Malaria Elimination Project Quarterly Report (FY18Q1)

CAMBODIA MALARIA ELIMINATION PROJECT

Cambodia Malaria Elimination Project

Quarterly Progress Report- Year 2, Quarter 1 October 1-December 31, 2017

Submission Date: January 31, 2018

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

Submitted by: Sharon Thangadurai, Chief of Party University of Research Co., LLC. House #10, Street No. 214, Sangkat Cheychumneas, Khan Duan Penh, 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 (FY18Q1)

TABLE OF CONTENTS

TABLE OF CONTENTS ...... iii

Acronyms ...... iv

1. Introduction ...... 5

2. Progress Toward achieving CMEP OBJECTIVES ...... 7 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...... 7 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 ...... 11 2.3 Objective 3: Strengthen national malaria surveillance systems and M&E appropriate for malaria elimination and control activities ...... 16 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 ...... 18 2.5 Project Management ...... 20 Oversight and Coordination ...... 20 Procurement ...... 21 Financial Management ...... 21 Human Resource Management ...... 22

3. Resolving challenges from FY 17 Q4 ...... 23

4. Challenges and actions taken or proposed ...... 23

5. Plans for next Quarter and upcoming events ...... 24

i Cambodia Malaria Elimination Project Quarterly Report (FY18Q1)

ACRONYMS

AOP Annual Operational Plan SBCC Social and Behavior Change Communication BTB CAP-Malaria Control and Prevention of Malaria CMEP Cambodia Malaria Elimination Project CBO / CSO Community Based Organization / Civil Society Organization CDC Centers for Disease Control and Prevention CNM Cambodia National Malaria Center COP / DCOP Chief of Party /Deputy Chief of Party COR Contracting Officer’s Representative EDAT Early Diagnosis and Treatment EMMP Environmental Mitigation and Monitoring Plan GSSHealth Global Scientific Solutions for Health GUC Grants Under Contract HF Health Facility HPA Health Poverty Action IPC Interpersonal Communication ITN Insecticide-Treated Net KKR Krakor LLIN / LLIHN Long Lasting Insecticidal Net / Hammock Net M&E Monitoring and Evaluation MC Malaria Consortium MEAF Malaria Elimination Action Framework 2016-2020 MMP Mobile and Migrant Populations MMW Mobile Malaria Worker MoH Ministry of Health MOP Malaria Operational Plan MRS Maung Russey NAMRU-2 Naval Medical Research Unit-2 OD / ODMS Operational Health District / OD Malaria Supervisor PERSUAP Pesticide Evaluation Report and Safer Use Action Plan PHD / PMS Provincial Health Department / Provincial Malaria Supervisor PKV Phnom Kravanh PMI President’s Malaria Initiative PP Private Provider PPM Private Public Mix PMP Performance Management Plan PSK Population Services Khmer STA Senior Technical Advisor SOP Standard Operating Procedure SPL Sampov Loun TMK Thmar Kaul UNOPS United Nations Office for Project Services URC University Research Co., LLC USAID United States Agency for International Development VMW Village Malaria Worker VHSG Village Health Support Group WHO World Health Organization

i Cambodia Malaria Elimination Project Quarterly Report (FY18Q1)

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 Operational District (SPL OD) and support its dissemination and 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. Year 1 and 2 activities are implemented in four ODs in (Sampov Loun (SPL), Battambang (BTB), Maung Russey (MRS), Thmar Kaul (TMK)) and two ODs in Province (Phnom Kravanh (PKV) and Figure 1. CMEP targeted Operational Districts Krakor (KKR)) (Figure 1). In FY18 Quarter 1 (Q1) (October 1 to December 31, 2017), CMEP continued full- scale implementation of activities as follows: • Provided support to a network of health facilities (HFs), village/mobile malaria workers (V/MMWs) and private providers (PPs) in case management and malaria surveillance through regular monthly meetings and supervision visits. • Initiated insecticide treated net (ITN) mass distribution to villages with an Annual Parasite Incidence (API) 5 and above per 1,000 population • Conducted refresher training and orientation of single low dose primaquine use for confirmed P. falciparum(Pf)/mixed (Pf/P. vivax (Pv)) cases in 5 transitional ODs under objective 2 • Elaborated a two day basic entomology training program for OD/Provincial Health Department (PHD) and HF (malaria supervisor) staff • Supported CNM and ODs/HFs to conduct planned supervision visits to VMWs and PPs • Collaborated with partners on supporting implementation of a new surveillance strategy adopted by CNM in FY2017.

CMEP Indicators in Progress against each performance indicator is presented in the following file. FY17 and Q1FY18.xlsx

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Cambodia Malaria Elimination Project Quarterly Report (FY18Q1)

Figure 2. CMEP Summary of Activity Progress (October-December 2017)

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Cambodia Malaria Elimination Project Quarterly Report (FY18Q1)

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: In Q1, the CMEP team started preparing the scope of work for a short term technical advisor who will be recruited to conduct the costing analysis to evaluate the programmatic effectiveness, scalability and cost of the malaria elimination operations in SPL. The analysis will document best practices and identify key components of the elimination package that can be feasibly and effectively replicated in other ODs. This analysis will establish investment and operational costs of the malaria elimination model and inform policy decisions on further roll out of the SPL 1-3-7 elimination model. The terms of reference will be finalized and submitted to the USAID/PMI for review and approval in January 2018. [Act 1.1.2.]

Task 2. Sustain universal Long Lasting Insecticidal Net (LLIN) coverage:

Mass distribution: In support of CNM/Global Fund/UNOPS initiative for a nationwide ITN mass distribution campaign, in FY 18 Q1, CMEP’s team and 47 participants including PHD/OD and HF staff from all targeted ODs in Battambang and Pursat provinces (with the exception of TMK as all existing endemic villages must have an API > 5/1,000), joined a national two-day microplanning development workshop on ITN mass distribution held by CNM and UNOPS on November 20-22, 2017. [Act. 1.2.1] Participants received detailed instructions and guidance on conducting censes and distributing LLINs to residents and migrants and mobile populations (MMPs). CMEP provided technical input in preparing and conducting the national planning workshop. However, all costs were covered by UNOPS and CMEP’s estimated budget for this activity remained unspent. In order to support ITN mass distribution [Act.1.2.2], after the National Planning Workshop, CMEP trained 19 HF staff as trainers to train VMWs/MMWs for conducting census in SPL. These staff have since trained 56 VMWs/VHVs and 28 village chiefs. Trained community workers conducted a census in SPL OD in line with CNM criteria to estimate the required number of ITNs per household, based on the national ratio of 1/1.8 for residents, and 1/1 for MMPs. Based on these criteria, in SPL 9,250 households will receive 34,650 ITNs through the mass distribution campaign in FY18 Q2. Ensure continuous distribution of LLINs: In line with the updated list, CMEP’s target for continuous LLIN distribution was 86 villages in SPL OD [Act 1.2.3]. Taking into consideration the upcoming ITN mass distribution campaign, CNM did not provide any nets for continuous distribution in FY18 Q1. Therefore, the number of LLINs deployed as buffer stock at the VMW and HF level was 171 (3% of 6,450 LLINs planned) [Act1.2.4]. However, CMEP distributed 1,996 LLINs to target populations during outreach and response activities (versus 6,450 planned) [Act 1.2.5]. Net top up and malaria education to households: VMWs conducted 1,269 (82% of Q1 target 1548 visits) visits to households for net use monitoring, net top-ups and health education [Act 1.2.6]. As a result, 14,694 household members received health education on malaria prevention and LLIN use.

