in 2018. A similar trend was also observed during 2019. Based on the outcome of the activities village stratification processes will be carried out in all ODs from Q4 with geographical (‘geo’) maps. Provide TA to CNM on data visualization and outbreak module development for MIS The distribution of the CMEP OD Bulletins for FY 18/FY19 has contributed to the TA to CNM on data visualization. The bulletins provide useful visual representations of OD cases and species and are also provided in the local language. [Act 3.2.4] CNM supervision [Act 3.2.5]: During Q3, several visits were conducted by CNM technical units to CMEP target areas. Table 3 summarizes these visits. Table 3. Summary of CNM Technical Unit visits in Q3 Unit from CNM Q3 Planned Q3 Actual Percentage ITN unit 0 6 600%

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3)

Pharmacy unit 5 5 100% Laboratory unit 4 5 125% PPM unit 4 4 100% VMW unit 0 0 NA Health Education Unit 0 5 500% M&E unit 0 5 500% Epidemiology unit 9 1 11% Entomology 2 1 50% Total 24 32 133% Task 3. Support further development and implementation of electronic data reporting and use platform CMEP continues to monitor and follow up on the use of smartphones designated to VMWs and tablets designated to HF/OD staff that provide notification and reporting of malaria cases and stock status of malaria commodities. Task 4. Strengthen capacity to conduct entomologic monitoring Conduct entomology training for OD and PHD staff [Act 3.4.1.]: No entomology training was provided during FY19 Q3. However, a CMEP/CNM joint monthly vector surveillance was conducted at 1 sentinel site in Pursat province, in April and June 2019 which included a single vector survey conducted in June 2019. [Act 3.4.4]. This activity was conducted by a team including CNM, PHD, OD, HC, VMWs and CMEP staff for 5 night collection days of mosquitoes per month by using 3 different collection methods. Table 4 shows the results for the Q3 entomology monitoring visit in June 2019 (all of the data from the monthly collections were entered into a database developed by CMEP, which will be handed over to the CNM entomologist after the completion of the work by CMEP). Table 4. Summary of June 2019 entomological sentinel site collections

Collection No. of Total Anopheles No. of different An. Culicines Method traps collected Spp.

CDC Light Traps 5 23 6 296 Cattle bait trap collections 2 1125 15 1083 Human Landing collections 2 9 5 480 Overall, it was observed that there was an increasing trend in the number of Anopheles mosquitos collected during this peiod compared to the last collection, which may be due to the start of the rainy season. Cattle bait traps still provide the highest number of Anopleles mosquitoes collected (the other CDC light traps and Human landing collections are not so productive). All collected mosquitoes were identified, verified and stored. It was also noted that despite the absence of An. dirus, a few An. maculatis and An. minimus were collected primarily from the cattle bait traps. To know the infective rates, species confirmation, resistance mechanism and status of the collected mosqitoes, necessary molecular tests should be carried out as early as possible. As per the discussion CMEP had with CNM officials and the CDC entomologist, it was decided to conduct some mosquito collections in the forest border area to explore the presence of known vectors parallel to the monthly monitoring. In June CMEP and CNM conducted 3 nights with 2 light trap collections (assisted by VMWs and touch point volunteers) in the O’Chrov entry point and captured 10 Anopheles mosquitoes belonging to 4 species (1 An. dirus, 2 An. minimus, 6 An. maculatus, 1 An. other species). As this collection has captured the majority of known Anopheles vectors, it was decided to include this activity

