Mahefa Miaraka FY2017 Quarter 2 Report I

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Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 2 Report i

USAID COMMUNITY CAPACITY FOR HEALTH PROGRAM - Mahefa Miaraka

Cooperative Agreement No. AID-687-A-16-00001

FY2017 Quarter 3 Progress Report April 1 to June 30, 2017 Re-Submission In Response to USAID Comments: September 6, 2017

USAID Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 3 Report

USAID COMMUNITY CAPACITY FOR HEALTH PROGRAM - Mahefa Miaraka

FY2017 Quarter 3 Progress Report April 1 to June 30, 2017 Re-Submission In Response to USAID Comments: September 6, 2017

Cooperative Agreement No. AID-687-A-16-00001

Submitted to: Dr. Jocelyne ANDRIAMIADANA, AOR USAID/Madagascar in Antananarivo, Madagascar

Prepared by: JSI Research & Training Institute, Inc. USAID Community Capacity for Health Program – Mahefa Miaraka JSI Research & Training Institute, Inc. Résidence Lavalley Près Lot IIK 50H Mahatony Alarobia, Antananarivo (101)

Tel: 20.22.425.78/ 79

Cover photo: Market day in Andranotojy Fokontany, Morondava District, Menabe Region. Mothers and their children wait for an outreach activity to be conducted by the head of the basic health center. Photo: Chuanpit Chua-oon, JSI Research & Training Institute, Inc.

DISCLAIMER: This document is made possible by the support of the American people through the United States Agency for International Development (USAID). The contents of this document are the responsibility of JSI Research & Training Institute, Inc. (JSI) and do not necessarily reflect the views of USAID or the United States Government.

Page ii USAID Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 3 Report

Table of Contents

Executive Summary of Achievements in Q3 FY2017 ...... 1 Introduction ...... 3 Sub IA 1.1 Increasing Skills and Competencies of CHV ...... 4 Sub IA 2.1. Community-Level Health Promotion and Sensitization to Increase Healthy Behavior and Uptake of Health Services and Products ...... 17 Sub IA 2.2 SBCC Capacity of Community Stakeholders ...... 19 Sub IA 2.3 Innovations to Promote Adolescent and Youth Health...... 21 Intervention Area 3: Health Service Planning, Management, and Governance ...... 22 Sub IA 3.0 Reinforcement of GOM Capacity...... 22 Sub IA 3.1. Introduction and Promotion of CSB Improvement ...... 23 Sub IA 3.2. Pharmaceutical and Commodity Forecasting...... 23 Sub IA 3.3. Health Data Quality, Management, and Use ...... 24 Sub IA 3.4. Referral System Strengthening between CHVs and CSBs ...... 24 Sub IA 4.1 Program Monitoring, Evaluation, and Performance System ...... 24 Sub IA 4.2 Learning Management ...... 25 Sub IA 4.3 Cross-Cutting Issues ...... 26 Challenges and Proposed Solutions for Q3 FY2017 ...... 27 Administrative and Financial Management ...... 27 Sub IA 0. 1 Operation (Administration, Finance, and Partnership) ...... 27 Sub IA 0. 2 Administration ...... 27 Sub IA 0.3 Financial Management ...... 28

Annexes Annex 1. Activity Table Q3, FY2017 Annex 2. Project Performance Review, PPR (Q3, FY2017) Annex 3. Environment Monitoring and Mitigation Report, EMMR (Q3, FY2017) Annex 4. List of Communes in Mahefa Miaraka Program in Q3, FY2017 Annex 5. Participation in the Central-Level Working Groups and Meetings Annex 6. Success Stories Annex 7. International Trips at the End of Q3 FY2017

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List of Tables

TABLE 1 – PNSC COORDINATION STRUCTURES CREATED IN THE PROGRAM REGION Q3 FY2017 ...... 4 TABLE 2 – CHV MALARIA SERVICES BY REGIONS IN Q3 FY2017 ...... 8 TABLE 3 - REFERRAL CASES FROM CHVS TO CSBS, HOSPITALS, OR MOBILE CLINICS IN Q3, FY2017 ...... 8 TABLE 4 – SAYANA PRESS USE BY REGIONS IN Q3, FY2017 ...... 9 TABLE 5 – CHV REPORTED STOCK-OUT OF HEALTH TRACER PRODUCTS IN Q3, FY2017 ...... 13 TABLE 6 – NUMBER OF TIMES PEOPLE REACHED BY KEY HEALTH MESSAGES IN Q3, FY2017 ...... 20 TABLE 7 - MAHEFA MIARAKA’S CUMULATIVE EXPENSES AS OF JUNE 30, 2017 ...... 29

List of Figures

FIGURE 1- MAHEFA MIARAKA’S REGIONS AND DISTRICTS ...... 3 FIGURE 2- CHV TRAINING AS OF JUNE 30, 2017 ...... 5 FIGURE 3- RESULTS FOR CU5 WITH MUAC MEASUREMENT IN Q3, FY2017 (N=74,332) ...... 7 FIGURE 4- CASES OF CU5 TREATED FOR C-IMCI BY CHVS IN Q3 FY2017 ...... 7 FIGURE 5- REGULAR FAMILY PLANNING USERS IN THE PROGRAM, BY AGE GROUP, Q3 FY2017 ...... 9 FIGURE 6- NEW FAMILY PLANNING USERS IN THE PROGRAM, BY AGE GROUP, Q3 FY2017 ...... 10 FIGURE 7- COUPLE YEARS OF PROTECTION BY FAMILY PLANNING METHODS, Q3 FY2017 ...... 10 FIGURE 8- STOCK-OUT OF CHILD HEALTH TRACER PRODUCTS AT CHVS IN Q2 AND Q3 FY2017 ...... 12 FIGURE 9- STOCK-OUT OF FAMILY PLANNING HEALTH TRACER PRODUCTS AT CHVS IN Q2 AND Q3 FY2017 ...... 12 FIGURE 10- MALARIA EVOLUTION IN THE PROGRAM REGIONS REPORTED BY CHVS IN Q3 FY2017 ...... 15 FIGURE 11- SBCC COVERAGE THROUGH MULTIPLE COMMUNICATION CHANNELS IN Q3 FY2017 ...... 19 FIGURE 12- SANITATION AND HYGIENE AT CHVS’ HEALTH HUT AS OF JUNE 30, 2017 ...... 20 FIGURE 13- HIGH-VISIBILITY EVENTS IN Q3 FY2017 ...... 21

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Acronyms and Abbreviations

ACT Artemisinin-based combination therapy ANC Antenatal care CHV Community health volunteer CHX Chlorhexidine c-IMCI Community-based integrated management of childhood illnesses CoSan Comité de Santé CSB Centre de Santé de Base (basic health center) CU5 Children under 5 DLP National Malaria Control Program DPLMT Directorate of Pharmacies, Laboratories and Traditional Medicine DPS Direction de la Promotion de la Santé (Division of Health Promotion) DSFa Direction de la Santé Familiale (Division of Family Health) EFP Essential family practice EMAR Equipe de Management Régionale (Regional Health Management Team) EMAD Equipe de Management de District (District Health Management Team) EMMR Environmental Mitigation & Monitoring Report FKT fokantany (village or collection of hamlets, lowest administrative level) FP Family planning FY Fiscal Year GBV Gender-based violence GOM Government of Madagascar HIV Human immunodeficiency virus HMIS Health management information system IA Intervention area IFA Iron folic acid IR Intermediate result IPTp-SP Intermittent preventive treatment during pregnancy with sulfadoxine-pyrimethamine JSI JSI Research & Training Institute, Inc. LLITN Long-lasting insecticide-treated bed net MAHEFA Malagasy Heniky ny Fahasalamana (Community-Based Integrated Health Program) MOH Ministry of Health MOU Memorandum of Understanding MUAC Mid-upper arm circumference NGO Nongovernmental organization PNSC Politique Nationale de Santé Communautaire (National Policy for Community Health) PSI/ISM Population Services International /Integrated Social Marketing Project PSM Procurement and Supply Management RLG Radio listening group RDT Rapid diagnostic test SBCC Social behavior change communication SDSP Service de District de la Santé Publique (District Health Office) USAID United States Agency for International Development VAT Value Added Tax WASH Water, sanitation, and hygiene

Page v USAID Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 3 Report

Executive Summary of Achievements in Q3 FY2017

This is the first quarter that the USAID Community Capacity for Health Program implemented the revised FY 2017 Annual Implementation Plan (approved by USAID on May 12, 2017). The reduced obligation resulted in decreased programmatic activities in Q3 and Q4, compared with the plan stated in the Cooperative Agreement for fiscal year 2017.

While the USAID Community Capacity for Health Program experienced the above-mentioned funding level challenge, the Program team was able to adjust. In May, a workshop was held in Antananarivo where all management-level staff from the central, regional, and district offices discussed implications of the reduced budget in field operations and how to proceed with activities in Q3 and Q4 as planned in the revised FY2017 Implementation Plan. One of the most important results of this workshop was that all management-level staff accepted the financial change with a positive perspective and conveyed it to stakeholders at the regional, district, and commune levels, namely officials of the Government of Madagascar (GOM), community leaders such as fokontany heads, and community health volunteers (CHV).

Despite the reduced program activities, this quarter saw an increase in CHV services. The following highlights summarize the main achievements.

Functioning Community Health Volunteers. By the end of June 2017, the Program recorded 5,415 functioning CHVs (55 percent of the total 9,844 CHVs in the Program’s seven regions) who had already received training to provide monthly reports to their respective basic health center or Centre de Santé de Base (CSB) and provide services in family planning (short methods including injectables); referral for antenatal care visits (ANC) and delivery at the CSB; community-based integrated management of childhood illnesses (c-IMCI); community surveillance; and promotion of healthy behaviors especially in the areas of nutrition, water, sanitation, and hygiene (WASH). A total of 185,313 children under 5 (CU5) and 142,636 women were seen by the functioning CHVs for the following services in the third quarter of FY2017:

• 56,762 CU5 for c-IMCI. • 84,939 CU5 for weighing. • 43,612 CU5 for vaccination referral. • 110,132 women for family planning. • 8,122 pregnant women for referral to CSB for ANC 1 and 7,389 for ANC 4. • 4,216 pregnant women for referral to CSB for delivery. • 8,895 pregnant women for referral to CSB for vaccination. • 3,882 women for referral to CSB for long-term contraception.

High Stock-out Rate Reported by CHVs. In Q3, the stock-out level for all health tracer products was lower than Q2, but still high (Figure 8). The high stock-out rate in Q3 for both child health and family planning tracer products can be caused by internal factors derived from the CHVs and factors that are external to them. The internal factors are:

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• Again linked to lack of cash on hand, CHVs only keep stock of health products for the services frequently needed in the community. For example, stock-out of condom in Q3 was from 54-63% compared to only 17-20% for injectables of the same period.

The external factors causing stock-out with CHVs during this quarter are: • At the supply level (CSB): stock-out of CSB malaria products at CSB, limited provision of malaria products given to CHVs by CSBs and packaging of some malaria products make it difficult for CSB to split among CHVs; • At the supply level (PA): stock-out of some child health and family planning tracer products at the products at the provision points (PA) managed by the Integrated Social Marketing (ISM) Project; • At the Program level: The Program needs to revive the provision system between CHV, provision points (PA), and CSB; • At the national-level: A gradual closing out of field activities by the PSI/ISM project affected availability of some health products at the commune level; and the coordination system on national supply chain by the Procurement and Supply Management (PSM) Program is not yet efficient.

The above factors combined affect the availability of health commodities at CHVs. It is expected that the stock out levels will continue to improve as the coordination between all partners involved is better and the products are available continually in-country. Discussion on how the Program plans to address these issues is presented under section IA1 on health commodities.

Strengthening the GOM’s Capacity to Use Data for Monitoring Health Performance of the District. In May and June 2017, the Program team organized a review session with 24 government district health offices or Service de District de la Santé Publique (SDSP) to analyze routine data collected from both the CHV and CSB levels. The Program and the SDSP teams decided on the routine health indicators to be monitored and discussed during the review session. The sessions were appreciated by the SDSP team and in some cases, helped the district health team prevent malaria outbreaks. More information is reported under section Intervention Area (IA) 1 on Malaria Activities.

During the third quarter of FY2017, management and compliance systems continued to support program work. The main achievements of the USAID Community Capacity for Health Program during the reporting period are presented according to the IAs. A table detailing the activities conducted and the Performance Plan Report (PPR) are included in Annexes 1 and 2 respectively. In addition, the environmental compliance achievements during the third quarter of FY2017 are presented in Annex 3.

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Introduction

USAID awarded the five-year Cooperative Agreement (No. AID-687-A-16-00001) for the USAID Community Capacity for Health Program to JSI Research & Training Institute, Inc. (JSI) on June 6, 2016. JSI collaborates with three partners for the implementation of the program: Action Socio- sanitaire Organisation Secours, Family Health International 360, and Transaid. The program has two objectives and three intervention areas (IAs):

Objective 1. Strengthen public sector capacity to plan, deliver, and manage community health services Objective 2. Strengthen community engagement in health

IA 1. Community engagement and ownership of health services IA 2. Behavior change and health promotion IA 3. Health service planning, management, and governance

The Program reflects USAID’s commitment to providing high-quality community health services that integrate with the formal health system; addressing key drivers of maternal, newborn, and child mortality; and responding to client needs while promoting visibility of community health in Government of Madagascar (GOM) efforts to reduce maternal, newborn, and child mortality. The Program contributes directly to the USAID/Madagascar Health Population and Nutrition’s Intermediate Results (IRs) 1 and 2 health sector strategy, for which the development objective is “Sustainable Health Impacts Accelerated for the Malagasy People.”

The USAID Community Capacity for Health Program, locally known as Mahefa Miaraka, operates in a total of 4,887 fokontany; 456 communes; and 34 districts in the regions of Analanjirofo, Boeny, DIANA, Melaky, Menabe, SAVA, and Sofia. A full list of the communes in the program regions are presented in Annex 4. The program will provide services to approximately 6.1 million people, or 23.3 percent of the country’s total population.

Figure 1- Mahefa Miaraka’s Regions and Districts1

1Number of districts in each region is in parentheses.

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Intervention Area 1 (IA 1): Community Engagement and Ownership of Health Services

Key Achievements: 1. By the end of June 2017, half of the CHVs in the Program (5,415 of 9,844, or 55%) are functioning meaning they can provide integrated health services. All of them began working since the former MAHEFA Program. 2. Both functioning and new CHVs began receiving technical training in this quarter (refresher training for functioning CHVs and pre-service for new volunteers). 3. 982 new CHVs received training on c-IMCI and began their practicum. 4. 185,313 cases of children under 5 (CU5) and 142,636 cases of women were seen by the functioning CHVs for integrated health services in Q3. 5. 85% of the functioning CHVs attended a monthly meeting at the CSB in June 2017.

Sub IA 1.1 Increasing Skills and Competencies of CHV

1.1.1 Reinforcement of Capacity of Members of PNSC Structures

PNSC Coordination Structures. By the end of this quarter, almost all coordination structures (5,367 of 5,384 or 99 percent) for the National Policy for Community Health (Politique Nationale de Santé Communautaire or PNSC) were created by the local government in line with the recommendations from the National Policy for Community Health. All coordination structures at the regional (7), district (34), and commune levels (456) were created and a total of 2,267 members of these structures received the PNSC orientation training. At the fokontany level, a total of 4,870 PNSC structures (or COSAN FKT) in the seven program regions, were created and 3,881 fokontany heads received the PNSC orientation (Table 1).

Table 1 – PNSC Coordination Structures Created in the Program Region Q3 FY2017

Structures created as PNSC Coordination Structures Targets Remaining of June 30, 2017 Comité de Coordination pour l’Approche Communautaire – Région (Coordination Committee for Community Health at 7 7 - the Regional Level) Comité de Coordination pour l’Approche Communautaire – District (Coordination Committee for Community Health at 34 34 - the District Level) Commission Communale de Développement de la Santé 456 456 - (Commune Commission for Health Development) Comité de Santé Fokontany (COSAN fokontany) 4,887 4,870 17 Total 5,384 5,367 17

Another table below, requested by USAID, shows the number of members of each structure.

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Coordination Committees Already Created at the end Remaining for Community Health of Q3 FY2017 Structure Coordination Members Coordination Members Committees Committees CCAC – R (regional level) 7 165 0 0 CCAC – D (district level) 34 922 0 0 CCDS (commune level) 456 5,185 0 0 Cosan Fokontany (fokontany 4,870 9,844 17 34 level)

1.1.2 Pre-Service Training, Continuing Learning, and Supervision of CHVs

CHV Training. In the seven Program regions, 9,844 CHVs were selected by their communities and have already been officially nominated by the commune. Of these, 55 percent (5,415) of CHVs are already functioning as they have already received training on integrated health topics from the former MAHEFA Program. Some of the functioning CHVs have received refresher training courses under the current Program. Since Q2 some of the remaining 4,429 CHVs began and will continue to receive a series of trainings to become functional and provide integrated health services in FY2018. All the CHV trainings were conducted by the CSB heads. Detailed information on technical training received by the CHVs under the Program as of June 30, 2017 is presented in Figure 2 below. Despite a decrease in the number of trainings organized in Q3 and Q4 due to reduced budget received in FY2017, the Program will be able to reach the training targets for FY2017. While the number of functioning CHVs is currently at 5,415, the number of CHVs trained on different topics exceeds this number. This is because in addition to the functioning CHVs, the remaining 4,429 CHVs have also begun their training in some topics. However, they will not become functioning until they receive the entire series of pre-service training and practicum required and begin providing integrated health services.

Figure 2- CHV Training as of June 30, 2017

CHV Monthly Meeting at CSB. In addition to the technical training conducted by CSB heads, all CHVs (per the national community health policy or PNSC) are required to attend a monthly meeting called by the CSB heads who supervise them. The Program provides both technical and financial support for the monthly meetings, at which the CSB heads provide in-service training and

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updated technical information to CHVs and check and approve their monthly reports. The highest CHV attendance rate at the CSB monthly meeting in Q3 was in June, at which 5,527 CHVs (85 percent) participated. Informational interviews with a number of CHVs indicate that monthly meetings are stimulating because they meet other CHVs and see their supervisors in person.

Community Health Data. Another purpose of the CSB monthly meeting is for CHVs to submit monthly reports to their supervisors. Community reporting by CHVs is detailed in IA3 (section 3.3.1 on CHV Monthly Reporting to CSB; 3.3.2 on Integration of Data from CHV Routine Reporting into MOH's HMIS), and cross-cutting section 4.1.2 on Data Reporting, Quality and Use.

1.1.3 Quality of CHV Services

The Program and government officials continued to conduct supervision visits to make sure the services provided by CHVs meet quality norms and are within national standards. A total of 2,806 CHVs received supportive supervisions in Q3 (1,104 or 39 percent by CSB heads; Equipe de Management Régionale (regional health management team) (EMAR); Equipe de Management de District (district health management team) (EMAD); and 1,702 or 61% by Program staff). More information on CHV supervision is presented under section Sub IA 3.0 on Reinforcement of GOM’s Capacity to Provide Technical Training and Supportive Supervision to CHVs.

Services Provided by CHVs in Q3 FY2017

This section presents the integrated health services provided by CHVs in the Program regions in the reporting quarter.

CHV’s Services in Maternal, Newborn, and Child Health

Prevention of postpartum hemorrhage and newborn cord infection (using misoprostol and chlorhexidine (CHX) 7.1%). At the very end of the MAHEFA Program, all functioning CHVs received training on CHX and misoprostol. Therefore, the MAHEFA Program team did not have an opportunity to monitor the use of these two products before close of the field activities in February 2016. In Q2, the Program conducted refresher trainings on misoprostol and CHX as a way to revitalize the use of these two interventions. Unfortunately, the stock-out at the provision points until May resulted in low utilization reported by CHVs in this quarter (misoprostol for 331 pregnant women and CHX for use on 1,011 newborns). The difference in the two numbers does not mean difference in use but instead difference in reporting mechanism. CHX use is reported through the MOH monthly report form. Misoprostol was added for use at the community level after the MOH monthly form was developed. Accordingly, the data on misoprostol is not reported as systematically as CHX (only 28% of the CHVs who submitted the MOH monthly form reported misoprostol use). The Program will continue to make sure that the misoprostol reporting rate is equal to the MOH monthly report.

Nutrition. CHVs continued to provide growth monitoring services via routine weighing and measurement of middle-upper arm circumstance (MUAC). CHVs keep a record of all children under 5 (CU5) in their community. In Q3, a total of 103,303 CU5s were recorded by the CHVs in the program regions. Of the children recorded, CHVs weighed 82 percent (84,939), and measured the upper arm circumcision (MUAC) of 74,332. Overall, this is an increase, as compared to 65,169 CU5 who were weighed and the 48,167 who received MUAC in Q2. Figure 3 also shows that only 2 percent of CU5 has a MUAC measurement under 125 mm compared to 3 percent in Q2. The slight decrease in the CU5 malnutrition rate indicated by the MUAC, could be a result of more regular growth monitoring service activities and nutrition messages given by CHVs may have also contributed to the decrease in the malnutrition in Q3.

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Figure 3- Results for CU5 with MUAC Measurement in Q3, FY2017 (n=74,332)

c-IMCI Services for Children under 5. A significant part of a CHV’s mandate is to provide CU5 services including diagnosis, treatment, counseling, and referral to CSBs as necessary. Key Q3 results in this area are presented below. Information on the Program’s malaria activities that are not part of the CHV c-IMCI services on malaria are presented later in the report. As shown in Figure 4 below, CHVs received 56,762 c-IMCI cases of CU5 but only 28,849 cases received treatment. A high stock- out level in this quarter could lead to non-treatment among some c-IMCI cases seen by CHVs. Out of CU5s seen by CHVs in this quarter, CHV tests a child for malaria, Manja District, almost half (45 percent or 25,653) were fever Menabe Region cases. Among fever cases seen by CHVs, more than half (54% or 13,810) were tested malaria positive and received artemisinin-based combination therapy (ACT). CU5s with simple diarrhea treated by CHVs is, at 6,097, lower in Q3 than the 7,154 in Q2. For cases of CU5 with pneumonia treated by CHVs, there is a slight increase in Q3 (8,942) over the 8,085 in Q2.