1 Activity 1,1.1. was completed in Year 1 and is not applicable to the Q1 reporting period

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Cambodia Malaria Elimination Project Quarterly Report (FY18Q1)

No supportive supervision visit was conducted by the CNM ITN Unit. [Act 1.2.7]. This was due to CNM’s staff availability which was limited due to other commitments, and the visits were postponed to Q2 (two visits should be conducted throughout the year). Task 3. Ensure Early Diagnosis and Treatment (EDAT) and follow up: CMEP activities covered 244 points of care in Q1 [Act. 1.3.1]. In SPL, all 2,649 (100%) suspected malaria cases received a parasitological test. Figure 3. Map of reported malaria cases by origin in SPL OD, Oct- Half (50%) of individuals Dec 2017 were tested by VMWs, 22% by HFs and the remaining 28% by PPs. Out of all individuals tested, 65 cases (2.5%) were confirmed positive. All 65 cases notified in SPL were imported (see Figure 3 for a case distribution map). Thirteen cases (20%) were imported from Pursat, 12 (18%) from and the rest from other provinces in Cambodia. Nine cases were linked to old cases that were classified as imported cases during the previous malaria episode. Out of nine, 8 were Pv and 1 Pf cases. The patient with Pf malaria experienced the same Pf infection 1 month before the current episode (Pv may be relapse cases and Pf either drug resistant or a treatment failure case). These cases are not depicted in Figure 3. Out of 65, 10 (15%) were Pf/mixed and 55 (85%) Pv malaria cases (Figure 4). Most cases (85%) were among males (55 male, 10 female). Two of the 65 cases were among children aging from 5 to 14 years old. The highest number of cases were notified in district (25) compared to Phnom Proek (18) and Sampov Loun (7) districts. Figure 4. Number of confirmed malaria cases in SPL per species in Oct-2016-Dec 2017

Pf/Mix Pv Total

27 26 24 15 17 17 15 23 15 9 13 21 11 11 11 11 9 11 7 13 9 7 6 7 12 8 11 7 3 5 6 6 8 4 3 4 3 3 4 3 1 2 0 2 2 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-18 Nov-17 Dec-17

In SPL, 44 malaria cases out of 65 positive cases (68% versus 86% in Year 1) received three days of directly observed therapy (DOT) (Figure 5) [Act 1.3.2]. DOT completion rate was lowest for private providers (with only 32% of providers providing DOT treatment in line with national guidelines versus 78% of HFs and 100% of VMWs). In quarter 2 of FY 2018 CMEP will intensify its capacity building activities aimed at private providers to eliminate this performance gap. DOT coverage of Pv cases was 64% and 100% for Pf. All 10 Pf/mixed cases were reached through reminder messages via the mHealth application and were automatically transferred to a response team to conduct the 28-day follow up. However, due to high mobility, only 2 out of the 10 patients received the needed monitoring. [Act. 1.3.3]

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Cambodia Malaria Elimination Project Quarterly Report (FY18Q1)

Figure 5. Implementation of DOT in SPL OD per species

120% 100% 80% 60% Pf/Mix 40% 20% Pv 0%

In FY18 Q1, no patients were hospitalized for second line treatment [Act 1.3.6]. CMEP incorporated the recommendations on use of single low dose primaquine (SLD-PQ) in monthly meetings with VMWs and HF staff. This quarter, 188 VMWs and HF staff received refresher training on SLD-PQ use [Act. 1.3.4] Nine out of 10 (90%) Pf/mixed cases diagnosed in Q1 received SLD-PQ treatment. Case management training was conducted for 17 heath facility staff (Q1 target 15) [Act 1.3.9a] and for 87 VMWs (Q1 target 80). [Act 1.3.9b]. CNM pharmacy, lab and diagnosis and treatment units did not accomplish planned supervision visits in Q1. Depending on availability of CNM staff members these visits will be rescheduled in quarters 2 and 3. [Act. 1.3.10] Task 4. Malaria case reporting, investigation, and response In FY18 Q1, 53 cases out of 65 (82%) were notified within 1 day via the SMS Day-0 mHealth system, investigated within 3 days and response provided within 7 days [Act.1.4.1-1.4.3]. All HFs and VMWs followed an established 1-3-7 surveillance practice. Delayed case notification by private providers (with 37% or 7/19 of cases notified within day 1) resulted in lower performance against this indicator compared to baseline 100% achieved by the end of Year 1. As private providers need additional guidance on malaria case notification within the 1-3-7 elimination model, performance gaps in this area will be addressed through bi-monthly meetings. Task 5. Strengthen case management, reporting, and response to all malaria cases in the private sector The CMEP team updated the list of private providers in SPL with 63 private providers enrolled in the private public mix (PPM)[Act.1.5.1].2 One bi-monthly meeting was conducted in November 2017 as planned and 57 providers attended (90%) [Act 1.5.3]. HF/OD staff provided two bi-monthly supervision visits to all 63 private providers in October and December and to six PPs who were absent during the monthly meeting in November to collect data and provide feedback on quality of reporting on malaria cases. 26 visits were accomplished (versus 14 planned) to all 63 private providers [Act 1.5.4]. PPM in SPL started in July 2017 with the first bi-monthly meeting with PPs in September 2017. Visits to PPs for data collection were subsequently conducted in October and December, making the numbers of visits greater than the target (as 2 meetings were held for some instead of 1). Task 6: Build capacity and strengthen systems to manage elimination activities3 Supporting VMWs monthly meetings: Monthly meetings continued in FY18 Q1 to support capacity building of VMWs and HF staff. Meetings were held during the fourth week of October, November and December. On average, 95% (160/168) of VMWs attended the monthly meetings. In total in Q1, 471 VMWs attended meetings versus 480 planned (98%). [

2 Act 1.5.2. Conduct refresher train registered PPs on EDAT, referral and reporting is not applicable to this reporting period 3 No targets were set for activities 1.6.6. and 1.6.8. Therefore, these are not included in Q1 report.

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Cambodia Malaria Elimination Project Quarterly Report (FY18Q1)