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3) for the same area with the current monthly sentinel entomology surveillance plan to obtain more information on vector bionomics in the forest/forest border areas. 2.4 Objective 4: Build capacity of Ministry of Health (MOH) to manage, intensify, and sustain malaria control and elimination efforts particularly at the OD level Task 1. Develop and implement a plan to strengthen technical and management capacity at National, PHD and OD levels2 OD AOP development [Act 4.1.4.]: The development of Year 4 AOPs began at a meeting of CMEP PP and OD staff in Pursat (26th to 28th June). Internal Competency Assessment (ICA) course for selected malaria microscopists [Act 4.1.7] The National Competency Assessment (NCA) was conducted in BTB for selected BTB, PST and PLN lab staff (12 candidates). The activity took place from 24th to 30th March 2019 but was reported in Q3 (April 2019). The results of the NCA are provided in Annex 2, Table 1. Laboratory quality assurance [Act 4.1.8]: From April to May 2019, the CMEP Lab Supervisor conducted supervision visits to labs at RHs/HCs for 5 elimination ODs (along with the BTB Provincial Lab Supervisors from BTB, SPL, TMK, MRS ODs) and provided on the job training as part of these visits for Bovel I HC, Prey Chik HC and Prey Trolach HCs. Results for these supervison visits are provided in Annex 2, Table 2. The visits included dissemination of the new Operational Manual for the quality assurance of malaria diagnosis for PHDs. During Q3 and as part of the NCA program, CNM provided further training for selected microscopists. Annex 2, Table 3 provides a summary of these results. During Q3, slide crosschecking for CMEP Lab QA was carried out in PLN, BTB, SPL, TMK and MRS ODs. Annex 2, Table 4 provides a summary of these results. Provide on the job training and mentoring by CNM units [Act 4.1.9]: There was no specific training provided on entomology during Q3; however there was foci investigation and management training that was conducted for 48 participants in Siem Reap (June 20-21) for 6 Cambodian elimination provinces (BTB, PLN, Siem Reap, Kompong Thom, Banteay Meanchey and Kompong Chhnaing). CMEP foci investigation training is planned for early Q4 (July 2019) and foci investigation implementation plans will follow this training. E-Payment [Act 4.1.10]: The e-payment system is used to pay per diems, transportation and other allowances through mobile payments. During Q3, CMEP did not implement any further e-payments for VMWs in the ODs. Task 2. Support CNM and MOH to develop and maintain a system for on-going technical and management capacity development Provide technical assistance to CNM [Act 4.2.1]: There were 32 technical assistance feedback sessions provided by CMEP to CNM in Q3. CMEP progress review [Act 4.2.2.]: No activity for this in FY19 Q3. Task 3: Improve malaria policies and guidelines [Act 4.3.1]: In Q3, the CMEP team worked with CNM, WHO, CHAI and other partners during several meetings to develop and finalize:  Foci investigation SOPs/forms and training materials

2 Activities 4.1.1-4.1.3 are not applicable to the reporting period

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3)

 Pv radical treatment and G6PD testing tool/materials  Drug policies (meeting co-organized by CNM & WHO)