Figure 4- Cases of CU5 Treated for c-IMCI by CHVs in Q3 FY2017

Malaria Diagnostic and Treatment by CHVs. As malaria is one of the most serious health issues in the Program’s seven regions, CHVs have an important role in promoting practices such as sleeping under insecticide-treated mosquito nets, destroying mosquito habitats, and seeking health service for fever, especially among CU5s. In Q3, CHVs received a total of 39,463 CU5 with fever and tested 80 percent (or 32,170) of those with fever using a Rapid Diagnostic Test (RDT) kit. The reason for not testing the remaining CU5s may be a shortage of RDT kits including gloves because CHVs are

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trained to automatically test all CU5 fever cases with RDT and use gloves for infection prevention. Of the 32,170 CU5s tested, 56 percent (17,977) were positive for malaria. Unfortunately, 77 percent of the malaria positive cases received ACT treatment, which may have to do with ACT availability. ACT is further discussed later in this section of the report. Table 2 also shows that Boeny and Melaky have the highest positive rate in the program area, at 68 percent and 67 percent respectively, in Q3. This may be a result of the malaria outbreak in Q2. More malaria activities are presented later in IA1.

Table 2 – CHV Malaria Services by Regions in Q3 FY2017

Malaria services by CHVs Boeny DIANA Melaky Menabe SAVA Sofia Total CU5 fever case 1,616 875 11,284 12,774 1,608 11,306 39,463 CU5 with fever tested with RDT by CHV 965 481 9,728 10,117 1,386 9,493 32,170 CU5 with fever tested positive with RDT 661 136 6,509 5,132 356 5,183 17,977 CU5 with fever treated with ACT by CHV 593 73 5,626 3,697 223 3,598 13,810

Referral Services for Women and Children under 5. One of the CHVs’ main services is to provide counseling and referral services for women to the CSB for ANC visits, follow-up, delivery and long- term method for family planning. The ANC visits are opportunities for women to receive malaria- prevention therapy, including intermittent preventive treatment during pregnancy with sulfadoxine- pyrimethamine against malaria (IPTp-SP), long-lasting insecticide-treated bed nets (LLITN), iron folic acid (IFA), and tetanus vaccinations. CHVs also referred CU5 for danger signs, vaccination, and treatment of malnutrition, among other services available at CSBs. Table 3 shows the number of individuals referred and the types of referrals by CHVs during Q3 FY2017. In this quarter, 32,504 women and 48,181 CU5 were referred by CHVs to the CSB. Of the referred women, 21 percent (6,847) were counter-referred by CSB for follow up services with the CHVs. Among the CU5, the counter referral rate was 39 percent, or 18,962 of 48,181 cases referred. The table also shows that during this quarter, CHVs referred a total of 43,612 CU5 for vaccination, representing 91 percent of the CU5s referred to CSB for any reason.

Table 3 - Referral Cases from CHVs to CSBs, Hospitals, or Mobile Clinics in Q3, FY2017

Referral services by CHVs Type of service Number of women referred in Q3, FY2017 First prenatal consultation including tetanus Malaria, maternal and vaccination, IFA, intermittent preventive newborn care 8,122 treatment in pregnancy, and LLITN Pregnant women for fourth ANC Malaria, maternal and 7,389 newborn care Pregnant women for delivery Maternal and newborn care, 4,216 assisted delivery Pregnant women for vaccination Maternal care 8,895 Long-acting contraception Family planning 3,882 (306 CSB and 3,576 Maries Stopes) Subtotal: number of women referred to CSBs 32,504 Pregnant women with confirmed counter-referral 6,847 (21% of referred from CSB back to CHVs cases) Cases of CU5 referred for vaccination Child care 43,612 Cases of CU5 referred for malnutrition Child care 796

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Referral services by CHVs Type of service Number of women referred in Q3, FY2017 Cases of sick CU5 with danger signs (newborns, Malaria, treatment of malaria, acute respiratory infection, and diarrhea) complicated cases, water 2,045 treatment Cases of sick CU5 from miscellaneous causes Child care 1,728 Subtotal: number of CU5 referred to CSBs 48,181 CU5 with confirmed counter-referral from CSB 18,962 (39% of back to CHVs referred cases)

CHV’s Services in Family Planning and Reproductive Health

Regular FP Users. At the end of this quarter, the functioning CHVs reported that they provided FP services to 110,132 regular users (Figure 5), an increase of 1.4 times from 75,323 in Q2. Women between 15–19 years of age constitute almost a quarter of the regular FP users (25,622 of 110,132, or 23 percent). The largest group of FP regular users are women 25 years old and above, at 41 percent (45,558 people). Among the 34,809 regular users recorded by the CHVs in Q3, 17,394 (Figure 6) are new and the other 17,415 are most likely the regular users who returned to CHVs for family services in Q3. CHVs reported giving Sayana Press to 4,303 women in Q3, an increase of 3.4 times from 1,266 women in Q2. Table 4 shows Sayana Press use by regions.

Table 4 – Sayana Press Use by Regions in Q3, FY2017

FY2017 Boeny DIANA Melaky Menabe SAVA Sofia Total Q2 (Jan–Mar 2017) 10 0 43 773 0 440 1,266 Q3 (April–May 2017) 140 46 254 2,663 189 1,011 4,303

Figure 5- Regular Family Planning Users in the Program, by Age Group, Q3 FY2017

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Figure 6- New Family Planning Users in the Program, by Age Group, Q3 FY2017

New FP Users. Figure 6 above shows that in Q3, women under 25 years old constituted the majority of the new users (at 71 percent of the total new users or 12,370 out of 17,394) Seven percent (or 1,246) were adolescents 10–14 years old.

At the end of Q3, the Program recorded 25,170 couple years of protection (CYP). The injectable remains the most popular method used by women, representing 86 percent of the total CYP during the reporting period (Figure 7).

Figure 7- Couple Years of Protection by Family Planning Methods, Q3 FY2017

1.1.4 Women- and Youth-Friendly Environment and Services

Situation Analysis on Gender-Based Violence (GBV). During this quarter, the study protocol on GBV was finalized and submitted to the MOH Ethics Committee and the JSI IRB. The Program is waiting for the result from the committee. Due to reduced budget in FY2017, the study will be conducted in FY2018.

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1.1.5 Health Commodities and Work Tools for CHVs

Health Commodities for CHVs. In Q3, the stock-out level for all health tracer products was lower than Q2, but still high (Figure 8). The high stock-out rate in Q3 for both child health and family planning tracer products can be caused by internal factors derived from the CHVs and factors that are external to them. The internal factors are:

• Between the two Programs (MAHEFA and Mahefa Miaraka), many CHVs exhausted their revolving drug fund therefore cannot replenish their stock at the minimum level; • Linked to the above, CHVs keep their health products at the lowest level possible due to lack of cash; • Also, linked to the above CHVs resupply their health products once a month when they attend the CSB monthly meetings. This means when they produce their monthly report, their stock level is extremely low or in some cases completely out of products due to services provided during the month; and • Again linked to lack of cash on hand, CHVs only keep stock of health products for the services frequently needed in the community. For example, stock-out of condom in Q3 was from 54-63% compared to only 17-20% for injectables of the same period.

The above factors combined affect the availability of health commodities at CHVs. It is expected that the stock-out levels will continue to improve as the coordination between all partners involved is better and the products are available continually in the country. To address some above factors, the Program will take the following actions in the next quarter:

• Resupply CHVs with health product kits to be provided as part of the pre-service or refresher training as available; • Continue to remind CHVs to keep a minimum level of health products using stock management tool; • Continue to remind CSB heads to add CHVs’ malaria product needs in their quantification exercise; • Remind the CSB heads to review the CHVs’ monthly report (stock section) and make sure to replenish the malaria products appropriately to the service level of the CHVs; • At the commune level, continue to communicate CHVs’ stock-out rates with the CSB (for malaria products) and at PA (for other family planning and child heath tracer products) to the MOH and PSI; and • At national level, share monthly stock-out rates reported by CHVs with relevant partners - with the MOH (Directorate of Pharmacies, Laboratories and Traditional Medicine, DPLMT and National Malaria Control Program, DLP) and PSM project for malaria products and with PSI/ISM project for other family planning and child heath tracer products.

Page 11 USAID Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 3 Report

Figure 8 and 9 below show an overall improvement in the stock-out level for both child health and family planning tracer products managed by CHVs. The Program will continue to coordinate and work with all relevant partners to make sure that the stock-out rate continues to be lower in future quarters.

Figure 8- Stock-out of Child Health Tracer Products at CHVs in Q2 and Q3 FY2017

Figure 9- Stock-out of Family Planning Health Tracer Products at CHVs in Q2 and Q3 FY2017

Page 12 USAID Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 3 Report

Table 5 – CHV Reported Stock-out of Health Tracer Products in Q3, FY2017

Reported Stock-out Health Products with CHVs Apr-17 May-17 Jun-17 Child health/malaria products (CHV resupply these products with CSB) Actipal and ASAQ Nourrisson (Infant) 50% 50% 61% Actipal and ASAQ Enfant (Child) 46% 47% 56% Paracetamol 500 39% 38% 46% Child health products (CHV resupply these products with the ISM project provision points) CHX 50% 46% 51% RDT 35% 35% 41% Zinc and ORS 30% 26% 28% Amoxicilin 28% 27% 31% family planning products (CHV resupply these products with the ISM project provision points) Condoms 54% 53% 63% Cycle beads 42% 39% 48% Oral contraceptive (Lofemenal/Microgynon) 22% 20% 23% Injectables (Depoprovera-Megestron) 17% 16% 20%

Since the CHVs began their services, the Program Teams at both national and regional levels have coordinated with the PSI teams. Using the monthly information from the CHVs, the Program district team communicates to the Program regional team who holds a monthly meeting with the PSI regional team. At the national level, Mahefa Miaraka shared the progress in the CHVs’ training for PSI to better plan their supply in the regions. Based on the experience with the distribution of viasur, we would suggest PSI to (1) use data to better quantify the starting kit for CHVs and distribute them timely; (2) prioritize the distribution of the starting kit using the social marketing channels through PA that are more effective to reach CHVs, and; (3) anticipate the redeployment of the products giving the expiration date with regards to the seasonality of the related diseases. Unfortunately, the close-out preparations of the PSI/ISM project caused some confusion and, in some cases, stock-outs of health products at the PA. An example of this confusion is presented below. Despite the above, the Program has implemented a few measures to remedy the stock-out situation as below: a) Sharing monthly data on stock-outs by region with all involved (PSI/ISM, PSM and DLP) – b) Continuing to have a monthly meeting at the regional level between PSI/ISM and Mahefa Miaraka c) Sharing and discussing data on stock-outs at the monthly meetings between CSB and CHV d) Sharing and discussing data on stock-outs at the monthly meetings between EMAD and the Program district team e) Sharing and discussing data on stock-outs at the monthly meetings between EMAR and the Program regional team f) Sharing and discussing data on stock-outs at the monthly meetings at the national level (on malaria products at the meeting held by DLP and other health products at the meeting held by DPLMT) g) Participating in the cascade training on logistics and management of health products including the CHVs, so CSB and the PHA-G-DIS can improve the availability of products in the field h) Working with the SDSP and CSB to supply the CHVs as necessary should the PA have stock-outs and vice-versa.

Page 13 USAID Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 3 Report

Below is the table requested by USAID showing the names and locations of stockouts.

Percentage of CHVs having stockout in June 2017 Boeny DIANA Melaky Menabe SAVA Sofia Number of CHV 225 1134 696 1091 297 2573 Number of fokontany 117 596 362 620 877 1467 Zinc and ORS/viasur Less than ]30% - ]16% - ]16% - 30%] ]30% - 50%] ]30% - 50%] 15% 50%] 30%] Amoxicilin Less than 50% and ]30% - ]16% - ]30% - 50%] ]16% - 30%] 15% more 50%] 30%] Actipal and ASAQ Enfant (Child) 50% and 50% and 50% and 50% and 50% and 50% and more more more more more more 3ASAQ Enfant 50% and ]30% - ]30% - 50% and 50% and ]30% - 50%] more 50%] 50%] more more RDT ]30% - ]30% - 50% and ]30% - 50%] ]30% - 50%] ]30% - 50%] 50%] 50%] more Paracetamol 500 50% and 50% and 50% and ]16% - 30%] ]30% - 50%] ]30% - 50%] more more more CHX 50% and 50% and ]30% - 50% and 50% and ]16% - 30%] more more 50%] more more Condom 50% and 50% and 50% and 50% and 50% and 50% and more more more more more more Cycle beads 50% and ]30% - ]30% - 50%] ]30% - 50%] ]30% - 50%] ]30% - 50%] more 50%] Injectables (Depoprovera-Megestron) Less than ]16% - ]16% - ]16% - 30%] ]16% - 30%] ]16% - 30%] 15% 30%] 30%] Oral contraceptive ]16% - 30%] ]16% - 30%] ]30% - 50%] ]16% - 30%] ]16% - 30%] ]16% - 30%] (Lofemenal/Microgynon)

1.1.6 Motivation Activities for CHVs and FKT Heads

Due to the reduced budget in FY2017, the only motivation activity for the CHV in this quarter is presented below.

Community Support. The Program recorded a total of 1,180 health huts or Tobys (254 newly built in Q3) by the community for use by CHVs in the Program regions at the end of June 2017. This represents 98 percent (1,205) of the target for Tobys to be built by the community in FY2017. Of those built, 77 percent (917) are equipped with chairs, table, and shelf; 51 percent (605) have a waste pit; and 39 percent (466) a latrine. The Program will continue to encourage communities to make sure that all Toby built have basic equipment, latrines and waste pits.

1.1.7 Malaria Activities in the Program

Support to SDSP and CSB for Prevention of Malaria Outbreaks. In Q3, the Program team began a monthly review meeting with Service de District de la Santé Publique (SDSP) to review health performance of the CHVs of all communes in the district. The Program generated a dashboard of 40 selected indicators and with the SDSP reviewed the community health performance of each commune in the district to identify potential outbreaks including malaria. In Q3, these joint reviews helped the SDSP in Manja District, Menabe, to be able to act quickly to contain the malaria outbreaks.

Page 14 USAID Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 3 Report

Community Health Volunteers’ Role in Malaria Prevention and Control. In Q3, CHVs in the Program regions continued to provide c-IMCI services and promote key messages on malaria prevention using LLITN, destroying mosquito habitats, seeking treatment for fever, ANC visits including use of IPT. The CHVs’ c-IMCI services and other malaria services for pregnant women are presented below.

Malaria Cases of CU5 Reported by CHVs. As noted, among the c-IMCI services provided by the CHVs is malaria prevention, diagnosis, treatment of simple cases, referral of complications, and reporting malaria cases seen and treated. Figure 10 shows malaria cases as reported by CHV at the end of Q3 FY2017. CHVs are trained to automatically test each fever case with RDT and when positive, they will treat a child with ACT or refer complicated cases to CSB. As shown in the figure, not all fever cases were tested and not all the malaria tested positive cases receive treatment. This was mainly due to stock-out of the malaria products at CHVs. Among fever cases seen by CHVs in the Program regions, around half were tested malaria positive.

Figure 10- Malaria Evolution in the Program Regions Reported by CHVs in Q3 FY2017

Promoting the Use of Long-Lasting Insecticide-Treated Bed Nets (LLITN) at the Community Level. The USAID Community Capacity for Health Program promotes the use of LLITN through multiple communication channels: radio diffusion, social behavior change communication (SBCC) activities conducted by the CHVs and fokontany heads, and high visibility events such as health days and campaigns. Additionally, the Program promotes the use of LLITN on the household card that explains the importance of sleeping under mosquito nets, especially for CU5 and pregnant women. In Q3, the Program staff also participated in a workshop organized by Blue Ventures on correct use of LLITN at the community level and supported the SDSP and CSB to distribute mosquito nets in the malaria outbreak districts.

Referral of Pregnant Women for Malaria-Prevention Therapy with Sulfadoxine-pyrimethamine (IPTp- SP). One of the CHVs’ main services is to provide counseling and refer women to the CSB for ANC visits, follow-up, and delivery. These visits are opportunities for women to receive malaria- prevention therapy, including intermittent preventive treatment during pregnancy with sulfadoxine- pyrimethamine (IPTp-SP), LLITN, IFA, and tetanus vaccinations. As reported earlier, during this quarter, a total of 8,122 pregnant women were referred by CHVs for the first ANC visit and 7,389 for the fourth ANC visit.

Page 15 USAID Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 3 Report

Pharmacovigilance. By the end of the quarter, 3,081 CHVs received the training on pharmacovigilance as part of their c-IMCI training. In FY2018, all 9,844 CHVs in the Program regions will receive training on pharmacovigilance.

Malaria Products at the Community Level. As explained in detail under section 1.1.5 on health commodities for CHVs, the Program team continued to participate in the national-level coordination and working groups related to community logistics. At the commune and district levels, the Program team coordinates on a monthly basis with the CSB and SDSP to advocate for: 1) inclusion of CHV malaria product needs with the CSB’s quantification exercise; and 2) distribution of malaria products to CHVs. The monthly data review at CSB is a good forum to discuss malaria products for CHVs.

Malaria Prevention at the Community Level. Messages on malaria prevention and control are part of the key health messages diffused through multiple communication channels in the Program. More information on this is presented in the next section.

1.1.8 Program Activities Directly Related to WASH

CHV training All of the pre-service and refresher trainings for the community health volunteers in Q3 included WASH. By the end of Q3, 5,415 CHVs were functioning after receiving a pre-service or refresher training that includes WASH, namely c-IMCI, CHX/Misoprostol and SBCC (3,081 for c-IMCI, 5,481 for CHX/Misoprostol and 6,785 for SBCC respectively).

Social Behavior Change Communication activities WASH messages are developed and disseminated routinely through several communication channels organized by the Program, namely: through 48 local radio stations in seven regions, through the approach called Ménage Modèle and Ménage Parrain for WASH and youth actions; through the commune champion (KMSm) approach where WASH is one of the indicators; through the CHVs’ routine promotional activities including counseling for case management; and through all high-visibility health events organized by the regional, district and commune-level health offices. As a result, 337,231 people have received sensitization on WASH including 6,097 cases of diarrhea that received counseling on key WASH messages.

Materials and tools on WASH used at the community level To successfully implement the activities mentioned above, the Program developed, produced, distributed and trained all relevant actors above to use the materials and tools successfully. Also as explained above, WASH messages are among key health messages diffused by the program so the materials and tools on WASH are among the materials used in all the activities described above, such as “fiche ménage”, jobaids for CHVs.

1.1.9 Program Activities Directly Related to immunization

Immunization is one of the CHVs’ responsibilities, namely referring children and pregnant women for necessary vaccinations at the government’s health facilities. Below is a more detailed description of the program activities in the third quarter that are directly related to immunization.

Roll out of SBCC activities at the community level During Q3, the Program supported the Mother and Child Health Week in the 34 districts and 732 CSB, including immunization services. This included mainly routine vaccination, “vaccination de rattrapage” and active research of vaccine-preventable diseases. The Program provided its support in the transportation of vaccines and management tools from districts to CSB and in outreach services in the fokontany in collaboration with CHVs, as well in the supervision of the uptake of the services during the MCHW. With regards to the polio campaign, the next one will be scheduled in FY2018.

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Reach Every Child (REC) Approach: participation in the development of training curriculum and materials for use at the community level (by CHVs) The Program staff has actively participated in the MOH’s effort to implement the REC approach in Madagascar. The MOH’s REC training manual and materials are developed until the CSB level. The manual was pre-tested with the national coaches for the regions. Using the CSB curriculum and materials, the Program assisted the MOH to adapt/simplify the training curriculum and materials for use by the CHVs. In Q3, the manual and materials were completed and the MOH is planning cascade trainings for priority districts and CSB starting in Q4 FY2017 or Q1 FY2018. In FY2018, all CHVs in the seven Program regions will be trained in the REC approach and will begin the REC activities.

Link between CHVs and CSB for immunization activities At the end of Q3, 5,444 CHVs received training on community surveillance for vaccine- preventable diseases (figure 2). They check child health cards during home visits which are prioritized based on the family inventory and mapping of children to be vaccinated. They then refer those who need to complete their series of vaccinations to the CSB. The CHVs have a monthly report form that they submit to CSB heads at the monthly meetings, during which they also use the “bac à fiches” at the CBS to identify children from their fokontany who need to be referred in order to be fully immunized. The CHVs then inform those families to bring children for vaccination, especially the parents of newborns through 12 month old infants. As a result, 43,612 children have been referred to CSB for vaccination during Q3.

Secondly, the Program supports the outreach activities (stratégie avancée) of the CSB. Every time the CSB heads conduct technical supervision of CHVs, they may plan as appropriate to vaccinate the children who have not yet completed their vaccinations. In that case, prior to their supervision visits, during the monthly meeting, the CSB heads inform CHVs of perdus de vue cases so that the CHVs can inform the families and have the children ready for the vaccination by the CSB heads during his/her supervision visit/stratégie avancée.

Intervention Area 2 (IA2): Behavior Change and Health Promotion

Key Achievements: 1. The number of times people received health messages from different Program communication channels in Q3 is 2,259,646 (878,977 people from the SBCC activities conducted by CHVs; 930,100 people from radio diffusion; and 450,569 people from the health campaign and health day celebration organized jointly by the CSBs and the CHVs). 2. In this quarter, CHVs delivered key health messages to a total of 878,977 people (121,551 people through home visits, 202,930 people who came for services at the health huts, and 554,496 people through the education sessions. 3. 48 local radio stations began or continued diffusing key health messages, on average three times a day and between 10–18 days a month.

Sub IA 2.1. Community-Level Health Promotion and Sensitization to Increase Healthy Behavior and Uptake of Health Services and Products

During this quarter, the USAID Community Capacity for Health Programme continued to develop promotional tools, developed materials, and began a series of trainings for community actors on the SBCC approach. Details are below.

