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 2 Progress Report January 1 to March 31, 2017

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

USAID COMMUNITY CAPACITY FOR HEALTH PROGRAM - Mahefa Miaraka

FY2017 Quarter 2 Progress Report Re-Submitted: June 5, 2017 (after USAID comments)

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: Community Health Volunteer dresses a child after weighing in Maintirano District, Melaky Region. 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.

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Table of Contents

Executive Summary of Achievements in Q2 FY2017 ...... 1 Introduction ...... 2 Intervention Area 1 (IA 1):Community Engagement and Ownership of Health Services .... 3 Sub IA 1.1 Increasing Skills and Competencies of CHV in Priority Interventions ...... 3 Sub IA 1.2. Sustainability of the CHV Model...... 11 Sub IA 1.3 Strengthening of Community Structures, ...... 11 Sub IA 1.4 Promoting Universal Health Care Access and Coverage ...... 12 Intervention Area 2 (IA2): Behavior Change and Health Promotion ...... 13 Sub IA 2.1. Community-Level Health Promotion and Sensitization to Increase Healthy Behavior and Uptake of Health Services and Products ...... 13 Sub IA 2.2 Capacity of Community Stakeholders in SBCC ...... 14 Sub IA 2.3 Innovations to Promote Adolescent and Youth Health, with a Focus on Reaching Rural, Underserved, and Married Youth ...... 16 Intervention Area 3: Health Service Planning, Management, and Governance ...... 17 Sub IA 3.0 Reinforcement of GOM Capacity...... 18 Sub IA 3.1. Introduction and Promotion of Non-Clinical Quality Improvement ...... 18 Sub IA 3.2. Pharmaceutical and Commodity Forecasting...... 18 Sub IA 3.3. Health Data Quality, Management, and Use ...... 19 Sub IA 3.4. Referral System Strengthening between CHVs and CSBs ...... 20 Monitoring and Evaluation, Learning Management, and Cross-Cutting Issues ...... 21 Sub IA 4.1 Program Monitoring, Evaluation, and Performance System ...... 21 Sub IA 4.2 Learning Management ...... 22 Sub IA 4.3 Cross-Cutting Issues ...... 22 Challenges and Proposed Solutions for Q2 FY2017 ...... 23 Administrative and Financial Management ...... 23 Sub IA 0. 1 Operation (Administration, Finance, and Partnership) ...... 24 Sub IA 0. 2 Administration ...... 24 Sub IA 0.3 Financial Management ...... 25

Annexes Annex 1. Activity Report Q2, FY2017 Annex 2. Project Performance Review, PPR (Q2, FY2017) Annex 3. Environment Monitoring and Mitigation Report, EMMR (Q2, FY2017) Annex 4. List of Communes in Mahefa Miaraka Program in Q2, FY2017 Annex 5. International Trips at the End of Q2 FY2017 Annex 6. Success Stories Annex 7. Participation in the Central-Level Working Groups and Meetings Annex 8. JSI Responses to USAID Comments with Additional Figures on Selected malaria Indicators

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List of Tables

Table 1 – Comparison of cIMCI Services by CHVs between Q2 FY2016 (MAHEFA) and Q2 FY2017 (Mahefa Miaraka) ...... 6 Table 2 – Comparison of Selected Malaria Indicators between Q2 FY2016 (MAHEFA) and Q2 FY2017 (Mahefa Miaraka), by Region ...... 6 Table 3 - Referral Cases from CHVs to CSBs, Hospitals, or Mobile Clinics in Q2, FY2017 ...... 7 Table 4 – Reasons for Non-Functionality and Plans to Revitalize the Mutuelle de Santé ...... 12 Table 5 – Current Situation of Emergency Transport Activities Started in the MAHEFA Program ...... 13 Table 6 - Program Participation in the GOM Health Days and Campaign in Q2 FY2017 ...... 14 Table 7 - Mahefa Miaraka’s Cumulative Expenses as of March 31, 2017 ...... 25

List of Boxes

Box 1 – A Child Being Weighed by CHVs, Maintirano District, Melaky Region ...... 4 Box 2 – Joint Visit USAID and MOH Led by MOH Secretary General, Sofia Region ...... 11 Box 3 - TOT for members of the PNSC Structures on SBCC in Sofia Region ...... 14 Box 4 - Supervision Visit by MOH Regional Trainer, Boeny Region ...... 18 Box 5 - Supervision Visit by CSB Head, Menabe Region ...... 19 Box 6 – CHVs’ Response to Malaria Outbreaks in Melaky and Boeny Regions ...... 20 Box 7 – Madagascar’s Booth at the 2017 Institutionalizing Community Health Conference, Johanesburg, South Africa ...... 22

List of Figures

Figure 1- Percentage of CHV who Received c-IMCI Training in Q2 FY2017, by Region (n=9,774) ...... 4 Figure 2- Results for CU5 with MUAC Measurement in Q2, FY2017 (n=48,167) ...... 5 Figure 3- Cases of CU5 Treated for c-IMCI by CHVs in Q2 FY2017 ...... 5 Figure 4- Regular Family Planning Users in the Program, by Age Group, Q2 FY2017 ...... 7 Figure 5- New Family Planning Users in the Program, by Age Group, Q2 FY2017 ...... 8 Figure 6- Couple Years of Protection by Family Planning Methods, Q2 FY2017 ...... 8 Figure 7- Stockout Reported by CHVs for Child Health Tracer Products, Q2 FY2017 ...... 9 Figure 8- Stockout Reported by CHVs for Family Planning Tracer Products, Q2 FY2017 ...... 9 Figure 9- People Reached by Multiple Channels for Key Health Messages in Q2 FY2017 ...... 15 Figure 10- Photos from High-Visibility Events in Q2 FY2017 ...... 17

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Acronyms and Abbreviations

ACT Artemisinin-based Combination Therapy AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care ASOS Action Socio-sanitaire Organisation Secours CCAC-D Comité de Coordination pour l’Approche Communautaire – District (Coordination Commitee for Community Health at the District Level) CCAC-R Comité de Coordination pour l’Approche Communautaire – Region (Coordination Commitee for Community Health at the Regional Level) CCDS Commission Communale de Développement de la Santé (Commune Commission for Health Development) CCH Community Capacity for Health CHV Community Health Volunteer CHX Chlorhexidine 7.1% c-IMCI Community-based Integrated Management of Childhood Illnesses CoSan Comité de Santé (Members of the CoSan fokontany are Community Health Volunteers) CSB Centre de Santé de Base (Basic Health Center) CU5 Children Under 5 CYP Couple Years of Protection DDS Direction des Districts Sanitaires (District Health Division) DEC Development Experience Clearinghouse DEP Direction des Etudes et Planification (Research and Planning Directorate) DLP Direction de Lutte Contre le Paludisme (Malaria Control Division) DPEV Direction du Programme Élargi de Vaccination (Division of the Expanded Programme on Immunization) DPS Direction de la Promotion de la Santé (Division of Health Promotion) DSFa Direction de la Santé Familiale (Division of Family Health) DRSP Direction Régionale de la Santé Publique (Regional Public Health Directorate) EMAR Equipe de management régionale (Regional Health Management Team) EMAD Equipe de management de district (District Health Management Team) EMMR Environmental Mitigation & Monitoring Report EPI Expanded Program on Immunization ETS Emergency Transport System FHI360 Family Health International360 FKT fokantany (village or collection of hamlets, lowest administrative level) FP FamilyPlanning FY Fiscal Year GAVI Global Alliance for Vaccination and Immunization GBV Gender-Based Violence GOM Government of Madagascar HIV Human Immuno Deficiency Virus HMIS Health Management Information Systems IA Intervention Areas ICHC Institutionalizing Community Health Conference IEC Information, Education, and Communication IFA Iron Folic Acid IGA Income Generating Activities IR Intermediate Results IPTp-SP Intermittent preventive treatment during pregnancy with sulfadoxine-pyrimethamine JSI JSI Research & Training Institute, Inc. LLITN Long Lasting Insecticide-Treated bed nets KMSm Kaominina Mendrika Salama miabo (Champion Communes for Health) MAHEFA Malagasy Heniky ny Fahasalamana (Community-Based Integrated Health Program)

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MOH Ministry of Health MOU Memorandum of Understanding MUAC Mid-Upper Arm Circumference NGO Non-Governmental Organization ORSEC Organisation des Secours (Emergency Evacuation Plan) PNSC Politique Nationale de Santé Communautaire (National Policy for Community Health) PSI/ISM Populations International Service/Integrated Social Marketing Project Q Quarter QI Quality Improvement RLG Radio Listening Group RDT Rapid Diagnostic Test SBCC Social Behavior Change Communication SIDA Syndrome d’Immuno Deficience Acquise SDSP Service de District de la Santé Publique (District Health Office) SE/CNLS Secrétariat Exécutif/Comité National de Lutte contre le SIDA (Executive Secretary/National Committee on HIV/AIDS) STIs Sexually Transmitted Infections TOTs Training of Trainers USAID United States Agency for International Development VAT Value Added Tax WASH Water, Sanitation, and Hygiene

Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 2 Report 1

Executive Summary of Achievements in Q2 FY2017

The activities and achievements presented in this report are the results of the extremely rapid and successful start-up of the USAID Community Capacity for Health Program or Mahefa Miaraka. Less than 10 months into the program, this quarter saw an acceleration of the field activities, despite challenges including unusually high numbers of malaria cases and other health outbreaks, insecurity and violence in villages in the Menabe and Melaky Regions, and the Enawo cyclone, which caused damage in many Mahefa Miaraka program intervention sites. Community health volunteers (CHVs) and centre de santé de base (CSB) or basic health center staff were among the injured and those who died as a result of these events.

In this quarter, the Mahefa Miaraka program team focused efforts and resources to make sure that the CHVs, especially those in the 24 districts from MAHEFA, fully resumed their health service activities, which included a series of trainings on two key areas using new Ministry of Health (MOH) materials. The first was data management, with CHVs learning how to use MOH’s recently revised integrated health record and transcribe the information into the monthly reporting forms. The second area was the community-based integrated management of childhood illnesses (c-IMCI), using the MOH’s five-day training curriculum. The cascading training approach allowed MOH master trainers to train regional and district trainers, who provided training-of-trainers (TOT) to staff of the CSB, who later conducted the training for the CHVs in their catchment areas. The series of trainings allow the CHVs to perform their work correctly per the MOH’s new standards and norms.

Effective collaboration with the Government of Madagascar (GOM) through the regional authorities who provided overall support to the program and technical support and supervision from MOH staff enabled these CHVs to provide integrated health services to 141,757 cases of children under 5 (CU5) and 91,746 women. The following highlights summarize the main achievements of this quarter.

Beginning of health services at the fokontany level. By the end of March 2017, the program had trained and supported a total of 1,976 fokontany (FKT) heads (representing 40% of the program total); 5,933 CHVs (61%) on data management; and 2,916 CHVs (30%) on c-IMCI. Examples of the health services provided by CHVs in this quarter are presented below.

• 8,449 CU5 cases diagnosed and 7,154 cases treated of diarrhea (3,718, 52% girls). • 9,210 CU5 cases diagnosed and 8,085 cases treated of pneumonia (4,212, 52% girls). • 27,880 CU5 cases and 11,355 cases treated of malaria (5,809, 51% girls). • Provided family planning services for 75,323 women; 18,141 couple years of protection (CYP) during the quarter. • 65,169 CU5 weighed by CHVs, out of which 41,072 or 63% are children under 2 years (CU2). • 31,049 CU5 referred by CHV for vaccination. • 528,185 people received key messages via CHV education group sessions; 114,954 people via CHV home visits; and 217,430 people via counseling at the health hut (Toby).

Strengthened the continuum of care by linking health services at the fokontany and commune levels. Mahefa Miaraka supported monthly meetings, on-site CHV supervision, and organization of the government’s health campaign and health days, resulting in better communication and coordination between the CSB and the CHVs. During this quarter, a total of 33,294 CU5 were referred by CHVs to services at CSBs for vaccination, treatment of malnutrition and danger signs, and other services. Additionally in this quarter, a total of 17,589 women were referred to CSBs for antenatal (ANC) visits, follow-up, and delivery.

Ownership from local authorities and leaders. By the end of this quarter, Mahefa Miaraka helped create the structures to manage the community activities based on the National Policy for Community Health (Politique Nationale de Santé Communautaire, or PNSC) at the regional and district

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levels. At the commune level, a total of 439 (96%) created their PNSC structure. By the end of March 2017, a total of 17,612 local participants (GOM officials, members of PNSC structures, community organizers, and others) were participating in the planning, implementation, and monitoring of the program activities. Their participation will help assure that activities will contribute to the health goals and objectives of the region, district, and commune.

During the second quarter of FY2017, management and compliance systems continued to support program work. The main achievements of Mahefa Miaraka during the reporting period are presented according to the three intervention areas (IAs) which include the challenges and corrective measures undertaken. 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 second quarter of FY2017 are presented in Annex 3.

Introduction

USAID awarded the five-year Cooperative Agreement (No. AID-687-A-16-00001) for the Mahefa Miaraka 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 (ASOS), Family Health International 360 (FHI360), 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

Mahefa Miaraka 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 GOM efforts to reduce maternal, newborn, and child mortality in Madagascar. Mahefa Miaraka will contribute directly to the USAID/Madagascar Health Population and Nutrition’s Intermediate Results (IRs) 1 and 2 of USAID’s health sector strategy, for which the development objective is “Sustainable Health Impacts Accelerated for the Malagasy People.”

Mahefa Miaraka operates in 4,774 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% of the country’s total population.

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

Key Achievements in Q2: 1. Community health structures created and members received training. 2. Almost a third (30%) of CHVs received cIMCI training. 3. CHVs resumed providing health services and reporting to CSBs on a monthly basis. 4. Schools for youth activities selected. 5. Communities with mutuelle de santé or emergency transport reviewed activities and identified areas for improvement.

Sub IA 1.1 Increasing Skills and Competencies of CHV in Priority Interventions to Reduce Maternal, Newborn, and Child Mortality, as well as in Data Collection and Use

1.1.1 Reinforcement of Capacity of Members of PNSC Structures on CHVs’ Priority Interventions

PNSC Coordination Structures. By the end of this quarter, Mahefa Miaraka helped to create the structures to manage the community activities based on the National Policy for Community Health (Politique Nationale de Santé Communautaire, or PNSC) at the regional and district levels. At the commune level, a total of 439 communes (96%) created their PNSC structure. In Q2, a total of 255 GOM and 2,919 community leaders (1,727 CHVs, 886 FKT heads, and 306 Commission Communale de Développement de la Santé [Commune Commission for Health Development/CCDS]) received orientation to PNSC and 817 members received a training-of-trainers (TOT) on the community champion approach and on Mahefa Miaraka’s program strategy and approaches for Social Behavior Change Communication (SBCC).

Management of Community Health Data. During this quarter, the Mahefa Miaraka program staff has been working on modifications to the CHV’s integrated record book with concerned divisions of the MOH: Family Health Division (Direction de la Santé Familiale, DSFa); the Directorate of the Expanded Program on Immunization (Direction du Programme Élargi de Vaccination, DPEV), the Research and Planning Directorate (Direction des Etudes et Planification); the District Health Division (Direction des Districts Sanitaires, DDS); and the Malaria Control Division (Direction de Lutte Contre le Paludisme, DLP). CHVs began using the MOH’s new form to complete and submit monthly reports to their supervisors i.e., (CSB head).

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

Training Program for CHVs and Fokontany Heads. The MOH revised the training curriculum for CHVs in integrated cIMCI in early 2016. Mahefa Miaraka program staff at the central office assisted the MOH to prepare the training materials including the curricula for the training of trainers. Beginning in January, Mahefa Miaraka and the MOH master trainers trained 47 regional and 269 district trainers in the seven program regions. After that, the MOH trainers at the regional and district levels conducted the TOT for the CSB staff (709), who in turn conducted the c-IMCI training for CHVs in their CSB catchment area. In Q2, a total of 2,916 of 9,774 CHVs (30%) received a c- IMCI training (Figure 1).

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Figure 1- Percentage of CHV who Received c-IMCI Training in Q2 FY2017, by Region (n=9,774)

By the end of March 2017, a total of 5,933 CHVs also received training on data management so they could begin using the MOH’s revised integrated record book and monthly report form.

Non-Clinical CHV Supervision Visits. During this quarter, 1,751 CHVs received on-site supervision visits. Of these, 952 were supervised by the fokontany heads, 128 by members of CCDS, and 671 by the Mahefa Miaraka program staff. The CHV clinical supervisions conducted by the MOH officials in this quarter are presented under IA3.

1.1.3 Quality of CHV services

Government officials and the Mahefa Miaraka program staff started to conduct supervision visits to make sure the services provided by CHV meet quality norms and are within national standards. The Mahefa Miaraka program will begin using the community score card approach to increase CHV service quality next quarter. Box 1 – A Child Being Weighed by Services Provided by CHVs in Q2 FY2017 CHVs, Maintirano District, Melaky Region During this reporting period, CHVs began providing basic services according to the continuum-of-care chart. The information presented below is from the CHV’s monthly report form. Details of services are presented below.

Maternal, newborn and child health (MNCH)

Prevention of postpartum hemorrhage and newborn cord infection (using misoprostol and chlorhexidine 7.1%) Mahefa Miaraka participated in the MOH orientation to scale up the use of misoprostol and chlorhexidine (CHX). A total of 1,032 newborns received CHX in this quarter. In addition, Mahefa Miaraka worked with Direction de la Santé Familiale (DSFa) or Division of Family Health to distribute 30,320 doses of misoprostol

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and 50,478 doses of CHX for use by the CHVs and CSB in the seven regions.

Nutrition. In Q2, CHVs weighed 65,169 CU5, of whom 41,092 (63%) were CU2. CHVs also measured the middle upper-arm circumstance (MUAC) of 48,167 CU5 at their health hut or Toby (Box 1 and Figure 2). During this quarter, CHVs referred 1,019 malnourished CU5 for treatment at the health facilities (Table 3 under IA 3 on referral cases).

Figure 2- Results for CU5 with MUAC Measurement in Q2, FY2017 (n=48,167)

c-IMCI Services for Children under 5 (CU5). A significant part of a CHV’s mandate is to provide services to CU5 including diagnosis, treatment, counseling, and referral to CSBs as necessary. Key results in this area during Q2 are presented below. In Q2, these services were only provided by CHVs in ongoing districts from MAHEFA because CHVs in the new Mahefa Miaraka districts (Analanjirofo, 6 districts; SAVA, 3 districts; and Sofia, 1 district) have not yet been trained. Figure 3 shows that the CHVs started to resume their services, evidenced by the number of children receiving treatment for pneumonia during the three months of Q2 FY2017.

Figure 3- Cases of CU5 Treated for c-IMCI by CHVs in Q2 FY2017

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In comparing the cases of CU5 treated by CHVs during this quarter, the first quarter that CHVs provided and reported their services under the Mahefa Miaraka program, with the last quarter (Q2 FY2016) of the former MAHEFA program, the trend is very promising (Table 1 below shows a comparison between the two periods). Though the numbers for Q2 FY2017 appear low, the rate of achievement is high, especially considering that Q2 FY2016 was the peak performance of the CHVs under MAHEFA, and that Q2 FY2017 performance was understandably low for Mahefa Miaraka as the CHVs started to resume health services provision with program support. Additional considerations are that CHV involvement in the intensive training program activities in Q2 and in the MOH’s health campaign in March 2017 resulted in CHVs having less time to provide services. Given these considerations, it is notable that for these child health indicators, Mahefa Miaraka is already one-third or more of the way toward achieving peak quarterly performance of the former program.

Table 1 – Comparison of cIMCI Services by CHVs between Q2 FY2016 (MAHEFA) and Q2 FY2017 (Mahefa Miaraka)

c-IMCI simple cases treated by CHVs Cases Cases treated % of cases treated by by CHV in Q2 treated (Q2 CHVs in Q2 FY2017 FY2017 FY2016 (Mahefa compared to (MAHEFA) Miaraka) Q2 FY2016) CU5 cases with diarrhea & no dehydration received 22,535 7,154 32% Viasur, ORS, and/or zinc CU5 cases with simple pneumonia treated by CHVs 21,625 8,085 38% CU5 cases with fever N/A 33,554 CU5 cases with fever treated with ACT 20,343 11,355 56% Total of CU5 cases treated in c-IMCI 64,503 26,594 41%

Malaria. Similar to the other c-IMCI services, CHV’s services in malaria in Q2 resumed smoothly, as shown in Table 2 below, which compares the malaria services in Q2 FY2016 and in Q2 FY2017. The table also shows a higher number of malaria cases in Q2 FY2017 (tested positive and treated with ACT) due to the malaria outbreaks in Besalampy District of Melaky and in Soalala District of Boeny. The CHVs in these two districts were heavily involved in the response to the outbreaks. More details on the outbreaks and the responses are presented in IA3 of this report.

