Quarterly Progress Report - Year 4, Quarter 3 April - June 2020

CAMBODIA MALARIA ELIMINATION PROJECT

Cambodia Malaria Elimination Project

Submission Date: 30th July 2020

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

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

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

TABLE OF CONTENTS

Acronyms ...... iii

1. Introduction ...... 1

2. Progress Toward achieving CMEP OBJECTIVES ...... 2 2.1 Objective 1: Develop a scalable, evidence-based elimination model in SPL OD and support its dissemination and replication for malaria elimination in Cambodia. ... 2 2.2 Objective 2: Support scale-up of high quality malaria control and prevention interventions in five to eight ODs, where gaps in coverage or quality exist ...... 9 2.3 Objective 3: Strengthen national malaria surveillance systems and M&E appropriate for malaria elimination and control activities ...... 13 2.4 Objective 4: Build capacity of Ministry of Health (MOH) to manage, intensify, and sustain malaria control and elimination efforts particularly at the OD level ...... 14 Procurement ...... 18 Financial Management ...... 18 Human Resource Management ...... 20

3. RESOLVING CHALLENGES FROM FY20 Q2 ...... 20

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

5. PLANS FOR NEXT QUARTER AND UPCOMING EVENTS ...... 21 ANNEX 1 CSO FY20 Q3 RESULTS TABLES ...... 22 ANNEX 2 LAB QA/MICROSCOPY TRAINING TABLES ...... 25 ANNEX 3 – PV Radical Cure Treatment Status ...... 26

ACRONYMS

ACT Artemisinin-based Combination Therapies AHEAD Action for Health Development (CSO in Cambodia) AOP Annual Operational Plan ASMQ Artesunate + Mefloquine BKN Bakan BTB Battambang CHAI Clinton Health Access Initiative CMEP Cambodia Malaria Elimination Project CBO/CSO Community Based Organization/Civil Society Organization CDC Centers for Disease Control and Prevention CNM Cambodia National Malaria Center CO Contracting Officer COP/DCOP Chief of Party/Deputy Chief of Party COR Contracting Officer’s Representative COVID-19 2019 novel cornoavirus cRDT Conventional Rapid Diagnostic Tests DOT Directly-observed therapy EDAT Early Diagnosis and Treatment G6PD Glucose 6 Phosphate Dehydrogenase HC, HF Health Centre, Health Facility HH Household hsRDT Highly-Sensitive Rapid Diagnostic Tests IDQA Internal Data Quality Assessment IEC Information, Education and Communication IP Intensification Plan IP2 Intensification Plan 2 IPC Institute Pasteur in Cambodia IRB Institutional Review Board ITN Insecticide-Treated Net KRK Krakor LLIN/LLIHN Long Lasting Insecticidal Net/Hammock Net M&E Monitoring and Evaluation MIS Management Informationn System MMP Mobile and Migrant Populations MMW Mobile Malaria Worker MoH Ministry of Health MRS Maung Russey NECHR Cambodia Ethics Committee for Health Research NTG National Treatment Guidelines NSP National Strategic Plan OD/ODMS Operational Health District/OD Malaria Supervisor ODTL/ODTLA Operational District Team Leader/OD Assistant TL OEC Operation Enfant Cambodge (CSO in Cambodia) PCR Polymerase Chain Reaction PHD/PMS Provincial Health Department/Provincial Malaria Supervisor PFDA Partner For Development in Action (CSO in Cambodia) PKV Phnom Kravanh PLN Pailin PMI President’s Malaria Initiative PMS Provincial Malaria Supervisor PNP Phnom Penh POC Point of Contact

III

PP Private Provider PPM Private Public Mix PQ Primaquine PSI Population Services International PSWGME Provincial Special Working Group Malaria Elimination QA Quality Assurance Re-ACD Reactive Case Detection RDT Rapid Diagnostic Tests RH Referral Hopsital SBCC Social and Behavior Change Communication SLDPQ Single Low Dose Primaquine SOP Standard Operating Procedure SPL Sampov Loun SPM Sampov Meas STA Senior Technical Advisor TA Technical Assistance TMK Thmar Kaul TO Technical Officer TPR Test Positivity Rate UNOPS United Nations Office for Project Services URC University Research Co., LLC USAID United States Agency for International Development VHSG Village Health Support Group VMW Village Malaria Worker WHO World Health Organization