2.1.1 SBCC Strategy, Approaches, Materials, and Tools

Review of the Radio Listening Group (RLG) Approach and Tool. To promote community solutions to local health problems, RLG activities will be conducted spontaneously as part of the CHV routine

Page 17 USAID Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 3 Report

home visits and village health promotion activities. The CHVs will be equipped with a radio and a discussion guide with questions and answers. For CHVs in zones without radio reception, the Program will provide registered key health messages and essential family practices (EFP) on a card to be inserted in the radio (as currently practiced by people residing in these zones who use registered songs to listen to music from their radio). In Q4, the Program will develop 15-minute stories or dramas on key health messages and EFP that will be more entertaining and appealing to local audiences than radio spots. Also, in this quarter, the Program began a partnership discussion with the executive secretary of the National Committee on AIDS (Secrétariat Exécutif Comité National de Lutte contre le SIDA) for the radio posts and the Office National de Nutrition for joint development of key messages on nutrition.

Household Cards on Essential Family Practices. Using the model household (ménage modèle) and care group household (ménage parrain) approach, the Program delivered 338,580 household cards. These cards present EFPs for newborns, 0–11 months, infants from 12–23 months, young children from 24–59 months, and pregnant women. All EFPs are taken from the MOH’s health cards. Household cards on malaria, water, hygiene and sanitation (WASH), nutrition, and youth will be developed in Q4. Household cards are used to encourage families to adopt good health practices (becoming ménage modèle) and expand the adoption to other families (becoming ménage parrain). The CHVs and fokontany heads are responsible for monitoring and reporting the use of cards.

Program staff trains CHVs to use household cards in Bealalana District, Sofia Region.

2.1.2 Repositioning the Women’s and Children’s Health Cards as the Cornerstone of SBCC Strategies

A total of 239,856 health cards (119,928 women’s and 119,928 children’s) were distributed to the CHVs this quarter. Additionally, 46,220 health cards (23,110 women’s and 23,110 children’s) were distributed for use at the government health facilities or CSB. The Program uses health messages from the women and children’s health cards to develop household card EFP.

2.1.3 Development and Dissemination of Information, Education, and Communication

In this quarter, the Program developed 18 tales, 11 dramas, and 29 spots on family planning, gender equality, WASH, nutrition, vaccination, maternal and newborn care, and malaria prevention. These products were developed with and/or validated by the relevant divisions of the Ministry of Health (MOH) namely the Division of Family Health (DSFa); the Division of Health Promotion (DPS), specifically the Service d’Appui et de Coordination pour la Promotion de Santé (SACPS), and the communication office of the Direction Division of the Expanded Program on Immunization (Programme Élargi de Vaccination).The Program also disseminated 19 MOH-developed audio products to local radio stations.

Page 18 USAID Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 3 Report

Sub IA 2.2 SBCC Capacity of Community Stakeholders

2.2.1 SBCC Skill-Building for Community Leaders

In this quarter, 6,785 CHVs received SBCC training including use of household cards. As in all trainings conducted by the Program, the SBCC training follows the cascade approach where the first training of trainers was conducted jointly by the MOH trainers.

2.2.2 SBCC Activities at the Community Level

People Reached by Program SBCC Activities. In this quarter, the Program used multiple communication channels to promote key health messages and EFPs: 1) work of CHVs (counseling at health hut, home visits, and community-based education sessions); 2) radio diffusion; and 3) high visibility events. Figure 11 shows the number of people reached through different communication channels in Q3. Radio diffusion is the primary source, delivering health messages to 930,100 people. The second-biggest source is the CHV, who reached 878,977 people with key health messages through their three main SBCC activities. The same people may be reached multiple times by different communication channels. Table 5 also shows the number of times people were reached by key health messages in the Program area in Q3 FY2017. During this quarter, CHVs also conducted 33,890 home visits and 12,690 education sessions).

Figure 11- Number of People Reached Through Multiple Communication Channels in Q3 FY2017 (n=2,259,646)

The same key health messages presented different formats (media, printed, and oral) and delivered regularly through multiple communication channels (CHVs, household model and members of the care group, high-visibility events and radio) complement each other and could lead to the adoption of healthy behaviors among community members. The number of times that people receive the same messages and through different channels also is an important factor that leads to behavior change. Table 5 in the next page shows number of times people were reached by different key health messages in the Program area in Q3 FY2017.

Page 19 USAID Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 3 Report

Table 6 – Number of Times People Reached by Key Health Messages in Q3, FY2017

Key messages Women Men Total Communicable diseases and WASH 171,215 159,919 331,134 Non-communicable diseases 110,230 102,712 212,942 Family planning 221,904 184,141 406,045 Maternity without risks with malaria prevention 161,757 137,939 299,696 c-IMCI including malaria prevention 219,252 193,373 412,625 Exclusive breastfeeding 170,687 135,372 306,059 Nutrition 166,173 142,719 308,892 Vaccination 278,809 234,216 513,025 Youth and adolescent health 144,142 132,223 276,365

Media Activities for Promotion of Key Health Actions. At the end of Q3, a total of 48 local radio stations (12 additional in Q3) began or continued diffusing media products revised by the program. All focused on disease prevention and promoted EFPs to improve the community’s health status. Using the GOM’s Millennium Development Goal (MDG) and the 2016 Program baseline survey, it is estimated that 16.7 percent of women of reproductive age were exposed to maternal and child health messages and that 930,100 people were reached through radio diffusion during Q3.

Participation in the GOM-Organized Health and WASH Days. In Q3, CHVs, fokontany heads, and program staff participated in many high-visibility events organized by the government. In total, 450,569 people received key health messages at these events. A collage of photos from these events in Q3 is presented in Figure 13.

Sanitation and Hygiene at CHVs’ Toby: In this quarter, the Program continued to monitor the hygiene and sanitation facilities available at the health huts. At the end of June 2017, the program recorded 1,180 health huts built by the community for use by CHVs. Figure 12 presents the sanitation and hygiene facilities built by the community at the health huts. The Program’s strategy is to first encourage the community to build the health hut for CHVs. Once the hut is built and the CHVs begin working in the hut, the community is encouraged to build a latrine, handwashing station, and waste disposal pits. The gradual process makes it easy for the community to manage. The Program will continue to make sure that all CHV health huts built by the community will eventually be equipped with hygiene and sanitation facilities.

Figure 12- Sanitation and Hygiene at CHVs’ Health Hut as of June 30, 2017

Sanitation and Hygiene in the Community. The Program continued to promote the construction and use of improved latrines in all of its program areas. During this quarter, the program recorded 3,334

Page 20 USAID Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 3 Report

newly built latrines by the community. This increased a cumulative number of improved latrines to 10,635 at the end of Q3 FY2017. Open defecation-free evaluation and certification activities will be conducted in Q4.

Figure 13- High-Visibility Events in Q3 FY2017

Sub IA 2.3 Innovations to Promote Adolescent and Youth Health

2.3.1 Strengthening Local Structure to Promote Youth Health

During this quarter, the Program team supported and participated in a two-day workshop organized by the MOH/DSFa. A total of 88 messages related to the prevention of unwanted and early pregnancy, GBV and substance addiction among young people were collected from all stakeholders and projects working in the area of youth reproductive health. The messages focused on youth behaviors and communication between parents and family planning. A list of messages was submitted to the MOH/DPS for final approval. The approved messages will then be used by all projects and development organizations in Madagascar for in-school and out-of-school youth activities.

2.3.2 School-Based Youth SBCC Activities

The in-school family planning and reproductive health promotion and prevention activities will begin in Q4 when schools start.

Page 21 USAID Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 3 Report

2.3.3 SBCC Activities for Out-of-School Youth

The USAID Community Capacity for Health Program’s effort to reach out-of-school youth includes media campaigns and community-level SBCC activities. Some health messages diffused by the local radio stations promote youth reproductive health and use of family planning. CHVs and fokontany heads encourage young households (young couples) to become ménage modèle and ménage parrain. After this, they act as the health champions to encourage other young households to adopt EFP listed in the household cards. CHVs also distribute FP invitation cards to young women who are regular FP users to give to other young women. 5,745 FP cards were distributed by the CHVs to regular FP users in Q3.

Intervention Area 3: Health Service Planning, Management, and Governance

Key Achievements: 1. Out of the 5,527 functioning CHVs, 5,415 (93 percent) attended the monthly meeting organized by the 489 CSBs. 2. 24 district health offices (SDSP) and 489 CSB started monthly meetings with the Program staff to review selected health indicators to follow community health performance at the commune and district levels. 3. 2,806 CHVs (52 percent of functioning CHVs) received supportive supervisions in this quarter. 4. Program staff participated in 38 technical meetings and working groups led by GOM during Q3.

Sub IA 3.0 Reinforcement of GOM Capacity

3.0.1 Coordination with MOH

Participation in Central GOM-Organized Technical Meetings and Workshops. During Q3, Program staff at the central office attended 38 technical meetings (see Annex 5). Examples of GOM health initiatives participated in by Program staff include:

• Preparation of the 2018 Country Malaria Operation Plan. • Quantification of the 2018 national FP product needs. • Revision of the community family planning and reproductive health training curriculum. • Revision of the National Community Health Policy. • Preparation of the family planning law. • National demographic dividend activities. Community health monthly review meeting between the SDSP Miandrivazo District and the • Community DQA tool development. program team, Menabe Region • Universal health coverage. • Reaching each child approach in Expanded Program on Immunization.

Capacity Building of GOM Officials. During this period, the Program team started a monthly review exercise with the government health offices at the district and commune levels. The Program generated a dashboard of 40 selected indicators and with the 24 SDSP reviewed the

community health performance of each commune in the district to identify potential health outbreaks, functionality and quality of the CHV services, and quality and rate of CHV monthly reports. The same exercise was conducted at the 489 CSBs during the CHV monthly meeting to review the community health performance of each

Page 22 USAID Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 3 Report

fokontany in the commune. The monthly review meeting is also an opportunity for the SDSP, the Program teams, CSB heads, and CHVs to make a joint plan to improve the health performance of their respective communes and districts.

CHV Technical Supervision (monthly meetings and supportive supervision). In Q3, a total of 5,415 functioning CHVs (93 percent of the annual target) attended the monthly meeting led by CSB heads. As the program gains momentum, it is expected that the participation rate will continue to increase. A total of 2,806 CHVs received supportive supervision in Q3 (1,104 or 39 percent by CSB heads, EMAR, and EMAD, and 1,702 or 61 percent by Program staff). The monthly meetings are also an opportunity for CHVs to submit their monthly reports and receive updates and continued technical training. The CHVs also discuss work-related difficulties and challenges and ask advice from the CSB heads.

Heads of CSB during June 2017 meeting with CHVs in DIANA, Sofia, Menabe and Boeny Regions

Sub IA 3.1. Introduction and Promotion of CSB Improvement

3.1.1 CSB improvements

This activity was postponed to FY2018 due to reduced funding received in FY2017. The Program continues to refine the study protocol for the CSB survey, which will be submitted for approval by the national Ethics Committee in Q4.

Sub IA 3.2. Pharmaceutical and Commodity Forecasting

During this quarter, staff participated in six meetings/workshops related to national supply of community health products (details in Annex 5). Additionally, the Program team had a series of coordination and work meetings with the team from the PSI/ISM and PSM projects to discuss details of collaboration at the national, regional, and district levels to ensure availability of essential health products for CHVs in the Program areas.

The Program will begin the commodity activities at the district and commune levels in FY2018.

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Sub IA 3.3. Health Data Quality, Management, and Use

3.3.1 CHV Monthly Reporting to CSB

In 2016, the Ministry of Health changed the reporting requirement of the CHVs. CHVs who work in the same fokontany are required to submit a combined monthly report instead of individual reports, as previously done. In Q3, a total of 5,042 out of 5,415 functioning CHVs in the Program regions (93 percent) submitted their monthly report to the CSB heads. More information on CHV reporting is presented under the cross-cutting section.

3.3.2 Integration of CHV Data into MOH's Health Management Information System (HMIS)

In Q3, the Program began to export CHV monthly data in 24 districts where CHVs are functional into the SDSP’s HMIS. This will continue to be one of the routine activities in upcoming quarters.

3.3.3 Integrated Community-Based Surveillance of Preventable Diseases

The Program worked with the MOH to develop a training curriculum for CHVs on community surveillance. A total of 5,481 CHVs received training on this topic and started collecting information.

3.3.4 Data Use for Performance Review

As reported earlier under the section on “Capacity Building of GOM Officials,” the Program started to use a list of selected indicators at the district level generated by the Program database to monitor program progress on a monthly basis and prepare improvement plans.

Sub IA 3.4. Referral System Strengthening between CHVs and CSBs

3.4.1 Referral System between CHVs and CSBs

Progress in this area was reported under IA1.

3.4.2 Referral System between Health and Other Services

The study protocol on GBV was finalized, submitted, and presented to the National Ethics Committee during this quarter. The Program is waiting for the results from the Committee. The actual field survey will take place in FY2018 due to financial shortage in FY2017.

Monitoring and Evaluation, Learning Management, and Cross- Cutting Issues

Sub IA 4.1 Program Monitoring, Evaluation, and Performance System

Key Achievements in Q3: 1. Increased CHV monthly reporting rate from 69% in Q2 to 93% in Q3. 2. Began and conducted 38 DQA sessions. 3. Introduced data use for joint monthly review between the SDSP and the Program District Team. 4. Used data for district and commune health performance review by SDSP, CSB and CHV at monthly meetings.

4.1.1 Data Management

Page 24 USAID Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 3 Report

During Q3, continued to refine the electronic database system. A 5-day workshop was held from June 12–19, 2017 in Antananarivo for the regional-based monitoring and evaluation staff. This workshop aimed at improving staff skills and commitment to: 1) processing community data correctly; 2) identifying critical points hindering data quality and corrective actions needed; 3) learning DQA process and tools; and 4) sharing data and dashboards with GOM, community stakeholders, and other Program staff to improve performance. A total of 26 staff (18 regional and 8 central) participated.

4.1.2 Data Reporting, Quality, and Use

The PNSC mandate calls for CHVs to submit reports of their health activities every month. All CHV monthly reports are checked and approved (with signature and official stamp) by the CSB heads. Only approved monthly reports are processed by the Program and/or the health district team. More information on the CHV data reporting is presented in the Annex 6. The average reporting rate among functioning CHVs this quarter was 93 percent, an increase from 69 percent during the last quarter. The reporting rate is only among functioning CHVs since the new CHVs have not yet started their services. The Program’s annual target for the reporting rate in FY2018 is 75 percent.

Thirty-eight DQAs were conducted by the Program’s regional monitoring and evaluation staff at the district, commune and fokontany levels during this quarter. Issues raised in the DQA sessions related to: 1) a shortage or lack of integrated record books at the health hut, and; 2) errors in reporting five selected indicators (i-CU5 tested with RDT; ii-CU5 with pneumonia treated; iii-CU2 weighed; iv-pregnant women referred for ANC4, and; v-new users of FP). The DQA sessions in Q3 revealed that 4 percent of the verified reports had transcription errors on i-CU5 tested with RDT, and 18 percent on iii-CU2 weighed. In response to the shortage noted, in Q4 the Program will send record books to CHVs who need them. In response to the CHV report errors, the Program contacted relevant and sent job aids (one on how to check CHV monthly reports and the other on how to count and report FP users) to CSB heads.

As already reported, the Program introduced the use of data, reported in the monthly report of the CHVs, to review program progress with SDS and the heads of CSB. A list of selected indicators at the district level generated by the Program’s database on a monthly basis is used in the monthly meeting with the SDSP and the Program teams. The same indicators generated at fokontany level are also discussed by the CSB heads and the CHVs during their monthly meetings.

4.1.3 Technology Use to Improve Health Services

During this quarter, the Program began transferring electronic data from the CHVs’ reports to the District Health Office data system on a monthly basis. In Q4, the Program’s data system will allow online access at the district level through a web portal. The Program’s district team will then be able to generate the monthly report of selected indicators themselves, instead of receiving the reports from the central office as was done in Q3.

Sub IA 4.2 Learning Management

4.2.1 Studies, Surveys, and Review Workshops for Improvement of Program Performance

The studies and surveys planned in the Program were reported under IA1, IA2, and IA3.

4.2.2 Dissemination

As reported in IA2, the Program participated in several high-visibility events to showcase Program activities and achievements during this quarter, one of which is highlighted below.

Page 25 USAID Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 3 Report

Participation at the America Week (25–26 April, 2017), Antananarivo

2017 marks the 150th anniversary of diplomatic relations between the United States and Madagascar. To celebrate, the U.S. Embassy organized a series of activities under the theme 'America Week' from 25th to 26th April 2017. Events included an exhibition showcasing activities supported by the USG.

In the photo at top, U.S. Ambassador Robert T. Yamate and representatives of the Malagasy Government visited the booth displayed by the USAID Community Capacity for Health Program. More than 370 visitors visited the Program booth (photos on bottom) during the two-day event at the Antananarivo City Hall.

Sub IA 4.3 Cross-Cutting Issues

• Sustainability Mechanisms. As presented throughout this report, the Community Capacity for Health Program continued to promote a sense of ownership and developed capacity among GOM officials at the local level and community actors through start-up workshops and technical trainings. Using the cascade training approach, GOM officials at each level were trained to conduct the training for their own staff. • Gender Equality and Female Empowerment. The Program team continued to participate in national-level gender working group meetings. • Environmental compliance. The Program’s Environmental Mitigation and Monitoring Report (EMMR) is presented in Annex 3. In Q4, the Program will design a revision of the waste management plan poster for use by the CSB and CHVs that will include the instructions received from the Mission Environmental Officer (MEO) in the Q2 EMMR. • Family Planning Compliance. At the end of June 2017, 99 percent of Program staff had completed the online family planning course.

Page 26 USAID Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 3 Report

Challenges and Proposed Solutions for Q3 FY2017

CHALLENGES SOLUTIONS 1. Availability of GOM to conduct the • Some trainings were combined with the CHV monthly training and supervision for CHVs meeting with CSBs 2. Stock-out of CHV management • Organize dispatch of the tools to CHVs with the SDSP tools and CSB • Photocopy 3. Stock-out of CHV commodities • Hold coordination meeting with MOH, PSI, and PSM • Negotiate availability of commodities at CSB for CHVs with CSB, SDSP, and Direction Régionale de la Santé Publique • Work with CSB heads and CHVs to manage stock available at the CSB level and make sure CSB heads share their stock with CHVs • Communicate with PSI at the regional level when PAs have stock-out 4. Mobile banking • Of the 3 options tested, identify the appropriate one for each commune • Define measures to accompany the selected option 5. Certification of ODF villages • Negotiate planning for the evaluation with DIREAU 6. Emergency evacuation plan • Reinforce the importance of elaboration and formalization of plan and its display at supervision and monthly meetings

Administrative and Financial Management

Key Achievements: 1. 92 percent of the program staff (252 of 274) were recruited and oriented. 2. Three additional memorandum of understanding (MOU) with other development partners were signed in Q3. 3. The Program launched the process to begin electronic payments in the field. 4. Nine motor vehicles and 41 motorbikes procured.

Sub IA 0. 1 Operation (Administration, Finance, and Partnership)

0.1.1 Administrative and Financial System

During Q3 of FY17, the administrative and financial teams in all offices continued activities according to the systems established.

Sub IA 0. 2 Administration

In Q3, all program offices, including those at the district level, were fully functioning. Central-level teams provided monitoring visits and on-the-job support to regional and district teams.

0.2.1 Human Resources

By the end of June 2017, the Program had filled 92 percent of available positions (252 of 274). This slight decrease from the previous quarter is due to a few staff resignations. Some resigned to pursue public health courses while others secured civil servant positions within the Government. Some mid-

Page 27 USAID Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 3 Report

level staff recruited for regional or district-level positions ultimately decided to stay with the Government instead of working long-term for the Program.

Also in this quarter, the Program’s regional director for Sofia traveled to Zambia to attend the Africa Transportation Technology Transfer (T2) Conference from May 8-10, 2017. His travel was funded by Transaid. The Program’s Senior Advisor for Community Health traveled to Burkina Faso from the 18-20 of April to participate in a CEDEAO forum on Good Health Practices (Bonnes Pratiques en Santé – FBPS). JSI held a joint management training and programming workshop at the central office in Antananarivo. All seven regional directors and 34 district coordinators participated.

0.2.2 Information and Technology System

The information technology (IT) team continued to focus supplying the Program team with electronic equipment (laptops, printers, and cameras), deciding on the most appropriate equipment for the Program’s various intervention zones, and plans to cope with power shortages.

0.2.3 Procurement and Distribution Management

The procurement and distribution staff provides bi-monthly updates to the technical staff throughout the supply chain process. During Q3, nine four-wheel drive vehicles and 41 motorcycles for use at the regional and district Program offices were dispatched as planned while the customs and administrative clearances were underway.

0.2.4 GOM and Partner Management

The Program continued to collaborate with several GOM offices regarding labor law, taxes, and other operations to make sure that the program’s operations are in line with the evolving national regulations. During Q3, the Program also signed MOUs with Public Health District Offices for use of office space. This process is expected to be finalized by the end of the current fiscal year. Discussions with other partners about potential MOUs are ongoing.

0.2.5 Reporting to USAID and GOM

On April 28, 2017, JSI submitted a revised implementation plan to USAID. The Q2 progress report (technical and financial) was submitted to USAID on April 30, 2017, received approval, and was uploaded to the Development Experience Clearinghouse.

In Q3, JSI submitted the required report related to payment performed in CY2016 to the Revenue Authorities using the new e-reporting system. JSI also submitted the CY2016 report to the Ministry of Foreign Affairs under the Accord de Siège requirements.

Sub IA 0.3 Financial Management

0.3.1 Financial Procedures

During Q3, the Program conducted the last pilot activities related to the use of mobile banking to transfer program funds to the district and commune levels in Mandritsara District of the Sofia Region and Soalala District of the Boeny Region. JSI is documenting the experiences from using mobile banking for payment to CHVs directly, payment through CSB heads, and payment through Program staff. The technological platform at the Program’s central office is ready. Electronic payment will be available only in the communes with cashpoints.

Page 28 USAID Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 3 Report

0.3.2 Financial Reporting to USAID

During Q3, the program submitted the financial report (SF425) for to the previous quarter to USAID. The accruals report was submitted with an understanding that the remaining obligation would be sufficient through mid-November 2017.