Act 1.6.1]. CMEP OD teams also visited eight VMWs at their homes to review progress and provide on-site mentoring (versus 24 planned as general attendance at regular meetings was good, and there was no need to make additional home visits to those who were present) [Act 1.6.2]. Integrated supervision from ODs to HFs: Five supervision visits were conducted to all 10 HFs in October 2017 based on the CNM supervision checklist [Act 1.6.3]. Twenty-three confirmed malaria cases were clinically audited. All of them were correctly treated according to national treatment guidelines. No ACT or RDT stock outs or potential stock outs were detected at the time of supervision. Data verification on total tests, total confirmed cases and total treated cases were also performed. Data verification confirmed the accuracy of the reported data. Feedback was provided to health facility staff on the need to improve recording of individuals’ weight and malaria species. Stock monitoring: There was no need to reallocate stock during the Quarter, as the stock at HF’s was secure [Act 1.6.4.]. Refresher training on 1-3-7- approach: CMEP conducted training for OD, HF staff and VMWs on the revised Case Investigation Form in September 2017. One hundred and eighty- three individuals (including 5 OD, 4 regional hospital, 19 health facility and 154 VMWs) received this training though monthly meetings (Act. 1.6.5). The new CNM case investigation form was introduced to OD/HC staff in Sept 2017, but full training for the surveillance malaria elimination operation manual has not been provided (will be provided in March). After the surveillance technical working group meeting, the investigation form and mobile app has to be revised as some part of the training had to be postponed to Q2/Y2 (after CNM updates the app system for tablet and smart phones). District Special Working Group For Malaria Elimination: 6 meetings were conducted, 3 meetings in October 2017 and 3 meetings in December 2017 in the 3 administrative districts of Kamrieng, Phnom Proek and Sampov Loun. [Act 1.6.7]. On October 11, 2017, the CNM Director and his staff joined a district special working for malaria elimination meeting in Sampov Loun OD (41 participants included district vice governor, all public offices in the district, military, police, NGOs and CNM, BTB PHD, SPL OD and HFs). The Director appreciated and encouraged participation of members in this multi-sectoral collaboration to work together to eliminate malaria. The Director also emphasized technical points on the safety of SLD-PQ administration by health workers and encouraged administration of SLD-PQ. The Director visited two HFs in SPL OD (Buor & ) before travelling to Pailin. Task 7. Social and Behavior Change Communication (SBCC) for malaria elimination4 All 2,649 individuals tested for malaria received IPC for malaria education [Act 1.7.1]. In addition to malaria patients, IPC was provided to 134 people from high-risk groups during case response activities [Act 1.7.2]. At the farms, VMWs organized small group education sessions to deliver malaria key messages by using their IPC skills and job aids developed by CMEP. As a result of this work, 17,212 MMPs at farms were reached with malaria outreach educational activities in FY18 Q1. Task 8. Support civil society organizations (CSOs/CBOs) to complement malaria elimination activities CMEP’s sub-grantee, Action for Health Development (AHEAD), started project implementation on September 15, 2017 in SPL.[Act 1.8.1.]5 During the reporting period, AHEAD collaborated closely with local authorities, ODs, HCs, VHSGs and VMWs in SPL. AHEAD identified 56 MMP settlements and provided malaria education and testing services

4 No target was set for activity 1.7.3 in Q1 5 Fixed Amount Award Grant No. FY17.7030.G01

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Cambodia Malaria Elimination Project Quarterly Report (FY18Q1) to all 56. AHEAD organized 22 small group sessions which covered 669 individuals. (Q1 target 30 sessions). 118 suspected malaria cases were referred to VMWs and HFs for testing. AHEAD provided follow up to find out how many of referred individuals reached VMWs/HFs (collaborating with VMWs where possible). For all cases (100%), the referral was completed successfully. Nevertheless, none of these cases were confirmed positive with malaria. Task 9. Conduct operational research in the context of malaria elimination The CMEP team continued consultations with PMI/USAID on planning the research aimed at evaluating the use of highly sensitive RDTs in the context of case investigations in elimination areas. The CMEP team expects that the protocol will be finalized and submitted to the CNM ethical review committee for approval in Q2 [act 1.9.1]. Task 10. Refine existing malaria elimination tools, SOPs, and guidelines CMEP continued its operations in line with the existing malaria elimination tools, SOPs and guidelines submitted to the USAID mission on October 31, 2017. No amendments were made in any of these tools during FY18 Q1 [Act 1.10.1].

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 CMEP’s implementation plan for transitional ODs under objective two was based on the needs assessment and OD situational analysis conducted in Q3 of FY 2017. Therefore, no additional in-depth analysis was conducted in Q1 of FY 2018. Specific needs assessment activities undertaken for ITN mass distribution are described under Task 2. [Act 2.1.1 and 2.1.2] Task 2. Ensure universal coverage with LLINs Mass distribution: As also described under Objective 1 Task 1, CMEP in collaboration with UNOPS provided support to CNM in ITN mass distribution. After the National Planning workshop held in November 2017[Act. 2.2.1], CMEP trained 57 HF staff as trainers for census training for VMWs/MMWs in BTB, MRS, KRK and PKV. TMK OD was excluded from the national ITN distribution campaign because all their existing endemic villages have API less than 5. These trainers then trained 320 Village chiefs, 554 VMWs and 112 VHV in 320 villages. The number of households and ITNs to be distributed per OD is as follows: BTB: 15,250 HHs, 52,300 ITNs; MRS: 17,050 HHs, 61,450 ITNs; KRK: 19,600 HHs, 64,850 ITNs; PKV: 29,752 HHs, 85,700 ITNs. Distribution will continue in FY18 Q2. [Act 2.2.2] Continuous LLIN distribution and top up monitoring: CMEP updated the list of villages and big farms for continuous LLIN distribution. 297 villages and big farms were included in the list (versus 294 planned) [Act 2.2.3]. During the week of November 6, 2017, CMEP requested 38,000 LLINs and 19,000 LLIHNs from UNOPS to deploy them as a buffer in VMWs’ villages and target farms/companies, and then provide further continuous distribution through ITN monitoring and top-up mechanism by VMWs at households and farms [Act 2.2.4]. Due to ongoing mass distribution, UNOPS did not yet provide (during the reporting period) any additional ITNs for continuous distribution. Therefore, CMEP only distributed 589 ITNs (versus 22050, this can be explained by overlapping with the mass distribution campaign) in target ODs under objective 2. [Act. 2.2.5] No LLINs were distributed to big farms by MMWs in Q1 [Act 2.2.6]. While there has not been significant deployment of ITNs to VMWs during this period, VMWs/MMWs still conducted outreach visits to households and farms to top up ITNs using remaining nets, along with SBCC activity and EDAT services, when required. However, 4,273 (88%) visits were accomplished (versus 4,851 planned) by VMWs to households for use monitoring and health education [ Act 2.2.7]. 31,572 individuals received malaria education through IPC (versus 36,180 planned). [Act 2.2.8]

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Cambodia Malaria Elimination Project Quarterly Report (FY18Q1)

Task 3. Ensure EDAT and follow up Provide ongoing support in malaria diagnosis and treatment: CMEP activities covered 810 point of care units in FY18 Q1 in the targeted sites (versus 774 planned) [Act 2.3.1]. In the 5 ODs, 11,649 individuals were tested, 3,355 were confirmed with malaria and 3,377 cases were treated during the reporting period (see Figure 6). An observed variance between the numbers of confirmed and treated cases can be explained by under recording of all tested cases. Among confirmed cases, 47% (1,565) were Pf/mixed and 1,790 cases (53%) were Pv cases. Three day DOT was provided to 774 Pf/mix cases by VMWs (49% of total 1565 Pf/Mix cases confirmed during the reporting period. [Act. 2.3.2]. Only 1 Pf/mix case received SLD primaquine treatment, indicating providers have not yet started its use after the orientation [Act 2.3.3]. There was no severe malaria case that would require hospital treatment in Q1, therefore hospitalization did not occur. [Act. 2.3.4]

Figure 6. Confirmed malaria cases in 5 ODs

1000 900 800 700 600 500 400 300 200 100 0

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Confirmed Malaria Cases Malaria Confirmed 2016 2017 OD 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Battambang 22 16 24 9 31 12 11 29 47 54 43 52 31 35 38 kravanh 112 108 92 76 86 74 83 290 469 465 422 500 796 862 644 Krakor 101 95 81 14 69 46 77 174 371 290 291 250 305 294 222 Thmar Koul 2 1 2 0 4 0 1 5 5 3 3 4 5 3 3 Maung Russey 9 12 14 6 10 6 17 40 62 52 35 28 39 43 35