CNM SBCC strategy development: [Act 4.3.1] The strategy book modification will now be finalized in Q4 (CMEP has been part of supporting CNM in drafting the strategy). 3. PROJECT MANAGEMENT Oversight and Coordination CMEP Field Visits: In April CMEP COP and STA conducted site visits to 5 HFs in SPL, BTB and PLN with OD counter parts. The key findings of the visits included concerns around the stock monitoring of malaria commodities (compared with a real time update of the stock), inconsistencies between paper recording and the actual stock balance available at pharmacies, and systematic testing for malaria among targeted population not increasing as much as recommended and therefore leading to a hightest positivity rate. In April 2019, CMEP PP team along with 9 ODTLs held a full day meeting and reviewed and updated the CMEP Activity Tracker and CMEP Q2 report. On 8th May 2019, CMEP DCOP, STA and Senior BCC advisor visited forest rangers trained as MMWs and VMWs in Pramoy HC catchment areas. It was observed that the forest rangers were already playing an active role as MMWs. However, it was disappointing that that among 16 locations where 31 forest rangers were trained as MMWs, only 4 locations were providing active malaria services as mentioned above (however, due to a USAID temporary stop work order, forest rangers had to stop all MMW related activities later in Q3 until further clarification on this is provided by USAID). From 27 to 30th May 2019, CNM team from PP visited Pursat province prior to the MoH Ministers planned visits to PKV. CMEP team worked closely with the CNM team on arranging logistics and provided all relevant data/information to CNM for the ministerial visit. On 3rd-4th June 2019, CMEP PP and OD teams facilitated the visit of health minister from Pursat to Phnom Kravanh at the ‘triangle’ area of the 3 provinces of Pursat, Kg Speu & Kg Chhnang. On 4th June 2019, all participants went to the forest location to meet the forest goers/workers and observe and discuss malaria testing (at O’Chrov point near border of Kg. Speu). On 11th -14th June 2019, CMEP technical/M&E team conducted an assessment on radio call- in show program/public service announcements in PKV and BTB ODs (see pages 6 and 11). On 24th -25th June 2019, the CMEP held an all staff meeting in Pursat. After DCOP presented the objectives each OD then presented a summary of their key project activities, achievements, and challenges followed by Q&A/discussion. Admin/finance, M&E targets, and key technical highlight presentations were provided followed by a plenary discussion for staff. From 26th, to 28th June 2019, the Year4/OD AOP preparation and development meeting was held in Pursat. CMEP PP & OD teams, PMS and ODMS staff worked on the OD Malaria 2020 AOPs. DCOP introduced the objectives of the meeting along with the CMEP Y4 Priorities and participants were grouped into 9 individual OD teams who worked on their respective work plans and budgets. Draft AOPs were then shared/discussed highlighting any changes/priorities for Yr 4. The meeting concluded with COP summarizing priority activities including Pv radical treatment, Foci investigation, DOT, day 28 followup, VMW monthly meetings, and PPMs. Sub-grant Oversight and Management: OD teams conducted monthly field visits to monitor activities by the CSOs and provided necessary technical support. CMEP OD team leaders organized routine monthly meetings with the CSOs to recieve updates on progess to discuss challenges and seek solutions to improve the implementation.

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3)

Meetings with USAID (including COR, PMI-USAID team): COR-CMEP monthly meeting was held on 5th April, areas covered included; CMEP's corrective action plan/implementation; malaria case increase in Pursat; status of modification for SPM and BKN ODs to move to elimination; Preparations for World Malaria Day; Quarterly Review and Central Review by CMEP; request by CNM on TA support to GF's area, HsRDT and Pv Radical Cure. On 8th April 2019 CMEP COP and STA joined the launch of 2 USAID funded projects at Sofitel Phnom Penh Phukeetra: (1) Enhance Quality of Healthcare Activities (EQHA) implemented by FHI and (2) Promoting Healthy Behavior (PHB) implemented by PSI. The USAID Financial review commenced on 29th April. The ‘Entrance Meeting’ was held with the COR, the USAID Finance Controller, and from CMEP the COP Finance & Admin Manager. Two URC HQ staff also attended. The plan for the financial review was presented, along with a brief on how the process would proceed. During the review period, various interviews were held with specific CMEP staff to gather information. On 2nd May COP, participated in the USAID Cambodia COP meeting. The meeting provided an update on the Missions current planning, strategy and budgeting. Highlights included discussions on the USAID ‘Indo-Pacific strategy’ and the USAID ‘Self-reliance journey’. On 7th May 2019, a malaria situation/‘action plan’ review update meeting was held with PKV OD team, PKV HC, CMEP teams (PP, PKV, SPM and BKN ODs) and 2 staff from PMI (Dr. Rida Slot and David Sintasath). After the meeting a village census activity commenced as part of the action plan - 22 villages were selected for interventions based on the prevalence of malaria cases/hotspot areas. The village census exercise was completed by 17th May 2019. On 16th May, CMEP team met John Gimnig (CDC) and Vector Link COP, to explain specific CMEP activity components (hsRDT study, concept note for implementation of Pv radical treatment, G6PD testing, foci investigation/management, entomological monitoring, proposed pilot on hammock/net set preferences and LLIN durability monitoring). John Gimnig also met CNM (Tho Sochantha/Sokny) to review various sentinel site activities. On 24th May 2019, COR-CMEP monthly meeting was held at the US Embassy in Phnom Penh. The meeting focused on the visit of the Health Minster to Pursat on 3rd to 4th June with the CNM/PHD teams. The meeting was also the last one for Noah Sprafkin before his departure. CMEP PPM/MMP Coordinator participated in the USAID’s Gender and Development Dialogue, entitled “Bridging the Digital Gender Divide in Cambodia: Successes, Challenges and Opportunities for Female Empowerment in the Digital World on 3rd June 2019. COP attended the ‘all’ Cambodia COP meeting on 25th June. Subjects discussed included the ‘Leahy’ vetting process, Royal Government of Cambodia engagement, update on ‘Protecting Life in Global Health Assistance (PLGHA)’, and updates on ‘Notwithstanding Authority’. Meetings with CNM and Other Partners: On 8th April 2019, CMEP COP, STA, DCOP, CM QA Advisor and CMEP OD teams joined a meeting with CNM director/CNM technical/M&E teams, PHD directors/technical team, OD director, ODMS of PKV and KRK ODs. The meeting discussed why cases in PKV OD remain high and how to deal with this. On 9 April 2019, CMEP COP, STA, DCOP, CM QA Advisor along with CMEP Pursat and PKV OD team joined a meeting with 2 governors from PKV and Veal Veng district under the PKV OD catchment areas (Governor/Veal Veng & Deputy Governor/PKV). The meeting, led by the CNM director, was to update on the PKV malaria situation and ongoing interventions. The key points mentioned were a) District governors appreciate efforts of CNM/CMEP to reduce malaria in their districts, b) Agreement to work with village/commune chiefs to locate MMP entry points, c) Measures need to be taken to improve coverage/usage of ITNs along