0.3.3 VAT (Value Added Tax)

In Q3, the program team received a revised procedure for VAT reimbursement issued by USAID in collaboration with the MOH. JSI continues to submit VAT reimbursement requests for suppliers to the GOM through the MOH on a regular basis. During this quarter, JSI re-submitted request for VAT reimbursement related to prior years on hold with MOH.

0.3.4 Expenditures

A summary of Program expenditures through Q3 FY2017 is presented in Table 7 below. Note that expenses made during Q3 FY2017 were less than the projections presented in the Program’s accruals report and the SF425 from June 30, 2017. This is due to the lag in processing home and field office expenses in JSI’s accounting system, as well as inclusion of accrued costs.

In this quarter, JSI recorded a decrease in the cost share previously reported due to an adjustment performed on the MOH salaries for the GOM officials in Sofia participating in the Program activities. JSI continues to seek cost share and will report to USAID on a quarterly basis.

Table 7 - Mahefa Miaraka’s Cumulative Expenses as of June 30, 2017

TOTAL EXPENDITURES BUDGET LINE ITEMS AS OF JUNE 30, 2017 TOTAL EXPENDITURES BY FUNDING TYPE (IN US$) A049-Malaria A052- MCH A053- FP/RH A054- Water

SALARIES 1,318,642 583,837 402,337 224,326 108,143 CONSULTANTS 3,355 1,485 1,024 571 275 TRAVEL, TRANSPORTATION, AND PER DIEM 183,282 81,149 55,922 31,180 15,031 ALLOWANCES 85,816 37,996 26,184 14,599 7,038 EQUIPEMENT, MATERIALS, AND SUPPLIES 960,837 425,416 293,165 163,457 78,799 OTHER DIRECT COSTS 352,596 156,114 107,582 59,983 28,917 PROGRAM COSTS 2,377,308 1,052,567 725,351 404,425 194,965 SUBRECIPIENTS 386,580 171,161 117,951 65,765 31,704 TOTAL DIRECT COSTS 5,668,417 2,509,725 1,729,516 964,305 464,871

INDIRECT COSTS / OVERHEAD 236,493 104,709 72,157 40,232 19,395

TOTAL COSTS 5,904,910 2,614,434 1,801,673 1,004,537 484,266

COST SHARE (1,064)

GRAND TOTAL 5,903,846

Page 29

USAID COMMUNITY CAPACITY FOR HEALTH PROGRAM - Mahefa Miaraka

Cooperative Agreement No. AID-687 -A-16-00001

FY2017 Quarter 3 Progress Report April 1 to June 30, 2017 Re-Submission: September 6, 2017 (in response to USAID comments)

ANNEXES

Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 3 Report (ANNEXES) 2

USAID COMMUNITY CAPACITY FOR HEALTH PROGRAM - Mahefa Miaraka

FY2017 Quarter 3 Progress Report Submitted: July 28, 2017

ANNEXES

Cooperative Agreement No. AID-687-A-16-00001

Submitted to: Dr. Jocelyne ANDRIAMIADANA, AOR USAID/Madagascar in Antananarivo, Madagascar

Tel: 20.22.425.78/ 79

Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 3 Report (ANNEXES) 3

List of Annexes

Annex 1. Activity Report Q3, FY2017

Annex 2. Project Performance Review, PPR (Q3, FY2017)

Annex 3. Environment Monitoring and Mitigation Report, EMMR (Q3, FY2017)

Annex 4. List of Communes in Mahefa Miaraka Program in Q3, FY2017

Annex 5. Participation in the Central-Level Working Groups and Meetings

Annex 6. Success Stories

Annex 7. International Trips at the End of Q3 FY2017

Annex 8. JSI Responses to USAID’s Comments

Annex 1: Activity Table Q3 FY2017 Program codes Results

FY2017 Actual Actual Explanation of Next steps to Planned activities Indicators targets Actual Expected Q4 Q2 Expected Q3 Q3 delays/gaps address gaps revised Q1

MNCH MALARIA NUTRITION FP/RH WASH Number Sub-IA Number Activity - No. Sub Activity 1st - No. Sub Activity 2nd 0. Overall Field Operations 0.0 Start-Up and annual planning Activities 0.0.1 One-Time Start up Activities Conduct regional launch of the # of regional launch 5 (Boeny, CCH program in the regions workshops Melaky, Annual target X X X X X 0 0 1 1 (combined with the regional DIANA, 4 - N/A already - annual start-up workshops) SAVA, and reached Analanjirofo) 0.0.2 Annual Planning Activities Submit next year (FY2018) Annual implementation plan X X X X X 0 0 2 1 annual implementation plan to submitted and approved by 1 1 USAID USAID 0.1 OPERATIONS (Administration. Finance. and Partnership) 0.1.1 Administrative and financial operations system Update as needed the program % of staff oriented on the Operations Manual and updates Employee Manual and provide X X X X X 0 1 1 4 annual refresher training to 100% 100% 100% 100% 100% 100% staff

0.2 Administration 0.2.1 Human Resources Management Recruit program staff as % of staff recruited over the X X X X X 0 2 1 2 needed positions in the staffing plan 100% 90% 92% 94% 92% 100%

The activity that carries over many fiscal years has the same activity code. The activity code under the same category continues from the last fiscal year. Annex 1: Activity Table Q3 FY2017 Program codes Results

FY2017 Actual Actual Explanation of Next steps to Planned activities Indicators targets Actual Expected Q4 Q2 Expected Q3 Q3 delays/gaps address gaps revised Q1

MNCH MALARIA NUTRITION FP/RH WASH Number Sub-IA Number Activity - No. Sub Activity 1st - No. Sub Activity 2nd 0. Overall Field Operations Provide orientation to staff in % of staff trained CCH's operations, technical X X X X X 0 2 1 3 approaches, and M&E system 100% 100% 100% 100% 100% 100%

Train relevant CCHP staff and # and % of relevant CCH stakeholders on FP compliance staff who receive certificate 100% 100% 100% from the FP online course 71% 93% 99%

X 0 2 1 4 # and % of stakeholders who receive training on USAID FP compliance N/A - - - - TBD

Provide ongoing capacity % of staff benefiting from X X X X X 0 2 1 5 building for staff at central, capacity building activity 100% - 100% 100% 100% 100% regional and district levels

0.2.2 Information and Technology System Set up and maintain IT system # of CCHP offices with at program offices functioning electronic X X X X X 0 2 2 1 8 8 8 8 8 8 equipment

Conduct training to staff in use % of staff trained and maintain computer X X X X X 0 2 2 2 equipment as part of staff 100% 100% 100% 100% 100% 100% orientation

FY2017 Actual Actual Explanation of Next steps to Planned activities Indicators targets Actual Expected Q4 Q2 Expected Q3 Q3 delays/gaps address gaps revised Q1

MNCH MALARIA NUTRITION FP/RH WASH Number Sub-IA Number Activity - No. Sub Activity 1st - No. Sub Activity 2nd 0. Overall Field Operations Improve database for % of CCH office use administrative and financial electronic data base for X X X X X 0 2 2 3 information administration and finance 100% 100% 100% 100% 100% 100% purposes

0.2.3 Procurement and Distribution Management Develop the annual # of annual procurement 1 procurement plan plan developed (FY2018)

Target X X X X X 0 2 3 2 - - N/A already reached

Start and monitor % of procurement plan procurement process based on successfully carried out X X X X X 0 2 3 3 annual procurement plan 100% 46% 18% 85% 82% 100%

Communicate and inform # of internal information CCH team members sharing sessions on acquisition and distribution procurement and X X X X X 0 2 3 4 50 10 18 27 18 4 process and provide status distribution organized updates on a regular basis

FY2017 Actual Actual Explanation of Next steps to Planned activities Indicators targets Actual Expected Q4 Q2 Expected Q3 Q3 delays/gaps address gaps revised Q1

MNCH MALARIA NUTRITION FP/RH WASH Number Sub-IA Number Activity - No. Sub Activity 1st - No. Sub Activity 2nd 0. Overall Field Operations 0.2.4 GOM and Partner Management Establish formal partnership # of partners with signed Annual target X X X X X 0 2 4 3 (via MOU) with US and non- MOU 7 2 3 3 3 US partners reached

0.2.5 Reporting to USAID and GOM Submit annual report to # of final report approved 1 Annual target X X X X X 0 2 5 1 USAID by USAID and uploaded on 1 - - - DEC (for FY2016) reached

Submit quarterly progress # of progress report X X X X X 0 2 5 2 report to USAID approved and uploaded on 4 - 1 1 1 1 DEC

Submit annual report to GOM # of annual report 1 X X X X X 0 2 5 3 submitted to GOM - - - 1 (for 2016)

0.3 Financial Management 0.3.1 Financial procedures Set up and operationalize # of offices with functioning X X X X X 0 3 1 1 CCHP financial system financial system in place 8 8 8 8 8 8

Improve operations system as % of CCHP staff oriented X X X X X 0 3 1 2 needed and orient staff on the new financial 100% 100% 100% 100% 100% 100% updates

FY2017 Actual Actual Explanation of Next steps to Planned activities Indicators targets Actual Expected Q4 Q2 Expected Q3 Q3 delays/gaps address gaps revised Q1

MNCH MALARIA NUTRITION FP/RH WASH Number Sub-IA Number Activity - No. Sub Activity 1st - No. Sub Activity 2nd 0. Overall Field Operations 0.3.2 Financial Reporting to USAID Submit quarterly accruals # of accruals report X X X X X 0 3 2 1 4 1 1 1 1 report to USAID submitted to USAID Submit quarterly financial # of SF425 submitted to X X X X X 0 3 2 2 4 - 1 1 1 1 report or SF425 form to USAID 0.3.3 VAT USAID Submit and follow-up regularly # of VAT requests on VAT reimbursement submitted to MOH (every Target X X X X X 0 3 3 1 1 - 3 - 3 requests with MOH/DLUM year in May) reached

The activity that carries over many fiscal years has the same activity code. The activity code under the same category continues from the last fiscal year. 1.1.1 Reinforcement of capacity of members of PNSC structures at commune and Fokontany level on CHVs'priorityoninterventions Fokontanylevel and commune at structures ofmembersPNSC ofcapacity Reinforcement 1.1.1 use and collection datamortality in as well as maternal, child neonataland reduce to priorityintervention of CHVin competencies and skills Increasing 1.1 Intervention Area 1 (IA1): CommunityIntervention 1 Area (IA1): Engagement and Ownership ofHealth Services X X X X MNCH X X X X

MALARIA Programcodes X X X X NUTRITION X X X X FP/RH X X X X WASH 1 1 1 1 Sub-IA Number 1 1 1 1 Activity Number 1 1 1 1 1st Sub - Activity No. 1 2 4 3 2nd Sub - Activity No. workshops with local stakeholders local with workshops start-up regional three-day Organize COSAN FKT monthly meeting) monthly FKT COSAN or workshop launch district the at done be to (orientation activities their out carry to CHVs support to structures local PNSC of roles and interventions priority CHV's PNSC, on orientation Provide levels commune and district the at above as workshop same the Organize PNSC structure is not yet created at created yet not is structure PNSC the commune and FKT levels (this levels FKT and commune the Identify and assist to create if the the if create assistto and Identify activity is to be done during the the during done be to is activity district launch workshop) launch district Planned activities Planned role and CHVs activities CHVs and role their PNSC, on oriented heads FKT of # activities CHVs and role their PNSC, on oriented members CCDS of # activities CHVs and role their PNSC, on oriented levels district and regional the at members of # level fokontany the at up set structure coordination PNSC of # level commune the at up set structure coordination PNSC of # level district the at up set structure coordination PNSC of # level regional the at up set structure coordination PNSC of # workshops up start commune and district the in participants # workshops up start regional in participants # Indicators Annex 1: Activity Table Q3 FY2017 Annex 1: Activity FY2017 targets FY2017 revised 14,367 4,555 4,555 1,386 4,887 874 456 185 34 7 Actual Actual 14,386 14,386 2,995 2,995 1,179 1,179 3,301 320 265 Q1 21 1 Actual Actual 1,478 1,478 3,226 886 367 367 127 Q2 13 6 - Expected Expected Results N/A N/A N/A N/A N/A N/A Q3 - already reached already reached already reached already reached already reached already Annual target target Annual target Annual target Annual target Annual target Annual target Annual Actual Q3 Actual reached 91 - 9 Explanation ofExplanation delays/gaps Next steps steps Next to address to gaps Expected Q4 Expected 17 ------1.1.2 Pre-service training. continuing learning and supervision ofCHVs supervision learningand continuing training. Pre-service 1.1.2 Intervention Area 1 (IA1): CommunityIntervention 1 Area (IA1): Engagement and Ownership ofHealth Services X X X X MNCH X X X X

MALARIA Programcodes X X X X NUTRITION X X X X FP/RH X X X X WASH 1 1 1 1 Sub-IA Number 1 1 1 1 Activity Number 2 2 2 2 1st Sub - Activity No. 5 4 3 2 2nd Sub - Activity No. training they had already received received already had they training including workshops start-up district and/or regional the during region each in CHVs existing Identify districts new in CHVs for training initial districts: 10 For new exist doesn't it if officially nominate and select to FKT assistthe and FKT) (CoSan CHV of existence districts: 10 For new CSB) at meeting monthly the of part or training seperate as out carried be can training (series of curriculum training revised MOH's to according CHVs for training refresher Conduct districts Foron-going 24 Planned activities Planned Identify Identify Conduct Conduct : districts on data management (RMA) management data on districts new in trained are who CHVs of # (c-IMCI) districts new in certified and trained are who CHVs of # CHVs nominated have that FKT of # districts ongoing in surveillance Community on trained are who CHVs of # districts ongoing in nutrition on trained are who CHVs of # districts ongoing in CHX and Miso on trained are who CHVs of # (c-IMCI) districts ongoing in certified and trained, are who CHVs of % and # districts on-going for tools management data in trained are who CHVs of # record training with CHVs existing of List Indicators Annex 1: Activity Table Q3 FY2017 Annex 1: Activity FY2017 targets FY2017 (1 per region) per (1 revised 1,739 1,739 5,850 5,596 5,850 2,485 5,850 585 5

Actual Actual Q1 5,631 7

- - - -

Actual Actual 1,705 1,705 2,916 2,483 433 433 302 Q2 Expected Expected Results 5,850 5,850 150 150 N/A N/A N/A Q3 39 Annual target target Annual target Annual target Annual Actual Q3 Actual reached reached reached 5,444 1,179 5,481 165 165 35 Explanation ofExplanation delays/gaps Next steps steps Next to address to gaps already reached reached already Expected Q4 Expected Annual target target Annual 1,501 381 381 406 369 - - Intervention Area 1 (IA1): CommunityIntervention 1 Area (IA1): Engagement and Ownership ofHealth Services X X X MNCH X X X

MALARIA Programcodes X X X NUTRITION X X X FP/RH X X X WASH 1 1 1 Sub-IA Number 1 1 1 Activity Number 2 2 2 1st Sub - Activity No. 7 6 5 2nd Sub - Activity No. regular supervision visits from FKT FKT from visits supervision regular Forallldistricts: districts new in CHVs for training initial districts: 10 For new under IA3) under reported also is activity --- this CSB) by (organized heads FKT and CHVs namely FKT COSAN for meeting monthly Support IA3 under presented is e-learning on information more -CHVs) of learning continuing for tablet use will (CCDS members CCDS and head Planned activities Planned CHVs receive receive CHVs Conduct Conduct meeting monthly the in participating CHVs of # clinical non - staff CCH by conducted supervision on-site receive who CHVs of # clinical - staff CCH by conducted supervision on-site receive who CHVs of # clinical - MOH by conducted supervision on-site receive who CHVs of # clinical - EMAR and EMAD by conducted supervision on-site receive who CHVs of # clinical - staff CSB by conducted supervision on-site receive who CHVs of # clinical non - member CCDS by conducted visits supervision on-site receive who CHVs # clinical non - heads FKT by conducted visits supervision on-site receive who CHVs # districts new in surveillance Community on trained are who CHVs of # Indicators Annex 1: Activity Table Q3 FY2017 Annex 1: Activity FY2017 targets FY2017 revised 5,850 2,040 2,385 3,030 1,568 663 128 952 30

Actual Actual 1,070 1,070 Q1 - - - - -

Actual Actual 5,242 5,242 671 483 128 952 Q2 30 Expected Expected Results 5,852 5,852 1,202 N/A N/A N/A N/A 685 951 312 Q3 - already reached reached already reached already reached already Annual target target Annual target Annual target Annual Actual Q3 Actual 5,527 5,527 978 724 315 789 - Explanation ofExplanation delays/gaps Next steps steps Next to address to gaps Expected Q4 Expected 5,852 5,852 1,178 2,241 1,568 391 348 1.1.6 Motivation activities forFKTCOSAN (CHV)FKT heads and Motivationactivities 1.1.6 FKT)COSAN and (CCDS FKT level and commune the at (appropriatematerials) workand tools.aidjob forstructure Equipment PNSC 1.1.5 services and environment friendly youth and Women 1.1.4 Intervention Area 1 (IA1): CommunityIntervention 1 Area (IA1): Engagement and Ownership ofHealth Services X X X X MNCH X X X

X MALARIA Programcodes X X X X NUTRITION X X X X FP/RH X X X X WASH 1 1 1 1 1 Sub-IA Number 1 1 1 1 1 Activity Number 5 2 6 4 3 1st Sub - Activity No. 1 7 2 2 1 2nd Sub - Activity No. under IA3) under reported also is activity --- this CSB) by (organized heads FKT and CHVs namely FKT COSAN for meeting monthly Support the regional and national levels national and regional the at activities program in participating activities. generation income visits. exchange CSC. KMSm. through recognition social namely heads) FKT and (CHVs COSAN for activities motivation Review IA3) under presented are GOM for (materials chief). FKT and (CHV members FKT COSAN and members CCDS to jobaids and tools materials. necessary Provide violence gender-based on study a Design assessmenttools quality service CHV Develop Planned activities Planned of the cooperative) the of member also are they if twice counted not should employees paid - (note eBox the from dividend or employment paid receive who actors community of # program CCH the for activities motivation describing document of # jobaids and materials tools, work receive who head FKT of # jobaids and materials tools, work receive who CHV #of jobaids and materials tools, work receive who members CCDS of # approved protocol # assessmentdevelopped quality service CHV for tools of # meeting monthly the in participating members CCDS of # meeting monthly the in participating heads FKT of # Indicators Annex 1: Activity Table Q3 FY2017 Annex 1: Activity FY2017 targets FY2017 revised 1,900 7,418 1,900 100 233 81 1 1 5 Actual Actual 371 Q1 19 77 1 - - - - - Actual Actual 1,976 1,976 1,976 4,906 195 195 Q2 23 - - Expected Expected Results N/A N/A N/A N/A N/A Q3 4 - - already reached already reached already reached already reached already Annual target target Annual Annual target target Annual target Annual target Annual Actual Q3 Actual 5,481 1 5 Protocol submitted in Q3 Q3 in submitted Protocol but not yet approved yet not but Explanation ofExplanation delays/gaps Next steps steps Next to address to gaps already reached reached already reached already Expected Q4 Expected Annual target target Annual target Annual 19 4 1.3.1. Functionality and reinforcement of community health structure health ofcommunity reinforcement and Functionality 1.3.1. planning sanitation and improve to health CCDS and CoSan including structures. ofcommunity Strengthening 1.3 IA3) under presented GOM by (supervision FKT COSAN namelyheads andCHVs to supervision Supportive 1.2.1 system formal public the of CHVinto integration full CHVmodelincluding ofthe Sustainability 1.2 Intervention Area 1 (IA1): CommunityIntervention 1 Area (IA1): Engagement and Ownership ofHealth Services X X X X MNCH X X X X

MALARIA Programcodes X X X X NUTRITION X X X X FP/RH X X X X WASH 1 1 1 1 1 Sub-IA Number 1 3 2 3 Activity1 Number 1 1 6 1 1st Sub6 - Activity No. 2 1 3 1 2nd Sub2 - Activity No. and/or equip permanent health hut hut health permanent equip and/or build to community the Encourage levels national and regional the at activities program in participating activities. generation income visits. exchange CSC. KMSm. through recognition social namely heads) FKT and (CHVs COSAN for activities motivation Review review meeting among PNSC actors actors PNSC among meeting review coordination/program quarterly a convene to district the Support so do to assistthem and levels all at structure PNSC established yet haven't that regions the encourage and exisitng Identify --- 1.1.2.6 ----activity as same staff) CCH and CCDS, COSAN, from CHVs to visits supervision Support CHVs for (Toby) Planned activities Planned coordination/program review meeting review coordination/program quarterly convene that district of # level FKT to regional from place in structures) operational and (coordination structure PNSC have that district and region of # members CCDS by conducted visits supervision receive CHV of # heads FKT by conducted visits supervision receive CHV of # members CCDS by conducted visits supervision receive heads FKT of # shelf and chair table, of minimum a with equipped Toby of # community the by built Toby the in work who CHVs of # activities generation income the in participate who actors FKT-level of # Indicators Annex 1: Activity Table Q3 FY2017 Annex 1: Activity FY2017 targets FY2017 revised 1,500 2,411 68 9 Actual Actual 1,152 425 Q1 - - Same activities (1.1.1.3 and 1.1.1.4) as above therefore not repeating here repeating not therefore above as 1.1.1.4) and (1.1.1.3 activities Same Actual Actual 1,854 707 Q2 86 9 Same activities (1.1.2.6) as above therefore not repeating here repeating not therefore above as (1.1.2.6) activities Same Expected Expected Results N/A N/A N/A 500 Q3 already reached already reached already Annual target target Annual target Annual Actual Q3 Actual 2360 210 Explanation ofExplanation delays/gaps Next steps steps Next to address to gaps Expected Q4 Expected 2,411 158 X X X 1.4.2 Increase access to health care via emergency transport viaemergency care health to access Increase 1.4.2 fund) equity and solidarityfund (mutuelle. scheme financing viahealth care health to access Increase 1.4.1 system transport emergency and mutuelle) (i.e. micro-insurance fund). programs equity GOM(e.g. entitlement coverage.including and access Promotingcare 1.4 health universal manageorhealth CommunetoChampionKMSm Approachcommunity Using 1.3.2. Intervention Area 1 (IA1): CommunityIntervention 1 Area (IA1): Engagement and Ownership ofHealth Services X X MNCH X X X X X