Table 2 – Comparison of Selected Malaria Indicators between Q2 FY2016 (MAHEFA) and Q2 FY2017 (Mahefa Miaraka), by Region

Cases in Q2 Cases in Q2 Indicators FY2016 FY2017 (MAHEFA) (Mahefa Miaraka) 27,880 (71% CU5 with fever tested with RDT by CHV 39,433 compared to Q2 FY2016) 14,781 (38% of the 13,834 (50% of the CU5 presenting fever who tested positive with RDT by CHV cases tested) cases tested) 8,799 (60% of the 11,355 (82% of the CU5 with fever treated with ACT by CHV positive cases) positive cases)

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, and delivery. These 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,

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among other services available at CSBs. Table 3 shows the number of individuals referred and the types of referrals by CHVs during Q2 FY2017. In this quarter, there were 17,589 women and 33,294 CU5 referred by CHVs to receive health services at the CSB. The table also shows that during this quarter, the CHVs referred a total of 31,049 CU5 for vaccination, representing 93% of the CU5 cases referred to CSB for any reason.

Table 3 - Referral Cases from CHVs to CSBs, Hospitals, or Mobile Clinics in Q2, FY2017

Referral services by CHVs Type of service Number of women referred in Q2, FY2017 First prenatal consultation including tetanus Malaria, maternal and vaccination, IFA, intermittent preventive newborn care 6,974 treatment in pregnancy, and LLITN Pregnant women for fourth antenatal care visit Malaria, maternal and 5,914 newborn care, Pregnant women for delivery Maternal and newborn care, 3,535 assisted delivery Long-acting contraception Family planning 1,166 Sub-total: number of pregnant women referred 17,589 to CSBs Pregnant women with confirmed counter-referral 4,176 from CSB back to CHVs Referral services by CHVs Types of service Number of CU5 referred in Q2, FY2017 Cases of CU5 referred for vaccination Child care 31,049 Cases of CU5 referred for malnutrition Child care 1,019 Cases of sick CU5 with danger signs (newborns, Malaria, treatment of malaria, acute respiratory infection (ARI), and complicated cases, water 1,226 diarrhea) treatment Sub-total: number of cases of CU5 referred to 33,294 CSBs CU5 with confirmed counter-referral from CSB 11,050 back to CHVs

Family Planning and Reproductive Health

At the end of this quarter, the CHVS in the 24 districts of the former MAHEFA program reported that they provided FP services to 75,323 women, of whom 17,691were new users (Figures 4 and 5). FP services for the 10 new districts will begin later in the year after CHVs receive FP training. Figure 6 shows the couple years of protection recorded at the end of March 2017.

Figure 4- Regular Family Planning Users in the Program, by Age Group, Q2 FY2017

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Figure 5- New Family Planning Users in the Program, by Age Group, Q2 FY2017

Figure 6- Couple Years of Protection by Family Planning Methods, Q2 FY2017

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1.1.4 Women- and youth-friendly environment and services

Situation Analysis on Gender-Based Violence (GBV). Mahefa Miaraka finalized a study protocol on this topic that will be submitted for approval to the MOH Ethics Committee in Q3. The study results will determine the types of GBV activities in the program.

Activities for In-School Youth. During this quarter, 34 officials from the district education office and program staff met with the 38 schools selected for youth activities. A total of 340 teachers, 50 students between 10–24 years old (class levels 4 and 5), and 608 parents participated in the meetings in seven regions. The following topics were identified as important messages for youth in school:

• For parents: messages on communication between parents and children. • For students: messages on reproductive health, including prevention of unwanted and early pregnancy, early marriage, STIs and HIV, substance addiction, menstrual hygiene, and family planning. 1.1.5 Equipment and Appropriate Work Tools, Job Aids, and Materials for Community Actors (CHV, Fokontany Heads, and Members of CCDS)

Health Commodities for CHVs. When the MAHEFA program ended its field activities in Q2 FY2016, the stockout level reported by the CHVs was between 3 and11% for child health tracer products and 2 and 15% for family planning tracer products. As the new Mahefa Miaraka program began its field-level activities in Q2, we found that the stockout levels reported by the CHVs were extremely high (Figures 7 and 8). One explanation for this is that some CHVs finished their stock and did not replenish it during the gap between the two programs. To remedy this problem, the program team is coordinating with DLP for malaria products and the PSI/ISM project for other CHV health products to furnish the new startup kits. The program will monitor and report stockout levels at the CHVs to both the national supply chain system and the social marketing for CHV health products on a regular basis to reduce stockout levels.

Figure 7- Stockout Reported by CHVs for Child Health Tracer Products, Q2 FY2017

Figure 8- Stockout Reported by CHVs for Family Planning Tracer Products, Q2 FY2017

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Materials for Community Activists. During the quarter, the Mahefa Miaraka program distributed work tools and materials to 5,932 community actors (3,218 CHVs, 2,347 fokontany heads, and 367 members of the CCDS). The materials were distributed as part of the orientation workshops and trainings. Other materials namely bags, uniforms, and supplies; work tools and job aids; management tools; training tools; and IEC materials will be produced and distributed in upcoming quarters.

1.1.6 Motivation Activities for CHVs and FKT Heads

The motivation activities conducted in Q2 FY2017 are presented below.

• Community Support. The program recorded a total of 927 health huts or Toby, built by the community for use by 1,854 CHVs. Of the huts built, 76% (707) are equipped with chairs, desks, and/or shelves.

• Financial Incentive through Income-Generation Activities (IGA). The program recorded 86 CHVs who continue the sale of the water, sanitation, and hygiene (WASH) products to generate income. Additionally, a total of 23 community actors in Miandrivazo District of Menabe Region received 200,000AR each from the profit- sharing between members of the eBox activities. Some members are employees of the eBox, so they receive monthly salaries in addition to their share of the profit.

• Link with the Public System via Monthly Meeting and Onsite Supervision. A total of 7,218 community actors (5,242 CHVs [88.4%] of those trained in data management and 1,976 Fokontany heads) participated in the monthly meeting at the CSB (2,585 CHVs in January, 5,202 in February, and 5,242 in March 2017). These meetings forge a stronger working link between the community and the CSB and are an opportunity for the CSB and the Mahefa Miaraka program to provide technical updates and information.

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• Official Visits. CHVs reported that official visits from people from outside the community motivate them because such visits indicate that their efforts are appreciated. In this quarter, a total of 30 CHVs received a visit from high-level MOH officials in their Toby (see Box 2).

Box 2 – Joint Visit USAID and MOH Led by MOH Secretary General, Sofia Region

In March 2017, Vandro, a CHV, received a visit from the high-level officials. She was asked to demonstrate how she provides injectable family planning services. She used the checklist and followed procedures, and the MOH visitors praised her outstanding work.

Sub IA 1.2. Sustainability of the CHV Model, including Full Integration of CHV into the Formal Public System

1.1.7 Supportive Supervision Visits to CHVs

As reported above, a total of 1,751 CHVs received supervision visits from FKT heads, CCDS, and Mahefa Miaraka program staff in this quarter. The intensive training activities and the MOH’s March polio campaign took priority over on-site CHV supervision visits.

Sub IA 1.3 Strengthening of Community Structures, including CoSan and CCDS, to Improve Health and Sanitation Planning

1.3.1 Functionality and Reinforcement of Community Health Structure Activities to strengthen the capacity of members of the PNSC coordination structure were reported above under section 1.1.1. In Q2, the Mahefa Miaraka teams at the district and regional levels in Melaky, Menabe, and SAVA participated in the government-led coordination meeting.

1.3.2 Using Champion Commune or KMSm Approach to Manage Community Health

Training Curriculum for the Revised KMSm Approach. In Q2, a total of 115 members of PNSC structures (9 CCAC-R, 34 CCAC-D, and 72 CCDS) from Boeny, DIANA and Sofia and 33 Mahefa Miaraka program staff received training on the revised Kaominina Mendrika Salama miabo (champion communes for health [KMSm]) approach. The KMSm activities will be conducted at the community level in later quarters.

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Sub IA 1.4 Promoting Universal Health Care Access and Coverage, Including Entitlement Programs (e.g. GOM equity fund), Micro-Insurance (i.e. mutuelle de santé), and Emergency Transport System

1.4.1 Increase Access to Health Care via Community Health Financing Scheme (Mutuelle, Solidarity fund and Equity Fund)

In this quarter, the program made a rapid survey among the 33 communes that started their mutuelle activities under the former MAHEFA program. The result of the survey shows that 17 communes continue their activities. Table 4 explains the reasons why some are no longer functioning. Among these, some of the communes would like to revitalize their activities and they identified ways to do so. A success story on mutuelle de santé in Annex 6 shows that the mutuelle could increase access and utilization of services at the CSB.

Table 4 – Reasons for Non-Functionality and Plans to Revitalize the Mutuelle de Santé Started in the MAHEFA Program

Reasons for non-functionality Action plans by the communes to revitalize in case of non-functionality Local context a. Work closely with local police or security 1. Insecurity and geographical accessibility agents to protect the mutuelle groups. challenges. b. Request financial support from private sector 2. Poor quality of health services. groups such as Madagascar Oil to support CSB so they can provide better services. Management a. Hold management meetings to review the 1. Lack of availability and transparency group’s progress; if needed renew management among management members members and internal procedures/rules. 2. Lack of communication among b. Set up internal audit system (mise en place de management members. commissaires aux comptes). 3. The management members lack commitment to make sure the mutuelle activities work and often wait for the program to follow up Membership a. Revise membership payment plan. 1. Community inability to pay. b. Promote awareness for membership. 2. Lack of information about the mutuelle c. Mobilize local resources namely local de santé. companies, local associations or NGOs as 3. source of financial support.

1.4.2 Increase Access to Health Care via Emergency Transport

FKT’s Health Evacuation Plan. During Q2, The Mahefa Miaraka program staff located a copy of the Organisation des Secours, ORSEC (Emergency Evacuation Plan), which is available up to the commune level. In this quarter, 318 fokontany made health evacuation plans.

Emergency Transport. Of the 150 fokontany that benefitted from the emergency transport system (ETS) during the former MAHEFA program, Mahefa Miaraka received data on 79%, or 118 fokontany. Among these, more than half (54%) reported that their means of emergency transport are still functioning and in use. In this quarter, 32 fokontany have not yet reported their ETS activities therefore their data will be reported in Q3. Table 5 below presents details of the functionality of the ETS in the program area.

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Table 5 – Current Situation of Emergency Transport Activities Started in the MAHEFA Program, End of March 2017

Number Number Number of of FKT of FKT FKT with Data not Region District Commune that with non- yet received functional functional received ETS ETS ETS DIANA Antsiranana II Mahavanona 21 0 21 0 Anivorano 16 3 9 4 Andranofanjava 10 8 2 0 MENABE Morondava Analaiva 10 6 3 1 Bemanonga 12 3 8 1 Miandrivazo Akondromena 12 5 7 0 SAVA Vohemar Ampanefena 12 4 1 7 Antsirabe Nord 9 2 1 6 Nosi Be 11 5 1 5 SOFIA Mandritsara Antanandava 19 14 1 4 Mandritsara 9 9 0 0 Pont Sofia 9 5 0 4 TOTAL 5 12 150 64 54 32

For FKT with non-functioning ETS, reasons relate to damages to the means of emergency transport and lack of funds to repair them. These FKT reported that they will organize to repair the means of emergency transport and continue to sensitize members to the importance of the ETS and make sure it continues to work.

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

Key Achievements: 1. 520,563 people were reached by CHV education group sessions; 244,842 people by CHV home visits; and 203,078 people by counseling at the Toby. 2. The TOT for regional and district levels began in this quarter. A total of 115 government trainers received training in SBCC approach. 3. 36 local radio stations began diffusing key messages.

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 program revised and developed materials and began a series of training for community actors on the Social Behavior Change Communication (SBCC) approach and tools. Details are presented below.

2.1.1 SBCC Strategy, Approaches, Materials and Tools

MOH Division of Health Promotion (DPS) and Mahefa Miaraka program staff developed the training curriculum and conducted the TOT for Boeny, DIANA, and Sofia Regions. The lessons from this TOT will be used to finalize the training curriculum for use in the next quarters. The trainers will

Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 2 Report 14

conduct the TOT for the PNSC structures at the commune levels, who will conduct the SBCC training for the community actors (CHVs and FKT heads).

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

A total of 287,574 health cards (143,787 women’s and 143,787 children’s health cards) were reprinted and sent to the regions in March. In addition to routine use by the CHVs and CSB staff, the cards will be distributed to women and children who don’t yet have the cards during the MOH- led Mother and Child Health Week scheduled for April 25, 2017. The larger cards will be the main tool used by CHVs as part of their promotional activities.

2.1.3. Development and/or Reproduction and Dissemination of Tools and Information, Education, and Communication (IEC) Materials for Use by CHVs and CSBs

A total of 13 audio products based on FP, gender, nutrition, and malaria prevention, as well as four types of household cards based on the health of pregnant woman’s and children ages 0 to 59 months were pre-tested and finalized. Other IEC materials (household cards and certificates for Ménages Modèles and Ménages Parrains) will be used by CHVs and FKT heads starting in Q3.

Sub IA 2.2 Capacity of Community Stakeholders to Assess Community Needs, Develop Key Messages, and Advocate for Improved Services

2.2.1 SBCC Skill-Building for Community Leaders

As reported above, Mahefa Miaraka conducted a TOT in March 2017. A total of 115 participants (members of the CCAC-R/C and members of the CCDS) learned about the program’s SBCC strategies, tools, and their role in training CHVs and FKT heads in their respective districts or regions. The training of the community actors as well as the community-level SBCC activities will begin in Q3.

Box 3 - TOT for members of the PNSC Structures on SBCC in Sofia Region

2.2.2 Roll Out SBCC Activities at the Community Level

Participation in the GOM-Organized Health and WASH Days. In Q2, CHVs, fokontany heads, and program staff participated in two high-visibility events organized by the government , International Women’s’ Day on March 8 and the World Water Day on March 22. Additionally, the program participated in the MOH-led polio campaign (March 23–25). People reached by these events are presented in Table 6 below. A collage of photos from these high-visibility events are presented in Figure 10.

Table 6 - Program Participation in the GOM Health Days and Campaign in Q2 FY2017

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Number of GOM- people organized reached by Program participation (activities) health days key and campaigns messages International 145,881 The Mahefa Miaraka program participated in the three events in Q2 in Women’s day various ways: (March 8) 1. Planning. World Water 10,138 2. Joining parade. Day (March 22) 3. Organizing a booth or a table with information on program and CHV Polio campaign 336,331 activities and CHV service provision including promotion and (March 23–25) distribution of health products for family planning and water treatment. 4. Participation in other activities such as debate, competitions, and sports events. 5. Participated in the debrief sessions organized by the regional government office 6. Provided financial support to some activities.

Media Activities for Promotion of Key Health Actions. In Q2, a total of 36 local radio stations started diffusing media products revised by the program. Also in Q2, a total of 18 tales, 13 spots, and 11 drama pieces were revised and are being diffused by the local radio in the program areas. The key messages are on maternal and child health, including ANC, nutrition, vaccination, malaria prevention, and WASH. All are focused on prevention of diseases and promote essential family practices to improve community’s health status. The results from the Millennium Development Goals survey in 2013 showed that in the program seven regions, 46% of women of reproductive age and 53% of men of reproductive age were exposed to radio at least one times per week. Also, results from the CCH Baseline survey showed that 16.7% of women of reproductive age were exposed to MCH messages. The number of people exposed to radio diffusion is estimated using the information from both MDG survey and CCH Baseline survey and assuming that at least 16.7% of men of reproductive age were exposed to radio. In total, 392,347 persons were reached through radio diffusion during Q2.

The program contacted the Executive Secretary of the National Committee on AIDS (Secrétariat Exécutif Comité National de Lutte contre le SIDA) for radio posts to be provided to the community actors in the program areas. The program team started to revise the radio listening group (RLG) approach including the facilitator’s manual. The SBCC training in March included information on the RLG activities and how to set up them up at the community level.

SBCC Activities Implemented by Community Actors. As reported above, the TOT conducted for the PNSC coordination structures at the regional and district levels were conducted in March 2017. SBCC community-level training and activities will follow in Q3. During this quarter, the program delivered key health messages using several communication channels. Figure 9 presents people reached by multiple channels for key messages in the program in the second quarter of FY2017. CHVs (in orange color charts in Figure 9) constitute the largest source of key health messages in this quarter.

Figure 9- People Reached by Multiple Channels for Key Health Messages in Q2 FY2017

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Waste Management at CHVs Toby. In Q2, the program recorded 927 health huts or Toby built by the community for use by CHV as their work place. Of these, 707 (76%) had basic furniture (shelves, table, and chair), 403 (44%) were equipped with a latrine, and 503 (54%) with a waste disposal pit.

Sanitation and Hygiene. Mahefa Miaraka promoted the construction and use of improved latrines in its program areas. During this quarter, the program team made a fokontany-level survey. The survey shows that there are 7,301 new improved latrines found in the program regions. This is the number of latrines that the program will use as a baseline.

Sub IA 2.3 Innovations to Promote Adolescent and Youth Health, with a Focus on Reaching Rural, Underserved, and Married Youth

2.3.1 Strengthening Local Structure to Promote Youth Health

On February 27 and 28, 2017, the MOH office for Reproductive Health (under the Division of Family Health) held a workshop for stakeholders working in the area of youth and reproductive health. A total of 45 people participated in this workshop to coordinate the youth and reproductive health intervention according to the MOH’s annual action plan for 2017, and inventory the IEC materials and documents on youth and reproductive health activities. This workshop was an opportunity for stakeholders to develop the national platform for the coordination of youth and reproductive health program. The Mahefa Miaraka program presented on innovations in youth approaches such as “jeunes modèles” and “jeunes parrains.” In Q3, the program will work with the MOH to finalize key messages for youth in- and out-of- school.

2.3.2 School-Based Youth SBCC Activities

The activities under this section are reported under IA1.

2.3.3 SBCC Activities for Out-of-School Youth

As reported above, SBCC activities will begin in Q3, at which time the ménage modèle and ménage parrain approach will be rolled out in the communities. Within this approach, the FKT heads and CHVs will solicit couples under 24 years old to be ménage modèle and ménage parrain and reach out to other young couples in their communities to promote the package of key health actions.

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Figure 10- Photos from High-Visibility Events in Q2 FY2017

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

Key Achievements: 1. 5,242 CHVs participated in the monthly meeting led by the CSB heads. 2. 1,025 MOH trainers (47 at the regional level [EMAR], 269 at the district level [EMAD], and 709 CSB heads or deputies) received TOT on the revised c-IMCI guidelines. 3. Mahefa Miaraka program staff participated in 73 technical sessions led by GOM during Q2 (10 coordination meetings, 46 working session/workshops, and 17 other meetings).

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Sub IA 3.0 Reinforcement of GOM Capacity to Provide Technical Training and Supportive Supervision to CHVs and Community Leaders

3.0.1 Coordination with MOH

Participation in Central GOM-Organized Technical Meetings and Workshops. During Q2, Mahefa Miaraka staff at the central office attended 73 technical meetings organized at the central level (see Annex 7). It is important that the program staff receive updates on current GOM initiatives. The main technical themes of the meetings during this quarter were: maternal, newborn and child health; family planning; c-IMCI; and nutrition and national priorities and policies including PNSC, community logistics, universal health coverage, and reaching each child approach in Expanded Program on Immunization (EPI).

Capacity Building of GOM Officials. Mahefa Miaraka uses the cascading training approach for training community actors namely FKT heads and CHVs. Use of this training approach means that the program conducted a TOT for 1,025 GOM officials (47 from the regional level, 269 from the district level and 709 CSB heads or designated CSB staff. Additionally, in this quarter a total of 115 members of the PNSC structures received a training of trainers on the SBCC strategy and Box 4 - Supervision Visit by MOH Regional approaches. Trainer, Boeny Region

Technical Supervision by GOM for CHVs (monthly meeting and supportive supervision). In Q2, a total of 1,043 CHV received on-site supervision visits by GOM officials. The majority of the CHV visits were by the CSB heads (688 or 66%), followed by the EMAD (286 or 27%). The CHV visited by the regional health trainers and by the MOH officials were 39 (4%), and 30 (3%) respectively. in March, a total of 5,242 CHVs and 1,976 FKT heads participated in meetings for CHVs to submit their monthly reports and receive updates and continuing technical training. The CHVs also discuss work-related difficulties and challenges and ask advice from the CSB heads.

Sub IA 3.1. Introduction and Promotion of Non-Clinical Quality Improvement Process and Tools (e.g. Patient Flow, Wait Time, Strategic Use, and Placement of IEC Materials)

3.1.1 Non-clinical CSB improvements

In Q2, the Mahefa Miaraka team continued to prepare a study protocol on the CSB survey. The survey protocol will be submitted and presented for committee approval in Q3 FY2017.

Sub IA 3.2. Pharmaceutical and Commodity Forecasting in Order to Ensure that CSBs Order Commodities in a Timely Manner, Maintain Appropriate Stock Levels, and Maintain Appropriate Storage Conditions

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During this quarter, staff of Mahefa Miaraka participated in eight meetings related to national supply of health products to be used at the community level (details in Annex 7). Additionally, our program team had a series of coordination and work meetings with the team from the PSI/ISM project 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. A memorandum of understanding (MOU) between the two projects was signed in March 28th. In Q3, the Mahefa Miaraka program plans to provide the old CHV sites and CSBs with chlorhexidine 7.1% and misoprostol.