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3) with adequate SBCC materials, d) CNM to ensure adequate supplies to all service delivery point levels (testing, drugs, LLINs/LLIHNs etc), e) malaria to be integrated into the agendas of district level meetings and assigned malaria technical persons to attend, and f) setting up of ‘telegram’ app to help share information on malaria to all stakeholders in PKV/KRK ODs. On 19 April 2019 at CNM, CMEP/COR team met with CNM Director and CNM Chief of technical bureau to discuss CNMs request for possible CMEP TA support to 8 new elimination provinces under CNM implementation lead. COR requested CNM to provide core activities and budget estimates that would inform PMI/CMEP to assess the request. CMEP M&E Team attended two meetings at CNM (27th May and 7th June) regarding the planning for the next Cambodia Malaria Survey (CMS). Participants included COR, WHO, CHAI, and UNOPS. The CMS is likely to be implemented by October 2019. CNM Mid Term Review (MTR) : On 26 June 2019, COP attended the meeting at CNM together with all partners regarding the MTR of the malaria program/MEAF in Cambodia. Meeting with CNM/Partners on Pv Radical Cure: On 4th April, CMEP COP and STA joined discussions on PQ quantification and Pv radical treatment at CNM with partners. Several draft tools that had been developed were shared with partners. Meeting with CNM on Malaria OR Network Coordination: On 22nd and 23rd April 2019, CMEP COP, SPTA and STA joined the annual meeting of APMEN in Bangkok. URC was voted as a new member of APMEN on 22nd April 2019. Meeting with CNM/Partners on World Malaria Day Planning: On 25th April, COP, STA and Senior BCC Advisor with CMEP BTB OD teams joined the World Malaria Day (WMD) event in Samlot district, Battambang province. On 25th April 2019, a WMD event was held in where the Minister of Health attended (CMEP was represented by Dr. Narran). On the same day, a WMD event was in PKV OD where Pursat PHD chaired the event for stake holders and community members, CNM. DCOP/CMEP OD staff also presented. WMD in Pailin province also took place on the same day with CNM/OHD/CMEP staff. Meeting with CNM on Intensification Plan: On 2 April 2019, CMEP COP/STA met with CNM/partners (WHO, USAID, UNOPS, CHAI, PSI, CARE, CRS) to discuss the implementation of the Intensification Plan (IP). So far results indicate some progress, however improved service delivery from MMWs is required to effectively contribute to HFs and VMWs (it had been expected that MMWs would capture more malaria cases as they are working in the hotspot areas). There was also discussions on stock monitoring via tablets at the ODs. On 27th April 2019, at Pursat CMEP office, COP, DCOP, STA and Senior BCC advisor met with Pursat CMEP coordinator, PKV CMEP OD team and KRK CMEP ODTL to review high malaria case situation in Pursat/PKV OD. The team developed an ‘Action Plan’ as an extra task to the routine/current activities for PKV OD which included specific activities and timelines on forest, BCC components, coordination/engagement, and monitoring and management. On 2nd May, DCOP, STA and SPTA joined meeting at CNM on the intensification plan progress. It was remarked that in CMEP areas testing is still low which leads to a high TPR. On 6th June 2019, CMEP STA attended a meeting at CNM to discuss the implementation of intensification plan (IP) in 7 burden provinces in which PKV/KRK are included. The IP will complete after 1 year by August 2019 and an extension of the plan will then be considered. Participation in Foci Investigation field testing with CNM/Other Partners: On 4 April 2019, CMEP COP, DCOP and STA joined meeting at CNM with WHO, CHAI and CNM to work on foci investigation SOP and relevant tools (Desk review, HH enumeration, Mapping,