MALARIA Programcodes X X X X X NUTRITION X X X X X FP/RH X WASH 1 1 1 1 1 Sub-IA Number 4 4 4 4 3 Activity Number 2 1 1 1 2 1st Sub - Activity No. 2 6 5 2 2 2nd Sub - Activity No. launch workshops launch district and regional the during KMSm on indicators) and approach (including pager one Review workshop) launch district the during done be (to levels FKT and commune district. the at stakehoders relevant with workshop review ETS Conduct activities santé de mutuelle the of review rapid a Conduct mutuelle) with communes new and (existing fund) equity and solidarity (mutuelle. insurance health micro CCHP their out carry to communes Assistthe schemes financing health micro of analysis situational the Design Planned activities Planned review workshop, by type of their role their of type by workshop, review the in participate who people of # held workshop of # sessionreview the in participate who people of # mutuelle) with communes (existing activities mutuelle their continuing communes of # IRB national the by approved protocol of # pre-testKMSm the in participated KMSm structures coordination PNSC of members of # pretested and developped tools KMSm of # sessions review KMSm the conducting districts of # Indicators Annex 1: Activity Table Q3 FY2017 Annex 1: Activity FY2017 targets FY2017 (activity 1.1.1.2) (activity revised 1,020 125 56 34 17 1 1 Actual Actual 1,055 Q1 34 - - Actual Actual 125 Q2 56 17 1 - - - Expected Expected Results N/A N/A N/A N/A N/A N/A Q3 - already reached already reached already reached already reached already reached already reached already Annual target target Annual target Annual target Annual target Annual target Annual target Annual Actual Q3 Actual - Explanation ofExplanation delays/gaps Next steps steps Next to address to gaps Expected Q4 Expected 1 - - - X X Intervention Area 1 (IA1): CommunityIntervention 1 Area (IA1): Engagement and Ownership ofHealth Services MNCH X X

MALARIA Programcodes X X NUTRITION X X FP/RH WASH 1 1 Sub-IA Number 4 4 Activity Number 2 2 1st Sub - Activity No. 4 3 2nd Sub - Activity No. and use of the emergency transports emergency the of use and functionality the sure make to FKTs MAHEFA by provided transport emergency ofmeans existing For FKTwith monitor use monitor and plan evacuation emergency health their develop to CHVs) and heads (FKT FKT COSAN ForallFKT Planned activities Planned : Assist CSB. CCDS and and CCDS Assist CSB. : : Continue support to to support Continue : evacuation plan plan evacuation emergency written a have who Fkt # ETS functioning with (village) fokontany supported USG- of /% # Indicators Annex 1: Activity Table Q3 FY2017 Annex 1: Activity FY2017 targets FY2017 revised 2,234 100 Actual Actual Q1 - - Actual Actual 318 Q2 64 Expected Expected Results 670 Q3 12 Actual Q3 Actual 296 15 Explanation ofExplanation delays/gaps Next steps steps Next to address to gaps Expected Q4 Expected 1620 21 X X X X 2.1.2. Repositioning the woman's and child's health cards as the cornerstone of SBCC strategies ofSBCC cornerstone the ascards health woman's child's and the Repositioning 2.1.2. materialsapproaches.tools strategy. and SBCC 2.1.1 products and services ofhealth uptake behavior and healthy increase to promotion sensitization andhealth Community-level 2.1 promotion health and (IA2):Behavior Area change 2 Intervention X MNCH X X X X X MALARIA Programcodes X X X X X NUTRITION X X X X X FP/RH X X X X X WASH

2 2 2 2 2 Sub-IA Number

1 1 1 1 1 Activity Number

2 1 1 1 1 1st Sub - Activity No.

2 8 7 6 4 2nd Sub - Activity No. and FKT levels by CCDS, CSB, FKT heads FKT CSB, CCDS, by levels FKT and commune the at use for curricula training SBCC update tools. and approach strategy, SBCC of review the of results the Basedon messages health important promote to cards health children and women of use the Encourage messages health key coherence ensure to meetings coordination national SBCC the in Participate level community the at use for SDA 8-10 identify above, actions key the Among CCHP in use (SDA) for Actions Doable Small develop or update evaluation, the of results the Basedon CHVs and Planned activities Planned CSB by distributed cards health child of # CHVs by distributed cards health child of # CSB by distributed cards health women of # CHVs by distributed cards health women of # quarter) per one least(at participated meeting of # level community the at use for adopted actions doable and small of # CCH for adopted actions doable and small of # updated cirricula training of # Indicators Annex 1:Activity FY2017 Table Q3 At least 4 least At FY2017 FY2017 revised targets 120,677 120,677 23,110 23,110 8-10 56 2 Actual Actual Q1 33 2 ------Actual Actual Q2 7 2 5 - - - - - Results Expected Q3 Expected N/A 2 2 - - - - - Annual target target Annual Actual Q3 Actual reached 119,928 119,928 already already 23,110 23,110 5 0 - Explanation ofExplanation delays/gaps Next steps to steps Next address gapsaddress 749 749 - - Expected Q4 Expected 23 2 1 - 2.2.2 Roll out SBCC activities at the community level community the at activities SBCC out Roll 2.2.2 forleaders community skill-building SBCC 2.2.1 foradvocateimproved services and messages key develop needs, community assess to stakeholders ofcommunity Capacity 2.2 CSBs andCHVs by materials(IEC)communication forand use information, oftools and dissemination andeducation and/orreproduction Development 2.1.3. promotion health and (IA2):Behavior Area change 2 Intervention X X X X X MNCH

X X X X X MALARIA Programcodes

X X X X X NUTRITION

X X X X X FP/RH X X X X X WASH

2 2 2 2 2 Sub-IA Number

2 2 2 1 1 Activity Number

2 2 1 3 3 1st Sub - Activity No.

2 1 2 3 2 2nd Sub - Activity No. invitation cards and capitalize use of health health of use capitalize and cards invitation FP youth, GBV, care, of continuum the using areas technical emerging and new (including SDA and strategy the on based products and tools SBCC develop or Update by CHVs and FKT heads) FKT and CHVs by reported and (accompanied activities SBCC out carry to actors community Support campaigns health and celebration days health led GOM the in Participate care of continuum the per utilization and services improved for advocate and promote to SBCC on members) CCDS and CHVs and heads FKT (COSAN: stakeholders community Train use monitor and CHVs and heads FKT CCDS, CSB, train to, materials and tools SBCC revised Distribute cards) Planned activities Planned IEC materials (home visit) (home materials IEC or sensitization CHV messagesthrough health to exposed beneficiaries of # participated campaigns # SBCC on trained heads FKT CHVs of # SBCC on trained members CCDS of # materials IEC sessionsusing education CHV through messages health to exposed people of # care of continuum the with aligned and developped newly or updated materials and tools SBCC of #

of health day celebration and and celebration day health of Indicators Annex 1:Activity FY2017 Table Q3 FY2017 FY2017 139,234 139,234 revised targets 865,025 7,418 7,418 10 71 9 Actual Actual Q1 4 - - - - - 124,486 520,563 Actual Actual Q2 72 - - 3 4 Results Expected Q3 Expected 139,234 139,234 432,513 1,742 1,742 N/A 3 1 Annual target target Annual Actual Q3 Actual reached reached 121,551 394,228 already already 6,632 6,632 2 0 Explanation ofExplanation delays/gaps Next steps to steps Next address gapsaddress

already reached already Expected Q4 Expected Annual target target Annual 139,234 139,234 786 5

1 2.3.2 School-based youth SBCC activities SBCC youth School-based 2.3.2 health promote youth to localstructure Strenghthening 2.3.1 marriedand rural, reaching underserved on afocus with health, youth and promoteadolescent Innovationsto 2.3. promotion health and (IA2):Behavior Area change 2 Intervention X X X MNCH

X X X MALARIA Programcodes

X X X NUTRITION X X X X FP/RH X X X X WASH 2 2 2 2 2 Sub-IA Number 3 2 2 2 2 Activity Number 2 2 2 2 2 1st Sub - Activity No. 2 7 6 4 3 2nd Sub - Activity No. communes communes new in radio to access with communities and zones reception radio Identify and train teachers teachers train and school in activities health youth place in Put practices wastemanagement and hygiene good in CSB and CHV Support slabs latrine and sur'eau of sale including activities WASH of promotion begin to CoSan) and CCDS of side clinical (non CoSan and CCDS Support groups listening radio for materials facilitator Revise Planned activities Planned the commune, district and region and district commune, the by organized events day health visbility high- the in participate that schools of # pit wastedisposal with equipped Toby permanent of # soap with station handwashing and latrine with Toby permanent of # certification ODF official receive that villages of # facility sanitation improved an to access gaining people of # households by built newly latrine improved of # developped materials facilitator's of # updates RLG of List # messages health broadcasting station radio of # products of types by disseminated products media of # Indicators Annex 1:Activity FY2017 Table Q3 FY2017 FY2017 revised targets 27,545 27,545 5,988 5,988 494 494 279 28 13 1 1 - Actual Actual 533 376 Q1 ------Actual Actual 12,626 12,626 7,301 7,301 503 403 Q2 28 13 97 1 - Results Expected Q3 Expected 6,210 6,210 1,350 N/A N/A N/A N/A 165 165 - - Annual target target Annual target Annual target Annual Actual Q3 Actual reached reached reached reached 15,336 15,336 already already already already 3,334 3,334 102 63 - - Explanation ofExplanation delays/gaps Next steps to steps Next address gapsaddress Expected Q4 Expected 7,325 7,325 1,592 NA 279 28 - - 1 - - 2.3.3 SBCC activities forout-of-schoolyouth activities SBCC 2.3.3 promotion health and (IA2):Behavior Area change 2 Intervention MNCH MALARIA Programcodes NUTRITION X X FP/RH WASH 2 2 Sub-IA Number 3 3 Activity Number 2 3 1st Sub - Activity No. 2 2 2nd Sub - Activity No. cards to their peers their to cards invitation FP distribute to users regular FP are who youth married with Work teachers train and school in activities health youth place in Put Planned activities Planned Couple-years of protection or CYP or protection of Couple-years (age15-19) contraception modern of users new of % users regular FP are who youth married by distributed cards invitation FP of # preparation the in participate who youth of # preparation the in participate who teachers of # activities preparation the in participate who parents of # activities preparation the in participate who officials GOM of # activities preparatory begin and selected schools of # MOH by approved and developped youth messageson of # Indicators Annex 1:Activity FY2017 Table Q3 FY2017 FY2017 revised targets 53,000 53,000 87,750 TBD TBD 13 24 63 38 6 Actual Actual Q1 - - - - Actual Actual 18,401 32% Q2 13 24 63 38 6 - Results Expected Q3 Expected 23,066 N/A N/A N/A N/A N/A 20% - - Annual target target Annual target Annual target Annual target Annual target Annual Actual Q3 Actual reached reached reached reached reached already already already already already already 25,170 5,745 5,745 48% - Explanation ofExplanation delays/gaps - Next steps to steps Next address gapsaddress - Expected Q4 Expected 82,005 82,005 27,830 20% ------3.0.2Capacity reinforcement and materials in GOM for community health regional,at district and commune level 3.0.1Coordination with MOH 3.0Reinforcement capacityprovide ofto GOM technical training and supportive supervision CHVsto and community leaders Intervention3Area (IA3):Health service planning, management and governance X X X X MNCH X X X X MALARIA Program codes Program X X X X NUTRITION X X X X FP/RH X X X X WASH 3 3 3 3 Sub-IA Number 0 0 0 0 Activity Number

2 1 1 1 1st Sub - Activity No.

1 7 6 4 2nd Sub - Activity champions” cohortas of national “community health Formalizetechnical experts existingMOH --- training --- in to conducted be referralg) counter and referral tablet of use includingsupportive supervision f) GBV and youth, women services e) friendly community d) logistics data c) management continuumof care model SBCCincluding to matchreadjusted priority b) interventionsby CHVs communitya) health on: EMAD and for EMAR of TOT Conductseries platformfor community health jointlyand managea national technology USAIDand to Workwith MOH establish regional Hold quarterly meetings review Plannedactivities and trainand CSB that #EMAR becometrainers #of meetingsparticipated #ofheld district meetings review #of regional held meetings review healthchampion group by National# meetingsconducted community functionaland established National community healthchampion group Indicators Annex 1:FY2017 Activity Table Q3 FY2017 targets revised 35 43 5 4 1 8 Actual Q1 25 34 4 - - - Actual Q2 47 5 9 4 - - Results ExpectedQ3 N/A N/A N/A N/A - - ActualQ3 reached reached reached reached already already already already Annual Annual Annual Annual target target target target 6 - Explanationof delays/gaps Nextsteps to addressgaps ExpectedQ4 1 - - - - X Intervention3Area (IA3):Health service planning, management and governance X MNCH X X MALARIA Program codes Program X X NUTRITION X X FP/RH X X WASH 3 3 Sub-IA Number 0 0 Activity Number 2 2 1st Sub - Activity No. 2 1 2nd Sub - Activity GBV and youth, women services e) friendly community d) logistics data c) management continuumof care model SBCCincluding to matchreadjusted priority b) interventionsby CHVs communitya) health on: EMAD and for EMAR of TOT Conductseries g) referralg) counter and referral system tablet of use includingsupportive supervision f) GBV and youth, women services e) friendly community d) logistics data c) management SBCCincluding priority b) interventionsby CHVs communitya) health for CSB of TOT Conduct on: series training --- in to conducted be referralg) counter and referral tablet of use includingsupportive supervision f) Plannedactivities -- data on CHVs trained presented under IA1) under datatrained presented on-- CHVs #CSB thatbecometrainers for CHV trainand CSB that# EMAD becometrainers Indicators Annex 1:FY2017 Activity Table Q3 FY2017 targets revised 732 207 Actual 381 164 Q1 Actual 709 269 Q2 Results ExpectedQ3 N/A N/A ActualQ3 reached reached already already Annual Annual target target Explanationof delays/gaps Nextsteps to addressgaps ExpectedQ4 - - X X X 3.0.3Technical supervision CHVsfor GOM by (monthly meeting and supportive supervision) Intervention3Area (IA3):Health service planning, management and governance MNCH X X X MALARIA Program codes Program X X X NUTRITION X X X FP/RH X X X WASH

3 3 3 Sub-IA Number 0 0 0 Activity Number 3 3 2 1st Sub - Activity No.

2 1 3 2nd Sub - Activity under IA3) under YPEs tojobaids and COSANs, CCDS, CHVs, materials,necessary Provide toolsand eLearningreportand on supervision) of tablets (for use CHV including CCH and staff, MOH, EMAR, EMAD, COSAN,CCDS, CSB representatives, Supportfromto visits CHVs supervision COSANmembersat CSB level regroupements Supportmonthly (CHV meetings (materialsfor GOMare presented Plannedactivities ) for CHVs and otherand for ) CHVs months lastthe -clinicalthree in by EMAD conducted supervision on-site who #receive of CHVs by CSBlast the threemonthsconducted in supervision on-site who #receive of CHVs meetingat CSB participate #heads of FKT monthlythe in CSB #participateof CHV monthlythe in meetingat jobaids #of CSBwork tools, whoreceive materialsand jobaidsand work tools,#who ofreceive EMAD materials jobaidsand work tools, who #receive of materials EMAR Indicators Annex 1:FY2017 Activity Table Q3 FY2017 targets revised 1,900 5,850 3,030 663 732 207 35 Actual 1,070 371 Q1 - - - - - Actual 1,976 5,242 286 700 709 269 Q2 47 Results ExpectedQ3 1,202 5,852 N/A N/A 298 N/A N/A N/A ActualQ3 reached reached reached reached reached Annual already already already already Annual Annual Annual 5,527 target target target target 315 789 Explanationof delays/gaps Nextsteps to addressgaps ExpectedQ4 1,541 5,852 62 23 - - - - X X X 3.2.1Community logistics ensureto unruptured supply of health commodities CHVat use 3.2Pharmaceutical and commodity forecasting in ensureorderto that CSBsordercommodities in timelya manner, maintain appropraite stock levels and maintain appropriate storageconditions facilityfor and CHV 3.1.1Non-clinical improvements CSB 3.1Introduction and promotion of non-clinical quality improvement process and tools patient(e.g flow, strategic use and placement of IEC materials), etc Intervention3Area (IA3):Health service planning, management and governance MNCH X X X MALARIA Program codes Program X X X NUTRITION X X X FP/RH X X X WASH 3 3 3 3 Sub-IA Number 0 1 2 2 Activity Number 3 1 1 1 1st Sub - Activity No. 2 2 1 2 2nd Sub - Activity eLearningreportand on supervision) of tablets (for use CHV including CCH and staff, MOH, EMAR, EMAD, COSAN,CCDS, CSB representatives, Supportfromto visits CHVs supervision schedule programregularup set and meeting coordination Hold meeting with PSI/ISM logisticscoordination groups Participate USAIDGOMand in led CSB Design survey Plannedactivities #of meeting held #of meeting participated national IRB Number protocolof survey approvedby the visits who supervisions #conduct ofCHV EMAR visits #who supervisions ofconduct EMAD CHV # ofvisits CSB supervisions whoconductCHV months clinicallast the three- in by MOH conducted supervision on-site who #receive of CHVs months clinicallast the three- in by EMAR conducted supervision on-site who #receive of CHVs Indicators Annex 1:FY2017 Activity Table Q3 FY2017 targets revised 601 14 68 18 14 1 5 8 Actual Q1 2 3 - - Actual Q2 30 39 2 5 Results ExpectedQ3 N/A N/A N/A 601 14 68 3 1 ActualQ3 reached reached already already Annual Annual target target 300 65 3 3 2 Explanationof delays/gaps Nextsteps to addressgaps ExpectedQ4 301 11 1 3 - - - 3 1 X X X X 3.3.3Integrated Community-based surveillance of preventable diseases 3.3.2Integration of data from CHV routinereporting into MOH's HMIS 3.3.1CHV monthlyreporting CSB to 3.3Health data quality, management and use improveto patient outcomes; and reinforcement and/or development of community-based surveillance systems Intervention3Area (IA3):Health service planning, management and governance X X MNCH X X X X X X MALARIA Program codes Program X X X X X NUTRITION X X X X X FP/RH X X X X X WASH 3 3 3 3 3 3 Sub-IA Number 3 3 3 3 2 3 Activity Number 3 2 1 1 1 3 1st Sub - Activity No. 1 2 4 3 3 2 2nd Sub - Activity and CHVs and relatedto commodities availability forCSB ParticipateDPLMT/UTGLin activities on MOH protocol onMOH based of preventablesurveillance diseases supportingto conductCHVs community CSBand EMAD in EMAR, Assist forplans emergency response priority IEP to districts implement action to16 in DRSP support Provide needed as dataforand base SDSP data base) information(both forsystem programthe reportsinto computerized health Jointlymonthly withSDSPenterCHV monthly reportsto CSB Monitor of CHV’s athe submission fromCSB system dataHMIS into MOH's SDSP to monthly process Assist reports Plannedactivities preventable diseases surveillance activities surveillance preventablediseases community trained conducted #and of CHVs #campaigns participated MNCHW and datainto their onHMIS a monthly basis integrate#of district CHV who successfully #monthlyof CHV reportsapproved by CSB monthly reportsinto their HMIS CSB process #of district who successfully #of meeting held Indicators Annex 1:FY2017 Activity Table Q3 FY2017 targets revised 21,121 7,418 34 24 4 4 Actual Q1 3 2 - - - - Actual Q2 1 2 - - - - Results ExpectedQ3 3,140 24 1 2 - 5717 ActualQ3 5,444 6707 24 24 1 4 Explanationof delays/gaps Nextsteps to addressgaps ExpectedQ4 1,974 6306 24 24 1 2 X X X 3.4.1Referral system between CHVs and CSBs 3.4Referral system streghtening between CHVs and increaseCSBsto preventive andcare prompt treatment; and streghtening referral between health and other services (e.e gender violence) 3.3.5Sharingbest practices and lessons learned andamong CSB other community health actors 3.3.4Data use performancefor review Intervention3Area (IA3):Health service planning, management and governance X MNCH X X X X MALARIA Program codes Program X X X X NUTRITION X X X X FP/RH X X WASH 3 3 3 3 Sub-IA Number 4 3 3 4 Activity Number

1 1 5 5 1st Sub - Activity No.

2 1 2 1 2nd Sub - Activity process ofsummit the process at both national of workscope eligibilityincluding and learningsummit committee to develop formDRS and Jointly the withMOH withdanger sign of pregnantsystem women children and CCDSand tabletsusing to manage referral ofimproved referral CSBincluding system monitorJointly withEMAR/EMAD, use the for ways identify improvementand CSBsand CHVs referralbetween system referral exisiting counter and Review district) region,abstract1 region selects per district,abstracts district2 submits to the commune(each abstract1 submits to the Organizeannual regional learningsummit regional and levels Plannedactivities CHV to CHV CSB #of CU5from referred with danger signed of vaccination all series ofthe received and #of CU5 to referred health facility CHVs by atCSBsdelivery #of pregnantfor womenby CHVs referred 4 ANC received and by CHVs #of pregnant womento referred health facility updated counter# and Referal referal document #of participants at summitthe developed #criteriaof selection process selection and Indicators Annex 1:FY2017 Activity Table Q3 FY2017 targets revised 42,293 12,173 20,627 6,736 420 1 1 Actual Q1 1 ------Actual 11,050 3,094 3,535 5,914 Q2 0 - - Results ExpectedQ3 16,918 1,821 4,319 7,357 - - - ActualQ3 18,690 2,045 4,216 7,389 0 - - Explanationof delays/gaps Nextsteps to addressgaps ExpectedQ4 12,553 1,597 4,422 7,324 - - - 3.4.2Referral system between health and other services gender(e.g violence) Intervention3Area (IA3):Health service planning, management and governance X MNCH

X MALARIA Program codes Program

X NUTRITION

X FP/RH WASH

3 Sub-IA Number

4 Activity Number

1 1st Sub - Activity No.