Sub IA 3.3. Health Data Quality, Management, and Use to Improve Patient Outcomes; and Reinforcement and/or Development of Community-Based Surveillance Program

3.3.1 CHV Monthly Reporting to CSB

In this quarter, 13,193 monthly reports or Rapports d’Activités Mensuels were submitted to the CSB (3,714 in January; 5,138 in February; and 4,341 in March). Because this quarter was the first period during which field-level activities took place, the reporting pattern is not established but is expected to improve in later quarters. In this quarter some SDSP began to request that CHVs submit their monthly report by fokontany instead of by individual CHV as before as required by the MOH. JSI team will make sure that all CHVs in its region respect the new rule and begin to report their monthly report to CSB by fokontany from Q3 onward.

Box 5 - Supervision Visit by CSB Head, Menabe Region

“It is inspiring to see the Community Health Volunteers become more skillful and gain more trust from their community. Every time I make a supervision visit I’m amazed how 3.3.2 many children the volunteers treat.”, said Dr. Danielle, CSB head in Mahabo Commune (in black blouse) during a supervision visit in Anja fokontany.

Integration of Data from CHV Routine Reporting into MOH's HMIS

As explained above, starting in March the program will be able to process community data and share it with the district-level health offices. At the national level in Q2, the program team participated in ten meetings related to Health Management Information System (HMIS) organized by the MOH.

3.3.3 Integrated Community-Based Surveillance of Preventable Diseases

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The JSI team had several coordination meetings with the MOH/DPEV/DDS, GAVI, and Maternal and Child Survival Program teams to improve vaccination coverage and completion in the program areas. JSI simplified MOH’s job aid on community surveillance for community-level use. During this quarter, the CHVs and program staff in Boeny and Melaky regions participated in the MOH/DLP urgent efforts to respond to the malaria outbreaks (more information in Box 6). The program also participated in the MOH’s effort to strengthening immunization coverage using the “Reach Each Child Approach.”

Box 6 – CHVs’ Response to Malaria Outbreaks in Melaky and Boeny Regions

MOH officials, with assistance from CHVs (in blue Tshirt) prepared children for malaria test, Antsirasira fokontany, Besalampy district, Melaky Region

In December 2016, there was a malaria outbreak in Antsirasira community in Besalampy District, Melaky Region. This community is very isolated and hard-to-reach (125km on a footpath from the district town) and often has security problems with local bandits. Unfortunately, the outbreak report did not reach the MOH until January 2017. In response, the MOH’s team traveled to the site (it took 2 weeks from the time they left Antananarivo to the outbreak site). Before the arrival of the MOH team, the district health team and the CSB head near the community started testing and treating malaria positive cases and began prevention activities. The CHVs in the community worked with CSB heads and staff of the district health office until the arrival of the MOH delegation. In the Antsirasira fokontany (photo above), 76 cases were tested for malaria and more than one third or 29 cases were positive and received treatment.

Another outbreak occurred in March 2017 in Ambonara Fokontany of Soalala District in Boeny Region, not far from Antsirasira. Fortunately, the Mahefa Miaraka program staff was in the area for the monthly meeting at the CSB, and reported the outbreak to the program’s regional office, which informed the regional and district health offices. A response was organized immediately, again including district health teams, CSB staff, and CHVs to diagnose and treat malaria cases, and provide prevention messages.

This experience shows us that the early reporting and coordination among health partners can save lives and contain the outbreak more effectively. The Mahefa Miaraka program informs all of its district teams about the importance of early reporting on any disease outbreaks or epidemics in the program areas.

3.3.4 Data Use for Performance Review

In Q2, the Program and the regional and district health offices continued to discuss key indicators to be monitored through the program dashboards. The results are not final but will be in Q3, after which the dashboards will be developed and used.

Sub IA 3.4. Referral System Strengthening between CHVs and CSBs to Increase Preventive Care and Prompt Treatment and Strengthening Referral Between

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Health and Other Services (e.g. Youth Social Services and Gender-Based Violence)

3.4.1 Referral System between CHVs and CSBs

In Q2, the program team and MOH officials and community actors continued to discuss ways to improve the referral and counter-referral systems between the FKT and the commune levels (CHV to and from CSB). The program data presented in Table 3 under IA1 shows that almost one third or 30% of the total cases referred by CHVs to CSB were returned (or counter-referred) to CHVs (15,226 counter referred of 50,883 referred). These figures show that the referral and counter referral systems between CSB and CHVs work but needs improvement, and the program will strengthen these systems in the next quarters. More information was presented in IA1 earlier in this report.

3.4.2 Referral System Between Health and Other Services (e.g. Gender Violence)

The referral system between the health service sites and non-health service sites will be developed after the study on gender-based violence (GBV) is analyzed. When information on services related to GBV in the Mahefa Miaraka program areas and how they can be linked to the current health care system at the community level is available the program will plan activities accordingly.

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

Key Achievements: 1. The program data system was created and data collection tools started to be used. 2. Mahefa Miaraka staff attended 10 MOH-led meetings related to HMIS, of which two related to use of tablets to improve health performance. 3. An appointment to present three study protocols to the National Ethics Committee is set in Q3.

Sub IA 4.1 Program Monitoring, Evaluation, and Performance System

4.1.1 Data Management

During this period, the M&E team finalized the indicators and collection/reporting tools for all levels of the program, from FKT to the central level. The electronic data base system was created during this quarter and 179 program staff at the district and regional levels were training on the M&E system including data collection tools and data processing. The data processing began after the training.

4.1.2 Data Use

Program activities on data use are reported under IA3. Community data from this quarter will be used to test and finalize use of dashboards in Q3. These data will also be used by program staff to follow activities and results and also by CSB, SDSP, and Direction Régionale de la Santé Publique, DRSP (the regional public health directorate) during the joint review coordination meetings.

4.1.3 Technology Use to Improve Health Services

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This year, Mahefa Miaraka will focus on the use of technology to set up the current data system online and allow access to the data for CCH staff through web portal. Following discussions with its implementing partners, USAID proposed developing a system for CHVs using smartphones for data management and reporting, which will be piloted under the lead of USAID/Mikolo and the MOH. CCH will wait for the results of this pilot and postpone implementation of technology activities to FY2018.

Sub IA 4.2 Learning Management

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

The planned studies and surveys conducted in Q2 were reported earlier under IA1, IA2, and IA3. There were 13 joint review workshops organized in Q2 (four regional and nine at the district level) and conducted in five regions (SAVA, Menabe, Sofia, Melaky, and Analanjirofo).

4.2.2 Dissemination

During Q2, the program completed the first edition of the newsletter Zara ny Efa, presenting program information, community actors’ achievements, and technical updates for CHVs. Also, as reported under IA2, Mahefa Miaraka participated in several high-visibility events to showcase the program activities and achievements during this quarter. Approximately 19,000 community actors, partners, and program staff received this first edition.

In March 2017, the CCH program was among the delegation from Madagascar that participated in the Institutionalizing Community Health Conference 2017 (ICHC) in Johannesburg, South Africa. Policy and strategies for community health, sustainable financing systems, multi-sectoral and multi- stakeholder partnerships, equity and social accountability, research and innovations were discussed during this conference. Adapted from the ICHC declaration, the Government of Madagascar reiterated its commitment to community health and developed its action plan (Box 7).

Box 7 – Madagascar’s Booth at the 2017 Institutionalizing Community Health Conference, Johanesburg, South Africa

Sub IA 4.3

Cross-Cutting Issues

• Sustainability Mechanisms. As presented throughout this report, Mahefa Miaraka continued to promote a sense of ownership and created capacity among GOM officials at the local level

Community Capacity for Health Program – Mahefa Miaraka FY2017 Quarter 2 Report 23

and community actors through start-up workshops and technical training. Using the cascade training approach, GOM officials in each level are trained to conduct the training for their own staff at lower levels. • Gender Equality and Female Empowerment. The March 8 International Women’s Day celebration was an important event. Our program team participated in the debates and other activities aiming to promote gender equality and female empowerment at national and regional levels. Also in this quarter, the program team participated in the national-level gender working group meeting. • Environmental compliance. The Program’s Environmental Mitigation and Monitoring Report (EMMR) is presented in Annex 3.

Challenges and Proposed Solutions for Q2 FY2017

CHALLENGES SOLUTIONS 1. Security problem in some regions, • Staff has been reminded to consult local specifically Menabe and Melaky authorities for security situation before making a trip.

2. Inaccessibility in some sites due to rain • Adapt the timing of some activities during this and flood period. 3. Unavailability of commodities for CHV • Hold coordination meeting with PSI starter kits (lot de démarrage et de • Negotiate with CSB and DLP to supply CHVs with redynamisation des AC) malaria commodities

4. Some CHVs are unable to fill in the new • Identify gaps during supervision, monthly meetings, record book and monthly report forms and verification at the SDSP and build capacity of MOH, including data on distribution of accordingly at CHV monthly meetings at CSB. health cards and FP invitation cards • Conduct formative supervision for CHVs during on-site supervision visits by CSB, EMAD, and the program. • Use the peer approach to ensure that CHVs fill in correctly and check their management tools 5. Resurgence of malaria in the districts of • Remind the Mahefa Miaraka team at district level Besalampy (Melaky Region) and Soalala to report abnormal increases in cases in their (Boeny Region) areas as soon as possible • Reinforce malaria prevention activities by CHVs in their communities (LLITN use, and mosquito habitat cleaning). 6. Cleanliness of health huts is not • Conduct awareness sessions to community maintained members through the FKT heads to collectively clean the health hut. • Ask CSB heads to remind the FKT heads and CHVs of their role and responsibilities vis-à-vis health huts during monthly meetings.

Administrative and Financial Management

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Key Achievements: 1. 94% of the program staff (254 of 272) recruited by the end of this quarter. 2. A total of three MOUs with other development partners were signed in Q2. 3. Mahefa Miaraka launched the process to begin electronic payments in the field. 4. Nine motor vehicles and 41 motorbikes were procured.

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

0.1.1 Administrative and Financial System

During this quarter, the administrative and financial teams in all offices continued activities according to the systems established.

Sub IA 0. 2 Administration

In Q2, all program offices including the district level are fully functioning. Monitoring visits and well on-the-job supports have been provided by the central level to the regional and district teams.

0.2.1 Human Resources

By the end of March 2017, the program had recruited almost all staff (94%) or 254 out of of 272 staff. Of these, 158 are men and 96 are women (62% and 38%, respectively). All staff recruited received orientation and equipment and supplies to perform their work. Also in this quarter, the program’s director for finance and administration received an orientation on JSI administrative and financial system at the headquarters in Boston, USA, and participated in a refresher course for USAID Rules and Regulations for Grants and Cooperative Agreement organized by INSIDE NGO. All seven regional directors and some senior technical staff from the central office participated in a JSI management training workshop.

0.2.2 Information and Technology System

Efforts in Information Technology (IT) continued to focus on equipping the program team with necessary electronic equipment (laptops, printers, and cameras). During the nationwide internet disruption, the IT team had to look for alternative internet connection to ensure that the program activities were not interrupted.

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. In addition to the electronic equipment mentioned above, the program procured nine four-wheel drive vehicles and 41 motorcycles for use at the regional and district program offices.

0.2.4 GOM and Partner Management

Mahefa Miaraka 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 national regulations. During Q2, the program also signed three MOUs with PSI/ISM project, the USAID MEASURE Evaluation Project (includes JSI as partner), and the JSI-implemented GAVI Project. Discussions with other partners about potential MOUs are ongoing.

0.2.5 Reporting to USAID and GOM

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On January 30, 2017, JSI submitted the Q1 progress report (technical and financial) to USAID, received approval, and uploaded it to the DEC. There was no reporting required by GOM in Q1.

Sub IA 0.3 Financial Management

0.3.1 Financial Procedures

During Q2, Mahefa Miaraka piloted activities to use alternative (non-bank) money payment via telecommunications companies (mobile banking) to transfer program fund to the district and commune levels. Pilot activities in Mandritsara District of Sofia and Soalala District of Boeny Regions were hampered by the nation-wide internet disruption. This activity will continue in Q3.

0.3.2 Financial Reporting to USAID

During Q2, the program submitted the financial report (SF425) related to the previous quarter to USAID. The accruals report was included in the review process for a request of obligation incremental funding submitted to USAID in March 2017.

0.3.3 VAT (Value Added Tax)

In Q2, the program team participated in several meetings with USAID and MOH to discuss the VAT issues, especially the GOM’s commitment for VAT refund. JSI continues to submit VAT reimbursement request for suppliers to the GOM through the MOH on a regular basis.

0.3.4 Expenditures

A summary of Program expenditures through Q2 FY2017 is presented in Table 7 below. It is noted that the expenses made during Q2 FY2017 were less than the projections presented in the Program’s accruals report and the SF425 from March 31, 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 total of $50,826 of cost share from MOH salaries in Sofia ($28,086), Diana ($15,468), and Menabe ($13,516) as well as from contributions to the renovation of the Regional Health Office meeting room in Sofia ($756). JSI continues to seek cost share and will report to USAID on a quarterly basis.

Table 7 - Mahefa Miaraka’s Cumulative Expenses as of March 31, 2017 TOTAL EXPENDITURES AS BUDGET LINE ITEMS OF MARCH 31, 2017 (IN US$) SALARIES 905,626 CONSULTANTS 953 TRAVELS, TRANSPORTATION, AND PER DIEM 149,275 ALLOWANCES 64,654 EQUIPMENT, MATERIALS, AND SUPPLIES 559,569 OTHER DIRECT COSTS 265,413 PROGRAM COSTS 1,376,026 SUB-RECIPIENTS 294,033 TOTAL DIRECT COSTS 3,615,548 INDIRECT COSTS/OVERHEAD 183,562 TOTAL COSTS 3,799,110 COST SHARE 50,826 GRAND TOTAL 3,849,936

DISCLAIMER

This report 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.

USAID COMMUNITY CAPACITY FOR HEALTH PROGRAM - Mahefa Miaraka

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

FY2017 Quarter 2 Progress Report January 1 to March 31, 2017

ANNEXES

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

USAID COMMUNITY CAPACITY FOR HEALTH PROGRAM - Mahefa Miaraka

FY2017 Quarter 2 Progress Report Re-Submitted: June 5, 2017 (after USAID comments)

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 2 Report (ANNEXES) 3

List of Annexes

Annex 1. Activity Report Q2, FY2017

Annex 2. Project Performance Review, PPR (Q2, FY2017)

Annex 3. Environment Monitoring and Mitigation Report, EMMR (Q2, FY2017)

Annex 4. List of Communes in Mahefa Miaraka Program in Q2, FY2017

Annex 5. International Trips at the End of Q2 FY2017

Annex 6. Success Stories

Annex 7. Participation in the Central-Level Working Groups and Meetings

Annex 8. JSI Responses to USAID Comments with Additional Figures on Selected malaria Indicators

Annex 1. Activity Table Q2 FY2017 (Operations: Administrative and Finance) Program codes Results Results

Next steps Actual Explanation of Expected Planned activities Indicators FY2017 targets Expected Actual Expected to address Q2 delays/gaps Q3 Q1 Q1 Q2 gaps MNCH MALARIA NUTRITION FP/RH WASH Number Sub-IA Number Activity 1st Sub - Activity No. No. Activity - 2nd Sub 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 One region CCH program in the regions workshops 5 (Boeny, Melaky, completed their X X X X X 0 0 1 8 (combined with the regional DIANA, SAVA, 5 4 - - workshop earlier - annual start-up workshops) and Analanjirofo) than planned in FY2016 0.0.2 Annual Planning Activities Annual implementation Submit next year (FY2018) plan submitted and X X X X X 0 0 2 1 annual implementation plan to approved by USAID 1 N/A N/A - - - 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 Operations Manual and the updates X X X X X 0 1 1 4 Employee Manual and provide 100% 100% 100% 100% 100% 100% annual refresher training to t ff 0.2 Administration 0.2.1 Human Resources Management Recruit program staff as % of staff recruited X X X X X 0 2 1 2 needed over the positions in 100% 90% 90% 94% 100% the staffing plan

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%

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 Q2 FY2017 (Operations: Administrative and Finance) Program codes Results Results

Provide ongoing capacity % of staff benefiting building for staff at central, from capacity building X X X X X 0 2 1 5 50% N/A - 100% 100% 100% regional and district levels activity

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

Improve database for % of CCH office use administrative and financial electronic data base X X X X X 0 2 2 3 information for administration and 100% 100% 100% 100% 100% 100% finance purposes

0.2.3 Procurement and Distribution Management Develop the annual # of annual 1 X X X X X 0 2 3 2 procurement plan procurement plan (FY2018) N/A - - - - developed

Communicate and inform # of internal CCH team members information sharing acquisition and distribution sessions on X X X X X 0 2 3 4 process and provide status procurement and 50 21 10 27 18 18 updates on a regular basis distribution organized

0.2.4 GOM and Partner Management Establish formal partnership # of partners with (via MOU) with US and non- signed MOU X X X X X 0 2 4 3 7 2 2 3 3 2 US partners

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

Submit quarterly progress # of progress report

X X X X X 0 2 5 2 report to USAID approved and 4 - - 1 1 1 uploaded on DEC

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

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

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 1 report to USAID submitted to USAID Submit quarterly financial # of SF425 submitted X X X X X 0 3 2 2 - - 1 1 1 report or SF425 form to to USAID 4 USAID 0.3.3 VAT Submit and follow-up regularly # of VAT requests on VAT reimbursement submitted to MOH X X X X X 0 3 3 1 requests with MOH/DLUM (every year in May) - - - 3 -

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. 1.1.2 Pre-service training. continuing learning and supervision ofCHVs supervision and learning continuing training. Pre-service 1.1.2 1.1.1 Reinforcement of capacity of members of PNSC structures at commune and Fokontany level on CHVs' priority interventions priority on CHVs' level Fokontany and commune at structures ofPNSC ofmembers ofcapacity Reinforcement 1.1.1 1.1 Increasing skills and competencies of CHV in priority intervention to reduce maternal, neonatal and child mortality as well as in data collection and use and collection data in as well as mortality child and neonatal maternal, toreduce intervention priority in ofCHV competencies and skills Increasing 1.1 Intervention Area 1 (IA1): Community Engagement and Ownership of Health Services Services Health of Ownership and Engagement Community 1(IA1): Area Intervention X X X X X MNCH X X X X X

MALARIA Program codes X X X X X NUTRITI X X X X X FP/RH X X X X X WASH 1 1 1 1 1 Sub-IA 1 1 1 1 1 Activity 1 1 1 1 1 1st Sub - 2 1 3 4 5 2nd Sub - COSAN FKT monthly meeting) COSAN the district or workshop launch at to done be activities (orientation support CHVs to carry out their to structures local PNSC of roles CHV's priorityinterventions and onPNSC, orientation Provide equity and youth friendly approaches youthequity and friendly CLTS approach as , as well gender CHV competencies, supervision and general health management FKTon levels and at the commune members PNSC for Conduct training stakeholders local workshops with Organize three-day regional start-up levels commune atabove the district and Organize the same workshop as district workshop) launch the activity during is to done be FKT(this levels and the commune at created yet not is structure PNSC the if create to assist and Identify Planned activities of the last CSB annual work plan plan work annual the last CSB of the development in participating structures community where communes % of issues health on trained members CCDS # and FKT levels structure set upat the commune PNSC with district of # start upworkshops participantsthe regional in of # activities CHVs and role their PNSC, on oriented FKT heads of # activities CHVs and role their on PNSC, oriented members CCDS of # issues onhealth trained FKT# heads commune startcommune upworkshops and district the in participants # Annex 1: Activity Table Q2 FY2017 (Intervention Area 1) Area (Intervention FY2017 Q2 Table 1: Activity Annex Indicators FY2017 targets 14,367 1,362 1,362 4,332 4,332 1,341 3,466 3,466 100% 185 34 Expected Expected 13,561 3,286 3,286 1,341 185 Q1 24 - - - Results Actual Actual 14,386 14,386 2,897 2,897 1,179 265 Q1 21 - - - Expected Expected 1,435 1,435 3,466 3,466 2,161 100% 817 817 Q2 13 - Results Actual Q2 Q2 Actual 1,976 1,976 3,226 367 886 195 13 - - planning session during Q2. session during planning not the have did GOM for CCDS and FKT heads FKT heads and CCDS for Priority of the training in in the training of Priority can begin health services. Therefore, some training training some Therefore, CHV so for was theyQ2 are postphoned to Q3. postphonedto Q3. are Explanation of delays/gaps the planning. Next steps steps Next schedule for for schedule to address Will follow GOM's GOM's gaps Expected Q3 Expected ------Intervention Area 1 (IA1): Community Engagement and Ownership of Health Services Services Health of Ownership and Engagement Community 1(IA1): Area Intervention X X X X X MNCH X X X X X