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3)

Entomology, and Foci investigation form). Progress was made with all components of foci management, except PCR screening which is not yet finalized. On 30th April 2019, CMEP DCOP, STA and CM & QA Advisor joined a meeting at CNM to finalize the Foci investigation form/SOP with CNM, WHO and CHAI. The meeting agreed to test the form again at a CMEP area where Pf L1 cases have recently presented. On 3rd May, CMEP team (COP, DCOP, STA, and CM & QA Advisor) met CNM team (Dr. Sochantha/Sokny) and agreed on the 5th trip for entomology surveillance at Mol Chass village sentinel site (PKV) from 3rd to10th June and to continue this on a monthly basis July to Sep 2019. On 12th to14th June 2019, CNM, CMEP and WHO worked on preparation of training materials for foci investigation and management training. On 20th -21st June 2019 in Siem Reap, the 2 day training took place for 48 participants from 20 ODs of 6 elimination provinces (was co-organized by CNM, WHO with technical support from CMEP team). Meeting with IPC/Partners: On 13th June 2019, CMEP re-submitted the amended hsRDT study protocol to the Cambodian NECHR proposing (i) Expansion of study coverage to Pursat province with Battambang/Pailin provinces and (ii) Extension of study timeline to March 2020. Meeting with WHO/Partners: On 3rd May, CMEP (DCOP, STA, SPTA, CM & QA Advisor) joined the dissemination workshop of the MSF Research Project in . Topics included PCD, ACD (Re-ACD, Pro-ACD), hsRDT, and mass screening and treatment. On 17th May 2019 CMEP team (COP, DCOP & STA), John/CDC and WHO held a meeting to discuss the Pursat malaria situation and for the planned visit of WHO in May (21st-23rd May). On 30th May 2019, CMEP team (COP, STA & SPTA), joined a CNM-WHO organized meeting in Phnom Penh for the Annual Meeting on Antimalaria Drug Policy. Participants also attended from IPC, MORU, AFRIMS and MSF. The very high efficacy of the current ACT (ASMQ) was acknowledged and was recommended to be continued as first line treatment in Cambodia while also testing other ACTs, especially the ‘triple combination therapy’ of antimalarial drugs. On 11th June 2019, CMEP STA attended the dissemination workshop for the Lab QA Manual co-organized by CNM-WHO with participants from all malaria endemic provinces/ODs and NGO partners (importantly it was mentioned that new Lab policy means that microscopy services will only be expected at district/provincial RHs and no longer at HC level, and that RDT will be allocated at RHs to ensure diagnosis is available if the microscopist is not present). Meetings with PSM: On 23rd May 2019, CMEP team held a meeting with PSM team to introduce the new PSM team, and to share what had worked well so far between CMEP and PSM. The meeting discussed stock monitoring and current CPIRs. It was also agreed that PPM/MMP Coordinator would be the assigned CMEP focal person to coordinate with PSM team. PPM/MMP Coordinator & IT Specialist attended PSM LMIS training (30-31 May 2019). On 28th May 2019, CMEP submitted 2 CPIRs to PSM: (i) CPIR for 100,000 LLINs and (ii) CPIR for 50,000 LLIHNs for CMEP ITN continuous distribution in FY20. Procurement In FY19 Q3, CMEP received 1 project vehicle from PSI Cambodia Organization (see table 5). Table 5. CMEP Procured Items FY19 Q3 No. Item Unit Transfer/ Purchased date 1 Vehicle 1 09th April 2019 Financial Management During Q3, CMEP spent approximately 90% of its budgeted amount (see Table 8 for a summary of planned versus actual expenses during FY19 Q3). In Q4, CMEP will continue to maintain the expenditure in program activities as already