2 2nd Sub - Activity withdanger sign of pregnantsystem women children and CCDSand tabletsusing to manage referral ofimproved referral CSBincluding system monitorJointly withEMAR/EMAD, use the Plannedactivities who receive service from service MSMwho mobilereceive clinic for# of womenby CHV long-term referred FP from service CSBwho receive for# of womenby CHV long-term referred FP for follow-up by CHVs #%and of counter CU5 referred who are seen for follow-up by CHVs whoare seen #%and of counter pregnant referred women Indicators Annex 1:FY2017 Activity Table Q3 FY2017 targets revised 10,444 3,748 1,289 7,252 Actual 1,321 Q1 - - - Actual 1,166 4,176 Q2 - - Results ExpectedQ3 1,291 4,230 4,950 900 ActualQ3 3,576 18962 6,349 306 Explanationof delays/gaps Nextsteps to addressgaps ExpectedQ4 Annual target Annual target Annual target reached reached reached already already already 983 X X 4.1.2 Datause 4.1.1 DataManagement system performance evaluation and monitoring, 4.1 Program Management Learning and Evaluation,Performance 4.and IA Monitoring or Cross-Cutting x x x x MNCH X X x x x x

MALARIA codes Program X X x x x x NUTRITION X X x x x x FP/RH X X x x x x WASH 4 4 4 4 4 4 4 Sub-IA Number 1 1 1 1 1 1 1 Activity Number 2 1 1 1 1 1 2 1st Sub - Activity No. 1 7 6 5 4 3 2 2nd Sub - Activity No. meeting/program review meeting/program coordination quaterly the data in routine program the Use for CCHPuse dashboards and database Adapt at all DQA internal levelsConduct for datamanagement responsible SDSP and staff totraining M&E Provideinitial on-the-job and activitiesreports program and trips, supervision CHV'sRMA, sources: many from data program routine Manage system management data computerized Setup M&E program the in Train CCHPstaff Planned activities held that presents program data program presents held that review/coordination meeting program of quaterly % developped dashboards # team CCH by conducted DQA of internal # data manage to trained staff of M&E # types) (by submitted of reports % functional dataof system computerized # M&E inthe trained of people # Indicators Annex Table 1: Q3FY2017 Activity FY2017 revised targets 100% 100% 75% 75% 220 220 128 84 4 4 1 Actual Actual 227 Q1 ------Actual Q2 Actual 69% 179 127 1 - - - Results Expected 100% 100% 70% Q3 42 24 3 1 - Actual Actual 100% 100% 80% Q3 38 24 3 1 - Explanation of of Explanation monthly report report monthly submitted their their submitted than planned. than delays/gaps More CHVs More Next steps to address gaps address Expected 100% 100% 75% Q4 46 1 1 - - X X X X X 4.2.1 Studies, survey and review workshops for improvement of program performance performance program 4.2.1 improvement of for Studies, review workshops surveyand 4.2 Management Learning 4.1.3 health useimprove to services Technology Management Learning and Evaluation,Performance 4.and IA Monitoring or Cross-Cutting MNCH X X X X X

MALARIA codes Program X X X X NUTRITION X X X X FP/RH X X X X WASH

4 4 4 4 4 Sub-IA Number

2 2 2 1 1 Activity Number

1 1 1 3 3 1st Sub - Activity No.

7 6 5 2 1 2nd Sub - Activity No. start-up workshop) start-up regional district and the duirng team CCH CSB by (conducted CHVand between system referal counter Review and of referal workshop) regional district and the start-up during team CCH by (conducted Review ofapproach KMSm workshop) districtand start-up regional the during team CCH by (conducted Review of ETS system selected communes in system e-health Testthe use program for Develop system e-Health Planned activities # of review conducted of review # conducted of review # conducted of review # modulesvalidated# developped system e-Health # Indicators Annex Table 1: Q3FY2017 Activity FY2017 revised targets 39 39 34 34 3 1 Actual Actual Q1 38 38 38 38 - - Actual Q2 Actual - - - 1 1 Results - Expected Q3 2 - - - Actual Actual Q3 - - - 0 - Explanation of of Explanation delays/gaps Next steps to address gaps address - - - Expected Q4 2 - - - X X X X X 4.2.2 Dissemination Management Learning and Evaluation,Performance 4.and IA Monitoring or Cross-Cutting X MNCH X X X X X X

MALARIA codes Program X X X X X X NUTRITION X X X X X X FP/RH X X X X X X WASH

4 4 4 4 4 4 Sub-IA Number

2 2 2 2 2 2 Activity Number

2 2 2 2 2 1 1st Sub - Activity No. 4 3 2 1 8 5 2nd Sub - Activity No. national international and both meetings, conference in results program Present basis quarterly a on Efa Zara ny newsletter CHV the datain Present basis quarterly a on USAID newsletter in highlights program Feature Plan Management Learning the Implement workshops) start-up dayregional 3 the with (combined regions remaining in the program CCH ofRegional the launch workshop) regional district and the start-up during team CCH by (conducted RLG and parrain YPE, menage namely SBCCbased approaches Review of selectedcommunity- Planned activities # of meetings participated of meetings # editionsEfa of Zara# ny to USAID submited highlights # out carried are that plan activities ofinthe the % workshops of regional# launch conducted of review # Indicators Annex Table 1: Q3FY2017 Activity FY2017 revised targets 38,000 38,000 100% 39 39 10 4 4 Actual Actual 100% Q1 38 38 37 1 4 - Actual Q2 Actual 19,000 19,000 100% 73 - 0 - Results - Expected 100% TBD Q3 1 - - Actual Actual 100% Q3 - - 2 0 - Not requested by by Not requested Explanation of of Explanation delays/gaps USAID Next steps to address gaps address - - Expected 19000 100% TBD Q4 1 - ANNEX 2: PROJECT PERFORMANCE REVIEW (QUARTER 3, FY2017) USAID Technical themes/Indicators FY2017 Annual Target Achieved Achieved Achieved Remaining Comments codes in Q1 in Q2 in Q3 for FY2017 Family Planning Number of of USG assisted CHVs providing FP Male 2,760 - 1,866 2,699 61 On target 7.2-2 information, referrals, and/or services during the year Female 2,082 - 1,244 2,209 (127) Total 4,842 - 3,110 4,908 (66) MCH Number of newborns receiving chlorhexidine as part of Boys 5,630 - 529 518 4,583 Due to lower than expected funding obligation, the new born essential care Girls 5,630 - 503 493 4,634 the Program revised its FY 2017 work plan to match the reduced budget available. This change No code Total 11,260 - 1,032 1,011 9,217 affected CHV training therefore this annual target may not be reached.

WATSAN 3.1.6.8-5 Number of communities certifies as "open defecation Total 279 - - - 279 ODF evaluation and certification will take place in free" (ODF) as a result of USG assistance Q4. On target.

Number of people gaining access to an improved Male 13,772 - - 7,668 6,104 On target 3.1.1.2-2 sanitation facility Female 13,772 - - 7,668 6,104 Total 27,545 - - 15,336 12,208 NUTRITION Number of women reached with education on exclusive Male N/A N/A N/A N/A N/A On target 3.1.6 9-1 breastfeeding Female 44,188 - 18,454 46,357 44,188 Total 44,188 - 18,454 46,357 44,188 Number of children reached by USG-supported Male 101,560 - 17,528 111,550 101,560 On target 3.1.9.1-15 nutrition programs Female 119,222 - 19,753 128,620 119,222 Total 220,782 - 37,281 240,170 220,782 Number of children under two (0-23 months) reached Male 56,721 22,192 26,550 7,979 On target HL.9.2 with community-level nutrition interventions trhough Female 63,963 18,900 31,106 13,957 USG-supported programs Total 120,684 41,092 57,656 21,936 Number of pregnant women reached with nutrition On target HL.9.3 Total 25,223 12,888 15,511 9,712 interventions through USG-supported programs Number of individuals receiving nutrition-related Male 2,901 1,620 764 517 On target HL.9.4 professional training through USG-supported programs Female 2,695 1,296 415 984 Total 5,596 2,916 1,179 1,501 CUSTOM No code Number of communities having developped a Total Activity will start in FY2018 transportation system for health emergency ANNEX 3: ENVIRONMENTAL MITIGATION AND MONITORING REPORT Quarter III: April 1 – June 30, 2017

Title of the program: USAID Community Capacity for Health Program

Implementing Partner: JSI Research & Training Institute, Inc.

Country or Region: Madagascar, Southern Africa

Award number: Cooperative Agreement no. AID-687‐A‐16‐00001

Program Area: 3.1 HEALTH

Pursuant to the USAID IEE issued in October 7, 2013, for the period of 2014-2018 to cover environmental mitigation and monitoring measures for the health sector (3.1), the Program will contribute to the USAID/Madagascar Health Sector Portfolio – Use of Selected health Services and Products increased and Practices improved. Therefore, in FY 2017 the Program will apply as appropriate mitigation measures related to activities classified under negative determination with conditions that may affect the environment along with their implementation, as set forth in 22 CFR 216.

Concerned Program Elements of the USAID/Madagascar Health Portfolio are as follows:

3.1.2. Malaria 3.1.3. Maternal and child health 3.1.4. Family planning and reproductive health 3.1.5. Water, hygiene and sanitation 3.1.6. Nutrition.

The intervention categories as per the current IEE that are appropriate to the program include:

• Healthcare worker/delivery agent training and capacity building; healthcare workforce training, strengthening, and development; strengthening support for health service delivery • Social marketing, education, and behavior change communication (BCC), excluding WASH • Procurement, storage, management, distribution and disposal of public health commodities and equipment, strengthening public sector supply chain management • Water, sanitation and hygiene.

Life of Activity: FY2016 – FY 2021

Fiscal Year of Submission: FY 2017

Funding Begin: 06/06/2016 LOA Amount: $ 32,992,279 USAID: $ 29,992,981 Cost share: $ 2,999,298 Funding End: 06/06/2021 FY2017 Amount : $ 8,839,071 USAID: $ 8,035,519 Cost share: $ 803,552 ESR Prepared by: Chuanpit Chua-oon Date: March, 2017 Chief of Party - JSI/Mahefa Miaraka Date of Previous EMMR: - Date of Most Recent IEE: October 7, 2013

A. Status of the IEE No revisions or modifications of the IEE are needed.

An amended IEE is submitted.

B. Status of Fulfilling Conditions in the IEE, including Mitigation and Monitoring All mitigation measures were successful at preventing environmental impact as specified in the original IEE. An Environmental Mitigation and Monitoring Report (EMMR) describing compliance measures taken is attached.

Improved mitigation measures were adopted to reduce environmental impacts. An EMMR describing these improved compliance measures taken is attached.

Approval of the Environmental Status Report (as appropriate)

AOR ______Date:______

MEO______Date:______

REA ______Date:______

BEO ______Date:______

ENVIRONMENTAL STATUS REPORT

B. Status of Fulfilling IEE Conditions

In October 7, 2013, USAID issued a new IEE to cover the USAID/Madagascar Health, Population and Nutrition (HPN) portfolio “Use of Selected Health Services and Products Increased and Practices Improved” for the period 2014 – 2018. In the continuum of the CBIHP, the Community Capacity for Health Program CCHP/Mahefa Miaraka will therefore help achieve Goal 3 of the U.S. Madagascar Integrated Country Strategy 2015-2017, which states: “The Malagasy people and their environment remain resilient; they continually mitigate, adapt and transform from shockers or stresses.” The Program’s interventions will work toward Objective 3.2 of that goal, which is to “Improve health through increased use of targeted Malagasy health, nutrition, water and sanitation services.”

This document presents activities planned under Mahefa Miaraka’s QIII period as per its FY2017 work plan approved by USAID on November 3, 2016.

1. Environmental Mitigation and Monitoring Report – table for activities under Categorical Exclusion. As per the intervention categories mentioned above, Community Capacity for Health Program conducted following activities that are eligible for categorical exclusion of 22 CFR 216 during the present period of report: Start-up workshops of the program at district and communes levels (3,270 people gathered in QII).

Classes of actions as Actions implemented Remarks per 22 CFR 216.2(c) (2) (i) Education, technical In order to prevent and reduce waste, Mahefa Miaraka continued to adopt best practices from assistance, or training MAHEFA, as such : programs - minimize distribution of handouts at the above workshops gathering large groups of stakeholders including CHVs and fokontany leaders - Provide large bottles of water during workshops and trainings at all level of implementation of the program instead of individual bottles

2. Environmental Mitigation and Monitoring Report – table for activities under negative determination with conditions.

During the FY 2017 QIII period, activities classified under negative determination with conditions in the 22 CFR 216.3 (a) 2 (iii), and as described in the IEE 2014-2018 include:

1. Healthcare worker/delivery agent training and capacity building; healthcare workforce training, strengthening, and development; strengthening support for health service delivery

Under this category, the Community Capacity for Health Program planned refresher training activities for CHVs, in particular in c-IMCI (165 CHVs) and Misoprostol – CHX (5,481 CHVs) , and supportive supervision including malaria activities (7,492 CHVs) by the end of September 2017.

Planned activities Recommended mitigating actions Status of mitigative Any outstanding issues Remarks measures/ actions relating to required taken conditions - Training/ supportive supervision - Health care service delivery enhancement (excluding HIV/aids testing, surveillance and monitoring) 1.1.2.3 Conduct refresher Review and update as necessary training More CHV training on Miso training for CHVs according to curricula and SBCC materials related to 5,481/5,850 CHVs who and CHX is planned for Q4 MOH's revised training health care management and appropriate are trained on Miso and curriculum (training may be disposal using incinerators or improved CHX in ongoing done few times. Some training burial pits at health facilities for medical districts in Q3 may be done during the monthly waste, CHX tubes, used sharps, syringes CHV meeting) and needles, and expired drugs 1.1.2.5 Conduct initial training Refresher and continued training, and 165 CHVs trained in c- More CHV training on c- for CHVs in new districts supervision on appropriate handling, use, IMCI in Q3 IMCI is planned for Q4 storage and waste disposal of CHX tubes,

Planned activities Recommended mitigating actions Status of mitigative Any outstanding issues Remarks measures/ actions relating to required taken conditions 1.1.2.6 CHVs receive regular sharps, syringes and needles, gloves, 952 CHVs receive on- supervision visits from FKT head expired drugs following the EMMP poster site supervision from and CCDS members guide developed in MAHEFA and using FKT head (N/A) safety boxes and/or burial pits (The indicator above has been reported during Q2, the annual target is already reached) 1.2.1.1/3.0.3.2 Support 2,806 CHVs received Continue in Q4 supervision visits to CHVs from on-site supervision by CCDS, CSB representatives, CSB/EMAD/CCHP in EMAD, EMAR, MOH, and CCH the last three months staff

2. Social marketing, Education, and behavior change communication (BCC), excluding WASH

Planned activities Recommended mitigating actions Status of mitigative Any outstanding Remarks measures/actions taken issues relating to required conditions - Social marketing/education/outreach/community mobilization: Healthy Behavior Changes through multiple communication channels, including mass media, communication campaigns, education and technical assistance and training – Population behavior change regarding use and disposal of medical wastes, including condoms, medicines and other medical products, and expired pharmaceuticals – Social marketing for FP/RH products expanded to rural communities 2.2.1.2 Train community SBCC activities related to proper 6,632 CHVs/FKT heads trained on Continue in Q4 stakeholders (COSAN: FKT storage, use and disposal of used SBCC in Q3 heads and CHVs and CCDS condoms, unused and expired drugs, members) on SBCC to used syringes, and washing of promote and advocate for improved services and insecticide-treated nets utilization throughout the continuum of care

2.2.1.3 Conduct training on the There is no training on WASH in Q3. CLTS approach for CCDS and FKT COSAN members

3. Procurement, storage, management, distribution and disposal of public health commodities and equipment

Planned activities Recommended mitigating actions Status of mitigative Any outstanding Remarks measures/actions taken issues relating to required conditions

- Supply chain strengthening activities: provision of technical assistance to strengthen stock management and distribution - Procurement and distribution of Family Planning pharmaceuticals, point-of-use water treatment, malaria test/Diagnosis kits 2.2.2.7 Support CHV and Equip the permanent health huts and CSB 102/165 permanent Toby Continue in Q4 CSB in good hygiene and with disposal pit equipped with disposal pits waste management in Q3 practices

3.2.1.2 Hold coordination CHVs will be provided with training or 5,481/5,850 CHVs trained Continue in Q4 meeting with PSI/ISM refresher training on stock management in stock management of program and set up regular including expiry date and the appropriate Miso and CHX in ongoing meeting schedule related waste management processes to be districts followed as per the Madagascar National Waste Management Policy (2005) 165 CHVs trained in stock management of c-IMCI products in new districts

3.2.1.3 Participate in # of CHVs who sent full No CHVs reported DPLMT/UTGL activities sharp boxes to the CSB for during the present related to commodities disposal reporting period to bring back to the CSB availability for CSB and any full sharp box. CHVs

Planned activities Recommended mitigating actions Status of mitigative Any outstanding Remarks measures/actions taken issues relating to required conditions

3.2.1.4 Train CSB on Storage of the products according to the # CHVs with public health No CHVs reported This activity is N/A commodities management information provided on the manufacturer’s commodities returned back during the present for this period of including CHV commodity Materials Safety Data Sheet (MSDS) to the CSB reporting period any reporting as CHVs expired drug and sent supplied with new needs planning in line with back to the CSB products MOH protocols Return expired commodities to the health facility for CHVs

Appropriate disposal of expired drugs following the Madagascar National Waste Management Policy (2005)

4. Small-scale water supply and sanitation.

Planned activities Recommended mitigating Status of mitigating Any outstanding issues Remarks actions measures/actions taken relating to required conditions

- Water supply infrastructure and financing: small-scale sanitation infrastructure such as hygienic latrines, hand washing stations - Social marketing/education/outreach/community mobilization: BCC for WASH targeted on hand washing with soap, safe disposal of feces, and safe storage of drinking water at point-of-use - Policy support and small business promotion: train village level providers to use and sell WASH related services and supplies 2.2.2.6 Support CCDS and Building and use of appropriate 3,334 new improved latrines Continue in Q4 COSAN to begin promotion of improved latrines built in Q3 WASH activities including sale of sur'eau and latrine slabs Support Local masons on producing 312 local masons inventoried slabs 2.2.2.7 Support CHV and CSB in Equip the permanent health huts 63/165 permanent Toby Continue in Q4 good hygiene and waste and CSB with latrines equipped with latrine and hand management practices washing station in Q3

This indicator will be reported under the CSB survey in FY2018 102/165 permanent Toby Continue in Q4 equipped with disposal pits in Q3

Annex 4. List of Communes in Mahefa Miaraka Program in Q3 FY2017

The USAID Community Capacity for Health Program operates in 4,887 fokontany, 456 communes, and 34 districts in the regions of Analanjirofo, Boeny, DIANA, Melaky, Menabe, SAVA, and Sofia. The Program will work with 456 CCDS, 732 public CSB, and 9,844 CHVs to provide services to approximately 6,1million people, or 23.3% of Madagascar’s total population. Details of the communes are presented in the table below.