MALARIA Program codes X X X X X NUTRITI X X X X X FP/RH X X X X X WASH 1 1 1 1 1 Sub-IA 1 1 1 1 1 Activity 2 2 2 2 2 1st Sub - 6 4 2 5 3 2nd Sub - officially it if doesn't exist nominate and select to FKT the assist FKT) and CHV (CoSan existence of For new 10districts: at CSB) the monthly meeting part of carried out as seperate training or can be training of (series curriculum according to MOH's revised training CHVs for training Conduct refresher For on-going 24districts they had already received training start-up workshops including district and/or the regional during CHVs existing region each in Identify learning is presented under IA3 one- information CHVs) more - of learning continuing usefor tablet will head and CCDS members (CCDS supervision visitsFKT from regular For alll districts: CHVs receive districts initial training for CHVs in new Conduct For new 10districts: Planned activities Identify : c) (PCIME- districts new in certified and CHVstrained are of # who CHVs FKT that of # nominated have (PCIME-c) certified in ongoing districts and CHVstrained are of # who (RMA) certified in ongoing districts and CHVstrained are of # who record training with CHVs existing of List staff clinical - supervision conducted by CCH CHVs on-site receive of # who nonclinical - member CCDS supervision visits conducted by CHVs # on-site receive who nonclinical - FKT heads supervision visits conducted by CHVs # on-site receive who certified in new districts (RMA) and CHVstrained are of # who Annex 1: Activity Table Q2 FY2017 (Intervention Area 1) Area (Intervention FY2017 Q2 Table 1: Activity Annex Indicators (1 per region) per (1 FY2017 targets 1,844 1,844 2,213 2,213 6,116 6,116 5,696 7,496 7,496 2,213 5

Expected Expected 5,629 Q1 5 - - - - Results - - -

Actual Actual Q1 5,631 7 ------Expected Expected 1,155 1,155 1,314 2,249 2,213 2,213 2,213 2,213 6,116 837 302 Q2 - Results Actual Q2 Q2 Actual 1,705 1,705 2,483 483 128 952 433 246 302 CHVs is on-going the trained for Practicum CHVs is on-going the trained for Practicum onsite supervisions during onsite supervisions during have less time to conduct conduct to time less have wrkshops for CHVs, staff staff CHVs, for wrkshops Due to intensive training to intensivetraining Due others) and the program the program others) and from GOM (MOH and Explanation of delays/gaps this quarter. quarter. this Next steps steps Next to address gaps Expected Q3 Expected 2,040 2,040 150 39 ------1.1.4 Women and youth friendly environment and services services and environment friendly youth and Women 1.1.4 Intervention Area 1 (IA1): Community Engagement and Ownership of Health Services Services Health of Ownership and Engagement Community 1(IA1): Area Intervention X X X X MNCH X X X X

MALARIA Program codes X X X X NUTRITI X X X X X FP/RH X X X X WASH 1 1 1 1 1 Sub-IA 1 1 1 1 1 Activity 3 2 3 3 4 1st Sub - 7 4 2 2 3 2nd Sub - quality) on a quarterly basis quarterly ona quality) card (aimingto improve CHV service to conductheads community score FKT and support and CCDS Train IA3) this--- activity is also reported under heads (organized by CSB) CHVs FKT FKT namely and COSAN for monthly meeting Support GOM monitors CHV service quality quality service CHV monitors GOM respect the USAID FP compliance FP respect the USAID that monitor CHVs and Train youth needs gender-based violence (GBV) and on analysis on Conduct landscape

Planned activities

minimum quality score CHVs% achieved of who nonclinical - staff supervision conducted by CCH CHVs on-site receive of # who from the tablet tablet the from CHVs learning of # reported the monthly meeting in participating FKT heads of # meeting the monthly in participating members CCDS of # monthly meeting the CHVs in of # participating minimum quality score CHVs% achieved of who compliance FP in trained CHVs # FKT heads and CCDS by quality service conducted onCHV CSC of # supported districts supported health services in USG CHVs with satisfied clients of % completed # rapid of landscape analysis Annex 1: Activity Table Q2 FY2017 (Intervention Area 1) Area (Intervention FY2017 Q2 Table 1: Activity Annex Indicators FY2017 targets 1 study 1 6,144 3,466 6,663 8,329 1,582 40% 40% 35% 447 Expected Expected 1,070 1,070 371 Q1 ------Results Actual Actual 1,070 1,070 371 Q1 19 ------Expected Expected 1,246 1,246 6,210 6,210 3,023 3,023 279 Q2 ------Results Actual Q2 Q2 Actual 5,242 5,242 1,976 1,976 671 195 ------after the commune start the commune up after inaccessibility in some sites that had their workshop in in workshop their that had workshop. The communes communes The workshop. in Q2. Also, the monthly Also, Q2. in meteing was conducted March did not organize not organize March did their monthly meteing. Explanation of

This is due to This is due

delays/gaps

Next steps steps Next to address gaps Expected Q3 Expected 1,445 1,445 5,852 5,852 ------1.1.5 Equipment (appropriate work tools. job aid and materials) for PNSC structure at the commune and FKT level (CCDS and COSAN FKT) FKT) COSAN and (CCDS level FKT and commune the at structure forPNSC materials) and work jobaid tools. (appropriate Equipment 1.1.5 1.1.6 Motivation activities for COSAN FKT (CHV) and FKT heads Intervention Area 1 (IA1): Community Engagement and Ownership of Health Services Services Health of Ownership and Engagement Community 1(IA1): Area Intervention X X X X MNCH X X X

X MALARIA Program codes X X X X NUTRITI X X X X FP/RH X X X X WASH 1 1 1 1 Sub-IA 1 1 1 1 Activity 5 4 4 4 1st Sub - 1 4 3 5 2nd Sub - presented under IA3) under presented FKT chief). (materials for GOM are COSAN FKT members (CHV and and members to CCDS jobaids and Provide necessary materials. tools KMSm. CSC. exchange visits. income through recognition social namely COSAN (CHVs and FKT heads) Review motivation activities for the landscape analysis after commune and district the with for specific activites willbe discussed awareness champion” sites detail -- pilot sites become “gender- be to communes/districts Identify districts program torespond youth at CHV all in needs Integrate gender considerations and refersher training CHV of are integrated into the pre- and gender and youth friendly services messages trainings (all related to onGBV-awareness and women and to youth, servicesgirls and friendly CHVs) onpromoting and (FKT heads FKT COSAN for Conduct training

Planned activities

KMSm events KMSm receive special recognition at the CHV who FKT or of # heads referral mechanisms are in place where messaging, screening, and # gender-aware of communes CHVs and heads by--- type COSAN of FKT i.e. awareness gender-based violence messages in gender norms and disseminate to trained actors /community# health % of education sessions sessions education youth and topicsGBV intotheir including CHV reported of # and jobaids and receive work tools, materials who members CCDS of # jobaids work tools, materials and receive who FKT head of # tools, materials and jobaids work CHV receive who #of into their education sessions education into their youth and topics GBV including reported FKT heads of # Annex 1: Activity Table Q2 FY2017 (Intervention Area 1) Area (Intervention FY2017 Q2 Table 1: Activity Annex Indicators 8,734 CHVs8,734 3,466 Fkt3,466 FY2017 targets heads 3,466 8,734 2,166 TBD 837 894 Expected Expected Q1 ------Results Actual Actual Q1 ------Expected Expected 3,466 8,734 625 Q2 - - - - - Results Actual Q2 Q2 Actual 1,976 4,906 195 - - - - - Same explanation as in line line as in explanation Same 1.1.1.5 above. Only FKT Only above. 1.1.1.5 training in Q2 received heads who received Explanation of delays/gaps tools Next steps steps Next to address gaps Expected Q3 Expected ------1.3.1. Functionality and reinforcement of community health structure health ofcommunity reinforcement and Functionality 1.3.1. 1.3 Strengthening including ofstructures. community CoSan to andCCDS planning improve andsanitation health 1.2 Sustainability of the CHV model including integration full of CHV into the formal public system 1.2.1 Supportive supervision to COSAN FKT namely CHVs and FKT heads (supervision by GOM presented under IA3) under GOM presented by (supervision heads FKT and CHVs namely FKT toCOSAN supervision Supportive 1.2.1 Intervention Area 1 (IA1): Community Engagement and Ownership of Health Services Services Health of Ownership and Engagement Community 1(IA1): Area Intervention X X X MNCH X X X

MALARIA Program codes X X X NUTRITI X X X FP/RH X X X WASH 1 1 1 Sub-IA 2 1 1 Activity 6 1 6 1st Sub - 3 1 2 2nd Sub - (Toby) for CHVs for (Toby) hut health permanent equip and/or the communityEncourage to build ---- same---- as activity 1.1.2.6 --- staff) CCH and CCDS, COSAN, from supervisionSupport visits to CHVs national levels program activities at the regional and generation activities. participating in KMSm. CSC. exchange visits. income

Planned activities minimum of table, chair and shelf a with Toby equipped of # participate in the exchange visits who FKT CHV heads) and of # visits conducted by FKT heads CHV supervision receive of # members CCDS supervision visits conducted by # FKT of heads receive members CCDS by conducted visits CHV supervision receive of # generation activities the income in participate actors FKT-level who of # the cooperative) of member counted twice they if are also not should employees paid - (note the eBox from dividend receive paidemployment or community actors of # who national levels activities at the regional or the program in participate who FKT CHV heads and of # Toby by built the community the in CHVs work of # who Annex 1: Activity Table Q2 FY2017 (Intervention Area 1) Area (Intervention FY2017 Q2 Table 1: Activity Annex Indicators FY2017 targets 2,561 8,566 3,466 8,566 4,822 240 100 100 68 Expected Expected Q1 77 ------Results Actual Actual 1,152 425 Q1 77 ------Expected Expected 2,249 1,314 1,447 512 657 Q2 - - - - Results Actual Q2 Q2 Actual 1,854 707 952 128 23 86 - - - Same explanationSame as activity Explanation of 1.1.2.6 above 1.1.2.6 delays/gaps Next steps steps Next to address gaps Expected Q3 Expected 500 804 86 4 - - - - - Intervention Area 1 (IA1): Community Engagement and Ownership of Health Services Services Health of Ownership and Engagement Community 1(IA1): Area Intervention X 1.4.1 Increase access to health care via health financing scheme (mutuelle. solidarity fund and equity fund) equity and fund solidarity (mutuelle. scheme financing health via care tohealth access Increase 1.4.1 system transport emergency and mutuelle) (i.e. micro-insurance fund). (e.g. programs GOM equity entitlement coverage. including and access care health Promoting universal 1.4 1.3.2. Using Champion Commune or KMSm Approach to manage health community X X X X X X MNCH X X X X X X X

MALARIA Program codes X X X X X X X NUTRITI X X X X X X X FP/RH X X X X X X WASH 1 1 1 1 1 1 1 Sub-IA 3 3 3 3 3 3 4 Activity 1 1 2 2 2 2 1 1st Sub - 2 1 2 3 4 5 2 2nd Sub - review meeting among PNSC actors coordination/program quarterly the districtSupport to convene a assist them to do so do to them assist and levels all at structure PNSC regions that haven't yet established Identify exisitng and encourage the launch workshops launch district and the regional during onKMSm indicators) and approach Review one pager (including between new and on-going communes on-going and between new different are cycle pre-bronze KMSm of achievement for Indicators Note: implement the KMSm activities to communes Assist on-going their pre-bronze cycle pre-bronze their complete to communes new Assist their pre-bronze cycle pre-bronze their complete to communes old Assist including the MAHEFA model including equity funduse in Madagascar scheme and barrier analysis the of insurance health micro existing Conduct situation analysis on a Planned activities place from regional to FKT level structures) operational in and structure PNSC (coordination district that and have region of # review meeting coordination/program quarterly convene that district of # KMSm review sessions review KMSm the conducting districts of # activities organizerlead their of KMSm as a CCDS with communes of # (new districts) (new cycle pre-bronze KMSm their that communes complete of # (ongoing districts) (ongoing cycle pre-bronze KMSm their that communes complete of # analysis conducted barrier situation and of # Annex 1: Activity Table Q2 FY2017 (Intervention Area 1) Area (Intervention FY2017 Q2 Table 1: Activity Annex Indicators 456 communes 34 Districts 34 4,887 FKT4,887 5 Regions 5 Regions FY2017 targets 279 122 237 34 34 1 Expected Expected Q1 34 ------Results Actual Actual Q1 34 ------34 Districts 34 communes Expected Expected 5,205 FKT5,205 5 Regions 5 Regions 456 Q2 279 5 - - - - Results Actual Q2 Q2 Actual 34 Districts 34 communes 4,681 FKT4,681 7 Regions 7 Regions 439 9 0 - - - - some communes in Q2, the Q2, in communes some program could not provide not could provide program for CHVs, KMSm activities activities KMSm CHVs, for will beginwill later in the year. Due to intensive training to intensivetraining Due Due to inacessibility to to inacessibility to Due assistance/followup to to assistance/followup some communes. some Explanation of delays/gaps Next steps steps Next to address gaps Expected Q3 Expected 17 Communes 206 FKT ------X 1.4.2 Increase access to health care via emergency transport emergency via care tohealth access Increase 1.4.2 X Intervention Area 1 (IA1): Community Engagement and Ownership of Health Services Services Health of Ownership and Engagement Community 1(IA1): Area Intervention X X MNCH X X X X

MALARIA Program codes X X X NUTRITI X X X FP/RH WASH 1 1 1 1 Sub-IA 4 4 4 4 Activity 1 1 1 2 1st Sub - 5 3 4 2 2nd Sub - the training curriculum and conduct and curriculum the training develop above, onthe model Based activities) mutuelle their start to assistance to program proposal receive conditions can submitrequesite a eligibility requirements and pre- that (communes meet approach out strategy roll and the mutuelle and equity fund use of fund, solidarity including insurance (mutuelle) micro- for CCH model Develop mutuelle) with communes new and (existing equity fund) and solidarity (mutuelle. insurance health CCHPmicro their out carry to communes the Assist workshop) the district launch during done FKT (tobe levels and commune district. the at stakehoders relevant with workshop Conduct review ETS i if l l iidi f Planned activities # of workshop held workshop of # role their by type workshop, of the review in participate who people of # application that succeedtheir in model finance health CCHP micro carryingout for application submitting communes of # communes with mutuelle) mutuelle activities (existing their continuing communes of # curriculum training of # CCHP micro-insurance activities on oriented communes of # funds, equity fund) funds, insurance mutuelles. solidarity protectionsocial scheme(micro- # beneficiaries participating in a Annex 1: Activity Table Q2 FY2017 (Intervention Area 1) Area (Intervention FY2017 Q2 Table 1: Activity Annex Indicators mutuelle) FY2017 targets (activity (activity 1.1.1.2) (pour (pour 1,020 TBD TBD 244 34 33 1 Expected Expected 1,020 Q1 - - - - - Results Actual Actual 1,055 Q1 - - - - - Expected Expected Q2 20 - - - - Results Actual Q2 Q2 Actual 2,541 2,541 17 - - - - this is the commune-owned this is the commune-owned explain the importance. As the importance. explain Three communes decided decided communes Three that the program tried to to tried program the that activities despite the fact fact the despite activities and driven activities, the program could not could stop program to stop their mutuelle to stop mutuelle their Explanation of their decision. their delays/gaps Next steps steps Next to address gaps Expected Q3 Expected 17 - - - - - X X Intervention Area 1 (IA1): Community Engagement and Ownership of Health Services Services Health of Ownership and Engagement Community 1(IA1): Area Intervention MNCH X X

MALARIA Program codes X X NUTRITI X X FP/RH WASH 1 1 Sub-IA 4 4 Activity 2 2 1st Sub - 4 3 2nd Sub - evacuation plan and monitor use monitor and evacuation plan to develop their health emergency COSAN FKT (FKT heads and CHVs) FKT For all and use of the emergency transports the emergency use of and FKTs sure the functionality to make support Continue : to MAHEFA by provided transport emergency of means existing For with FKT Planned activities : Assist CSB. CCDS and and CCDS CSB. Assist : evacuatuion plan (50%) evacuatuion plan new/Strengthen emergency # Fkt who have a evacuatuion plan (75%) evacuatuion plan new/Strengthen emergency a have who CSB # functioning ETS ETS functioning fokontany (village) with supported /%USG- # of Annex 1: Activity Table Q2 FY2017 (Intervention Area 1) Area (Intervention FY2017 Q2 Table 1: Activity Annex Indicators FY2017 targets 2,234 593 100 Expected Expected Q1 - - Results Actual Actual Q1 - - Expected Expected Q2 100 - - Results Actual Q2 Q2 Actual 318 64 - The program is working to is working program The support all fokontany that fokontany support all transport is functionning. transport to make sure sure make to transport have the emergency that their means of of means their that Explanation of delays/gaps Next steps steps Next to address gaps Expected Q3 Expected 670 12 - X X X X X 2.1.1 SBCC strategy. approaches. materials and tools 2.1 Community-level health promotion and sensitization to increase healthy behavior and uptake of health services and products Intervention Area 2(IA2): Behavior change and health promotion 2.1.3. Development and/or reproduction and dissemination of tools and information, education and communication (IEC) materials for use by CHVs and CSBs 2.1.2. Repositioning woman's the and child's health cards as cornerstone the of SBCC strategies 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 2 2 2 2 2 2 Sub-IA 1 1 1 1 1 1 Activity 1 1 1 1 1 2 1st Sub - 6 4 8 5 7 2 2nd Sub - groups, and youth) WASH listener radio groups, parrains, (menages communities CCH in networks Conduct evaluation on existing social SDA for use at the community level community the at use for SDA Among the key actions above, identify 8-10 messages health cards to promote important health Encourage the use of women and children messages health key coherence ensure to meetings Participate the SBCC in coordination national use in CCHP or develop Small Doable Actions (SDA) for Based on the results of the evaluation, update CHVs FKT levels CCDS, by CSB, FKT heads and training curricula for use at the commune and tools. and SBCC update strategy, approach SBCC of review the of results the Based on Planned activities Annex 1: Activity Table Q2 FY2017 (Intervention Area 2) results for planning social networks for use of the completed# evaluation on distributed by CHVs # ofwomen health cards quarter) per one least (at participated meeting of # community level the at use for adopted small# of and doable actions adopted for CCH small# of and doable actions updated cirricula training # of distributed by CHVs health cards child # of distributed by CSB # ofwomen health cards distributed by CSB health cards child # of Indicators 240,000 320,000 118,650 79,100 At least 4 FY2017 targets 8-10 35 1 2 Expected Expected Q1 33 2 ------Actual Actual Q1 33 2 ------Q2 Expected 31,640 96,000 47,460 128,000 1 7 2 2 - Results Actual Actual Q2 Q2 7 2 5 ------were distributed only only distributed were therefore there was was there therefore Activity moved to to moved Activity at the end of Q2 The health cards Explanation of of Explanation recorded in Q2. in recorded no distribution delays/gaps later. Next steps to address gaps 31,640 96,000 47,460 128,000 Expected Expected Q3 2 2 - - - 2.2.1 SBCC skill-building for community leaders 2.2 Capacity of community stakeholders to assess community needs, develop key messages and advocate for improved services Intervention Area 2(IA2): Behavior change and health promotion 2.2.2 Roll out SBCC activities at community the level X X X X X MNCH X X X X X

MALARIA codes Program X X X X X NUTRITION X X X X X FP/RH X X X X X X WASH 2 2 2 2 2 2 Sub-IA 2 1 1 2 2 2 Activity 1 3 3 2 1 2 1st Sub - 2 2 3 1 3 2 2nd Sub - and monitor use CSB, FKT train to, CCDS, heads CHVs and Distribute revised SBCC tools and materials celebration and health campaigns days health led GOM the in Participate by CHVs and FKT heads) SBCC activities (accompanied and reported Support community actors to carry out ----- GOM trainers via training cascading FKTCCDS, heads CHVs and Conduct training on the WASH approach for care services and utilization per the continuum of SBCC to promote and advocate for improved heads and CHVs and CCDS members) on FKT (COSAN: stakeholders community Train cards cards) capitalize and use health of continuum of care, GBV, youth, FP invitation areas the using technical emerging and based on the strategy and SDA (including new Update or develop SBCC tools and products Planned activities Annex 1: Activity Table Q2 FY2017 (Intervention Area 2) and campaigns participated campaigns and # sensitization materials or IEC health messages through CHV to exposed beneficiaries of # FKT COSAN trainers for # ofCCDS who become materials education sessions using IEC CHV through messages # of people exposed to health continuum of care and aligned with the developped newly or updated SBCC tools of materials# and on SBCC trained members CCDS of # trained on WASH on trained CHVs and heads FKT of # interventions SBCC implement # ofFKT heads trained who on SBCC on trained heads FKT CHVs of #

of health day celebration Indicators 1,403,657 1,403,657 FY2017 targets 12,200 12,200 5,200 1362 1362 TBD 10 Expected Expected Q1 4 ------Actual Actual Q1 4 ------Q2 Expected 561,463 561,463 4,685 4,685 817 817 2 4 - Results 520,563 520,563 Actual Actual Q2 Q2 72 72 - - 3 4 - trainign are to moved trainign they can begin health activity 2.1.1.2 above 2.1.1.2 activity same explanation as same explanation CHV training took took training CHV services. All other priority in Q2 so Q2 in priority Explanation of of Explanation delays/gaps later. Next steps to address gaps Expected Expected 561,463 561,463 1,161 Q3 3 1 - - - - Intervention Area 2(IA2): Behavior change and health promotion X X X X MNCH X X X X