Table 1 provides a breakdown of confirmed malaria cases by species in the 5 OD’s. Overall, there was a significant increase in Pf and Pv cases from May 2017 onwards (especially in Phnom Kravanh and Krakor OD’s). The likely reasons for this included: (i) VMWs were fully functioning by May17, which meant there were more cases detected and reported; (ii) More people went to the forest areas after the plantation season finished who were exposed to high risk areas (especially males); (iii) CMEP/PHD/OD/HC’s did start to investigate villages with high reported cases, however the response activities did not work speedily enough to prevent transmission in the forest areas. Table 1. Breakdown of confirmed malaria cases by species in 5 ODs

OD species Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Battambang Pf 10 8 12 3 17 3 2 19 17 9 8 6 12 12 16 Pv 11 8 11 6 11 9 9 8 27 45 34 46 19 21 22 Mix 1 0 1 0 3 0 0 2 3 0 1 0 0 2 0 Thmar Koul Pf 2 0 1 0 1 0 1 2 2 0 2 3 4 2 0 Pv 0 1 1 0 2 0 0 2 2 3 1 1 1 1 3 Mix 0 0 0 0 1 0 0 1 1 0 0 0 0 0 0 Maung Russei Pf 3 9 7 6 3 4 7 24 29 23 17 10 12 14 19 Pv 6 2 7 0 7 1 7 15 31 26 16 15 25 28 16 Mix 0 1 0 0 0 1 3 1 2 3 2 3 2 1 0 Kravanh Pf 71 71 54 40 40 34 45 166 261 247 222 260 434 345 238 Pv 38 37 34 36 46 37 36 117 201 202 190 222 336 478 377 Mix 3 0 4 0 0 3 2 7 7 16 10 18 26 39 29 Krakor Pf 62 59 52 8 45 16 43 90 196 173 152 111 145 119 57 Pv 35 32 27 6 23 30 32 75 152 97 130 121 139 165 159 Mix 4 4 2 0 1 0 2 9 23 20 9 18 21 10 6 Outreach activities: Sixty eight percent of all confirmed malaria cases were in Phnom Kravanh (PKV) and 24% in Krakor (KRK) ODs. Maps showing village incidence are pasted below in Figure 7. Although there were some changes in the number of cases identified in individual

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Cambodia Malaria Elimination Project Quarterly Report (FY18Q1) villages, the general areas of concern remain the same with most representing areas near the forest.

Figure 7. Map of villages with high number of malaria cases in PKV and KRK

In response to a significant increase of malaria cases in these ODs since FY17 Q3 and continuing into FY18 Q1, CMEP performed outreach to worksites within the forest in PKV and KRK OD’s [Act 2.3.5]. Considering the various concerns raised in Y1 on this activity implementation by the team (including difficulties related to travel, safety, and gaining trust of forest workers and communities), CMEP and OD staff in KRK and PKV selected and trained 16 temporary MMW’s to operate as ‘Peer Malaria Educators’ and ‘Touch Point Volunteers’ (5 Peer Malaria Educator’s and 3 Touch Point Volunteers for each OD - CMEP and OD teams conducted 1-day training for these at Phnom Kravanh Health Center, Phnom Kravanh OD on Oct 03 and at Chheu Tom Health Center, Krakor OD on Oct 05, 2017). These temporary MMWs were instructed to report to VMWs in the nearest locations. The temporary MMW’s then completed pro-active case detection at hot spots that they identified through case management activities at HC/VMWs/Touch Points. The 16 temporary MMWs tested 673 people, and detected and treated 224 cases (Pf+PV). They also provided health education to 1,040 people and distributed 157 LLIHNs. These activities commenced in FY18 Q1 and are ongoing. CMEP discussed the response activities with CNM on meetings held on October 30th and December 22nd. Forest interventions: In FY18 Q1, CMEP continued to work with CNM to provide services to forest workers and forest communities, support the collaboration of the Ministry of Environment with CNM to provide services to forest rangers and community protection groups, as well as support CNM in liaising with the military and military partners such as AFRIMS and NAMRU-2. CMEP supported CNM to hold a meeting with partners on the future of forest intervention ‘packages’ on December 7, 2017. The meeting was useful to discuss what different partners were doing, but there were no specific decisions amongst key stakeholders on forest interventions and/or packages to be implemented. Therefore, CMEP postponed the distribution of the forest package intended to forest goers in KRK and KRV ODs, and instead moved forward with outreach interventions provided via mobile malaria workers [Act 2.3.6]. A future consideration is the concept of mobile clinics (teams composed of OD/HF/VMW and CMEP staff) which would be able to move from worksite to worksite distributing ITN’s and providing health education. Capacity building: The CMEP team and PMS provided orientation on SLD PQ to 438 HF staff and VMWs (versus 548 planned). Remaining 110 HF staff and VMWs from MRS and BTB will be oriented in January 2018 [Act 2.3.7]. CMEP conducted case management training for HF staff and VMWs trained under the CAP- Malaria project, who had not received refresher training in the last two years. The total Year 2 target for this training is 50 HF staff (BTB 20, KRV 10, MRS 10, TMK 10)[Act 2.3.8a] and 225 VMWs (BTB 110, KRK 50, KRV 50, MRS 15) [Act 2.3.8.b]. CMEP covered 15 HF staff [Act 2.3.8.a] and 63 VMWs[ Act 2.3.8.b] in Q1. Trainings will continue in FY18 Q2 to achieve

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Cambodia Malaria Elimination Project Quarterly Report (FY18Q1) full coverage in line with the planned targets. CNM supervision: Five supervision visits were planned by CNM’s pharmacy and laboratory units in Q1 [Act 2.3.10]. However due to unavailability of CNM’s responsible staff members, these visits were postponed to Q2. Supervision visits conducted by other CNM units are presented in relevant sections (see act 2.4.5).

Task 4. Strengthen case management and reporting in the private sector: Private Provider Mapping: CMEP updated the list of private providers in 5 ODs under Objective 2 with 236 PPs (versus 237 projected) enrolled within PPM. [Act 2.4.1]. One bi- monthly meeting was held in BTB OD in November 2017, while this meeting occurred twice (in October and December) in MRS, TMK, KRK and PKV. [ Act 2.4.3]. Required training was incorporated into meetings [Act. 2.4.2].The total number of PPs attending the meetings was 324 during Quarter 1 (some PPs were met twice during the period, and those that were not met in bi-monthly meetings were met during subsequent data collection visits). In addition, HF/OD teams visited private providers to review malaria case recording and reporting, and to collect necessary data and provide feedback. Seventy-seven of these visits were accomplished during the reporting period (each HF/OD visited approximately 5 PPs per visit). This is larger than the activity target of 50 for the quarter as it is a bi-monthly activity and some PPs received 2 visits during Q1 (this figure should be lower overall next quarter). In total, there were 387 private provider visits. [Act. 2.4.4] Supervision visits: Two supervision visits to private providers by CNM planned in Q2 were conducted in Q1 to BTB, MRS, and TMK OD. [Act. 2.4.5] No supply stock outs were revealed. Reviewers were satisfied with the DOT provision, compliance with national guidelines and timeliness and quality of reporting by private providers into MIS.