No. of No. of No. of District Communes Fokontany actual CSB CCDS

Région CHVs

AMBANJA SAHALAVA 9 1 1 14 AMBATOHARANANA 18 3 1 36 AMBODIMANGA II B 20 2 1 40 AMPASIMBE MANANTSATRANA 11 3 1 26 AMPASINA MANINGORY 25 3 1 50 ANTSIATSIAKA 19 2 1 38 BETAMPONA 9 1 1 18 FENERIVE EST FENERIVE EST 5 2 1 10 MAHAMBO 26 3 1 52 MAHANORO 6 1 1 12 MIORIMIVALANA 8 1 1 16 SARANAMBANA 16 2 1 30 VOHILENGO 17 2 1 22 VOHIPENO 22 3 1 41

FENERIVE EST 14 211 29 14 405 TOTAL

AMBATOHARANANA MNNR 11 1 1 24 AMBODIAMPANA MNNR 14 2 1 27 AMBODIVOANIO 15 2 1 30 ANALANAMPOTSY 11 0 1 18 ANDASIBE MNNR 8 1 1 16 MANANARA ANTANAMBAOBE 12 1 1 24 NORD ANTANAMBE 24 3 1 48

ANTANANANIVO 10 1 1 18 IMORONA 7 1 1 14 MAHANORO MNNR 5 1 1 9 MANAMBOLOSY 18 2 1 36 ANALANJIROFO

No. of No. of No. of District Communes Fokontany actual CSB CCDS

Région CHVs

MANANARA NORD 21 1 1 34 SANDRAKATSY 20 1 1 36 SAROMAONA 14 1 1 18 TANIBE 13 1 1 22 VANONO 12 2 1 22

MANANARA 16 215 21 16 396 NORD TOTAL

AMBANIZANA 3 1 1 8 AMBINANITELO 12 2 1 26 AMBODIMANGA RANTABE 7 1 1 15 ANANDRIVOLA 9 1 1 16 ANDRANOFOTSY 7 1 1 23 ANDRONDRONA 8 2 1 14 ANJAHANA 7 2 1 14 ANJANAZANA 10 1 1 17 ANKOFA 10 1 1 24 ANKOFABE 9 1 1 18 MAROANTSETRA ANTAKOTAKO 12 2 1 25 ANTSIRABE SAHATANY 6 2 1 12 MAHALEVONA 6 2 1 12 MANAMBOLO 10 2 1 20 MARIARANO 5 1 1 12 MAROANTSETRA 17 1 1 34 MORAFENO 7 2 1 8 RANTABE SUD 8 1 1 17 SAHASINDRO 5 1 1 14 VOLOINA 10 1 1 20

MAROANTSETRA 20 168 28 20 349 TOTAL

SAINTE MARIE AMBODIFOTATRA 21 10 1 44

SAINTE MARIE 1 21 10 1 44 TOTAL

AMBAHOABE 19 4 1 38

No. of No. of No. of District Communes Fokontany actual CSB CCDS

Région CHVs

AMBINANISAKANA 7 1 1 14

AMBODIAMPANA 5 1 1 10

ANDAPAFITO 16 2 1 32 SOANIERANA ANTANIFOTSY 12 1 1 24 IVONGO ANTENINA 13 4 1 26 FOTSIALANANA 9 2 1 18 MANOMPANA 7 3 1 14 SOANIERANA IVONGO 18 2 1 36

SOANIERANA 9 106 20 9 212 IVONGO TOTAL

AMBATOHARANANA I 12 1 1 24 AMBODIMANGAVALO 8 3 1 16 AMBOHIBE 14 2 1 28 AMPASIMAZAVA 7 1 1 14 ANDASIBE 12 2 1 26 VAVATENINA ANJAHAMBE 11 2 1 22 MAROMITETY 19 2 1 39 MIARINARIVO 14 3 1 30 SAHATAVY 8 2 1 16 TANAMARINA 5 0 1 10 VAVATENINA 17 1 1 40

VAVATENINA 11 127 19 11 265 TOTAL TOTAL 71 848 127 71 1671 ANALANJIROFO AMBARIMANINGA 5 1 1 10 ANTONGOMENA BEVARY 9 2 1 18 ANTSEZA 7 1 1 14

MITSINJO BEKIPAY 8 2 1 16 KATSEPY 7 3 1 14 MATSAKABANJA 12 3 1 24 MITSINJO 10 3 1 20

MITSINJO TOTAL 7 58 15 7 116 BOENY

No. of No. of No. of District Communes Fokontany actual CSB CCDS

Région CHVs

AMBOHIPAKY 14 5 1 28 ANDRANOMAVO 24 4 1 48

SOALALA ANTSAKOAMILEKA 8 3 1 16 SOALALA 13 3 1 26

SOALALA TOTAL 4 59 15 4 118 TOTAL BOENY 11 117 30 11 234 AMBALAHONKO 7 1 1 14 AMBALIHA 5 1 1 10 AMBANJA 19 2 1 30 AMBODIMANGA RAMENA 10 1 1 12 AMBOHIMARINA 6 2 1 8 AMBOHIMENA 5 1 1 10 AMBOHITRANDRIANA 6 1 1 12 ANKATAFA 4 1 1 10 ANKINGAMELOKA 8 1 1 16 ANOROTSANGANA 10 2 1 20 ANTAFIAMBOTRY 7 2 1 14 ANTRANOKARANY 10 2 1 20 AMBANJA ANTSAHABE CENTRE 0 1 8

ANTSAKOAMANONDRO 10 1 1 20 ANTSATSAKA 8 3 1 12 ANTSIRABE 16 1 1 32 BEMANEVIKY H/S 8 2 1 16 BEMANEVIKY OUEST 13 2 1 24 BENAVONY 0 1 8

DJANGOA 6 1 1 12 MAEVATANANA 6 1 1 12 MAHERIVARATRA 7 1 1 14 MAROTOLANA 13 2 1 26 MAROVATO 5 1 1 14

AMBANJA TOTAL 24 189 32 24 374

AMBAKIRANO 12 2 1 24 AMBILOBE AMBARAKARAKA 12 2 1 22 DIANA

No. of No. of No. of District Communes Fokontany actual CSB CCDS

Région CHVs

AMBATOBEN'ANJAVY 10 2 1 20 AMBILOBE 11 1 1 22 AMBODIBOANARA 8 1 1 16 AMPONDRALAVA 7 1 1 14 ANABORANO IFASY 12 1 1 24 ANJIABE HAUT 8 1 1 18 ANKARATRA SIRAMA 9 1 1 18 ANTANABE 6 1 1 16

ANTSARAVIBE 14 3 1 24

ANTSOHIMBONDRONA 6 2 1 11 BERAMANJA 20 2 1 36 BETSIAKA 13 4 1 24 MANAMBATO 7 2 1 14 MANTALY 12 1 1 24 TANAMBAO MARIVORAHONA 11 1 1 22 AMBILOBE 17 178 28 17 349 TOTAL ANTSIRANANA I DIEGO SUAREZ 25 3 1 50 ANTSIRANANA I 1 25 3 1 50 TOTAL AMBOLOBOZOBE 5 1 1 6 AMBONDRONA 9 1 1 18 ANDRAFIABE 5 1 1 14 ANDRANOFANJAVA 8 1 1 16 ANDRANOVONDRONINA 9 2 1 18 ANIVORANO NORD 21 3 1 32 ANKARONGANA 5 1 1 10 ANTSIRANANA II ANKETRAKABE 10 1 1 20 ANTANAMITARANA 5 1 1 10 ANTSAHAMPANO 10 2 1 20 ANTSAKOABE 2 1 1 4 ANTSALAKA 6 1 1 12 ANTSOHA 0 0 1 10 BOBAKILANDY 5 1 1 10 BOBASAKOA 3 1 1 6

No. of No. of No. of District Communes Fokontany actual CSB CCDS

Région CHVs

JOFFRE-VILLE 3 1 1 6 MAHALINA 6 1 1 12 MAHAVANONA 22 2 1 44 MANGAOKO 9 3 1 18 MOSOROLAVA 6 2 1 12 RAMENA 5 1 1 10 SADJOAVATO 3 1 1 6 SAKARAMY 5 1 1 10 ANTSIRANANA II 23 162 30 23 324 TOTAL AMBATOZAVAVY 5 2 1 10 AMPANGORINA 5 1 1 10 BEFOTAKA 4 1 1 12 NOSY BE BEMANONDROBE 8 3 1 12 DZAMANDZAR 9 2 1 18 HELL VILLE 11 1 1 22

NOSY BE TOTAL 6 42 10 6 84 1181 TOTAL DIANA 71 596 103 71

AMBATOMAINTY 12 1 1 24 BEMARIVO 8 3 1 16

AMBATOMAINTY MAKARAINGO 6 1 1 12 MAROTSILEHA 8 2 1 14 SARODRANO 5 1 1 10 AMBATOMAINTY 5 39 8 5 76 TOTAL ANTSALOVA 13 1 1 27 BEKOPAKA 12 1 1 23 BEMARAHA ANTSINANANA 5 0 1 10 ANTSALOVA MASOARIVO 10 3 1 20 SOAHANY 8 3 1 17 TRANGAHY 9 3 1 18 ANTSALOVA 6 57 11 6 115 TOTAL

AMBOLODIA SUD 9 1 1 18

AMPAKO 6 1 1 12 MELAKY

No. of No. of No. of District Communes Fokontany actual CSB CCDS

Région CHVs

ANKASAKASA TSIBIRAY 7 1 1 14

ANTSIRASIRA 6 0 1 12 BESALAMPY BEKODOKA 19 1 1 39 BESALAMPY 8 1 1 18 MAHABE 9 1 1 18 MAROVOAY SUD 6 1 1 12 SOANENGA 8 2 1 16 BESALAMPY 9 78 9 9 159 TOTAL ANDABOTOKA 12 1 1 24 ANDRANOVAO 5 1 1 10 ANDREA 9 1 1 18 ANKISATRA 8 1 1 16 ANTSAIDOHA BEBAO 8 1 1 16 ANTSONDRODAVA 8 1 1 16 BEBABOKY SUD 8 1 1 15 BELITSAKY 7 1 1 14

MAINTIRANO BEMOKOTRA SUD 8 1 1 16 BEREVO RANOBE 5 2 1 10 BETANATANANA 14 1 1 30 MAFAIJIJO 8 1 1 16 MAINTIRANO 8 1 1 16 MAROHAZO 10 2 1 20 MAROMAVO 3 1 1 6 TAMBOHORANO 7 1 1 15 VEROMANGA 5 1 1 10 MAINTIRANO 17 133 19 17 268 TOTAL ANDRAMY 17 1 1 33 ANTRANOKOAKY 7 2 1 14 MORAFENOBE BERAVINA 11 2 1 21 MORAFENOBE 20 4 1 39 MORAFENOBE 4 55 9 4 107 TOTAL 725 TOTAL MELAKY 41 362 56 41

No. of No. of No. of District Communes Fokontany actual CSB CCDS

Région CHVs

ABOALIMENA 8 1 1 16 AMBIKY 8 1 1 16 ANDIMAKA 11 1 1 22 ANKALALOBE 12 1 1 24 ANKIRONDRO 8 1 1 16 ANTSOHA 7 1 1 13 BEGIDRO ANKIROROKA 7 1 1 12 BELO BELINTA 9 1 1 18 TSIRIBIHINA BELO TSIRIBIHINA 21 1 1 54 BEREVO 8 1 1 16 BEROBOKA NORD 9 1 1 16 DELTA 10 1 1 9 MASOARIVO 10 1 1 18 TSARAOTANA 12 2 1 24 TSIMAFANA 13 2 1 26 BELO TSIRIBIHINA 15 153 17 15 300 TOTAL AMBIA 7 1 1 14 AMPANIHY 19 2 1 38 ANALAMITSIVALA 5 1 1 10 ANKILIVALO 9 1 1 18 ANKILIZATO 28 2 1 54 BEZEZIKA 5 - 1 10 MAHABO BEFOTAKA 12 1 1 22 BERONONO 6 1 1 11 MAHABO 7 1 1 14 MALAIMBANDY 19 2 1 38 MANDABE 16 2 1 32 TSIMAZAVA 8 1 1 16 MAHABO TOTAL 12 141 15 12 277

ANDRANOPASY 9 3 1 18

ANKILIABO 18 3 1 35

MANJA ANONTSIBE 13 2 1 24 MENABE

No. of No. of No. of District Communes Fokontany actual CSB CCDS

Région CHVs

BEHARONA 10 3 1 20 BETSIOKY 5 1 1 8 MANJA 13 2 1 26 SOASERANA 7 1 1 12 MANJA TOTAL 7 75 15 7 143 AMBATOLAHY 8 2 1 24 AMPANIHY 7 2 1 14 ANDRANOMAINTY 7 - 1 14 ANKAVANDRA 14 1 1 27 ANKONDROMENA 7 2 1 24 ANKOTROFOTSY 15 2 1 18 ANOSIMENA 5 2 1 18 BEMAHATAZANA 7 1 1 6 MIANDRIVAZO BETSIPOLITRA 7 1 1 9 DABOLAVA 5 1 1 12 ISALO 10 2 1 20 ITONDY 7 1 1 16 MANAMBINA 10 2 1 22 MANANDAZA 9 1 1 16 MIANDRIVAZO 8 1 1 18 SOALOKA 13 1 1 20

MIANDRIVAZO 16 139 22 16 278 TOTAL

ANALAIVA 23 2 1 46 BEFASY 23 7 1 44 BELO SUR MER 14 3 1 27 MORONDAVA BEMANONGA 26 3 1 52 MAROFANDILIA 8 2 1 14 MORONDAVA 18 1 1 36 MORONDAVA 6 112 18 6 219 TOTAL 1137 TOTAL MENABE 56 620 87 56

AMBALAMANASY II 11 1 1 22

AMBALAVELONA 5 1 1 10 SAVA

No. of No. of No. of District Communes Fokontany actual CSB CCDS

Région CHVs

AMBODIANGEZOKA 10 1 1 20

AMBODIDIVAINA 9 1 1 18

AMBODIMANGA I 10 3 1 20

ANDAPA 10 1 1 20 ANDASIBE KOBAHINA 4 1 1 8 ANDAPA ANDRAKATA 3 1 1 6 ANDRANOMENA 5 1 1 10 ANJIALAVABE 6 1 1 12 ANKIAKABE NORD 5 1 1 10 ANOVIARA 8 1 1 16 ANTSAHAMENA 7 1 1 14 BEALAMPOANA 9 1 1 18 BELAOKA LOKOHO 7 2 1 14 BELAOKO MAROVATO 6 2 1 12 BETSAKOTSAKO ANDRANOTSARA 8 1 1 16 DOANY 14 3 1 28 MAROVATO 5 1 1 10 MATSOHELY 6 1 1 12 TANANDAVA 8 2 1 16 ANDAPA TOTAL 21 156 28 21 312 AMBALABE 13 1 1 26 AMBINANIFAHO 9 2 1 18 AMBOHITRALALANA 12 2 1 24 AMPAHANA 16 3 1 32 AMPANAVOANA 11 1 1 24 AMPOHIBE 12 1 1 25 ANTALAHA ANDAMPY 12 2 1 26 ANTALAHA 23 3 1 83 ANTANANAMBO 15 2 1 27 ANTOMBANA 21 2 1 51 ANTSAHANORO 11 1 1 22 ANTSAMBALAHY 9 2 1 18 LANJARIVO 14 2 1 28

No. of No. of No. of District Communes Fokontany actual CSB CCDS

Région CHVs

MANAKAMBAHINY ANKAVIA 8 2 1 8 MAROFINARITRA 8 1 1 24 SAHANTAHA 7 1 1 13 SARAHANDRANO 7 1 1 14 VINANIVAO 11 2 1 22 ANTALAHA 18 219 31 18 TOTAL 485 AMBATOAFO 15 1 1 30 AMBOANGIBE 13 1 1 26 AMBODIAMPANA LOKOHO 12 3 1 24 AMBODIVOARA 15 2 1 30 AMBOHIMALAZA 9 3 1 20 AMBOHIMITSINJO 8 1 1 16 ANALAMAHO 9 1 1 18 ANDAPABE 7 1 1 14 ANDRAHANJO 9 2 1 18 ANDRATAMARINA 11 2 1 22 ANDREMBONA 6 1 1 12 ANJANGOVERATRA 25 1 1 50 ANJIALAVA 10 1 1 20 SAMBAVA ANJINJAOMBY 8 1 1 13 ANTINDRA 14 1 1 28 ANTSAHAVARIBE 22 1 1 44 ANTSAMBAHARO 7 1 1 14 BEMANEVIKA 12 2 1 22 BEVONOTRO 22 2 1 40 FARAHALANA 20 1 1 40 MAHASOA ANTINDRA 13 0 1 28 MAROAMBIHY 8 1 1 16 MAROGAONA 10 2 1 20 MAROJALA 13 1 1 26 MORAFENO 12 1 1 26 NOSIARINA 8 1 1 16 SAMBAVA URBAIN 16 2 1 32

No. of No. of No. of District Communes Fokontany actual CSB CCDS

Région CHVs

TANAMBAO DAOUD 13 3 1 26 SAMBAVA TOTAL 28 347 40 28 691 AMBALASATRANA 9 1 1 36 AMBINANIN'ANDRAVORY 8 2 1 18 AMBODISAMBALAHY 9 1 1 14 AMBORIALA 5 1 1 18 AMPANEFENA 15 1 1 10 AMPISIKINANA 5 1 1 28 AMPONDRA 4 2 1 10 ANDRAFAINKONA 5 1 1 20 ANDRAVORY 4 1 1 10 VOHEMAR ANTSIRABE NORD 17 5 1 10 BELAMBO 7 2 1 10 BOBAKINDRO 3 1 1 12 DARAINA 8 2 1 14 FANAMBANA 6 2 1 16 MAROMOKATRA LOKY 5 2 1 10 MILANOA 16 2 1 26 NOSIBE 8 3 1 14 TSARABARIA 11 3 1 20 VOHEMAR 10 2 1 14 VOHEMAR 19 155 35 19 TOTAL 310 TOTAL SAVA 86 877 134 86 1789 AMBALIHA 14 1 1 28 AMBARIJEBY-SUD 7 1 1 14 AMBOLOBOZO 22 4 1 44 ANALALAVA 15 3 1 36 ANDREVOREVO 3 0 1 6 ANALALAVA ANDRIMBAVONTSONA 10 1 1 22 ANGOAKA SUD 6 1 1 12 ANKARAMY 16 5 1 40

ANTONIBE 23 2 1 48 BEFOTAKA NORD 17 2 1 35 SOFIA

No. of No. of No. of District Communes Fokontany actual CSB CCDS

Région CHVs

BEJOFO 10 2 1 20 MAHADRODROKA 10 1 1 20 MAROMANDIA 10 1 1 20 MAROVANTAZA 6 1 1 12 MAROVATOLENA 11 2 1 22 ANALALAVA 15 180 27 15 TOTAL 379 AMBALAFAMINTY 6 1 1 12 AMBODIMADIRO 11 3 1 22 AMBODIMANARY 18 2 1 36 AMBODIMANDRESY 14 1 1 28 AMPANDRIANKILANDY 16 2 1 32 ANAHIDRANO 14 2 1 28 ANTSOHIHY ANDREBA 8 1 1 16 ANJALAZALA 14 4 1 28 ANJIAMANGIRANA 17 3 1 34 ANKERIKA 12 2 1 24 ANTSAHABE 23 3 1 46 ANTSOHIHY 7 1 1 14 MAROALA 7 2 1 14 ANTSOHIHY 13 167 27 13 TOTAL 334 AMBALAROMBA 5 1 1 10 AMBARARATA SOFIA 7 1 1 14 AMBARARATABE NORD 8 2 1 16 AMBATORIHA EST 15 2 1 31 AMBATOSIA 14 2 1 28 AMBODIADABO 8 1 1 16 BEALANANA AMBODIAMPANA 6 2 1 12 AMBODISIKIDY 8 1 1 16 AMBOHIMISONDROTRA 7 1 13 AMBOVONOMBY 8 1 1 16 ANALILA 6 1 1 12 ANJOZOROMADOSY 8 1 1 16 ANKAZOTOKANA 7 1 1 14

No. of No. of No. of District Communes Fokontany actual CSB CCDS

Région CHVs

ANTANANIVO HAUT 7 2 1 14 ANTSAMAKA 8 2 1 16 ANTSIRADAVA 5 1 12 BEALANANA 20 1 1 38 BEANDRAREZONA 12 3 1 24 MANGINDRANO 13 3 1 26 MAROTOLANA 17 1 1 34 BEALANANA 20 189 28 20 TOTAL 378 AMBARARATA 16 3 1 32 AMBODIMOTSO HAUT 11 2 1 16 AMBODIMOTSO SUD 15 2 1 30 AMBOLIDIBE ATSINANANA 20 3 1 40 ANKARONGANA 27 4 1 54 ANTSAKABARY 21 3 1 42

BEFANDRIANA ANTSAKANALABE 19 3 1 38 AVARATRA BEFANDRIANA AVARATRA 9 1 1 18 BELALONA 14 4 1 28 MAROAMALONA 10 2 1 20 MATSONDAKANA 10 1 1 20 MORAFENO 22 3 1 48 TSARAHONENANA 36 5 1 72 TSIAMALAO 26 4 1 54 BEFANDRIANA AVARATRA 14 256 40 14 512 TOTAL AMBANJABE 13 1 1 26 AMBATOMILAHATRANO 8 1 1 18 AMBODIMAHABIBO 11 1 1 22 AMBODISAKOANA 15 2 1 30 BORIZINY AMBODIVONGO 12 1 1 26 AMPARIHY 17 1 1 34 ANDRANOMENA I 10 1 22 ANDRANOMEVA 14 1 1 28 IHOBAKA 9 1 1 22

No. of No. of No. of District Communes Fokontany actual CSB CCDS

Région CHVs

LEANJA 22 2 1 56 MAEVARANOHELY 13 1 1 26 MAROVATO 20 2 1 40 PORT BERGE I 11 1 1 22 PORT BERGE II 20 1 1 34 TSARAHASINA 19 1 1 38 TSARATANANA 15 2 1 28 TSININGIA 11 1 1 24 TSINJOMITONDRAKA 26 2 1 52 BORIZINY TOTAL 18 266 22 18 548 AMBODIHAZOAMBO 9 1 1 18 AMBOHITOAKA 15 1 1 30 AMPASIMATERA 17 2 1 34 ANKIRIRIKY 13 2 1 26 ANOVILAVA NORD 10 2 1 20 MAMPIKONY BEKORATSAKA 23 2 1 48 BETARAMAHAMAY 9 1 1 18 KOMAJIA 11 1 1 22 MALAKIALINA 17 1 1 42 MAMPIKONY I 29 1 1 16 MAMPIKONY II 16 2 1 64 MAMPIKONY 11 169 16 11 TOTAL 338 AMBALAKIRAJY 14 2 1 29 AMBARIKORANO 3 1 1 12 AMBARIPAIKA 6 1 1 12 AMBILOMBE 7 1 1 16 AMBINAN'IFANGO 7 1 1 20 MANDRITSARA AMBOABOA 10 1 1 20 AMBODIADABO MAITSOKELY 6 1 1 12 AMBODIAMONTANA KIANGA 7 1 1 14 AMBOHISOA 8 1 1 22 AMBORONDOLO 4 1 1 8 AMPATAKA MARORENY 6 1 1 12

No. of No. of No. of District Communes Fokontany actual CSB CCDS

Région CHVs

ANDOHAJANGO 12 1 1 30 ANDRATAMARINA 5 2 1 10 ANJIABE 8 1 1 16 ANKIABE SALOHY 12 2 1 24 ANKIAKABE FONOKO 6 2 1 12 ANTANAMBAON'AMBERINA 8 1 18 ANTANANDAVA 12 1 1 28 ANTSATRAMIDOLA 9 1 1 18 ANTSIATSIAKA 5 1 1 10 ANTSIRABE CENTRE 8 2 1 16 ANTSOHA 6 1 1 18 KALANDY 14 1 28 MANAMPANEVA 7 2 1 14 MANDRITSARA 13 1 1 26 MAROTANDRANO 16 2 1 32 PONT SOFIA 5 1 1 12 TSARAJOMOKO 6 2 1 20 TSARATANANA 10 1 1 20 MANDRITSARA 29 240 35 29 TOTAL 529 TOTAL SOFIA 120 1467 195 120 3018 GRAND TOTAL 456 4887 732 456 9844

Annex 5. Mahefa Miaraka’s Participation in Central-Level Meetings and Workshops in Q3 FY2017

Avril 2017 Date Sujets Types de reunions Thème techniques SMNI, PF, Priorités Logistique HMIS Divers Séance PCIME-c, National communaut Coordination de Divers nutrition (PNSC, et aire travail autres politiques) 04/04/2017 1. Validation du protocole TRAC X  PF

04/04/17 2. Validation technique Plan X  d’action nationale budgétisée en PF

04/04/2017 3. Validation du protocole TRAC X  PF

05 /04/17 4. Réunion du Comité de X  Coordination MINSAN, DLP, USAID/PMI

06/04/2017 5. Comité Mobsoc préparant la X  Journée mondiale du Paludisme

06/04/2017 6. Célébration de la Journée X  Mondiale de la Santé 2017

06/04/17 7. Atelier d’orientation des X  formateurs centraux sur l’utilisation du Misoprostol et du Chlorhexidine

10 au 14 8. Quantification des besoins en X  avril 2017 Avril 2017 Date Sujets Types de reunions Thème techniques SMNI, PF, Priorités Logistique HMIS Divers Séance PCIME-c, National communaut Coordination de Divers nutrition (PNSC, et aire travail autres politiques) intrants antipaludéens

11/04/17 9. Réunion Hebdomadaire du X  Comité de Coordination de la Lutte contre le Paludisme.