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3) demonstrated during Q3. Table 8 provides a summary of Q3 expenditure with explanations. Table 6. CMEP planned vs. actual expenses FY19 Q3

Human Resource Management At the end of FY19 Q3, CMEP had 68 staff on board (with an approved total number of 71 staff). A new staff for the position of OD Data Assistant, at OD TMK, joined CMEP on 3rd June 2019.1 Procurment officer, 1 Finance Assistant and 1 Driver in Pailin are yet to be recruited. Q3 compares with Q2 where there were then 69 staff on board.

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3)

4. RESOLVING CHALLENGES FROM FY19 Q2 The challenges faced in Q2 were around the decision to move forward with foci investigation and Pv Radical cure. CMEP along with CNM and WHO were able to make remarkable progress, in getting the meetings organized and lobbying closely with CNM to have meetings organized to plan for foci SOP development and conduct the field testing which lead to the finalization of the foci investigation form. The foci investigation SOP development and the field testing was successfully completed in Q3. The foci investigation training for 6 provinces, which was jointly supported by CMEP, was completed in June 2019. PV Radical cure intervention and ways forward experienced some successes in Q3 when CMEP along with CNM organsied meetings to develop the SOP, and the Job Aids to roll out PV radical cure intervention in 2 CMEP provinces (out of a total of 4 provinces). CMEP team was instrumental in working closely with CNM to develop all materials needed for the intervention. 5. CHALLENGES AND ACTIONS TAKEN OR PROPOSED The challenges around the ways to report and work with PPMs in the existing CMEP work plan poses a few barriers to getting the data around PPM work. CNM has been challenging CMEPs work with PPM and influencing CMEP to totally stop work with PPMs even for referral and supervision. CMEP in consulation with COR and technical team is proposing for a modification request to be submitted to CO in Q4 which thus will support CMEP to quickly decide future work and reporting on PPM activities and indicators. As per MEAF (2016-2020) Pursat province was able to move to elimination as part of the Phase 2 plan. Given the high burden active status in PVN and KRK, CMEP tabled the issue with CNM not to move these 2 ODs to elimination but rather shall only move SPM and BKN to elimination stage subject to approval from PMI. CMEP has proposed for a modification to PMI in Q4 and thus waits for the approval. The challenge for PV radical cure is still around G6PD procurement and administration and also vetting the capacity and capability of ODs and HC staff to manage and monitor adverse events and having emergency services in place. The hospital assessment is yet to happen and training is still to take place. The finalization of the Job Aids, materials, and SOP is yet to be approved by CNM. The delays in these shall further lead to delay in the process and activities, and thus PV radical cure implementation shall not proceed as planned in Q4. 6. PLANS FOR NEXT QUARTER AND UPCOMING EVENTS CMEP as part of the Yr 3 Q4 work plan will see greater progress in Q4 while implementing the following :  Submission of contract modification for i) moving SPM and BKN to elimination ODs, ii) PPM indicator revision, and iii) budget realignments  Q4 Training on foci investigation for 6 CMEP ODs and expediting the implementation  Ongoing support and strong coordination in PKV as part of the intensification plan.  Radical cure finalisation of SOP, training and implementation, ensure procurement of G6PD and deploy it in HFs.  Submission of Y4 work plan and budgets.  Follow up on the hospital assessment for 3 CMEP provinces as part of PV radical cure intervention.  CMEP central program review meeting in September 2019.  Training on hsRDT newly expanded provinces stakeholders by CMEP and IPC