Task 5. Build capacity and strengthen systems to manage malaria control activities: CMEP Support to VMWs/MMWs: Regular monthly meetings for VMWs/MMWs were held in all 4 ODs during October-December 2017 (no VMW network exists in TMK OD).[Act 2.5.1] During these meetings, VMWs reported information on malaria cases, received supply of RDTs/ACTs from health center staff, received on the job training for case management including SBCC, case registration and reporting, ITN monitoring and top-up reports, and shared challenges (difficulties with DOT completion among MMP and forest-related workers; poor road conditions and long distance, unnecessary demands of topping up ITNs among the residents). On average, the number of VMWs who attended meetings was 336 (maintained at FY 2017 Q4 level that was 335). In total, 1,009 VMWs attended meeting versus 1,336 planned (76%). This lower figure can be explained due to only one VMW being required to attend the meeting from a household (often more than 1 VMW lives at the same household and only one of them is required to attend the meeting). The number of VMWs visited at home was on average 60 [Act 2.5.2]. In total, 179 VMWs were absent during regular gatherings (versus 131 in Q4 of FY 2017). This was higher than anticipated. During the Q2, CMEP teams at OD level will work with VMWs to encourage them to attend meetings to share experiences and build knowledge. Integrated supervision from OD to HFs [Act 2.5.3]: 80 supervisory visits were accomplished during the quarter (versus 66 planned). The number of visits includes both OD to HF visits and PHD to HF visits. The reason the number of visits is larger than the target can be explained due to extra sessions being required for capacity building work and follow up visits at service delivery points. Build capacity and strengthen systems to manage malaria commodities: CMEP provided support in stock monitoring and management to four target ODs (TMK, MRS, PKV, and KRK ODs). CMEP used their mHealth application (via laptops) and three ODs (TMK, MRS, and

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Cambodia Malaria Elimination Project Quarterly Report (FY18Q1)

KRK ODs) began reporting on commodity stocks in endemic health facilities [Act 2.5.4-2.5.5]. The application automatically geotags facilities and locations to allow close monitoring of places visited. In Quarter 1, 1,014 visits were conducted to health facilities. The weekly stock monitoring by CMEP in six target ODs revealed RDT ‘potential stock outs’ were reported 20 times (3%) from 6 HFs in 2 ODs (Battambang and Krakor) but no ‘stock out’ was detected. For artemisinin-based combination therapies (ACTs), potential stock outs were reported 24 times (3%) in 8 HFs in Krakor and Sampov Loun and stock outs occurred 5 times in 3 HFs in Battambang and Thmar Koul. The CMEP team and OD malaria supervisors took immediate actions to address ACT stock outs and potential stock outs to ensure adequate ACT and RDT needs in the ODs. Artemisinin-combination therapy (ACT) distribution: During the reporting period, there was no need to support ACT distribution in CMEP target ODs. Visits to selected VMWs from CNM VMW Unit: CNM VMW Unit carried out one visit to VMW’s in KRK and PKV OD’s. [Act. 2.5.6] . There positive findings for KRK/PKV included the fact that regular VMW meetings do occur at HC’s, reports from VMW’s in each HC are well maintained, VMW’s receive refresher training on malaria case management, they understand malaria testing, simple versus severe cases and maintain the record book. VMW limitations for KRK/PKV included weaknesses in recording cases/referred cases, inability to carry out 3-day DOT for all cases due to a mobile population and some of their malaria equipment/supplies being damaged or out of date. Provincial special working group for malaria elimination [ Act 2.5.7]: On December 25, 2017, CMEP COP and Team Leaders in Phnom Kravanh and Krakor ODs joined the Provincial Special Working Group for Malaria Elimination (PSWGME) meeting in . The meeting was chaired by the Provincial Vice Governor with 33 participants from all sectors in the provinces including public civil servants, military, police, NGOs, and governors/vice governors from all 6 administrative districts of the province. The meeting discussed several topics on malaria, including other health related issues such as counterfeit drugs and illegal private medical businesses as well as traditional medicines. PSWGME meeting in BTB province is planned in FY18 Q2.

Task 6. Strengthen BCC interventions for intensified malaria control

IPC to tested malaria cases and high-risk groups: All 11,649 tested individuals received IPC in FY18 Q1 (Act 2.6.1). 826 educational sessions were organized by the 3 Touch Points and 5 Peer Educators in KRK OD (Banok, Charm Chas, Kbal Tihean and Dongkeab Kadarm Villages) and in PKV OD (Veal Vong, Molchas, Doung Pol, Say, Veal, Khsaing and Tades Villages). These sessions targeted 1,040 people from high-risk groups with IPC/small group education on malaria prevention and treatment. MMWs provided malaria education to 752 MMPs in farms in 5 ODs. (Act 2.6.2). Malaria education campaigns at schools: To implement planned malaria education campaigns at selected schools in PKV and KRK ODs, the CMEP team in collaboration with CNM and the School Health Department of the Ministry of Education, Youth and Sports (MOEYS) developed a training curriculum, reviewed existing training materials developed within the CAP-Malaria project and agreed upon a six-month action plan [Act 2.6.4]. During December 4-8, 2017, CMEP in close collaboration with the School Health Department (SHD) and CNM organized two trainings for Provincial Department of Education (PoE) and District Unit of Education (DoE) staff, primary school directors and class teachers (for grades 4, 5 and 6). Thirty-seven participants from 16 schools attended the training in KRK OD and 50 participants from 15 schools in KRV OD. The sessions focused on five key technical areas, including malaria transmission, types of malaria species, malaria signs and symptoms, malaria

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Cambodia Malaria Elimination Project Quarterly Report (FY18Q1) health care seeking behavior and malaria prevention. Participants’ performance before and after sessions was measured via pre- and post-tests. After the training, test results improved from 77% to 94% in KRK OD and from 82% to 94% in PKV OD. [Act 2.6.5]. Trainings for 83 remaining target teachers will be conducted on January 8-12, 2018. Provincial/district education officers will monitor teachers’ performance in transferring malaria messages to students over the next 3 months.

Task 7. Support civil society and community-based organizations (CBOs) to implement interventions to transition toward malaria elimination: Provide support to selected CSO partners. [Act. 2.7.1]: During the reporting period CMEP worked actively with selected CSO partners to assist them with project start-up. On December 22, 2017, the CMEP team (M&E Officer, Compliance & Sub-grant coordinator and Senior BCC Advisor) met the CHADA team (Executive Director and 4 field coordinators and finance staff) to orient them on how to implement activities, mainstream gender in malaria BCC, branding, project indicators, data collection forms and quarterly reporting formats. CHADA’s representatives were also trained on procurement and financial management. CMEP provided guidance to both AHEAD and CHADA to adopted standard operating procedures for health education campaigns, MMP mapping and referral of suspected malaria patients. Implement sub-grant activities [Act 2.7.2]: AHEAD started implementation of planned activities in TMK. CMEP’s sub-grantee, Action for Health Development (AHEAD), started project implementation on September 15, 2017 in TMK OD.[Act 2.7.2]6 .During the reporting period, AHEAD collaborated closely with local authorities, ODs, HCs, VHSGs and VMWs. AHEAD identified 31 MMP settlements and provided malaria education and testing services to all 31. AHEAD organized 8 small group sessions which covered 253 individuals (FY18 Q1 target 8 sessions). Thirty-two suspected malaria cases were referred to VMWs and HFs for testing. AHEAD provided follow up to find out how many of referred individuals reached VMWs/HFs. In almost all cases (94%), the referral was completed successfully. Nevertheless, none of these cases were confirmed positive with malaria. AHEAD submitted their first invoice on October 10th 2017 (for FY17 Q4 activities). Regarding AHEAD expenditure in TMK during FY18 Q1, this proceeded as planned. Task 8. Operational research No operational research related activities were planned in FY18 Q1 under objective 2.