12/04/17 10. Elaboration TDR RSS X 

17 au 25 11. Atelier d’évaluation externe du X  Avril 2017 2ème Forum de la CEDEAO des bonnes pratiques en Santé et d’écriture du journal spécial sur les bonnes pratiques issues du 2ème Forum

20/04/2017 12. Coordination des activités X  d'approvisionnement en intrants de santé

TOTAL 12 02 09 01 07 00 00 00 05

Mai 2017 Date Sujets Types de reunions Thème techniques SMNI, PF, Priorités Logistique HMIS Divers PCIME-c, National communautaire Séance Coordination Divers nutrition (PNSC, et de travail autres politiques) 02/05/2017 1. Coordination des X  activités d'approvisionnement en intrants de santé

03 Mai 2. Journées Portes X  2017 Ouvertes Bureau au 04 Mai Central de coordination 2017 - Unité Coordination des Projets (BCC-UCP)

04/05/2017 3. Information sur X  l'utilisation de l'insecticide à effet rémanent.

8/05/17 au 4. Atelier de revue des X  13/05/17 modules de formation en suivi-évaluation et surveillance des programmes de lutte contre le paludisme au profit du personnel de la Direction de la Lutte contre le Paludisme

8 au 12 5. Orientation des staffs X  Mai 2017 région et district Analanjirofo, Mai 2017 Date Sujets Types de reunions Thème techniques SMNI, PF, Priorités Logistique HMIS Divers PCIME-c, National communautaire Séance Coordination Divers nutrition (PNSC, et de travail autres politiques) Maroantsetra, en RCCS

6. Echange avec l’équipe X  régionale sur les dispositions viables vis- à-vis de la conjoncture actuelle

15, 16, 18 7. Elaboration du MOP X  Mai 2017 2018

15 au 19 8. Développement et mise X  mai 2017 à jour du manuel des procédures et d'outils de gestion logistique des intrants de santé

17/05/2017 9. Réunion avec le groupe X  de travail Qualité des données du sous comité SIS MinSanP

23/05/17 10. Réunion régulière en X  Loi PF et PFI

24/05/17 11. Soumission du projet de X  loi PF à la commission sociale de l’Assemblée Mai 2017 Date Sujets Types de reunions Thème techniques SMNI, PF, Priorités Logistique HMIS Divers PCIME-c, National communautaire Séance Coordination Divers nutrition (PNSC, et de travail autres politiques) Nationale

26 et 29 12. Elaboration et validation X  mai 2017 de la grille d'évaluation de performance des AC, d'un guide de supervision des AC et d'un guide de planification

29 Mai 13. Revue du programme X  2017 au 02 Paludisme à Madagascar Juin 2017 de 2012 à 2017

TOTAL 13 01 08 03 05 00 02 01 05

Juin 2017 Date Sujets Types de reunions Thème techniques SMNI, PF, Priorités Logistique HMIS Divers PCIME-c, National communautaire Séance Coordination Divers nutrition (PNSC, et de travail autres politiques) 07-08-09 Juin 1. Réflexion sur les X  2017 modalités de collaboration des mutuelles de santé dans la démarche de la CSU

08/06/2017 2. Réunion de X  coordination Situation de stock de PSI, Lot de démarrage et de redynamisation, produits pour VAN PF

13 Juin 2017 3. Réunion du Comité X  «Roll Back Malaria » (RBM)

13/06/2017 4. Mise au point sur la X  situation des intrants antipaludiques au niveau du pays

14/06/2017 5. Rencontre avec le SMSR X  sur la disponibilité de spots radio

14/06/2017 6. Revue et Appropriation X  du Renforcement du Système de Santé Juin 2017 Date Sujets Types de reunions Thème techniques SMNI, PF, Priorités Logistique HMIS Divers PCIME-c, National communautaire Séance Coordination Divers nutrition (PNSC, et de travail autres politiques) 21 juin 2017 7. Communication X  Working Group

20-21/06/17 8. Atelier de validation des X  documents de normes et procédures de PEC du Paludisme

23/06/17 9. Etude de faisabilité d’une X  coordination efficace des appuis pour assurer la disponibilité des intrants au niveau des PhaGDis et PhaGeCom.

10. Réunion Hebdomadaire X  27/06/17 RBM.

27/06/1717 11. Table ronde sur le X  theme, Population et Développement Investissement sur la jeunesse pour la realization de la Dividende démographique à Madagascar

29 au 12. Formation sur la X  30/07/17 Communication pour le Juin 2017 Date Sujets Types de reunions Thème techniques SMNI, PF, Priorités Logistique HMIS Divers PCIME-c, National communautaire Séance Coordination Divers nutrition (PNSC, et de travail autres politiques) Changement de Comportement

29/07/17 13. Réunion Trimestrielle X  President’s Malaria Initiative

TOTAL 13 01 06 05 04 01 02 00 06

COMMUNITY HEALTH VOLUNTEERS AND DATA MANAGEMENT THIS SUCCESS STORY IS SUBMITTED TO USAID AS PART OF THE QUARTER 3 FY2017 PROGRESS REPORT

The USAID Community Capacity for Health program, locally known as Mahefa Miaraka, is a five-year (2016-2021) community-based integrated health program funded by the United States Agency for International Development (USAID). The Program is a collaborataion between the Ministry of Public Health, USAID, and JSI Research & Training Institiute, Inc. (JSI).

AT THE COMMUNITY

Magnanatsy (23 years old CHV) and Fety Manantsoa Jeremie (57 years old CHV) have a high and very important workload. Just like the other 9,844 Community Health Volunteers (CHVs) in the USAID Community Capacity For Health Program, they are responsible for managing a large number of forms for submission to the Ministry of Health (MOH).

Fety Manantsoa Jeremie, CHV, is coaching Magnanatsy

To provide services in family planning and in child health, the book into the four-page monthly report form. The photo above CHVs must first fill-out the individual record form, and, then, shows Magnanatsy doing the transcribing from the integrated later transcribe the information into the integrated health health record book into the monthly report form or Rapport Mensuel record book. All the services provided and activities conducted d’Activite (RMA). Fety Manantsoa Jeremie, who is a more experienced by the CHVs during the month need to be put in the integrated CHV, is coaching Magnanatsy to ensure that he correctly copies the record book. At the end of each month, the CHVs transcribe all the right information into the month’s report services and activities recorded in the integrated health record These are only a few examples of the forms that the CHV need to manage. Other forms the CHV is responsible for managing include: stock management forms for 10-13 health products, referral and counter-referral forms, register, etc. Just like the individual record forms, these forms need to be transcribed into the CHV’s integrated health record book and then into the RMA.

In June 2017, 5,415 CHVs out of a total of 5,527 functioning CHVs, (93 percent) attended the monthly meeting organized by 489 CSBs. Functioning CHVs means that they can provide integrated health services. Fety Manantsoa Jeremie fills the referral slips to give to a mother of sick child with danger signs to go and have treatment at CSB nearby

AT THE CSB

At the end of each month, all CHVs in the Program regions bring their integrated record book and their RMA to the monthly meeting at the CSB. As shown in the photos below, CSB heads go through the record books and the RMA with each CHV while teaching others to follow good examples as well as learn from bad examples. This exercise is not only to check for errors but also serves as the time for the CSB heads to reinforce technical points as seen in the CHV’s record books. The session usually lasts all day. After checking and making corrections (in three copies since the RMA is made in three copies/colors), the CSB heads sign the approved RMA and keep two copies- one for the CSB and one to be submitted to the District Health Office. The CHV has one copy that is left in their RMA book.

CSB heads coaching CHVs during monthly meeting AT THE DISTRICT HEALTH

“When I look at the Community Health Volunteer’s monthly reports, I understand why the basic health center or Centre de Sante de Base (CSB) reports less services provided to children under 5”, said Mr. Pierre Mbohova Octave, the Manja District Officer Responsible for the Government’s Health Management Information System (HMIS).

Each month, Mr. Octave and his two assistants process 15 CSB monthly reports (10 pages) and 150 CHV reports (4 pages) – the task takes the three of them eight days (from the 12th to the 20th) to process and then another seven days to make corrections. The final set of data is then sent to the regional health office before the 27th of every month. HOW FAR DO THE DATA TRAVEL?

The District of Manja in the Menabe region, is located in the west of Madagascar. Manja is one of the most remote districts in Menabe and is only easily accessible by vehicle eight months a year due to 21 water crossings ranging from large rivers to small creeks as shown in the photos below. It can take up to a week to travel to Manja during the rainy season. In the dry season, it takes at least eight hours on a rough dirt road for a four-wheel drive to make the journey from the region’s capital of Morondava to Manja.

The USAID Community Capacity for Health Program is committed to As the program moves forward, the reporting rate by CHV assisting the Ministry of Health to collect and integrate the com- continues to increase. Indeed in the last quarter the number munity-level data into the national HMIS on a monthly basis. At the of CHVs reporting increased from 4,920 at the end of March to end of June 2017, 93 percent of the 5,527 functioning CHVs submitted 5,415 at the end of June. Recognizing the importance of quality, their monthly reports or RMA. The data from these reports were consistent data, The Community Capacity for Health Program is processed by the Program team and exported into the MOH’s HMIS committed to contributing to the GOM database by assuring that system in early July. reports are submitted on time and with high quality data and are integrated into the Ministry’s database.

Annex 6. International Trips at the End of Q3 FY2017

Approved Trips in FY2016-FY2017 Trip Situation Update Q2, FY2017 No. No. of Origin Destination Trip purposes International No. of of travelers Trips Made Trips Plans for Remaining trips per trip in Q2, Q3, FY2017 Trips FY2017 JSI 1 3 Madagascar Uganda USAID’s International Conference on 1 for 3 people Completed (S Africa) Community Health. Participation of the Madagascar delegation at this conference is as requested by USAID/Madagascar. Two of the three participants are MOH staff. 1 2 Canada Madagascar COP and dependent travel to post Completed in FY2016 (Completed FY 2016) 3 1 US Madagascar JSI/Boston Home office program support for Completed in FY2016 Program start-up (Completed before September 2016 or FY 2016) 5 1 US Madagascar Boston Home office program support in 0 0 4 FY2017. These trips are in the approved proposal budget and include trips that support systems, financial management and compliance, and one annual senior management visit; the number of trips was incorrectly transcribed in the last Work Plan. We hired a new Key Personnel – the Finance and Administration Director, and since the prior staffer in this position left weeks before the new one could take over the functions, JSI was obliged to send home office staff in rotation to cover the supervisory functions. 5 1 US Madagascar JSI technical support trips in FY2017. 1 0 3 1

Approved Trips in FY2016-FY2017 Trip Situation Update Q2, FY2017 No. No. of Origin Destination Trip purposes International No. of of travelers Trips Made Trips Plans for Remaining trips per trip in Q2, Q3, FY2017 Trips FY2017 These trips include specialized clinical and HSS experts, monitoring & evaluation staff, strategic information and new technologies experts as needed, and the five trips are in the approved proposal budget. 2 1 Madagascar US COP annual home office meeting 1 0 Completed 1 3 Madagascar US Program staff orientation/training in Boston 1 0 1 1 2 Madagascar UK Staff orientation 0 0 1 FHI360 1 3 US Madagascar FHI360 Home office program support 1 1 Completed 1 1 South Africa Madagascar FHI360 Home office program support 0 0 1 1 1 US Madagascar FHI360 Home office program support 1 0 Completed 1 1 US Madagascar FHI360 Home office program support 0 0 1 1 1 US Madagascar FHI360 Home office program support 0 0 1 Transaid 1 1 UK Madagascar Transaid Home office program support for Completed in FY2016 Program start-up (completed FY2016) 1 1 UK Madagascar Transaid Home office program support 1 0 Completed 1 3 UK Madagascar Transaid Home office program support 2 1 1

*Two additional Community Capacity for Health staff members traveled internationally during Q3 on funds other than those of the Community Capacity for Health Program. Dr. Aymar Ramadany traveled to Zambia to attend the Africa Transportation Technology Transfer (T2) Conference from May 8-10, 2017. His travel was funded by Transaid. Dr. Robertine Rahelimalala traveled to Burkina Faso from the 18-20 of April to participate in a CEDEAO forum on Good Health Practices (Bonnes Pratiques en Santé – FBPS). Annex 8. USAID’s Comments on the Mahefa Miaraka Program’s Q3 FY2017 Report and JSI Responses (Comments received on August 30, 2017)

JSI’s responses are in the italic texts under each of the comments.

General comments

1) It is good to notice that, despite a decrease in the number of the training organized in Q3 and Q4 due to reduced budget, the project has made several achievements and will be able to reach the training targets for FY2017.

Thank you.

2) We have noticed a very good progress in the implementation of malaria activities, including coordination with DLP and other USG/PMI partners. Data and analysis in the report is comprehensive. It was agreed that CCH provides monthly malaria data to allow USAID to improve surveillance with DLP. Is this also CCH's understanding?

JSI reconfirms that it is also our understanding that Mahefa Miaraka will provide data on key DLP malaria indicators on a monthly basis, namely:

a) CU5 fever cases b) CU5 with fever who are tested with RDT c) CU5 tested positive with RDT d) CU5 with fever who are treated with ACT by CHV e) Percentage of CU5 malaria positive cases treated with ACT by CHV f) Percentage of CU5 testing positive for malaria g) Stock-out of malaria Child Health Tracer Products at CHVs.

3) CCH has received $6SOK Water funds. However, there is no mention or description of WASH activities implemented by the project in the narrative, except in the project's performance review that gives the number of communities certified ODF and the number of people gaining access to an improved sanitation facility.

Among the main changes the Program made in its revised FY2017 Work plan (p.2) following the reduced funding level, the training of CHVs on WASH will be reported in FY2018. However, as existing CHVs already trained under the former MAHEFA are operational, behavioral related WASH activities and promotion of WASH friendly approaches are ongoing in the field.

The Program activities related to water, sanitation and hygiene (WASH) are integrated in many of the Program’s routine activities and therefore there is no specific section on WASH in the report.

To respond to USAID’s comment, please see a more detailed description of the Program activities that have an aspect of water, sanitation and hygiene activities during Q3 FY2017. The text below is has now been added to the originally submitted Q3 report (in red colored text on page 14).

Program Activities Directly Related to WASH

4) It is the same remark on immunization. The project has received $lOOK polio and $lOOK immunization funds. But the project only talks about surveillance of diseases and anything on outreach immunization activities using the 'reach every child' approach.

Program Activities Directly Related to immunization

Immunization is one of the CHVs’ responsibilities, namely referring children and pregnant women for necessary vaccinations at the government’s health facilities. To respond to USAID’s comment, please see a more detailed description of the program activities in the third quarter that are directly related to immunization. JSI also added this text in the originally submitted Q3 report (in red colored text on page 14-15).

2 assisted the MOH to adapt/simplify the training curriculum and materials for use by the CHVs. In Q3, the manual and materials were completed and the MOH is planning cascade trainings for priority districts and CSB starting in Q4 FY2017 or Q1 FY2018. In FY2018, all CHVs in the seven Program regions will be trained in the REC approach and will begin the REC activities.

5) We would like to check the status of the gender-based violence and the community- based micro health finance scheme studies.

As reported on page 5 of the revised FY2017 work plan, due to reduced funding received in FY2017, data collection and reporting of these two studies are postponed to FY2018. Concerning the GBV protocol study, In June 30, 2017, the Program team presented the study protocol to the National Ethics Committee and is currently waiting for the results to be issued in Q4. Regarding the micro-finance scheme study, the protocol will be submitted at the October session of the Ethics Committee. At the moment, the Program team is making necessary preparations so that when the FY2018 work plan is approved, the field survey for these studies will be ready to be conducted.

Specific comments

Page 2 paragraph 5 on availability of some health products: could you provide us with the name of the missing products and location

Please see below and the table has also been added in the stock-out section on p.14 of the re-submitted Q3 report.

Please see Table 1 below, which shows the number of members of each structure and has been added in the re-submitted report.

Coordination Committees for Already Created at the end of Remaining Community Health Structure Q3 FY2017 Coordination Members Coordination Members Committees Committees CCAC – R (regional level) 7 165 0 0 CCAC – D (district level) 34 922 0 0 CCDS (commune level) 456 5,185 0 0 Cosan Fokontany (fokontany level) 4,870 9,844 17 34 Source: Mahefa Miaraka. Data base. June 30,2017

Page 5 on quality of CHV services: how does CCH coordinate with CSB Chief and EMAD on supervision of CHVs? Are there two [parallel supervisions? Does CCH have a transition plan on how to hand over supportive supervision of CHVs to the CSB chief or EMAD?

The Program team at the district level coordinates the supervision plan with members of EMAD and the CSB on a monthly basis. The supervisions are either done jointly or separately depending on a few main conditions: the capacity of the CSB heads (whether or not he/she needs to be coached by EMAD, EMAR or technical Program staff); skills and performance of the CHVs (whether or not he/she needs major support by a team of supervisors); performance of the overall fokontany on WASH indicators; and construction of equipped health hut for CHVs.

With regards to handover of the supportive supervisions, the Program’s current efforts have been focusing on making sure the supervisions are conducted on a regular basis by the CSB, and done correctly in a way that provides support to the CHVs. The goal for this phase is to make sure that the supervisions are well established as routine activities and that all stakeholders (CHVs, CSBs and fokontany leaders) see the importance of the CHV supervisions as an activity to: 1) increase the skills and service quality of the CHVs; 2) improve the supervision capacity of the CSB heads, and; 3) increase the overall health conditions of the fokontany because of the routine supervision/outreach activities conducted by the CSB heads. Once the supervisions are established routine activities, the Program can move into a gradual withdrawal of its financial support to these supervisions. The EMAD and EMAR are involved in supervising the CSB to make sure referral services are available and performed, and that they are able to provide quality training and supervision to CHVs.

Page 16: people reached by SBCC: the number does not add up. Total is 2,077,646.There might be some type of double counting as people can be reached through high visibility event and at the same time through radio for example. Please explain.

It is correct that the Program recorded the number of times people received health messages from different Program communication channels, which is 2,259,646 in total in Q3 FY2017. As the Program diffuses key health messages using multiple communication channels, the people who participated in more than one communication channel will be counted more than one time. However, it is true to say that in Q3, a total of 878,977 people received key health messages from the SBCC activities conducted by CHVs; 930,100 people from the radio diffusion; and 450,569 people from the health campaign and health day celebration organized jointly by the CSBs and the CHVs. The studies show that when people hear the same or similar health messages many times through different communication channels, they are most likely to adopt that behavior (Source: Wakefield et al. Lancet 2010

In Annex : Activity table, Page 12 on stock out: what kind of solution can CCH propose to address health products stock out (except malaria) given that these products are available at the PA level?

5 social marketing channels through PA that are more effective to reach CHVs, and; (3) anticipate the redeployment of the products giving the expiration date with regards to the seasonality of the related diseases. Unfortunately, the close-out preparations of the PSI/ISM project caused some confusion and, in some cases, stock-outs of health products at the PA. An example of this confusion is presented below.

Despite the above, the Program has implemented a few measures to remedy the stock-out situation as below:

a) Sharing monthly data on stock-outs by region with all involved (PSI/ISM, PSM and DLP) – b) Continuing to have a monthly meeting at the regional level between PSI/ISM and Mahefa Miaraka c) Sharing and discussing data on stock-outs at the monthly meetings between CSB and CHV d) Sharing and discussing data on stock-outs at the monthly meetings between EMAD and the Program district team e) Sharing and discussing data on stock-outs at the monthly meetings between EMAR and the Program regional team f) Sharing and discussing data on stock-outs at the monthly meetings at the national level (on malaria products at the meeting held by DLP and other health products at the meeting held by DPLMT) g) Participating in the cascade training on logistics and management of health products including the CHVs, so CSB and the PHA-G-DIS can improve the availability of products in the field h) Working with the SDSP and CSB to supply the CHVs as necessary should the PA have stock-outs and vice-versa.

The text above is also added on page 13 of the Q3 report under the health products section.

Page 17, table 6: what kind of prevention messages does CCH provide on non-communicable diseases which are not part of funding that USAID receives?

As per the PNSC and USAID priorities in maternal and child health, the Program supports the implementation of community-based services through CHVs that are in line with the national guidance and the WHO recommendations. To date, CHVs only provide promotional, preventative care and referral for leading causes of maternal, neonatal and child mortality. Therefore, the Program does not support any non-communicable diseases as per the list of the WHO.

Annex 3 on environmental compliance:1.1.2.3 section mentions the use of incinerator by CHVs. 1.1.2.6 Instead mentions the use of burial pits. Please ensure consistency in the correct method used for waste disposal as these two are contradictory.

Activity 1.1.2.3 does not mention incinerators for CHVs. The incinerator referred to here is GOM’s health facilities, which is the CSB. See quote below:

“Review and update as necessary training curricula and SBCC materials related to health care management and appropriate disposal using incinerators or improved burial pits at health facilities for medical waste, CHX tubes, used sharps, syringes and needles, and expired drugs”

The Program practices on waste management follow both USAID’s regulations and MOH’s regulations meaning that only disposal pits will be used by the CHVs at their health hut and the incinerator or improved burial pits will be used only at the CSB. As per the MOH’s guidance, CHVs are required to bring all hazardous medical waste to

6 the CSB, such as used syringes to be destroyed at the health facility. Therefore, the training of the CHVs includes the management of the medical waste, explaining the indicator in 1.1.2.3.

DISCLAIMER

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