MALARIA codes Program X X X X NUTRITION X X X X FP/RH X X X X WASH 2 2 2 2 Sub-IA 2 2 2 2 Activity 2 2 2 2 1st Sub - 5 3 6 4 2nd Sub - waste practices management Support CHV and CSB in good hygiene and latrine slabs WASH activities sale including sur'eau of and of CCDS and CoSan) to of begin promotion Support CCDS and CoSan (non clinical side groups Revise facilitator materials forradio listening ( Develop and disseminate radio clips communes withcommunities access to radio new in Identify radio reception zones and actualités ) that profile SBCC successes successes SBCC profile ) that Planned activities Annex 1: Activity Table Q2 FY2017 (Intervention Area 2) SBCC interventions targetedand radio for based with access to radio identified # ofzones and communities # List# updates RLG of group RLG by sessions, RLG the # of participants who attend key messages) messages) key (actualités,clips types by of messageshealth radio through to exposed beneficiaries of # WASH certificate WASH # ofhouseholds who receive ODF certificationofficial villages# of that receive improved sanitation facility # of households using # of SurEau sold by CHVs masons latrine# of slabs sold local by station with soap with station latrine and handwashing # of permanent Toby with built by households improved# of latrine newly Indicators FY2017 targets 30,000 10,000 1,844 5,000 1,561 TBD TBD TBD TBD TBD TBD 279 1 Expected Expected Q1 ------Actual Actual 376 Q1 ------Q2 Expected 1,844 TBD TBD TBD TBD 512 1 - - - - - Results Actual Actual 12,626 1,242 7,301 403 Q2 Q2 1 - - - - quarter as newly built Explanation of of Explanation improve latrinesimprove recorded in this this in recorded beginning of the since this is the the is this since We consider consider We delays/gaps program. program. Next steps to address gaps 14,602 Expected Expected 2,294 1,350 TBD TBD 140 165 Q3 ------Intervention Area 2(IA2): Behavior change and health promotion 2.3.2 School-based youth SBCC activities 2.3.1 Strenghthening local structure to promote youth health 2.3. Innovations to promote adolescent and youth health, with a focus on reaching rural, underserved and married X MNCH X

MALARIA codes Program X NUTRITION X X X X X FP/RH X X WASH 2 2 2 2 2 2 Sub-IA 3 3 3 2 3 3 Activity 1 1 1 1 2 1 1st Sub - 7 5 4 3 7 6 2nd Sub - marriage child preventing on messages especially performances their in messages health incorporate artists to local train and Identify pregnancy into the KMSm elective indicators elective KMSm the into pregnancy and marriages early of prevention to related Encourage communes to add indicators support withfollow étudiants up parrains to officers education and teachers Orient parents and community) their (for youth, marriage early pregnancy and early of prevention for aiming messages key Develop and disseminate channels multiple via responsabilities approach including their role and stakeholders on CCHP's youth health Train relevant district level and commune

Planned activities and provide provide and Annex 1: Activity Table Q2 FY2017 (Intervention Area 2) # of local artists local # of trained receive supervision visits # of etudiants parrains who elective indicators and pregnancy into the KMSm marriages early of prevention related to indicators # that ofcommunes add disseminated and developped messages of # health approach trained on CCHP's youth CSB members and CCDS of # soap hand washing station with CSB# of with latrine and pit equipped with waste disposal # of permanent Toby disposal pit # of CSB equiped with Indicators bronze level level bronze (not in pre- in FY2017) FY2017 targets 2,139 TBD TBD TBD TBD TBD TBD 200 442 408 Expected Expected Q1 ------Actual Actual 533 314 Q1 ------Q2 Expected 512 ------Results Actual Actual 503 384 Q2 Q2 15 0 - - - - Explanation of of Explanation delays/gaps - - Next steps to address gaps - - Expected Expected 165 Q3 ------Intervention Area 2(IA2): Behavior change and health promotion 2.3.3 SBCC activities for out-of-school youth out-of-school for activities SBCC 2.3.3 MNCH

MALARIA codes Program NUTRITION X X X X x FP/RH WASH 2 2 2 2 2 Sub-IA 3 3 3 3 3 Activity 2 2 2 3 2 1st Sub - 2 5 4 2 3 2nd Sub - and train teachers train and Put in place youth health activities in school school aftreschool birth giving in back reintegarte to mothers adolescent support to services provide schools Establish and monitor test programs where Support or others or activities healthclubs forexample school in peers their to cards invitation FP distribute users to areregular who FP youth married with Work work with other youth as étudiants parrains Identify and train teams of 2-3 students to étudiants parrains Planned activities to carry out health health out carry to Annex 1: Activity Table Q2 FY2017 (Intervention Area 2) after giving birth after giving school to back reintegrate to mothers adolescent identified# of pregnant parrains etudiant from messages receive who students of # commune, districtcommune, and region the by organized events the healthday high-visbility schools# of that participate in who are FP regular users are regular who FP distributed by married youth cards FP# of invitation least one time per month month per time one least at activities SBCC conduct # ofetudiant parrains formés leaders étudiants/jeunes # trained teachers of # contraception (age 15-19) of new% users ofmodern Indicators who who 144,596 FY2017 targets TBD TBD TBD TBD 816 816 136 68 Expected Expected Q1 ------Actual Actual Q1 ------Q2 Expected 11,983 20% ------Results Actual Actual 32% Q2 Q2 97 ------The Family planning cards were not yet yet not were cards disributed to the the to disributed Explanation of of Explanation CHVs in Q2. delays/gaps - - - Next steps to address gaps - - - Expected Expected 20% Q3 ------Intervention Area 2(IA2): Behavior change and health promotion MNCH

MALARIA codes Program NUTRITION X X FP/RH WASH 2 2 Sub-IA 3 3 Activity 3 3 1st Sub - 3 4 2nd Sub - menage parrains Encourage more young married couples to be mayor office the wed at newly for messages key Distribute

Planned activities Annex 1: Activity Table Q2 FY2017 (Intervention Area 2) at the mayor's office cards health women receive # ofnewly wed couples who parrains (under 24years old) # of new young menages CYP Couple-years ofprotection or Indicators 133,095 FY2017 targets 25,000 TBD TBD Expected Expected Q1 - - - Actual Actual Q1 - - - Q2 Expected 28,617 - - Results Actual Actual 18,401 Q2 Q2 - workshop therefore therefore workshop CHV spent time in provide services in in services provide have less time to to time less have Explanation of of Explanation delays/gaps training and and training Q2. - - Next steps to address gaps - - Expected Expected 44,752 Q3 - - 3.0.2 Capacity reinforcement and materials for GOM in community health at regional, district and commune level commune and district regional, at health community in GOM for materials and reinforcement Capacity 3.0.2 3.0.1 Coordination with MOH leaders community and CHVs to supervision supportive and training technical provide to capacity GOM of Reinforcement 3.0 governance and management planning, service 3(IA3):Health Area Intervention 3 3 3 3 3 Sub-IA Program 0 0 0 0 0 Activit 1 1 2 1 1 1st Sub 5 7 4 1 6 2nd Group annually (TAG) to meet Form Community Health Technical Advisory MOH quarterly coordination meeting --- training in combination to conducted be with referral counter and g) referral supportivef) supervision including tablet useof youth,e) women services friendly GBV and logistics community d) management c) data toreadjusted matchcontinuum model care of b) priority interventions CHVs by including SBCC a) community health on: EMAD series and Conduct TOT of for EMAR community health jointly manage a national technology platform for toWork with establish USAID MOHand and Hold regional quarterly review meetings review Hold regional quarterly cohort ofnational “community health champions” Formalize existing MOHtechnical as experts Planned activities established functional and National community health champion group community health champion group National by meetings conducted # # of meetings conducted with meetings of conducted TAG # # of regional review meetings held meetings review regional of # # of district review meetings held meetings review district of # community health established National technology platform for and train CSB and trainers that become EMAR # and train CSB and trainers that become EMAD # Annex 1: Activity Table FY2017 Q2 (Intervention Area 3) Indicators FY2017 FY2017 targets 28 116 136 35 1 4 1 1 Expected Expected 164 Q1 25 34 4 - - - - Actual Actual 164 Q1 25 34 4 - - - - Expected Expected 207 Q2 34 24 1 1 1 2 - Results Actual Actual 269 Q2 Q2 47 4 9 - - - - Explanation of of Explanation delays/gaps - Next steps steps Next to address address to gaps - Expected Q3 Expected 1 ------3.0.3 Technical supervision by GOM for CHVs (monthly meeting and supportive supervision) supportive and meeting (monthly CHVs for GOM by supervision Technical 3.0.3 Intervention Area 3 (IA3):Health service planning, management and governance governance and management planning, service 3(IA3):Health Area Intervention 3 3 3 3 Sub-IA Program 0 0 0 0 Activit 2 2 3 3 1st Sub 2 1 3 2 2nd MOH quarterly coordination meeting --- training in combination to conducted be with system referral counter and g) referral supportivef) supervision including tablet useof youth,e) women services friendly GBV and logistics community d) management c) data b) priority interventions CHVs by including SBCC a) community health on: CSB for TOT of series Conduct level level CSB at members COSAN other and CHVs for Support monthly meetings (CHV regroupements eLearning report and on supervision) staff,including CCH and tablets useof (for CHV MOH, CSB representatives, EMAR, CCDS, EMAD, Support supervision visits to CHVs fromCOSAN, IA3) under presented are GOM CCDS, CHVs, COSANs, and YPEs (materials for to jobaids and tools materials, necessary Provide Planned activities ) IA1) -- under data on CHVs trained presented CHV for trainers become that CSB # materials and jobaidsmaterials and tools, work receive who EMAR of # materials and jobaidsmaterials and tools, work receive who EMAD of # and jobaids and materials tools, work receive who CSB of # meeting at CSB meeting participate CHV of # in monthly the conducted by CSB by in last the monthsconducted three supervision on-site receive who CHVs of # at CSB meeting FKTparticipate of heads # in monthly the three monthsthree clinical EMARc- by conducted in last the supervision on-site receive who CHVs of # monthsthree -clinical EMAD by conducted in last the supervision on-site receive who CHVs of # Annex 1: Activity Table FY2017 Q2 (Intervention Area 3) Indicators FY2017 FY2017 targets 6,663 1,666 3,466 1,224 126 791 136 791 35 Expected Expected 1,070 448 381 Q1 ------Actual Actual 1,070 371 381 Q1 ------Expected Expected 6,210 1,472 3,466 320 732 Q2 130 739 84 38 Results Actual Actual 5,242 1,976 286 700 709 269 709 Q2 Q2 47 39 Alreadyexplained Explanation of of Explanation delays/gaps in IA1 Next steps steps Next to address address to gaps Expected Q3 Expected 5,852 1,202 298 14 - - - - - 3.1.1 Non-clinical CSB improvements 3.2.1 Community logistics to ensure unruptured supply of health commodities at CHV at commodities health of supply unruptured ensure to logistics Community 3.2.1 use CHV and facility for conditions storage appropriate maintain and levels stock appropraite maintain manner, timely a in commodities order CSBs that ensure to order in forecasting commodity and Pharmaceutical 3.2 Intervention Area 3 (IA3):Health service planning, management and governance governance and management planning, service 3(IA3):Health Area Intervention 3.1 Introduction and promotion of non-clinical quality improvement process and tools (e.g patient flow, strategic use and placement of IEC materials), etc materials), IEC of placement and use strategic flow, patient (e.g tools and process improvement quality non-clinical of promotion and Introduction 3.1 3 3 3 3 Sub-IA Program 1 1 1 1 Activit 1 1 1 1 1st Sub 4 5 3 2 2nd quality provide support to CSB to improve its service principleimprovement techniquesso and can they on serviceTrain quality support and EMAR/EMAD resources). financial and time -GOM availability water infrastructureon (depending resource to address specific points survey including the of jointly a tailored develop action plan CSB each of results and the surveyto the Present of SDSP/CSB Adapt and apply CSC process for CSB services CSB processfor CSC apply and Adapt infrastructure services, availability f) and basic of and equipment GBV includingfor systems referral e) outreach, and supervision d) forecasting, commodities a) use, and b) data management non clinical QI, c) forin improvement following the needs and areas: situations CSB survey to current Conduct identify

Planned activities quality score minimum achieved who CHVs of % / # CCDS) action plan is jointly responsible CSB by and monitoring for and implementation (CSB for person responsible and indicators timeframe, detailed with improvement facilities for plan action CSB of # monthsthree MOH- by clinicalconducted in last the supervision on-site receive who CHVs of # # QI for CSB conducted by EMAR/EMAD by for CSB QI conducted # # of CSC at CSB conducted by EMAD by at CSB CSC of conducted # analysis of findings of analysis conceptualization surveyfrom of the to participation MOHpersonnel of in all steps with surveycompleted of # the services in supported USG districts clients of % satisfied with CSB health Annex 1: Activity Table FY2017 Q2 (Intervention Area 3) Indicators FY2017 FY2017 targets TBD TBD 35% 123 306 12 70 1 Expected Expected Q1 ------Actual Actual Q1 ------Expected Expected Q2 3 - - - - - Results Actual Actual Q2 Q2 30 - - - - -

Explanation of of Explanation delays/gaps

Next steps steps Next to address address to gaps Expected Q3 Expected ------3.3.2 Integration of data from CHV routine reporting into MOH's HMIS HMIS MOH's into reporting routine CHV from data of Integration 3.3.2 3.3.1 CHV monthly reporting to CSB systems surveillance community-based of development and/or reinforcement and outcomes; patient improve to use and management quality, data Health 3.3 Intervention Area 3 (IA3):Health service planning, management and governance governance and management planning, service 3(IA3):Health Area Intervention 3 3 3 3 3 3 3 3 3 Sub-IA Program 2 2 2 3 2 3 3 3 3 Activit 1 1 1 2 1 1 2 1 2 1st Sub 4 3 2 4 1 2 2 3 3 2nd commodities availability for CSB and CHVs and CSB for availability commodities activitiesParticipate to in related DPLMT/UTGL and setupregularand schedule meeting program withHold PSI/ISM coordination meeting meeting including CHV's in quarterly the SDSP/CSB Support to an SDSP analysis present their of work coordination groups logistics led USAID and GOM in Participate the program data base and for SDSP data base) data SDSP for and base program data the health informationcomputerized system (both for Jointly monthly CHV with reports enter SDSP into basis quarterly supervision on CSB, of a to conducted be ascan conductDQA part oftheir routine on so DQA Train support they and EMAR/EMAD protocols (combined with activity 3.1.1.5) planning commodityCHV needs in line with MOH Train CSB on commodities including management data into MOH's HMIS system system HMIS MOH's into data CSB from reports monthly process to SDSP Assist meeting including CHV's in quarterly the SDSP/CSB Support CSB to an analysis present their of data Planned activities # of meeting held meeting of # # of meeting held meeting of # their presentation in quarterly the meeting, data in CHV that present ofSDSP % and # # of meeting participated meeting of # systems in place place in systems commodity quantification forecasting and operational with facilities health of # data into on their a HMIS monthly basis district of # who successfully integrate CHV monthly reports into their HMIS CSB process successfully who district of # on time facilities that reports submittedcomplete USG-supported of primary# health care quarterly meeting data inCHV their presentation in the ofCSB who % and their data# present and Annex 1: Activity Table FY2017 Q2 (Intervention Area 3) Indicators FY2017 FY2017 targets TBD 520 75% 75% 158 34 34 34 2 4 4 Expected Expected Q1 2 2 3 ------Actual Actual Q1 2 2 3 ------Expected Expected Q2 549 24 34 2 3 1 - - - Results Actual Actual Q2 Q2 2 2 5 ------Explanation of of Explanation delays/gaps - Next steps steps Next to address address to gaps - Expected Q3 Expected 158 34 34 2 3 1 - - - Intervention Area 3 (IA3):Health service planning, management and governance governance and management planning, service 3(IA3):Health Area Intervention 3.3.5 Sharing best practices and lessons learned among CSB and other community health actors health community other and CSB among learned lessons and practices best Sharing 3.3.5 review performance for use Data 3.3.4 diseases preventable of surveillance Community-based Integrated 3.3.3 3 3 3 3 3 3 3 Sub-IA Program 3 3 3 3 3 3 3 Activit 4 3 2 4 5 4 3 1st Sub 2 1 5 3 1 4 2 2nd diseases based on MOH protocol MOH on based diseases to conductcommunity surveillance ofpreventable Assist CSB and in supporting EMAD EMAR, CHVs emergency response priority districts to action implement plans for in to 16IEP supportProvide DRSP as needed Champions on a six-month basis including CHVs to MOH's the Community Health Support to an analysis DRS present their of work summit national at the level presentations in program the annual learning Support assist and MOHto and make DRS level regional the at program annual learningsummit to abstractsDRS prepare presentations and in the Support assist and and SDSP COSAN, CSB/CCDS, both national regional and levels including eligibility process and summit the of at work of scope develop to committee summit Jointly with learning formthe DRS MOHand learning summit national at the level highlight MOHs at the in program the annual champion) presentation to make program of Support assist and MOH(community health Planned activities surveillance activities surveillance community diseases preventable CHVs of conducted trained and # # campaigns and MNCHW participated MNCHW campaigns and # a six-month basis their presentation in MOHmeeting, on the data in CHV that present ofDRS % and # # of abstracts prepared of # developed process selection and criteria selection of # presentations of # selected regional of # presentations Annex 1: Activity Table FY2017 Q2 (Intervention Area 3) Indicators FY2017 FY2017 targets 6,663 34 3 7 1 2 7 Expected Expected Q1 3 4 - - - - - Actual Actual Q1 3 4 - - - - - Expected Expected Q2 1 1 - - - - - Results Actual Actual Q2 Q2 1 0 - - - - - Explanation of of Explanation delays/gaps Next steps steps Next to address address to gaps Expected Q3 Expected 3,140 1 - - - - - 3.4.1 Referral system between CHVs and CSBs and CHVs between system Referral 3.4.1 Intervention Area 3 (IA3):Health service planning, management and governance governance and management planning, service 3(IA3):Health Area Intervention 3.4.2 Referral system between health and other services (e.g gender violence) gender (e.g services other and health between system Referral 3.4.2 violence) gender (e.e services other and health between referral streghtening and treatment; prompt and care preventive increase to CSBs and CHVs between streghtening system Referral 3.4 3 3 3 3 Sub-IA Program 3 4 4 4 Activit 5 2 1 1 1st Sub 2 2 1 2 2nd selects 1abstract district) per district submits 2abstracts to region, the region submitscommune 1abstract to district, the annual regional (each learningsummit Organize pregnant women children and with sign danger of system referral using to manage tablets CCDS and includingCSB system referral improved Jointly monitor with useof the EMAR/EMAD, improvement for CHVsCSBsways and identify system and between referral counter and exisiting referral Review youth communicate and with CHV CSB and Review existing services related on GBV and Planned activities # of participants of # summit at the delivery at CSBs at delivery for CHVs by referred women pregnant of # updated document referal counter and Referal # clinic FP who receive service from MSM mobile long-term for CHV by referred women of # whoFP service receive from CSB long-term for CHV by referred women of # 4 ANC facility CHVsreceived by and to health pregnant of women# referred commune and district and commune level List ofexisitng services available at the vaccination CHVs and received all of the series of to health facility referred by CU5 of # CHV to CSB from referred signed with danger CU5 of # up follow- for CHVs by seen are who women pregnant referred counter of % and # seen by CHVs for follow-up follow-up for CHVs by seen who are CU5 referred counter of % and # Annex 1: Activity Table FY2017 Q2 (Intervention Area 3) Indicators (1 per region) (1 per FY2017 FY2017 targets 34,650 49,500 42,293 23,987 12,375 10,573 7,496 2,250 420 7 1 Expected Expected Q1 1 ------Actual Actual 1,321 Q1 1 ------Expected Expected 1,519 6,931 9,900 8,459 4,798 2,475 2,115 450 Q2 - - - Results Actual Actual 11,050 1,166 3,535 5,914 3,094 4,176 Q2 Q2 - - - - - Explanation of of Explanation delays/gaps Next steps steps Next to address address to gaps Expected Q3 Expected 13,861 19,800 16,918 3,038 9,595 4,950 4,230 900 - - - Intervention Area 3 (IA3):Health service planning, management and governance governance and management planning, service 3(IA3):Health Area Intervention 3 Sub-IA Program 4 Activit 2 1st Sub 3 2nd services youth for providers for or services GBV as such services referral to make CSB and CHVs Support Planned activities related GBV services GBV related to CSB and CHV by referred people of # # of youth referred for youth services youth of referred # Annex 1: Activity Table FY2017 Q2 (Intervention Area 3) Indicators FY2017 FY2017 targets TBD TBD TBD TBD Expected Expected Q1 - - Actual Actual Q1 - - Expected Expected Q2 - - Results Actual Actual Q2 Q2 - - Explanation of of Explanation delays/gaps Next steps steps Next to address address to gaps Expected Q3 Expected - - X X 4.1.3 Technology use to improve health services 4.1 Program monitoring, evaluation and performance system 4.1.2 Data use 4.1.1 Data Management Cross-Cutting or IA 4. Monitoring and Evaluation, Performance and Learning Management x x x x x MNCH X X x x x x x