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: CMEP worked on the revision of the Case Investigation and Re-Active Case Detection forms (with CNM and WHO). [Act 3.1.1] CMEP also supported orientation/refresher training to HF staff in SPL OD on the Case Investigation and Re-Active Case Detection forms. Support consistent use of the harmonized forms by providers: CMEP trained all health center staff (19) and four staff from referral hospitals in the use of the revised Case Investigation Form in SPL. Thus, CMEP trained 23 staff instead of the 20 planned. [Act 3.1.2.] Overall, 91% of providers submitted surveillance data on time (Figure 8) consisting of 100% health facilities, 95% VMWs and 83% from private providers. Low performance of private

6 Fixed Amount Award Grant No. FY17.7030.G01

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Cambodia Malaria Elimination Project Quarterly Report (FY18Q1) providers should improve next quarter through further training and supervision. Figure 8: Percentage of HFs, VMWs/MMWs, and private providers in target transitional ODs submitting surveillance data on time per national guidelines.

100% 100% 100% 99% 100% 98% 98% 100% 97% 97% 95% 95% 94% 94% 94% 95% 93% 90% 90% 87% 86% 86% 87% 85%

80% Battambang Thmar Koul Maung Russei Kravanh Krakor

Q2 FY2017 Q3 FY2017 Q4 FY2017 Q1 FY2018

Task 2. Provide technical assistance on data management and use7

Conduct RDQA at OD and selected HFs by ODMS/PMS and CMEP[Act 3.2.2]: CMEP’s RDQA work has so far comprised three monthly ‘partial’ RDQAs in the ODs (conducted mainly by government staff and assisted by CMEP staff during FY17 quarters 2, 3 and 4), and a separate ‘full’ annual RDQA exercise carried out by CMEP central M&E staff at selected OD and Health Center sites during FY18 Quarter 1. Partial RDQA results showed a reasonable level of discrepancies during FY17 quarters 2, 3 and 4 for the 6 ODs. Total malaria tests performed by VMWs/MMWs and health centers saw a discrepancy of 8% and 10% in Quarters 2 and 3, respectively. However, decreased to 2% in quarter 4. Overall the results show an acceptable level of routine data quality. Full RDQA results showed data verification for the selected four ‘F’ indicators is acceptable (‘Number of health workers trained in case management with artemisinin based combination therapy with USG funds is acceptable’, ‘Number of health workers trained in malaria laboratory diagnostics with USG funds’, ‘Number of ITNs purchased by USG funds that were distributed with USG funds’, ‘Number of ITNs purchased by other partners that were distributed with USG funds’). The M&E system assessment results varied slightly for the four indicators across the three selected ODs and six sampled HCs, and some weaknesses were apparent, including lack of data management training and a relatively low level of understanding of the CMEP monitoring and evaluation framework and specific indicators. Although both partial and full Year 1 CMEP RDQA exercise results were acceptable, CMEP will conduct follow-up data quality activities and related M&E trainings in the ODs in FY18 Quarter 2 and 3. In addition, further RDQA activities will be conducted to get additional results and observe subsequent improvements in data quality. Specific recommendations for improving CMEP DQA, along with a one-year improvement plan/timeline are provided in the separate RDQA Report submission. Provide TA to CNM on village based stratification and facilitate use of stratification tools [Act 3.2.3]: CNM presented the new strategy for allocating VMWs and bed nets using village based stratification on Dec 26-28. The new strategy will aim to reduce VMWs in areas with low reported incidence versus forecasted, and allocate additional VMWs in areas of higher reported incidence versus forecasted (i.e. to areas where API is > 5/1,000). Similarly, the distribution of nets will also be allocated according to reported incidence versus forecasted (i.e. to areas where API is > 5/1,000). CMEP will work with CNM to use the new threshold criteria to appropriately allocate VMWs and bed nets in the target ODs.

7 Act 3.2.1. Provide M&E training on data management, RDQA and use to target ODs and HFs is not relevant to Q1 reporting period.

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Cambodia Malaria Elimination Project Quarterly Report (FY18Q1)

Provide TA to CNM on data visualization and outbreak module development for MIS [Act 2.3.4] The CMEP team joined an outbreak response meeting at CNM on December 22, 2017 together with three CNM staff, and two WHO staff. CNM reviewed malaria data in all provinces and identified five provinces with an abnormal case increase. CNM requested further investigation with collection of screening data from previous outbreak responses. CMEP shared its results and experience in the two ODs of Pursat province (Phnom Kravanh and Krakor). This data may be used to further guide which elements should be included in the outbreak module within the MIS. CMEP will further discuss the possibility of providing TA for the guideline development with CNM. CNM supervision [Act 2.3.5]: Six visits were planned by CNM M&E and epidemiology central units to target ODs in Q1. CNM postponed the visits to FY18 Q2. Task 3. Support further development and implementation of electronic data reporting and use platform To reflect recent revisions made in the case investigation form currently used in malaria elimination areas, CMEP and CNM plan to revise the mobile application for malaria elimination surveillance in January 2018. [Act 3.3.1] Task 4. Entomology Training 8 Conduct entomology training for OD and PHD staff [Act 3.4.1.]: Based on the entomology strategy and training curricula elaborated in FY 2017 with CMEP support (that is currently processed by MoH and CNM for endorsement), CMEP’s Senior Technical Advisor in collaboration with the CNM entomology team, led by Mao Sokny, developed a 2-day module to build basic entomology competencies of PHD/OD and HF staff. In Q1 of FY2018, CMEP intended to train 16 PHD/OD malaria staff, however due to unavailability of trainers from CNM, the training was rescheduled for January 11-12, 2018 (the training will be conducted to selected groups in BTB, MRS and PKV OD’s totaling 6 days of training).

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 levels9 OD AOP development [Act 4.1.4.]: CMEP and CNM successfully conducted a 2-day workshop (November 28-29, 2017) to develop OD AOPs for 2018. The participants included 8 people from CNM (including the CNM director), 16 people from the 2 PHDs and 6 ODs, 1 participant from USAID/PMI (CMEP ACOR), 1 from UNOPS, 3 people from GHSC-PSM, and 12 from CMEP. The workshop discussed (i) CMEP Year 1 achievements (Oct 2016-Sept 2017), (ii) feedback from CNM on CMEP, (iii) national strategies for malaria elimination by phase and coverage allocated to different implementing partners, (iv) CMEP experience on OD AOP development and progress review, (v) CMEP year 2 workplan and (vi) group work to develop OD AOPs. At the end of the second day, the groups produced a draft OD AOP for all 6 ODs and presented it at the plenary session. The OD AOPs were finalized and signed by the CMEP representative on December 15th (All AOPs were signed by both parties and submitted to the mission on January 17th 2018). Laboratory quality assurance [Act 4.1.8]: Provincial malaria supervision for lab assessments was conducted in nine health centers in malaria endemic areas in BTB OD. The assessment found that although all HC’s have microscopes, lab materials, and staff trained in microscopy, they are generally not using these and overall, they rely on RDTs for malaria diagnosis. CMEP

8 No targets were set for activities 3.4.2-3.4.4 in Q1 FY 2018 9 Activities 4.1.1-4.1.3 and 4.1.5.-4.1.6. are not applicable to the reporting period