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3)

 Working with CSOs for Yr 4 planning and CSOs annual program review.

ANNEX 1 CSO FY19 Q3 RESULTS TABLES

Table 1. AHEAD Results FY19 Q3 Indicators Target Actual Target explanation 1. # of health education Achieved target campaigns organized in 120 120 high transmission villages 2. # of mobile/migrant and 3000 3729 Achieved above target due to more new settlers reached with MMPs in seasonal cassava and corn BCC messages through plantations areas IPC 3. # of LLINs distributed 250 2614 Achieved above target due to more to mobile/migrant MMPs in seasonal cassava and corn populations plantations areas 4. # of mobile/migrant 120 142 Achieved above target due to more settlements mapped MMPs in seasonal cassava and corn plantations areas 5. # of suspected malaria 300 331 Achieved above target due to peoples patients referred to improved understanding of malaria. VMWs/HFs Additionally screened 15 ( 8 men and 7 women) patients during ITN distribution and screened 708 (male: 339 and female :161) suspected patients during HE campaign 6.# of patients seeking 285 330 Achieved above target but 330/331 treatment at VMWs/HFs reffered patients reached VMWs/HFs (referred suspected cases (one patient lost due to heavy rain, reached VMWs/HFs) instead of going to VMW, the patient went back to his hometown)

7.# of reports of any 3 0 No increase cases or outbreak to be increase in malaria cases reported or outbreaks 8.# of meetings organized 4 6 Meeting and discussion with OD with OD and PHD by Director and ODMS for all four ODs CSOs during OD field monitoring. 9. # of government 4 9 Attended Pro-TWGH every month in meetings attended by Battambang and Pailin PHD. CSOs (Pro-TWGH Attended OD Monthly meeting meeting)

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3)

Table 2. OEC Results FY19 Q3 Indicators Target Actual Target explanation 1. # of health education campaigns 16 17 Achieved above target organized in high transmission villages 2. # of mobile/migrant and new 515 305 Not many MMPs moved to settlers reached with BCC messages work in the selected areas in Q3 through IPC 3. # of LLINs distributed to 429 563 Achieved above target. Most mobile/migrant population MMPs did not receive ITNs from OD. (LLIN=370, LLIHN=193) 4. # of mobile/migrant settlements 15 17 Achieved above target mapped 5. # of suspected malaria patients 359 43 Not many suspected malaria referred to VMWs/HFs patients were identified in Q3 6. # of patients seeking treatment at 359 43 All referred cases reached VMWs/HFs (referred suspected VMWs/HFs successfully cases reached VMWs/HFs) 7. # of report any increased malaria 3 0 Malaria cases or outbreaks did cases or outbreaks not occur in Q3 8. # of meetings organized with OD 3 3 Achieved target and PHD by CSOs 9. # of government meetings 3 3 Acheived target attended by CSOs (Pro-TWGH meeting)

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3)