MALARIA codes Program X X x x x x x NUTRITI X X x x x x x FP/RH X X x x x x x WASH 4 4 4 4 4 4 4 Sub-IA 1 1 1 1 1 1 1 Activity 2 1 1 1 1 1 2 1st Sub - 1 7 5 4 3 6 2 2nd Sub - meeting/program review meeting/program the quaterly coordination Use the program routine data in for CCHP use CCHP for Adapt database dashboards and levels DQAall at internal Conduct activities reports activities supervision trips, and program RMA, CHV's sources: many from data Manage program routine management system management Set upcomputerized data M&E M&E program the in staff CCHP Train responsible for dataresponsible for management to M&E stafftraining SDSP and Provide initialand on-the-job Planned activities held that presents program data meeting review/coordination program quaterly of % # dashboards developped by CCHby team # of internal DQA conducted manage datamanage # ofM&E staff trained to data SDSP of # trained to manage types) % of reports submitted (by functional system data computerized of # # of people trained in the M&E Annex 1: Activity Table Q2 FY2017 (Cross Cutting) Indicators FY2017 targets 100% TBD TBD 85% 220 483 128 41 1 Expected Expected 220 Q1 ------Results Actual Actual 227 Q1 ------Expected Q2Expected 100% 60% 128 220 45 1 - - Results Actual Q2 69% 179 127 1 - - - - Explanation of of Explanation monthly report submitted their their submitted than planned. delays/gaps More CHVs CHVs More Next steps to address gaps Expected Q3Expected 100% 70% 42 3 1 - - - X X X Cross-Cutting or IA 4. Monitoring and Evaluation, Performance and Learning Management X MNCH X X X X

MALARIA codes Program X X X X NUTRITI X X X X FP/RH X X X X WASH 4 4 4 4 Sub-IA 1 1 1 1 Activity 3 3 3 3 1st Sub - 4 2 1 3 2nd Sub - sickness surveillance) sickness continuing training, reporting and staff during on-site supervisions, EMAD, CSB, CCDS and CCH (eLearning to be used by EMAR, checklist MOH the on based services of application CHV, of video lessons correct on tablets) in register (and Develop selected communes selected in system e-health the Test program use program for system e-Health Develop b) Tracking supervision of CHVs a) CHVs for eLearning for: tablets Use i ti ti ) R Planned activities # VDO clips/lessons developped clips/lessons VDO # # modules validated developped modules e-Health # VDO clips clips VDO eLearning viewed CHVwho # Annex 1: Activity Table Q2 FY2017 (Cross Cutting) Indicators FY2017 targets 7,496 TBD 7 7 Expected Expected Q1 - - - - Results Actual Actual Q1 - - - - Expected Q2Expected 3 3 - - Results Actual Q2 1 1 - - Explanation of of Explanation delays/gaps - Next steps to address gaps - - - Expected Q3Expected 2 2 - - X X X X X X 4.2.1 Studies, survey and review workshops for improvement of program performance 4.2 Learning Management Cross-Cutting or IA 4. Monitoring and Evaluation, Performance and Learning Management MNCH X X X X X

MALARIA codes Program X X X X NUTRITI X X X X X FP/RH X X X WASH 4 4 4 4 4 4 Sub-IA 2 2 2 2 2 2 Activity 1 1 1 1 1 1 1st Sub - 2 1 6 5 4 3 2nd Sub - (conducted by external entity) baseline/CCHP new in districts Supplementary survey to OMS workshop) start-up district and regional the (conducted CCH by team during approach KMSm of Review external entity) external youth needs (conducted by based violence (GBV) and on gender-Landscape analysison (conducted by external entity) insurance or mutuelle de sante analysisSituation micro- on and district start-up workshop) by CCH team during the regional (conducted system ETS of Review by external entity) Facilities (CSB) survey (conducted Planned activities # of baseline survey conducted # of review conducted review of # Same as 1.1.4.2 activity Same as 1.4.1.2 activity # of review conducted review of # Same as 3.1.1.2 activity Annex 1: Activity Table Q2 FY2017 (Cross Cutting) Indicators FY2017 targets 38 38 1 1 1 1 Expected Expected Q1 38 38 1 - - - Results Actual Actual Q1 38 38 1 - - - Expected Q2Expected ------Results Actual Q2 ------Explanation of of Explanation delays/gaps Next steps to address gaps Expected Q3Expected ------X X X X X X 4.2.2 Dissemination Cross-Cutting or IA 4. Monitoring and Evaluation, Performance and Learning Management X MNCH X X X X X X X

MALARIA codes Program X X X X X X X NUTRITI X X X X X X X FP/RH X X X X X X X WASH 4 4 4 4 4 4 4 Sub-IA 2 2 2 2 2 2 2 Activity 2 2 2 1 1 2 2 1st Sub - 4 1 3 8 7 5 2 2nd Sub - quarterly basis a newsletter on Efa ny Zara CHV the in data Present basis quarterly a on newsletter USAID Feature program highlights in workshop) start-up district and regional the (conducted CCH by team during RLG and parrain YPE, menage namely based SBCC approaches community- selected of Review start-up workshop) theduirng regional and district CSB (conducted CCH by team and CHV between system referal counter and referal of Review national and international both conference meetings, results in Present program Management Plan Implement the Learning start-up workshops) (combined with the 3day regional program in the remaining regions Regional launch of the CCH Planned activities # ofZaraeditions Efa ny # highlights submited# highlights to USAID # of review conducted review of # # of review conducted review of # # of meetings# of participated that are carriedout that the of activities% the plan in # of regional launch workshops Annex 1: Activity Table Q2 FY2017 (Cross Cutting) Indicators 6 remaining FY2017 targets 52,228 regions 100% 38 38 10 4 Expected Expected 100% Q1 38 38 37 1 4 - Results Actual Actual 100% Q1 38 38 37 1 4 - Expected Q2Expected 13,057 100% TBD - - 1 - Results Actual Q2 19,000 100% 73 - - 0 - decided to provide provide to decided Not requested by by requested Not Explanation of of Explanation insetad of 1per each CHV with one newsletter newsletter one USAID in Q2 USAID in two CHVs as as CHVs two The program program The delays/gaps planned. Next steps to address gaps - - - Expected Q3Expected TBD 1 - - ANNEX 2: PROJECT PERFORMANCE REVIEW (QUARTER 2, FY2017)

USAID Technical themes/Indicators FY2017 Annual Achieved Achieved Remaining Comments codes Target in Q1 in Q2 for FY2017 Family Planning Number of of USG assisted CHVs providing FP Male 3,268 - 1,866 1,402 The program will continue to reach 90% of the information, referrals, and/or services during the year Female 2,179 - 1,244 935 CHVs under the former program to be fully 7.2-2 Total 5,447 - 3,110 2,337 functional.

MCH Number of newborns receiving chlorhexidine as part of Boys 24,500 - 529 23,971 This target was revised as most of the CHVs the new born essential care Girls 24,500 - 503 23,997 trained under the former program did not No code Total 49,000 - 1,032 47,968 continued to offer this service and 66% had stockout. Refresher training will be done in Q3.

WATSAN 3.1.6.8-5 Number of communities certifies as "open defecation Total 279 - - 279 Evaluation of these communities will be in Q4 free" (ODF) as a result of USG assistance Number of people gaining access to an improved Male 11,750 - - 11,750 Data on improved latrines newly built under the 3.1.1.2-2 sanitation facility Female 11,750 - - 11,750 program will be reported from Q3. Total 23,500 - - 23,500 NUTRITION Number of women reached with education on exclusive Male N/A N/A N/A N/A These targets were revised given the information 3.1.6 9-1 breastfeeding Female 210,000 - 18,454 210,000 received from the field that 20% of functional Total 210,000 - 18,454 210,000 CHVs in the ongoing 24 districts have changed Number of children reached by USG-supported Male 211,500 - 17,528 211,500 and SBCC training will be done only for 89% of 3.1.9.1-15 nutrition programs Female 238,500 - 19,753 238,500 the CHVs in these districts and 50% in the new districts and performance of CHVs was lower Total 450,000 - 37,281 450,000 th t d Number of children under two (0-23 months) reached Male 57,878 22,192 35,686 On target HL.9.2 with community-level nutrition interventions trhough Female 65,267 18,900 46,367 USG-supported programs Total 123,145 41,092 82,053 Number of pregnant women reached with nutrition On target HL.9.3 Total 59,956 12,888 47,068 interventions through USG-supported programs Number of individuals receiving nutrition-related Male 2,901 1,620 1,281 On target HL.9.4 professional training through USG-supported programs Female 2,695 1,296 1,399 Total 5,596 2,916 2,680 CUSTOM No code Number of communities having developped a Total Activities will start in FY2018 transportation system for health emergency Annex 3: Environmental Mitigation and Monitoring Report, Q2 FY2017

Title of the program: 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. and 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 and Cost share: $2,999,298) Funding End: 06/06/2021 FY2017 Amount : $ 8,839,071 (USAID: $8,035,519 and Cost share: $803,552) ESR Prepared by: Chuanpit Chua-oon Date: March, 2017 Chief of Party - JSI/Mahefa Miaraka Date of Previous EMMR: - N/A 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 QII 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 implemented Remarks actions as per 22 CFR 216.2(c) (2) (i) Education, In order to prevent and reduce waste, Mahefa Miaraka technical continued to adopt best practices from MAHEFA, as such : assistance, or - minimize distribution of handouts at the above workshops training gathering large groups of stakeholders including CHVs and programs 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 Q1I 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:

2.1 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 (6,116 CHVs), and supportive supervision including malaria activities (7,492 CHVs) by the end of September 2017.

Planned activities Recommended mitigating actions Status of mitigated Any outstanding issues Remarks measures/ actions relating to required taken in Q2 FY2017 conditions - Training/ supportive supervision - Health care service delivery enhancement (excluding HIV/aids testing, surveillance and monitoring) 1.1.2.3 Conduct refresher training Review and update as necessary training 2,483 CHVs trained in c- Training of CHVs on CHX will for CHVs according to MOH's curricula and SBCC materials related to health IMCI including waste be planned for Q3 and Q4 revised training curriculum (training care management and appropriate disposal management related to may be done few times. Some using incinerators or improved burial pits at malaria and diarrhea training may be done during the health facilities for medical waste, CHX tubes, commodities monthly CHV meeting) used sharps, syringes and needles, and expired drugs 1.1.2.5 Conduct initial training for Refresher and continued training, and 433 CHVs trained in c- CHVs in new districts supervision on appropriate handling, use, IMCI storage and waste disposal of CHX tubes, 1.1.2.6 CHVs receive regular sharps, syringes and needles, gloves, expired 952 CHVs who receive supervision visits from FKT head drugs following the EMMP poster guide on-site supervision and CCDS members developed in MAHEFA and using safety boxes 1.2.1.1/3.0.3.2 Support supervision and/or burial pits 700 CHVs received on- visits to CHVs from CCDS, CSB site supervision by CSB in representatives, EMAD, EMAR, the last three months MOH, and CCH staff

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

Planned activities Recommended mitigating actions Status of mitigated measures/ actions Any outstanding Remarks taken in Q2 FY2017 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 storage, 72 CCDS members trained on SBCC stakeholders (COSAN: FKT heads use and disposal of used condoms, unused and CHVs and CCDS members) and expired drugs, used syringes, and on SBCC to promote and washing of insecticide-treated nets advocate for improved services and utilization throughout the continuum of care 2.2.1.3 Conduct training on the 306 local masons inventoried In Q2 period, activity CLTS approach for CCDS and focused on inventory of FKT COSAN members 198 villages maintaining ODF status existing latrines and ODF villages and 12,200 FKT heads and CHVs trained on training of FKT heads WASH (Data for these indicators not yet and CHVs will start in available in Q2) Q3 accordingly

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

Planned activities Recommended mitigating actions Status of mitigated measures/ Any outstanding issues Remarks actions taken in Q2 FY2017 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 CSB in Equip the permanent health huts and 503 permanent Toby equipped with good hygiene and waste CSB with disposal pit disposal pits management practices 384/732 CSB equipped with disposal pit 3.2.1.2 Hold coordination CHVs will be provided with training or 2,483 CHVs trained in stock The DPLMT/ UTGL held the meeting with PSI/ISM program refresher training on stock management of c-IMCI products TOT for stock management at and set up regular meeting management including expiry date and the central and training of remaining CHVs will be schedule the appropriate related waste coordinated with PSM in management processes to be followed Q3/Q4 3.2.1.3 Participate in as per the Madagascar National Waste # of CHVs who sent full sharp boxes No CHVs reported during the DPLMT/UTGL activities related Management Policy (2005) to the CSB for disposal present reporting period to to commodities availability for bring back to the CSB any full sharp box. CSB and CHVs 3.2.1.4 Train CSB on Storage of the products according to # CHVs with public health No CHVs reported during the This activity is commodities management the information provided on the commodities returned back to the present reporting period any N/A for this including CHV commodity needs manufacturer’s Materials Safety Data CSB expired drug and sent back to period of the CSB reporting as CHVs planning in line with MOH Sheet (MSDS) supplied with new protocols Return expired commodities to the products health facility for CHVs Appropriate disposal of expired drugs following the Madagascar National Waste Management Policy (2005)

2.4 Small-scale water supply and sanitation.

Planned activities Recommended mitigating actions Status of mitigated measures/ Any outstanding issues Remarks actions taken in Q2 FY2017 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 COSAN Building and use of appropriate 7,301improved latrine inventoried Next period of report will be to begin promotion of WASH improved latrines at households on new built latrines. activities including sale of sur'eau and latrine slabs Support Local masons on producing 306 local masons inventoried Inventory of existing local slabs masons was the focus in Q2 5,000 latrine slabs sold by local and based on this, the program will follow their production masons (Data for this indicator not yet and sale of slabs available in Q2) 2.2.2.7 Support CHV and CSB in good Equip the permanent health huts and 403 permanent Toby equipped with hygiene and waste management CSB with latrines latrine and hand washing station practices 200 CSB equipped with latrines and This indicator will be reported hand washing station (Data for this under the CSB survey indicator not yet available in Q2) 503 toby equipped with disposal pits 384 CSB equipped with disposal pit

Annex 4. List of Communes in Mahefa Miaraka Program in Q2 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 9,774 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 CSB CCDS CHVs Région

AMBANJA SAHALAVA 9 1 1 18 AMBATOHARANANA 18 3 1 36 AMBODIMANGA II B 20 2 1 40 AMPASIMBE MANANTSATRANA 11 3 1 22 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 32 VOHILENGO 17 2 1 34 VOHIPENO 22 3 1 44

FENERIVE EST 14 211 29 14 422 TOTAL

AMBATOHARANANA MNNR 11 1 1 22 AMBODIAMPANA MNNR 14 2 1 28 AMBODIVOANIO 15 2 1 30 ANALANAMPOTSY 11 0 1 22 ANDASIBE MNNR 8 1 1 16

MANANARA NORD ANTANAMBAOBE 12 1 1 24 ANTANAMBE 24 3 1 48

ANTANANANIVO 10 1 1 20 IMORONA 7 1 1 14 MAHANORO MNNR 5 1 1 10 MANAMBOLOSY 18 2 1 36 ANALANJIROFO

No. of No. of No. of District Communes Fokontany CSB CCDS CHVs Région

MANANARA NORD 21 1 1 42 SANDRAKATSY 20 1 1 40 SAROMAONA 14 1 1 28 TANIBE 13 1 1 26 VANONO 12 2 1 24

MANANARA NORD 16 215 21 16 430 TOTAL

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

MAROANTSETRA 20 168 28 20 336 TOTAL

SAINTE MARIE AMBODIFOTATRA 21 10 1 42

SAINTE MARIE 1 21 10 1 42 TOTAL

SOANIERANA AMBAHOABE 19 4 1 38

No. of No. of No. of District Communes Fokontany CSB CCDS CHVs Région

IVONGO AMBINANISAKANA 7 1 1 14 AMBODIAMPANA 5 1 1 10 ANDAPAFITO 16 2 1 32 ANTANIFOTSY 12 1 1 24 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 24

VAVATENINA ANJAHAMBE 11 2 1 22 MAROMITETY 19 2 1 38 MIARINARIVO 14 3 1 28 SAHATAVY 8 2 1 16 TANAMARINA 5 0 1 10 VAVATENINA 17 1 1 34

VAVATENINA 11 127 19 11 254 TOTAL TOTAL 71 848 127 71 1696 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 CSB CCDS CHVs Région

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 38 AMBODIMANGA RAMENA 10 1 1 20 AMBOHIMARINA 6 2 1 12 AMBOHIMENA 5 1 1 10 AMBOHITRANDRIANA 6 1 1 12 ANKATAFA 4 1 1 8 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 0 ANTSAKOAMANONDRO 10 1 1 20 ANTSATSAKA 8 3 1 16 ANTSIRABE 16 1 1 32 BEMANEVIKY H/S 8 2 1 16 BEMANEVIKY OUEST 13 2 1 26 BENAVONY 0 1 0 DJANGOA 6 1 1 12 MAEVATANANA 6 1 1 12 MAHERIVARATRA 7 1 1 14 MAROTOLANA 13 2 1 26 MAROVATO 5 1 1 10

AMBANJA TOTAL 24 189 32 24 378 AMBILOBE AMBAKIRANO 12 2 1 24 DIANA

No. of No. of No. of District Communes Fokontany CSB CCDS CHVs Région

AMBARAKARAKA 12 2 1 24 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 16 ANKARATRA SIRAMA 9 1 1 18 ANTANABE 6 1 1 12

ANTSARAVIBE 14 3 1 28

ANTSOHIMBONDRONA 6 2 1 12 BERAMANJA 20 2 1 40 BETSIAKA 13 4 1 26 MANAMBATO 7 2 1 14 MANTALY 12 1 1 24 TANAMBAO MARIVORAHONA 11 1 1 22

AMBILOBE TOTAL 17 178 28 17 356 ANTSIRANANA I DIEGO SUAREZ 25 3 1 50

ANTSIRANANA I 1 25 3 1 50 TOTAL

AMBOLOBOZOBE 5 1 1 10 AMBONDRONA 9 1 1 18 ANDRAFIABE 5 1 1 10 ANDRANOFANJAVA 8 1 1 16 ANDRANOVONDRONINA 9 2 1 18 ANIVORANO NORD 21 3 1 42 ANTSIRANANA II ANKARONGANA 5 1 1 10 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 0

No. of No. of No. of District Communes Fokontany CSB CCDS CHVs Région

BOBAKILANDY 5 1 1 10 BOBASAKOA 3 1 1 6 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 8 NOSY BE BEMANONDROBE 8 3 1 16 DZAMANDZAR 9 2 1 18 HELL VILLE 11 1 1 22

NOSY BE TOTAL 6 42 10 6 84 TOTAL DIANA 71 596 103 71 1192 AMBATOMAINTY 12 1 1 24 BEMARIVO 8 3 1 16

AMBATOMAINTY MAKARAINGO 6 1 1 12 MAROTSILEHA 8 2 1 16 SARODRANO 5 1 1 10

AMBATOMAINTY 5 39 8 5 78 TOTAL

ANTSALOVA 13 1 1 26 BEKOPAKA 12 1 1 24 BEMARAHA ANTSINANANA 5 0 1 10 ANTSALOVA MASOARIVO 10 3 1 20

SOAHANY 8 3 1 16 TRANGAHY 9 3 1 18 MELAKY

No. of No. of No. of District Communes Fokontany CSB CCDS CHVs Région

ANTSALOVA TOTAL 6 57 11 6 114 AMBOLODIA SUD 9 1 1 18 AMPAKO 6 1 1 12 ANKASAKASA TSIBIRAY 7 1 1 14 ANTSIRASIRA 6 0 1 12

BESALAMPY BEKODOKA 19 1 1 38 BESALAMPY 8 1 1 16 MAHABE 9 1 1 18 MAROVOAY SUD 6 1 1 12 SOANENGA 8 2 1 16

BESALAMPY TOTAL 9 78 9 9 156 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 16 BELITSAKY 7 1 1 14

MAINTIRANO BEMOKOTRA SUD 8 1 1 16 BEREVO RANOBE 5 2 1 10 BETANATANANA 14 1 1 28 MAFAIJIJO 8 1 1 16 MAINTIRANO 8 1 1 16 MAROHAZO 10 2 1 20 MAROMAVO 3 1 1 6 TAMBOHORANO 7 1 1 14 VEROMANGA 5 1 1 10

MAINTIRANO TOTAL 17 133 19 17 266 ANDRAMY 17 1 1 34

MORAFENOBE ANTRANOKOAKY 7 2 1 14 BERAVINA 11 2 1 22

No. of No. of No. of District Communes Fokontany CSB CCDS CHVs Région

MORAFENOBE 20 4 1 40 MORAFENOBE 4 55 9 4 110 TOTAL TOTAL MELAKY 41 362 56 41 724 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 14 BEGIDRO ANKIROROKA 7 1 1 14 BELO TSIRIBIHINA BELINTA 9 1 1 18 BELO TSIRIBIHINA 21 1 1 42 BEREVO 8 1 1 16 BEROBOKA NORD 9 1 1 18 DELTA 10 1 1 20 MASOARIVO 10 1 1 20 TSARAOTANA 12 2 1 24 TSIMAFANA 13 2 1 26