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Cambodia Malaria Elimination Project Quarterly Report (FY18Q1) will continue to encourage use of microscopes at HFs where staff have been trained and equipment/materials are available, CMEP will help ensure regular supervision from PHD/CNM on lab services at HFs, and CMEP will ensures RDT has been monitored for adequate supply, expiration date and storage condition. Thirteen health centers and 1 referral hospital were supervised in MRS OD. Out of 14 facilities, only three (Regional Hospital, Kos Kralor HF and HF) use microscopy for malaria diagnoses. Although other HFs also have the required microscopy equipment, materials and trained staff, they are not using the equipment (similarly, the QA assessment conducted in Q4 of FY 2017 reported that none of the 16 health centers visited in TMK10 use microscopy). Microscopy was used by health centers in KRV (namely in Referral Hospital Phnom Kravanh, HC Pramoy, Samrong, Progil, Tasah and Bak Chinh Chean). A cross check of 114 slides revealed that on average 99% sensitivity, 100% specificity and 100% of accuracy. The need for replacing a microscope at Bak Chink Chean center was also declared. CMEP will recruit a lab supervisor to be based in BTB province, he/she will work with lab experts in the provinces (after National Competency Assessment conducted by CNM) to establish QA system with support from lab CNM and CMEP team at PP to work on QA microscopy at provincial/OD levels with regularly supervise and on the job training from Lab CNM unit team. Lab QA is only for microscopy. On the job training and mentoring by CNM units (Regional task forces and entomology) [Act 4.1.9] After the development of an entomological surveillance manual by the CMEP entomology technical group during the quarter, the team worked with the CNM Entomology Unit team to review the translation of the manual for malaria elimination purposes in Cambodia in . The CMEP team also worked on a curriculum and training materials for basic entomology for PHD/OD malaria supervisors. A training plan for this training will be developed in FY18 Q2. E-Payment [Act 4.1.10]: CMEP initiated e-payment pilot to 20 VMWs in Kamrieng Health Center, of SPL OD during the VMW monthly meeting on October 26, 2017. The e-payment system is used to pay per diems, transportation and other allowances through the use of mobile payments to 20 VMWs. During Q2, CMEP plans to expand to an additional five HCs, and by Q3 to all HCs in SPL.

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] MMP Strategy Dissemination Workshop: CMEP and WHO supported CNM to organize the MMP Strategy/Manual dissemination workshop held on October 18-19, 2017 in . One hundred seventeen participants attended the workshop from CNM, PHD, OD and NGOs. CMEP’s Senior Technical Advisor, Dr. Top Samphor Narann, played an active role as a trainer/co- facilitator during the workshop. CNM training on Surveillance for Malaria Elimination: CMEP’s Senior Technical Advisor spent two days, from November 13-14, 2017, with the WHO officer to prepare a training package on surveillance for malaria elimination. Responding to an urgent request from CNM, CMEP supported printing of training materials (Power Point handouts and case study papers) for the first training. CMEP’s Senior Technical Advisor spent the week of November 20-24, 2017 facilitating the training in Kampong Chhnaing province together with CNM and WHO.

10 Namely Bovil 2, Prey Kpous, , Kdol Tahen, Klaing Meas, Ampil pram deum, Knach romeas, Kouk khmum, Bansay treng, Tameun, Chroy sdaov, Boeung Prinh, Roung chrey, Tapoung, and O’tak

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Cambodia Malaria Elimination Project Quarterly Report (FY18Q1)

He was invited to assist in two more sessions in Banteay Meanchey and Siem Reap provinces on Dec 4-9, 2017 and Dec 11-16, 2017, respectively. Meeting on CNM supervision tools: CMEP’s M&E and PPM Officers joined a two-day workshop on December 11-12, 2017 with CNM and other relevant partners (CHAI, PSI, etc.) in Phnom Penh to discuss QA checklists for VMW and PPM supervision aiming to improve capacity and performance of VMWs and private providers within the malaria program. CMEP progress review [Act 4.2.2.]: Progress review of OD AOP implementation in PKV and KRK ODs was held together on November 20, 2017 at Pursat PHD office with 42 PHD staff participants including the PHD Director, OD staff, HFs and CMEP (other NGO partners were not available, i.e. PFD). The meeting reviewed achievements within the last quarter, challenges encountered, solutions and recommendations for improvement and next quarter’s action plan. Feedback on technical supervision from PHD/OD to HFs was also shared. National Annual Conference [Act 4.2.3]: In line with CMEP’s work plan, CMEP supported CNM to plan their National Annual Conference to be held on February 22, 2018 in Siem Reap. During FY 2018 Q1, CMEP conducted preparatory work with CNM representatives to develop a detailed budget plan. CMEP’s contribution will cover the conference venue, document/report printing, materials, per diem and transportation for CNM team, PHD and OD team from CMEP Battambang and Pursat provinces. Task 3: Improve malaria policies and guidelines [Act 4.3.1] As mentioned, CMEP worked with CNM in FY18 Q1 on an entomology manual. CMEP also initiated a consultation meeting with CNM and relevant partners on forest interventions to accelerate malaria services to the MMW’s and to discuss approaches to provide malaria services to groups of forest rangers and community volunteers. For vector mapping and control, representatives from IPC, NAMRU- 2, and CMEP met to discuss current available entomology data and WHO hired a new consultant to update the entomology surveillance document (the DCOP met with the consultant and WHO to discuss the report). CNM BCC strategy development: [Act 4.3.1] CMEP’s Senior BCC Advisor joined a CNM partners workshop on BCC strategy development in province on December 15, 2017.

2.5 Project Management Oversight and Coordination

CMEP Field Visit: CMEP’s technical, M&E, programmatic and financial teams from Phnom Penh visited target ODs several times during the reporting period. Visits focused on reviewing and improving M&E practices as well as planning and implementation of response activities. On October 10-13, 2017, CMEP’s COP and DCOP accompanied delegates from USAID’s mission and WHO to CMEP’s target ODs in Battambang and Pailin provinces. CMEP’s COP visited KRK OD on December 25, 2017, to meet with OD teams and community health workers and review the implementation of outreach and case management services. Sub-grant oversight and management: CMEP’s M&E Officer, Compliance and Sub-grants Coordinator and Senior BCC Advisor conducted orientation to sub grantees (AHEAD and CHADA) on procurement and financial management. Details are described under activity 2.7.1.

Meetings with USAID, CNM, Implementing Partners, and Others: (1) Meetings with the USAID COR Team The CMEP team had a series of meetings with the COR team on Year 2 work plan finalization (October 3), CMEP Year 1 Progress Review (October 26), preparation for annual DQA by USAID (November 22nd and 27th) followed by a field visit in the ODs. In December, the CMEP