Table 3. PFDA Results FY19 Q3 Indicators Target Actual Target explanation 2. # of mobile/migrant and Over achieved target, a total 1,182 new settlers reached with attendants (Male 660 and Female BCC messages through 522) including 102 of IPC mobile/Migrant. Of those participants, 113 (37 females) were 1120 1182 suspected for malaria by VMWs/MMWs during HE campaign. One patient was PV positive

3. # of LLINs distributed Over achieved target as more MMPs to mobile/migrant 1100 2760 who had no ITNs for use were populations identified 4. # of mobile/migrant Under achieved target because not settlements mapped 30 27 many MMP locations were identified 5. # of suspected malaria Over achieved because it was rainy patients referred to 362 659 season, many suspected malaria VMWs/HFs patients were found 6.# of patients seeking Achieved target. treatment at VMWs/HFs 95% 100% (referred suspected cases reached VMWs/HFs) 7.# of reports of any No report of malaria increase, increased malaria cases or because no case increase in this 12 0 outbreaks quarter compared with Last quarter in VMW record 8.# of meetings organized Achieved target. with OD and PHD (Pro- 12 12 TWGH meeting) 9. # of government Under achieved target because it was meetings attended by 12 11 dependent on the counterpart who CSOs organized the meeting

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3)

ANNEX 2 LAB QA/MICROSCOPY TRAINING TABLES

Table 1. The Results of the National Competency Assessment (Reported in Q3) Country Microscopists Parasite Species ID Counting Certification Place of Detection (%) (%+/-25%) Level Work (%) Cambodia Ms. Srey Kong 100 93 79 A CNM lab Cambodia Mr. Thay 91 77 43 B RH PST Vandy Cambodia Mr./ Ke 95 63 50 D RH KRK Sopheap Cambodia Mr. Chhorchen 86 57 64 D RH BKN Cambodia Ms Sean Chrip 95 45 36 D HC Thmor Da Cambodia Ms. Ke Saoran 86 80 50 B HC Chheutom Cambodia Ms. Sok 91 85 57 B RH BTB Botum Cambodia Mr. Nith Nan 77 50 36 D HC Kg Lpov Cambodia Mr. Vorn 86 61 57 D RH MRS Chanrong Cambodia Ms. Som 86 62 43 D RH SPL Bunny Cambodia Ms. Vath Sitha 100 76 36 C RH TMK Cambodia Ms. Sun Nin 91 86 50 B RH PLN

Table 2. Slide Bank for CMEP Lab QA ‘on the job training’ (April to May 2019)

HC lab HC lab Number OD Name of HC Results Results Remarks Slides Bank Correct Incorrect

2-days training provided Prey Trolach 6 100% 0 during lab supervision 1-day training provided MRS during lab supervision Prey Chik 6 83% 17% (error due to a species mistake) 1-day training provided during lab supervision TMK Borvel 1 5 80% 20% (error due to a false negative mistake)

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q3)

Table 3 CNM Malaria Microscopist Training Results

Microscopist Parasite detection (%) Species ID (%) Counting (% +/- 25%)

Ms. Srey Kong 100 100 60

Mr. Thay Vanndy 100 88 60

Mr. Ke Sopheap 100 73 20

Table 4. Slides crosscheck for Lab QA April-June 2019 in BTB and PLN Provinces

HC Lab HC Lab QA Lab QA Lab Name of OD result result result result HC Negative Positive Negative Positive

PLN Ou Chrar 04 00 04 00 Krachab 01 00 01 00 BTB BR 07 00 07 00 Tasanh 20 07 20 07 Sdao 19 (D281) 03 19 03 Plov Meas 07 00 07 00 Kompong 06 01 06 01 Lpov SPL RH SPL 09 05 09 05 Trang 0 0 0 0 Pichenda 0 0 0 0 TMK TMK RH 11 01 11 01 BV 03 01 03 01 MRS MRS RH 05 00 05 00 Prey 00 02 00 02 Trolach Preak 04 02 04 02 Chik TOTAL 96 22 96 22 ACCURACY 100% 100%

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