BELO TSIRIBIHINA 15 153 17 15 306 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 56 BEZEZIKA 5 - 1 10 MAHABO BEFOTAKA 12 1 1 24 BERONONO 6 1 1 12 MAHABO 7 1 1 14 MALAIMBANDY 19 2 1 38

MANDABE 16 2 1 32 TSIMAZAVA 8 1 1 16 MENABE

No. of No. of No. of District Communes Fokontany CSB CCDS CHVs Région

MAHABO TOTAL 12 141 15 12 282 ANDRANOPASY 9 3 1 18 ANKILIABO 18 3 1 36 ANONTSIBE 13 2 1 26 MANJA BEHARONA 10 3 1 20 BETSIOKY 5 1 1 10 MANJA 13 2 1 26 SOASERANA 7 1 1 14 MANJA TOTAL 7 75 15 7 150 AMBATOLAHY 8 2 1 16 AMPANIHY 7 2 1 14 ANDRANOMAINTY 7 - 1 14 ANKAVANDRA 14 1 1 28 ANKONDROMENA 7 2 1 14 ANKOTROFOTSY 15 2 1 30 ANOSIMENA 5 2 1 10 BEMAHATAZANA 7 1 1 14 MIANDRIVAZO BETSIPOLITRA 7 1 1 14 DABOLAVA 5 1 1 10 ISALO 10 2 1 20 ITONDY 7 1 1 14 MANAMBINA 10 2 1 20 MANANDAZA 9 1 1 18 MIANDRIVAZO 8 1 1 16 SOALOKA 13 1 1 26

MIANDRIVAZO 16 139 22 16 278 TOTAL

ANALAIVA 23 2 1 46 BEFASY 23 7 1 46 MORONDAVA BELO SUR MER 14 3 1 28 BEMANONGA 26 3 1 52 MAROFANDILIA 8 2 1 16

No. of No. of No. of District Communes Fokontany CSB CCDS CHVs Région

MORONDAVA 18 1 1 36 MORONDAVA 6 112 18 6 224 TOTAL TOTAL MENABE 56 620 87 56 1240 AMBALAMANASY II 11 1 1 22 AMBALAVELONA 5 1 1 10 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 ANDRAKATA 3 1 1 6 ANDRANOMENA 5 1 1 10 ANJIALAVABE 6 1 1 12 ANDAPA 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 ANTALAHA AMPAHANA 16 3 1 32 AMPANAVOANA 11 1 1 22 AMPOHIBE 12 1 24 1 ANDAMPY 12 2 1 24 SAVA

No. of No. of No. of District Communes Fokontany CSB CCDS CHVs Région

ANTALAHA 23 3 1 46 ANTANANAMBO 15 2 1 30 ANTOMBANA 21 2 1 42 ANTSAHANORO 11 1 1 22 ANTSAMBALAHY 9 2 1 18 LANJARIVO 14 2 1 28 MANAKAMBAHINY ANKAVIA 8 2 1 16 MAROFINARITRA 8 1 1 16 SAHANTAHA 7 1 1 14 SARAHANDRANO 7 1 1 14 VINANIVAO 11 2 1 22 ANTALAHA TOTAL 18 219 31 18 438 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 18 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 SAMBAVA ANDREMBONA 6 1 1 12 ANJANGOVERATRA 25 1 1 50 ANJIALAVA 10 1 1 20 ANJINJAOMBY 8 1 1 16 ANTINDRA 14 1 1 28 ANTSAHAVARIBE 22 1 1 44 ANTSAMBAHARO 7 1 1 14 BEMANEVIKA 12 2 1 24 BEVONOTRO 22 2 1 44 FARAHALANA 20 1 1 40

No. of No. of No. of District Communes Fokontany CSB CCDS CHVs Région

MAHASOA ANTINDRA 13 0 1 26 MAROAMBIHY 8 1 1 16 MAROGAONA 10 2 1 20 MAROJALA 13 1 1 26 MORAFENO 12 1 1 24 NOSIARINA 8 1 1 16 SAMBAVA URBAIN 16 2 1 32 TANAMBAO DAOUD 13 3 1 26 SAMBAVA TOTAL 28 347 40 28 694 AMBALASATRANA 9 1 1 18 AMBINANIN'ANDRAVORY 8 2 1 16 AMBODISAMBALAHY 9 1 1 18 AMBORIALA 5 1 1 10 AMPANEFENA 15 1 1 30 AMPISIKINANA 5 1 1 10 AMPONDRA 4 2 1 8 ANDRAFAINKONA 5 1 1 10 ANDRAVORY 4 1 1 8 VOHEMAR ANTSIRABE NORD 17 5 1 34 BELAMBO 7 2 1 14 BOBAKINDRO 3 1 1 6 DARAINA 8 2 1 16 FANAMBANA 6 2 1 12 MAROMOKATRA LOKY 5 2 1 10 MILANOA 16 2 1 32 NOSIBE 8 3 1 16 TSARABARIA 11 3 1 22 VOHEMAR 10 2 1 20 VOHEMAR TOTAL 19 155 35 19 310 TOTAL SAVA 86 877 134 86 1754

AMBALIHA 14 1 1 28 ANALALAVA AMBARIJEBY-SUD 7 1 1 14 SOFIA

No. of No. of No. of District Communes Fokontany CSB CCDS CHVs Région

AMBOLOBOZO 22 4 1 44 ANALALAVA 15 3 1 30 ANDREVOREVO 3 0 1 6 ANDRIMBAVONTSONA 10 1 1 20 ANGOAKA SUD 6 1 1 12 ANKARAMY 16 5 1 32 ANTONIBE 23 2 1 46 BEFOTAKA NORD 17 2 1 34 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 TOTAL 15 180 27 15 360 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 TOTAL 13 167 27 13 334 AMBALAROMBA 5 1 1 10 AMBARARATA SOFIA 7 1 1 14 BEALANANA AMBARARATABE NORD 8 2 1 16 AMBATORIHA EST 15 2 1 30

No. of No. of No. of District Communes Fokontany CSB CCDS CHVs Région

AMBATOSIA 14 2 1 28 AMBODIADABO 8 1 1 16 AMBODIAMPANA 6 2 1 12 AMBODISIKIDY 8 1 1 16 AMBOHIMISONDROTRA 7 1 14 AMBOVONOMBY 8 1 1 16 ANALILA 6 1 1 12 ANJOZOROMADOSY 8 1 1 16 ANKAZOTOKANA 7 1 1 14 ANTANANIVO HAUT 7 2 1 14 ANTSAMAKA 8 2 1 16 ANTSIRADAVA 5 1 10 BEALANANA 20 1 1 40 BEANDRAREZONA 12 3 1 24 MANGINDRANO 13 3 1 26 MAROTOLANA 17 1 1 34 BEALANANA TOTAL 20 189 28 20 378 AMBARARATA 16 3 1 32 AMBODIMOTSO HAUT 11 2 1 22 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 44 TSARAHONENANA 36 5 1 72 TSIAMALAO 26 4 1 52

BEFANDRIANA 14 256 40 14 512 AVARATRA TOTAL

No. of No. of No. of District Communes Fokontany CSB CCDS CHVs Région

AMBANJABE 13 1 1 26 AMBATOMILAHATRANO 8 1 1 16 AMBODIMAHABIBO 11 1 1 22 AMBODISAKOANA 15 2 1 30 AMBODIVONGO 12 1 1 24 AMPARIHY 17 1 1 34 ANDRANOMENA I 10 1 20 ANDRANOMEVA 14 1 1 28 IHOBAKA 9 1 1 18 BORIZINY LEANJA 22 2 1 44 MAEVARANOHELY 13 1 1 26 MAROVATO 20 2 1 40 PORT BERGE I 11 1 1 22 PORT BERGE II 20 1 1 40 TSARAHASINA 19 1 1 38 TSARATANANA 15 2 1 30 TSININGIA 11 1 1 22 TSINJOMITONDRAKA 26 2 1 52 BORIZINY TOTAL 18 266 22 18 532 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 46 BETARAMAHAMAY 9 1 1 18 KOMAJIA 11 1 1 22 MALAKIALINA 17 1 1 34 MAMPIKONY I 29 1 1 58 MAMPIKONY II 16 2 1 32 MAMPIKONY TOTAL 11 169 16 11 338 MANDRITSARA AMBALAKIRAJY 14 2 1 28

No. of No. of No. of District Communes Fokontany CSB CCDS CHVs Région

AMBARIKORANO 3 1 1 6 AMBARIPAIKA 6 1 1 12 AMBILOMBE 7 1 1 14 AMBINAN'IFANGO 7 1 1 14 AMBOABOA 10 1 1 20 AMBODIADABO MAITSOKELY 6 1 1 12 AMBODIAMONTANA KIANGA 7 1 1 14 AMBOHISOA 8 1 1 16 AMBORONDOLO 4 1 1 8 AMPATAKA MARORENY 6 1 1 12 ANDOHAJANGO 12 1 1 24 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 16 ANTANANDAVA 12 1 1 24 ANTSATRAMIDOLA 9 1 1 18 ANTSIATSIAKA 5 1 1 10 ANTSIRABE CENTRE 8 2 1 16 ANTSOHA 6 1 1 12 KALANDY 14 1 28 MANAMPANEVA 7 2 1 14 MANDRITSARA 13 1 1 26 MAROTANDRANO 16 2 1 32 PONT SOFIA 5 1 1 10 TSARAJOMOKO 6 2 1 12 TSARATANANA 10 1 1 20 MANDRITSARA 29 240 35 29 480 TOTAL TOTAL SOFIA 120 1467 195 120 2934

GRAND TOTAL 456 4887 732 456 9774

Annex 5. International Trips at the End of Q2 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 3 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.

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 5 1 US Madagascar JSI technical support trips in FY2017. 1 0 3 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

Annex 6. Increased Membership Expands Mutuelle de Santé Success

In February 2017, the Anjiamangirana commune in the Sofia region of Madagascar faced a problem. For the last four years, many members of commune had been able to access health services through a mutuelle de santé, a membership-based microfinance program where subscribers contribute a monthly fee in order to access free health services at the local health facility. The mutuelle, which was created with technical Francis (in yellow shirt) being interviewed by the Secretary General (in assistance from the MAHEFA project as an purple shirt) and his senior staff. element of the Government of Madagascar’s goal of reaching universal health care, had been an innovative way to ensure 369 member households, around 689 people, had health care. However, in October and November of the previous year, 23 members of the mutuelle had gone to access treatment with costs ranging from 5,000 to 10,000 Ariary (1.6 to 3.2 US$), resulting in a balance of 185,216. While all of the members had routinely paid their dues, these costs put the mutuelle at risk of running out of funds. When this challenge arose, Francis, the President of the Management Committee for the Anjiamangirana mutuelle de santé, worked hard to ensure the mutuelle would continue. Like the other eight members of the Management Committee, who are all volunteers, Francis has seen the mutuelle’s immense benefit firsthand.

“A few months ago, a three-year old boy named Herisoamanana Estolane with a fever was brought to see the community health volunteers (CHV),” Francis said. “The rapid test performed by the CHV confirmed that Estolane had malaria with a danger sign (extremely high fever). The CHV referred the boy to the health facility where his parents took him immediately. Estolane ended up spending 4 days at the CSB. Because his parents are members of the mutuelle, the parents did not pay for the treatment.”

Francis says this story, and others like it, motivate him to promote the mutuelle so that people will not be concerned about having cash to pay for the treatment since everyone will be covered by the mutuelle. As a result of his hard work promoting the mutuelle, an additional 118 households were recruited and became members. These new members not only helped to ensure the mutuelle had enough funds to continue, but also expanded the program’s overall reach.

During the most recent field supervision visit, the MOH’s Secretary General made the following recommendation to the Regional Public Health team that “The Anjiamangirana mutuelle de santé covers 10% of the population in five fokontany. This is impressive and should expand to other fokontany.”

Because Francis’ work and the Anjiamangirana mutuelle de santé’s success, the Mahefa Miaraka program (2016-2021), a follow-on to the MAHEFA program, is currently evaluating a performance of the existing 33 mutuelle de santé that were created with MAHEFA’s assistance. The results of the evaluation (expected to be available in July 2017), will help the program redesign its approach to assist the communes in creating sustainable health microfinance initiatives, including mutuelle de santé.

Meanwhile, the Anjiamangirana mutuelle de santé hopes to continue its progress. “Our goal this year is to have more members so our mutuelle de santé will be sustainable and the members’ monthly payments will be less,” Francis said.

CHAMPIONS FOR HEALTH EQUITY: WORKING TOGETHER TO ENSURE ACCESS TO HEALTH SERVICES FOR EVERYONE AT ALL LEVELS OF THE HEALTH SYSTEM

The Analalava district, located in the northwestern Sofia region of Madagascar, is home to 165,149 inhabitants as of 2016, many of whom are women of childbearing age and young children. The district is very difficult to access by land, especially during the rainy season, and instead is primarily reached by sea travel. As a result, the area is isolated and in the past has lacked quality health services for its most vulnerable residents.

JSI first began working in this district in January 2013 as part of the Community-Based Integrated Health program, locally known as MAHEFA, which ran from 2011 to 2016. As its name suggested, the MAHEFA program aimed to provide basic integrated health services at the community level. This work now continues under the Community Capacity for Health, or Mahefa Miaraka, project. Both projects’ success in the region is primarily due to the leadership and dedication of the district’s healthcare providers, from the district medical inspector down to a small army of passionate community health volunteers (CHVs).

INNOVATIVE LEADER

Doctor Rakotoarimanana Jimi: MEDICAL INSPECTOR1 IN THE ANALALAVA DISTRICT, SOFIA REGION

Dr. Jimi is a dedicated healthcare professional who moved to Analalava district seven years ago to serve as the main healthcare provider at a public health facility, or Centre Santé de Base (CSB). Three years later, he became the district Medical Inspector, a post he continues to hold today.

As Medical Inspector, Dr. Jimi’s mission is to preserve and improve the health of the citizens throughout the district; ensure quality, safety, and equality within the healthcare system; and protect the population from major health threats.

After taking the position, Dr. Jimi quickly realized that the district was so isolated that it lacked the supplies the district CSBs need to effectively treat patients. He also found that many CSBs in the district had unreliable operating hours, making it that much harder for community members to access care. As a result, the district was very behind in achieving national health objectives, including the infant vaccination

The Community Capacity for Health project, locally known as Mahefa Miaraka, is a five-year (2016-2012) 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 Insti- tiute, Inc. (JSI). Dr. Jimi Rakotoarimanana, Medical Inspector, Analalava district, Sofia region, February 2017.

1 Medical Inspector is the Director of the District Health Office. JANUARY - MARCH 2017 rate. Despite the intensification of the National Immunization Campaign, Dr. Jimi found that his district’s vaccination rate was under 70% in 2013, one of the lowest in the region.

In October 2016, Dr. Jimi and the Mahefa Miaraka Program team in the Sofia region organized a three-day Program start-up workshop to introduce the Program and its contributions to the National Policy on Community Health, as well as to solicit the district’s endorsement in making sure the Program achieves its goal: making sure all families living in the district have access to basic health care in their community. Dr. Jimi is very excited about the existence of the Program in his district because the Program’s goal is the same as one of the district’s health goals. The Program will assist the district health team in training, equipping, and supervising a total of 360 community health volunteers in his district. In Dr. Jimi’s opinion, these volunteers are the extended arms of the government health facilities, Dr. Jimi talking with the catholic clinic manager during outreach or CSBs, since they provide basic services in their communities activities, Sofia region, February 2017. in the following areas:

• Prevention and promotion of good health practices, such as the Catholic clinic in the village of Tsimahasenga where including water, hygiene, and sanitation childhood immunizations takes place monthly. The promising • Providing services in family planning results and the arrival of the Program increased Dr. Jimi’s confidence enough that he requested an increase for the district • Diagnosing and treating children under 5 with simple cases operating budget from the Regional Office of Sofia. This increase of malaria, diarrhea, and pneumonia or Community-based will ensure that quality health services are available both at the Integrated Management of Childhood Illnesses (c-IMCI) CSBs and at the community level via CHVs. • Conducting growth monitoring activities and promoting nutritional education sessions especially for pregnant BUILDING A TEAM and/or lactating women and children under 5 As an experienced heath care worker, Dr. Jimi knows that a • Referring women and children for further services community’s access to care at all levels, not just the CSB, is key at CSBs including antenatal care, delivery, vaccination, to improving health. Dr. Jimi has seen the value of CHV interven- and emergency treatment. tions but he also knows that the volunteers need supervisions to make sure their services follow the national standards and All community volunteers receive training from and are super- norms. He directs all his CSB heads to provide the supervision vised by the CSB heads. Dr. Jimi, his staff, and the Program staff to the CHVs in their areas. Dr. Jimi himself often takes time conducted training of trainers (TOT) to the CSB heads in all the to fit monthly visits to CHV health huts into his already heavy technical areas of the CHVs. The TOT is a good opportunity for workload. As a result, he is able to better understand field Dr. Jimi’s district team to mentor the CSB heads and monitor conditions. Additionally, as his relationship with the CHVs the functionality of the CSBs in the district. The Program provides increase, he also seeks feedback from them concerning the an opportunity for Dr. Jimi and his team to have additional visits performance of the CSBs in his district. These relationships to all CSBs in the district on a regular basis. and his first-hand knowledge of the field conditions are part of Dr. Jimi’s strategy to look for ways to improve services given Through the Program, Dr. Jimi had an opportunity to work closely at the CSBs and by CHVs in his district. and regularly with all 26 CSBs in the district to ensure a quality standard of healthcare for all residents. He is now able to Dr. Jimi was able to form partnerships with two specific CHVs organize the quarterly meetings for all CSB providers to monitor to provide health care support. These two CHVs, Fitiavana and reporting and provide updates on the health situation in each Marie-Jeanne, are highly motivated and effective CHVs whose commune. This collaboration extends to private health facilities, MY CHILDREN HAD NO PROBLEM AFTER EACH VACCINE, JUST A SMALL “ FEVER THAT QUICKLY WENT AWAY. I AM MORE OPTIMISTIC NOW THAT THE LITTLE ONE HAS GRADUATED BECAUSE SHE WILL HAVE A BETTER FUTURE. MY DREAM IS THAT SHE WILL ONE DAY BECOME A DOCTOR

TO TAKE CARE OF US LATER. ” — SOATIANA MARIE ORTENSE

Soatiana’s family proudly show Fabiolette’s immunization diploma, Sofia region, February 2017. dedication is reflected in their work. Together, Dr. Jimi, a district Fabiolette, is shown here smiling with her diploma, which she immunization coordinator, Biteny Gina, and the two CHVs worked received when she completed the full immunization series. together to improve the immunization rate. The team has clearly defined roles: CHVs sensitize parents while taking the weight Soatiana had all five of her children complete the vaccination and mid-upper arm circumference (MUAC) of the children, series. She credits her decision to effective radio campaigns on the CSB assistant and Dr. Jimi carry out follow-ups, and Biteny the importance of immunizations and the dedication of the two Gina completes the vaccinations. CHVs in her community, Marie Jeanne and Fitiavana. Soatiana was convinced that completing the series would not only keep As part of this work, the team met Soatiana Marie Ortense, 31, her children healthy, but also allow them to attend a school at who is married and the mother of five. Her oldest (14 yrs) helps his family in the fields when he is not in class. The youngest, which the completion of vaccinations was mandatory. According to Dr. Jimi, this achievement would not have been She even promoted the program to her sister-in-law, who decided possible without the CHVs and the MAHEFA and Mahefa Miaraka to vaccinate her first child at the local CSB in Tsimasengy. programs. At the end of the MAHEFA program in February 2016, 15,548 children under 5 received treatment for malaria, pneumo- Under the leadership of Dr. Jimi, with help from the two USAID nia and diarrhea in their communities (March 2015-February community health programs, the vaccination rate in Analalava 2016) and 22,693 children under 5 were referred for vaccination district has increased from under 70% in 2013 to 90% in 2016 and at the CSBs by the CHVs in the district of Analalava. the infant mortality rate among hospitalized is now less than 1%.

Marie-Jeanne measures a child’s mid-upper arm circumference (MUAC), Sofia region, February 2017.

THE VACCINATION RATE IN ANALALAVA DISTRICT HAS INCREASED FROM UNDER THE INFANT MORTALITY RATE IS NOW 70% TO 90% LESS THAN 1% AMONG THOSE TREATED AT IN2013 IN2016 HEALTH FACILITIES Teamwork during outreach activities: The District Immunization Coordinator, a CHV, and Dr. Jimi, Sofia region, February 2017.

So far, under the new Mahefa Miaraka Program, in the three months of the second quarter of FY 2017, 1,894 children under 5 have received treatment for malaria, pneumonia, and diarrhea in their communities and 752 children under 5 were referred for vaccination at the CSBs by the CHVs in the district of Analalava.

BEFORE THE MAHEFA PROGRAM, THERE WERE NO INTEGRATED HEALTH SERVICES AVAILABLE AT THE COMMUNITY LEVEL. Fitiavana and Marie-Jeanne explain immunization advantages and treatment related side effects to mothers, Sofia region, February 2017.