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Cambodia Malaria Elimination Project Quarterly Report (FY18Q1) team had an opportunity to meet the PMI Senior Technical Advisor during his visit to Cambodia. Two meetings were held to discuss project achievements, challenges, lessons learned and actions taken, as well as technical discussions on the forest package, case surveillance, highly sensitive RDT study, and other operational research (OR) topics. (2) Meetings with CNM and Other Partners Meeting with Procurement Supply Management (PSM): CMEP’s COP met with PSM (from HQ and from Phnom Penh) on November 30, 2017 to discuss approaches to improve supply chain of commodities within the malaria program at all levels. The National Cambodia Malaria Survey (CMS) 2017: CMEP’s COP and Senior Policy and Technical Advisor joined the dissemination of preliminary results of the National Cambodia Malaria Survey (CMS) 2017 at CNM on December 18, 2017. Data collection was conducted by the SBK Research and Development Company from September-October 2017 and data analysis and reporting was completed by Malaria Consortium (MC). The geographical domains designed for CMS 2017 are different from the previous CMSs and are categorized as (i) elimination areas, (ii) transitional areas and (iii) burden reduction areas. Previous CMSs categorized the domains as Tier 1 and Tier 2 which correspond to artemisinin resistant status. Several indicators were presented during the dissemination such as coverage of ITNs, utilization of ITNs, service seeking behavior, knowledge of malaria, etc. Preliminary results via these indicators do not seem satisfactory for several reasons, for example ITN coverage is low (around 40%) as the last national ITN distribution campaign was conducted in 2015; ITN use is also relatively low due to its availability and ITN preference; malaria service seeking at VMWs is at 4-12% due to interrupted VMW activities during all of 2016 and half of 2017. Nevertheless, knowledge of malaria looks very good among respondents, for instance cause of malaria transmission and prevention measures. No data can be obtained at this stage for CMEP target ODs. The final CMS 2017 report will be adjusted and ready to share in two months. Participation in ASTMH conference: CMEP’s team (COP, mHealth Specialist and Senior Policy and Technical Advisor) joined by a team member from CNM attended the 66th annual meeting of the American Society for Tropical Medicine and Hygiene (ASTMH) in Baltimore, Maryland, USA from November 5-9, 2017. A poster was provided on “Prevalence of K13 Mutation and Day-3 Positive Parasitemia in an Artemisinin-Resistant Malaria Endemic Area of Cambodia: A Cross-Sectional Study” and one oral presentation “Achieving Interruption of Locally Transmitted Plasmodium falciparum Malaria Cases through Piloting a Basic Essential Package of Activities for Malaria Elimination in the Context of Artemisinin Resistance, 2015- 2017” were delivered by CMEP and CNM authors. Procurement CMEP initiated procurement of two vehicles to support project operations. Required documents were submitted to the USAID mission on November 22nd. Approval of this procurement is pending. The list of procured items within CMEP in FY18 Q1 can be found in Table 2 below. Table 2 CMEP Procured Items FY18 Q1 No. Item Unit Purchased date 1. Laptops (for CMEP Staff and CNM ) 7 November 7th 2017 2. Printers 11 November 7, 2017

Financial Management

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Cambodia Malaria Elimination Project Quarterly Report (FY18Q1)

Human Resource Management

Figure 9: CMEP staffing progress through December 2017

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Cambodia Malaria Elimination Project Quarterly Report (FY18Q1)

60 47 47 150%

40 96% 96% 100% 20 50% 6/13% 1/2% 0 0% FY17 Annual FY2018Q1

Total Number of Staff Available Resigned Staff % of Staff Resigned % of Positions Filled of Total Staffing Needs

3. RESOLVING CHALLENGES FROM FY 17 Q4

Management related challenges and the need for organizational change: CMEP restructuring initiated in June 2017 was finalized in FY18 Q1 of with the recruitment of a new Chief of Party and M&E and SI Advisor. The former Chief of Party was transitioned to a Senior Technical Advisor Position. Considering that malaria case management is a major part of CMEP’s scope and that there is limited work of malaria microscopy in elimination settings, the QA/Lab/Diagnostics Advisor position was changed to Case Management/QA/Lab/Diagnostics Advisor position, filled by the previous Senior Technical Advisor. URC anticipates that these changes will substantially improve CMEP’s operations at all levels.

4. CHALLENGES AND ACTIONS TAKEN OR PROPOSED

Implementation of sub grants component through CSO engagement: URC acknowledges the need for intensified efforts to mobilize Civil Society Organizations, strengthen their capacity and engage them in malaria control. CMEP’s current approach to CSO contracting is based on a competitive selection process. Most CSOs with reasonable field work capacity but limited administrative resources fail to meet requirements of the competitive selection. In FY 2017 and early FY 2018 CMEP was only able to select and subcontract two CSOs out of six as per the work plan. URC proposes to modify its approach to CSO solicitation, evaluation and selection processes. A potential solution is to issue a “multi-tiered” Request for Applications (RFA) comprised of two stages: first, Concept Papers will be sought from prospective applicants, and second, Full Applications will be requested of CSOs selected after the concept paper submission. This will also include review of their organizational capacity and prior experience to implement community based public health programs (HIV/TB/Malaria). Only those applicants with the most-highly-evaluated Concept Papers will be invited to submit full applications (both technical and cost proposals). CMEP needs to allow CSOs to submit concept papers in Khmer. If the project idea laid out in the concept paper is accepted by the selection committee (CNM, CMEP observed by USAID/PMI) and the CSO has the experience and capacity to implement activities in a given geographic area, the CMEP team will provide further guidance in preparing a full project proposal. Thus, the first stage of the process will remain competitive; however at the second stage CMEP will assess capacity of CSOs, conduct needed capacity building, and guide CSO for developing a comprehensive proposal and a detailed implementation plan and then submit a sub-contract approval request to the mission. There may be a need to consider sole source procurement if the CSO is the only provider in a high priority geographic area. In consultations with the COR team, URC will come up with the relevant administrative and procurement arrangements to operationalize the above described process. ITN mass distribution: CMEP supports CNM and UNOPS in ITN mass distribution in its target ODs. Due to high volume, VMWs were not able to complete the villages and MMP census in KRK and PKV ODs (In some larger villages, additional persons such as deputy

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Cambodia Malaria Elimination Project Quarterly Report (FY18Q1) village chiefs were also involved in the census). The majority of VMWs finished the village census in late December, but further documentation work needed to be checked and completed by HC staff before the actual distribution could happen. That was one of the reasons why the actual distribution was delayed until January 2018. Mapping of MMP locations has been challenging in all ODs. This activity was integrated into the village census for mass distribution. Due to the difficulty of using manual maps or any GPS devices among VMWs/MMWs for capturing locations, these materials were not able to be completed by the end of census. These results should be available for reporting in Q2 Year 2. Therefore, continuous mapping and LLIN distribution through CSOs or community workers should be supported by CMEP on an ongoing basis. It should be noted that some villages excluded from the distribution list by CNM have an API > 5/1,000. Therefore, in agreement with CNM and UNOPS, CMEP will consider continuous ITN distribution in these villages through top-up visits to meet the needs.

5. PLANS FOR NEXT QUARTER AND UPCOMING EVENTS

In line with CMEP’s Year 2 work plan, approved on October 5, 2017, CMEP will continue activities in SPL and 5 transitional ODs. In summary, a major focus for CMEP implementation will be to achieve planned targets for year 2 Quarter 2, including training, supportive supervision, ITN distribution, IPC and small group education sessions among high-risk groups in all 6 ODs. This will include activities postponed from Q1 (Entomology training and CNM supervision). In response to CNM’s request to expand malaria elimination interventions in new ODs, which meet MEAF criteria for elimination coverage, URC developed a project expansion proposal to roll out activities to additional elimination and transitional ODs starting from Year 2 instead of Year 3, per contract. URC’s request for expansion of ODs is currently being reviewed by the Contracting Officer. According to this proposal, CMEP will expand its elimination model to 5 ODs including SPL, BTB, TMK, MRS and Pailin under objective 1 and will cover 4 ODs (KRK, PKV, SPV and Bakan) under objective 2 with the malaria control package. CMEP will continue to provide technical assistance to CNM in developing guidelines, improving surveillance policies and defining priority areas for operational research. CMEP leaders will join the USAID Mission Director visit in January 2018 to review the field implementation activities. Regular field visits will be undertaken by CMEP’s Monitoring and Evaluation Officer and Administrative and Finance Manager for OD teams’ support in financial management and data quality assurance.

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