The Mahefa Miaraka Program supports and works closely with 34 Medical Inspectors like Dr. Jimi. In turn, the Program supports 732 CSB heads from 34 districts in carrying out regular outreach activities to extend health services to remote communities and in supervising 9,800 community health volunteers working in the CSB catchment areas. 9,800 732 34 COMMUNITY CSB DISTRICTS HEALTH HEADS VOLUNTEERS LEADING BY EXAMPLE:

TWO WOMEN INSPIRE THEIR COMMUNITY TO USE FAMILY PLANNING FOR BETTER HEALTH WITH SUP- PORT FROM THE MAHEFA MIARAKA PROJECT

“The closest CSB is a 15 Kilometer walk from our fokontany. That’s why we began our

work as community health volunteer workers (CHVs). When we started, there was only one family planning user in our fokontany. “ — CHV

The CHVs and the fokontany Chief conduct a family planning Session in Sofia region, February 2017.

The Community Capacity for Health Before becoming Community Health Volunteers (CHVs) for the Androiavy fokontany in 2013, Zafinoro and Jeno didn’t know about project, locally known as Mahefa or use contraception. However, after their communities selected Miaraka, is a five-year (2016-2012) them as CHVs, and the USAID-funded Community-Based Inte- community-based integrated health grated Health program or Mahefa Miaraka trained and equipped them with necessary materials and tools to perform their health program funded by the United States services, both were convinced of the advantages of using family Agency for International Development planning. They knew at that time their work would be difficult, (USAID). The Program is a collabo- since most men and women in their village had very little rataion between the Ministry of Public knowledge of the family planning and local custom did not give women much power to make their own decisions about their Health, USAID, and JSI Research & own health. Training Institiute, Inc. (JSI). JANUARY - MARCH 2017 Zafinoro and Jeno began a series of sensitization activities among women on the ways family planning and the use of modern contraception can improve women’s health. At first, because of their strong local network and their good reputation in their village (which is partly why they were chosen to be CHVs by the community), most women they talked to understood the importance of family planning and many were ready to use the contraception. However, Zafinoro and Jeno realized at that time there were few woman who would actually come for FP services.

They learned that many women encountered resistance from their husbands and their mother-in-laws and the women were also concerned about the implications that would come from traditional beliefs and rumors in the community. As part of their new strategy, Zafinoro and Jeno became close to their fokontany Chief, Mr. Lazera, who is highly respected in the community and whose wife is already a regular family planning user. The two CHVs used this relationship, and Mr. Lazera’s influence, to

“To convince our community, it was nec- Jeno provides family planning services to a client. Sofia region.

essary for us and our husbands to be convinced of the practicality of using a convince husbands in the community during home visits and other outreach efforts. As a result, women from the community contraceptive method.“ felt confident in their ability to access family planning and began to come for family planning counseling with Zafinoro and Jeno — CHV with or without their husbands.

FAMILY PLANNING CLIENTS

One couple, Zafinoro and Jeno encountered in the Androiavy fokontany, Julienne and Fregis, have six children together. The last two were stillborn twins. In spite of this incident, the husband, Fregis, did not want to discuss family planning. In his view, children are blessings from God and contraception is unnecessary. However, the experience of losing her children was terribly traumatizing for Julienne, and she approached the CHVs to ask advice on the matter. After analyzing the family’s case,

Julienne, Fregis, and family in Sofia region. Zafinoro and Jeno came up with a strategy that in order to economic life. At the end of the discussion, Fregis and his mother convince Fregis, they need to also convince his mother (Julienne’s were convinced and agreed that Julienne and Fregis should mother-in-law). Per the local custom, mother-in-laws make or adopt a family planning method. are involved in any decisions regarding children. Also, the CHVs decided that they needed the support of Mr. Lazera, the Fokon- The two CHVs were also able to help Robertine Dox, who have tany Chief, who was willing to participate in the discussion. The been married for 11 years and have two children, Fidelah, 10, two CHVs and the Fokontany Chief paid a visit to Julienne and and Robertino, 4, and live in the Androiavy fokontany. Unlike Fregis’s family and called the mother-in-law, who lived next door, others in their community, the couple successfully utilizes a to come as well. The CHVs explained the advantages of family family planning. They were prompted to utilize a contraception planning for the health of the mother, as well as for family and method after the birth of their son, Robertino.

Robertine, Dox, and their children, Sofia region, February 2017

My wife encountered complications during the delivery of our son Robertino “ at the CSB. I was very afraid of losing her and I did not want to re-live that experience. I considered the benefits of family planning that the CHVs and Chief of our fokontany have been advocating. I spoke to my wife and she had also been thinking about it. When we came back from the hospital, we consulted Jeno and Zafinoro to advise us. ” — DOX, FAMILY PLANNING USER In addition to the health reasons to utilize contraception, family planning services right in their village instead of walking 15 Robertine and Dox also considered that their vocation as farmers km to the closest CSB. currently made financially supporting more than two children difficult, and they preferred to give their two children the best The CHVs’ recent strategy of involving the fokontany chief in possible future. They have high hopes for this future and dream sensitization the community on family planning partnered with of their children becoming mayors or doctors. their strategy to advocate directly with the husbands and the mother- in- laws will likely result in more users of the modern With their sensitization strategy, Zafinoro, Jeno, and Mr. Lazera family planning methods in the Androiavy fokontany. currently provide services to over 60 planning users. This number represents 32% of women of reproductive age (WRA) (185 out of The Mahefa Miaraka program trains, provides materials for, and total population 0f 752) that may need family planning. Compared conducts supportive supervision in 4,774 fokontany so they can to 5 years ago, when no one in their village knew about the mod- manage health activities, including supporting the community ern contraception and no one used any contraceptive method, health volunteers who live in the same fokontany. their achievement so far is remarkable. Now, women can have

The Fokontany Head (yellow jacket) and CHVs conduct family planning session with Families, Sofia region, February 2017.

As part of the program, community health volunteers and the healthy behaviors, use community-level health services, and seek fokontany chiefs will work together to make sure that the 6.2 higher-level care at the CSBs when needed. million inhabitants of the program’s seven regions will adopt Annex 7. Participation in the Central-Level Working Groups and Meetings in Q2 FY2017

Janvier 2017 Date Sujets Types de reunions Thème techniques SMNI, PF, Priorités Logistique HMIS Divers Séance PCIME-c, National communa Coordin de Divers nutrition (PNSC, et utaire ation travail autres politiques) 03 au 1. FDF en PCIMEc mise à jour X  06/01/2017 09 au 2. Renforcement des compétences des X  13/02/2017 membres et appui à l'opérationnalisation de l'UTGL 09 au 3. Atelier Technique du Staff de la Région X  14/01/17 SAVA 10/01/2016 4. Harmonisation du système d’informations X  Electronique 11/01/2017 5. Réunion du comité Communication pour X  la préparation de la Journée Mondiale de la Santé 12/01/2017 6. Préparation de la journée mondiale de la X  santé JMS du 07 AVRIL 2017 17/01/2017 7. Réunion de la Commission X  Communication pour la préparation de la Journée Mondiale de la Santé 19/01/2017 8. Résumé des activités 2016, compte rendu X  de mission, TDRs, PTA 2017 20/01/2017 9. Répartition et utilisation de misoprostol et X  Chlorhexidine 20/01/2017 10. Elaboration du : X  PSN 2018-2022 (deadline = Juin 2017) - et PMI-MOP (deadline = Mai 2017) 20/01/2017 11. Réunion de préparation de la JMS : Comité X  technique 23 et 12. Réunion du comité d’experts en normes : X  1

Janvier 2017 Date Sujets Types de reunions Thème techniques SMNI, PF, Priorités Logistique HMIS Divers Séance PCIME-c, National communa Coordin de Divers nutrition (PNSC, et utaire ation travail autres politiques) 24/02/2017 Elaboration des normes relatives au statut d’un CSB et BSD 24/01/2017 13. Acheminement des intrants ACT X  24/01/2017 14. Atelier d'orientation des Formateurs des X  agents de santé sur l'utilisation du Misoprostol et de la Chlorhexidine 24/01/2017 15. Comité Communication préparant la X  journée mondiale de la Santé 30/01/2017 16. Réunion du comité Technique Permanent X  en approche Atteindre Chaque Enfant (A.C.E) 25/01/2017 17. Réunion de coordination des comités X  préparant la Journée Mondiale de la Santé 2017: - Présentation powerpoint sur la Dépression par le Professeur Bertille Rajaonarison, Psychiatre - Présentation d'une proposition de plan de communication 30/01/2017 18. Coordination des activitésde journée X  mondiale de la Santé 30/01 au 19. Atelier d'orientation des Formateurs X  régionaux et districts sur la PCIMEc mise à 04/02/2017 jour 31/01/2017 20. Comité Communication préparant la X  journée mondiale de la Santé TOTAL 20 03 11 06 05 02 02 01 10

Février 2017 Date Sujets Types de reunions Thème techniques SMNI, PF, Priorités Logistique HMIS Divers Séance PCIME-c, National communau Coordin de Divers nutrition (PNSC, et taire ation travail autres politiques) 01/02/2017 1. Coordination de l’appui des PTF lié à la X  réalisation de la supervision intégrée des districts prioritaires 01/02/2017 2. Communication working group X  03/02/2017 3. Réunion de Coordination de la 22è édition X  de la SSME 06/02/2017 4. Préparation de la campagne FAV polio X  pour Mars 2017 07/02/2017 5. Réunion H6+ (UNFPA, UNICEF, OMS, X  ONUSIDA, UNWomen,WB) + USAID, AFD, 07/02/2017 6. Réunion Hebdomadaire du Comité de X  Gestion Achat et Stock (GAS) 07/02/2017 7. Comité Communication préparant la X  journée mondiale de la Santé 07 02 8. Réunion de travail pour la préparation de X  2017 la séance de validation des outils IEC CCH et la planification des team building pour la conduite des vagues de formation en cascade 08/02/2017 9. Réunion de préparation de la Journée X  Internationale de la Femme - 08 Mars 2017 09/02/2017 10. Préparation de la campagne FAV polio X  10è passage de Mars 2017 09/02/2017 11. Réunion sur l’élaboration du guide de X  redynamisation de la fourniture des

Février 2017 Date Sujets Types de reunions Thème techniques SMNI, PF, Priorités Logistique HMIS Divers Séance PCIME-c, National communau Coordin de Divers nutrition (PNSC, et taire ation travail autres politiques) contraceptifs injectables au niveau communautaire 10/02/2017 12. Réunion de Coordination de la 22è X  édition de la SSME 10/02/2017 13. Réunion du Comité «Roll Back Malaria » X  (RBM) du 13 au 14. Atelier de révision et validation des X  17/02/2017 documents de travaux du Sous-Comité du Système d’information Sanitaire 14/02/2017 15. Réunion Hebdomadaire du Comité de X  Gestion Achat et Stock (GAS) 14/02/2017 16. Sous-comité de mobilisation sociale pour X  la préparation de la campagne FAV polio 10è passage de Mars 2017 15/02/2017 17. Comité communication pour la X  préparation de la campagne FAV polio 10è passage de Mars 2017 15/02/2017 18. Sous-comité de mobilisation sociale pour X  la SSME Avril 2017 17/02/2017 19. Validation des supports de communication X  qui serviront d’outils de suivi des actions essentielles des carnets de santé de la mère et de l’enfant 20/02/2017 20. Célébration du 25 ème anniversaire X  d’ADRA à Madagascar 21/02/2017 21. Réunion du comité MOBSOC pour la FAV X  Polio 21/02/2017 22. Réunion de coordination hebdomadaire du X  comité de Gestion Achat et Stock (GAS)

Février 2017 Date Sujets Types de reunions Thème techniques SMNI, PF, Priorités Logistique HMIS Divers Séance PCIME-c, National communau Coordin de Divers nutrition (PNSC, et taire ation travail autres politiques) 22 au 23. Atelier bloqué du sous-comité MOBSOC X  23/02/2017 pour la préparation de la SAV/SSME Avril 2017 23/02/2017 24. Réunion de coordination pour la X  préparation de la JMS 2017 24/02/2017 25. 2ème Réunion de Coordination de la 22è X  édition de la SSME 27/02 au 26. Formation des formateurs sur la X  03/03/2017 surveillance et l'audit des décès maternels et néonataux 28/02/2017 27. Réunion sur la loi PF X  TOTAL 27 05 13 09 15 03 03 01 05

Mars 2017 Date Sujets Types de reunions Thème techniques SMNI, PF, Priorités Logistique HMIS Divers Séance PCIME-c, National communau Coordin de Divers nutrition (PNSC, et taire ation travail autres politiques) 01/03/2017 1. Préparation du MOPP 2018 X  01/03/2017 au 2. Intégration, Redynamisation et/ou X  03 Mars 2017 Renforcement des activités communautaires liées à la mutuelle de santé, au transport d’urgence et à la logistique communautaire 03/03/2017 3. Préparation de la Journée Mondiale du X  Paludisme 5

Mars 2017 Date Sujets Types de reunions Thème techniques SMNI, PF, Priorités Logistique HMIS Divers Séance PCIME-c, National communau Coordin de Divers nutrition (PNSC, et taire ation travail autres politiques) 06/03/2017 4. GTT Surveillance X  06/03/17/2017 5. Intégration, Redynamisation et/ou X  au 08/03/2017 Renforcement des activités communautaires liées à la mutuelle de santé, au transport d’urgence et à la logistique communautaire (Miandrivazo) 06-03-17 au 6. Célébration de la Journée X  08-03-17 Internationale de la Femme à Madagascar 06 au 10 7. Formation des formateurs sur X  /03/2017 l’approche KMSm et RCCS

07/03/2017 8. Réunion H6+ (UNFPA, UNICEF, X  OMS, ONUSIDA, UNWomen,WB) + USAID, AFD, 07/03/2017 9. GTT Statistiques sanitaires X  07/03/2017 10. GTT Qualité des données X  09/03/2017 11. GTT Resource X  09/03/2017 12. Présentation des dégâts cycloniques et X  demande de positionnement des PTF par le MOH 09/03/2017 13. GTT Recherche Evaluation X  09/03/2017 14. DLP X  10/03/2017 15. GTT Surveillance X  13/03/2017 16. GTT Qualité des données X  14/03/2017 17. Réunion du Comité «Roll Back X  Malaria» (RBM)

Mars 2017 Date Sujets Types de reunions Thème techniques SMNI, PF, Priorités Logistique HMIS Divers Séance PCIME-c, National communau Coordin de Divers nutrition (PNSC, et taire ation travail autres politiques) 18. Présentation et validation du TDR du X  14/03/2017 projet pilote avec Mikolo 15/03/2017 19. VAT Payment Procedures X  for USAID Implementing Partners

16/03/2017 20. Préparation de l'atelier de X  renforcement de capacités des agents de santé 16/03/2017 21. Débat thématiques pour la X  contribution effective des mutuelles de santé dans la Couverture Sanitaire Universelle 17/03/2017 22. Quantification nationale des besoins X  en intrants antipaludiques 17/03/2017 23. Réunion avec le groupe de travail X  Qualité des données du sous-comité SIS MinSanP 23/03/2017 24. Validation des résultats du monitoring X  SONU T2 et T3 2016 28/03/2017 25. Réunion de coordination X  hébdomadaire 28/03/17 26. Atelier de clôture du programme X  PASMI et partage des leçons apprises 30/03/2017 27. Réunion de coordination pour la X  préparation de la JMS 2017 TOTAL 26 02 22 02 00 04 03 08 11

Annex 8. PMI team feedback to Mahefa Miaraka Q2 report and JSI Responses

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

May 24, 2017

General:

1. Overall results achieved are encouraging and a very good activity description- Well done.

Thank you.

Specifics:

2. Pg 9- fig 7 on commodities: The report doesn’t show any positive changes during the QRT2 in terms of Malaria commodities stock which remained over 50%. Since MAHEFA works mostly in very hard to reach and remote areas and most affected areas with malaria, this is a concern. We look forward to more coordination and partnerships between PSM and MAHEFA to improve the commodity availability in the next QRT.

The Quarter 2 report was the first reporting period where the USAID Community Capacity for Health Program began to work at the community level. Prior to this reporting quarter, activities primarily related to Program start-up.

JSI has been working closely with the Direction de Lutte contre le Paludisme or DLP, Procurement and Supply Management or PSM project, and the Ministry of Health’s Offices at the regional, district and commune levels to address the issues of high stock out rates of malaria commodities. Starting in Q3, the USAID Community Capacity for Health Program team presented the malaria commodities situation both at the CHV and the CSB levels and in the coordination meetings at the national level with DLP and PSM during the DLP-led weekly meetings. Similarly, the CCH Program team began to present the same data and discuss ways to decrease stock out with PSI regional teams at regional and district levels.

During Q2, several meetings were conducted specifically with PSM to discuss the issue of CHV stock outs (meetings took place on January 23, February 16, March 3, and March 23).We will continue to have regular meetings and discussions with DLP, PSM and PSI to find the best approach to improve CSB forecasting to include CHVs needs to prevent and reduce stock outs.

3. Table 2- pg 6: add the total # of fever cases and a graphic representation of this case management cascade will be greatly appreciated-

The table was revised in the re-submitted report attached and the graphic representation is in annex 8.

4. It is critical especially for Malaria to dis-aggregate data per region at least. The more granular your data are the best it helps for management decision. Could you present a graph from table 2 (pg6) per region at least?

Corrected in annex 8 of the re-submitted report attached.

Environmental compliance

5. The CHVs that were equipped with the disposal pit, was there any guidance in regards to the location? Also how are they maintained?

During the MAHEFA Program (USAID’s CBIHP 2011-2016), CHVs received two job aids to help them better manage medical waste, the job aids on environmental compliance and on latrine construction. These two job aids present information on waste management including construction, use and maintenance of disposal pits. The USAID Community Capacity for Health Program team and MOH staff in the regional, district and commune teams who conduct the onsite supervision are mandated to monitor the CHV’s waste management activities using the grille de supervision, which includes CHV management of disposal pits.

A similar process will be conducted for the new community health volunteers who did not benefit from the former MAHEFA Program since they were not yet CHVs.

6. Is there any waste management plan/process cycle that is guiding the disposal of wastes?

Please see response above.

7. More mitigation measures should be added for building, use and maintenance of latrines

Please see more mitigation measures in the Annex 3: Environmental Mitigation and Monitoring Report, Q2 FY2017 (page 31-37). In addition, as mentioned under the EMMP, p. 104-105 of our April 28 revised FY2017 workplan, mitigation measures include the following:

a) Following the guidance on improved latrine construction (CHV curriculum): Pit latrines should not be installed where the water table is shallow or where the composition of the overlying deposits make groundwater or an aquifer vulnerable to contamination; should be installed at at least 15m and in a level lower than the water source. Washable slabs should be used. Properly decommission pit latrines. Do not leave pits open. Fill in unused capacity with rocks or soil. b) Follow-up on existing appropriate washable slabs with covers and disposal pits at the health huts and CSB. c) Following the disposal pit construction guide used in MAHEFA: Site waste storage and disposal areas are away from main buildings and will never be used in the future for latrine construction or culture. Disposal pits are always covered after use and cemented when full.

Additional Figures on Selected Malaria Indicators

Mahefa Miaraka SAVA DIANA Boeny 40,000 600 1200 2500 2303 1023 35,000 33,554 500 478 1000 899 2000 30,000 27,880 400 800 25,000 1500 1,289 20,000 300 263 261 600 1000 15,000 13,834 410 11,355 200 400 713 7 642 8,085 10,000 496 173 500 100 62 200 5,000 92 21 0 0 0 0

Melaky Menabe Sofia Legend 10000 12000 12000 8981 10533 9000 10236 CU5 fever cases 10000 10000 8000 7,511 9,165 8,753 CU5 with fever tested with RDT 7000 by CHV 8000 8000 6000 CU5 presenting fever who tested 5,015 positive with RDT by CHV 5000 4,417 6000 6000 CU5 with fever treated with ACT 4000 4,225 by CHV 4000 3,646 4000 3000 2,967 3,216 3,123 CU5 with pneumonia treated by 2,346 Amoxi/Cotrim/Pneumostop at the 2000 1,449 2000 2000 toby CU5 with diarrhea received ORS, 1000 Zinc/Viasur 0 0 0

Figure. Comparison of cIMCI Services by CHVs between Q2 FY2016 (MAHEFA) and Q2 FY2017 (Mahefa Miaraka)

DISCLAIMER

6/23/2017 John Snow Inc. Mail JSI responses on USAID feedbacks on Q2 report

Chuanpit ChuaOon

JSI responses on USAID feedbacks on Q2 report

Jocelyne Andriamiadana Fri, Jun 9, 2017 at 8:59 AM To: Yvette Ribaira Cc: Chuanpit ChuaOon , Elaine Rossi , Ben Vorspan , Eric Ramahandrisoa , Verohanitra Rabearihanta

This is to approve the JSI/CCH Q2 FY17 report version June 5, 2017. Please provide us with a hard copy for our file. Thanks,

Jocelyne

On Mon, Jun 5, 2017 at 8:55 PM, Yvette Ribaira wrote: [Quoted text hidden]

https://mail.google.com/mail/u/0/?ui=2&ik=e3ba1adbbb&jsver=nZ9otGMmGj0.en.&view=pt&msg=15c8b6fced22226b&q=jocelyne%20andriamiadana%27s%2C%20q2%20report&qs=true&search=query&siml=15c… 1/1