1. INTRODUCTION The USAID|PMI Cambodia Malaria Elimination Project (CMEP), 2016-2021, was launched on October 26, 2016 to support the Cambodian National Center for Malaria Control, Parasitology and Entomology (CNM) to reduce malaria morbidity and mortality and contribute towards malaria elimination goals nationwide by 2025. To reach this goal, the project has set up four strategic objectives to: 1. Develop a scalable, evidence-based elimination model in Sampov Loun OD and support its dissemination & replication for malaria elimination in Cambodia. 2. Support scale-up of high-quality malaria control and prevention interventions in five to eight ODs, where gaps in coverage or quality exist. 3. Strengthen national malaria surveillance systems and monitoring and evaluation (M&E) appropriate for malaria elimination and control activities. 4. Build capacity of malaria program to manage, intensify, and sustain malaria control and elimination efforts particularly at the OD level. The COVID-19 situation in Cambodia began to impact CMEP activities by mid March in FY20 Q2. Due to this, some of the activities were suspended, however in Q3, the work resumed as normal while following the COVID-19 protocols during meetings and workshops. CMEP started rescheduling the suspended activities since April 2020 and were able to complete almost all the suspended activities in Q3. CMEP activites were implemented without any interuptions and thus it was as able to complete the agreed workplan activites. CMEP team supported and facilitated the Mid Term Evaluation process that kick started in May 2020. The team had the skype call with the Evaluation team lead Mr Leopoldo on 17th May and supported and furnished all the documents on regular intervals to ensure the exercise is well informed with reports, documents and other project related data that the ET may need to assess the project implementation. The field work commenced from the 25th of May and field activities was coordinated by CMEP field team. The ET very much appreciated the support from the CMEP team during the critical time of COVID- 19 pandemic. The ET was able to complete all its tasks in the field and also the interviews and focus group discussion in time. The drafting of the report is in progress and would soon be circulated to all key stakeholders for their feedback and input. CMEP conducted the following key activities in FY20 Q3: . 32,416 of suspected cases were tested with 340 positive cases confirmed and all cases received appropriate treatment according to National Treatment Guidelines. . Among the seven CMEP elimination ODs in Battambang, Pailin and Pursat provinces, there were zero P.f/mixed cases in Q3. There was a total of 50 P.v cases and 5 suspected P.m/P.k cases in Q3. 54/55 (98%) of the P.v/Pm species cases were notified within 1 day, 53/55 (96%) were investigated within 3 days, and 52/55 (95%) responded to within 7 days. In the partial elimination ODs, Phnom Kravanh (PKV) and Krakor (KRK) there were 5 P.f/mix cases 5/5 (Day 1 = 100%, Day 3 = 100%, Day = 100%). . CMEP response to the P.f cases in Pursat ODs in Q3 continued and included monitoring daily/weekly cases, intensifying services at all points of care, and continued setup and support of touchpoint/peer educator volunteers. Out of the 42 Touch points/peer volunteers who performed as MMWs, regular mapping helped in identifying new hotspots and closing the exisiting ones that no more was qualified as hotspots. In Q3 currently there are 6 touch points volunteers and 5 peer educator volunteers in KRK, 22 touch points volunteers and 9 peer educator in PKV.

. In the 7 elimination ODs, CMEP deployed 21,357 ITNs as buffer stock to HFs and VMWs in Q3 (target=10,950). Through VMW outreach activities, the total ITN distribution was 15,308 (LLIN & LLIHN) to local residents and 3,540 ITNs to farms. . In the 2 transitional ODs, 7,175 ITNs were deployed as buffer stock (target 4,400) to HF and VMW levels, and 7,645 ITNs were distributed to local residents (target=3,800) and 184 ITNs to farms. . In Q3, 29 P.v cases were identified in elimination ODs for PV radical cure treatment, of which 22 were tested for G6PD which found that 20 patients were normal and 2 were deficient (zero invalid). 16 of these normal patients received 14 days PQ treatment, with no side effect or adverse reactions . Supported CNM technical units to conduct 34 planned supervision visits (target=39). . In Q3, there were 127 malaria suspected patients referred from Private Providers (PPs) to public health facilities in the 7 elimination ODs and 98% of PPs (190/193 planned) attended the PP meetings. In the 2 transitional ODs, 20 suspected patients were refered from PPs to public health facilities. 80% of PPs attended the PP meetings in these 2 ODs (51/64 planned). Figure 1 provides an infographic summary of CMEP progress in FY20 Q3. Progress against each performance indicator (PITT table) is presented in the file attached.

FY20PITTQ3.xlsx Figure 1. CMEP Summary of Activity Progress (April-June 2020)

2. PROGRESS TOWARD ACHIEVING CMEP OBJECTIVES 2.1 Objective 1: Develop a scalable, evidence-based elimination model in SPL OD and

support its dissemination and replication for malaria elimination in Cambodia. Task 1. Pre-implementation situational analysis of current malaria elimination operations in SPL: Rapid Situational Analysis and Needs Assessment Report1. Task 2. Sustain universal long-lasting insecticidal net (LLIN) coverage: Mass distribution: There was no mass distribution activity in FY20 Q3 for Objective 1, however there is a plan for mass distribution to be conducted in FY20 Q4. Ensure continuous distribution of LLINs: In line with the updated list of villages for ITN distribution, CMEP’s target for continuous LLIN distribution was 182 villages in the 7 elimination ODs [Act. 1.2.3]. In the elimination ODs, CMEP deployed 21,357 ITNs as buffer stock to HFs and VMWs in Q3 (10,950 planned). CMEP will further deploy ITNs in Q4, (using USG purchased ITNs). CMEP distributed 15,308 ITNs (9,438 planned) to target populations during outreach and response activities [Act, 1.2.5] and another 3,590 ITNs (target=417) were distributed to MMPs at big farms and MMP locations (the larger actual for this activity was due to increased outreach work by CSOs in some of the elimination ODs) [Act. 1.2.5.a]. Net top up and malaria education to households: In the 7 elimination ODs, VMWs conducted 1,269 visits (target=1,165) to households/farms for net use monitoring, net top-up and health education [Act. 1.2.6]. The number of ITN monitoring visits increased due to the number of VMW visits continuing at up to 5 visits per month. Visits to HH members/farm workers included health education for malaria prevention/LLIN use. There were 2 monitoring and supervision visits conducted from CNM ITN Unit to elimination ODs in Q3 [Act. 1.2.7]. Task 3. Ensure Early Diagnosis and Treatment (EDAT) and follow up: In the 7 elimination ODs, CMEP activities covered 442 points of care in Q3 (106 public health facilities, 317 VMWs, and 19 MMWs) [Act. 1.2.1] (this figure does not include private providers as they are no longer allowed to perform malaria tests and treatment). 14,904 of 15,030 (99%) suspected malaria cases received a parasitological test. 55% of individuals were tested by VMWs and 45% by HFs. Out of all the individuals tested there were zero P.f/mixed cases and 55 other cases were confirmed positive (50 P.v and 5 P.malariae/P.knowlesi). All 55 cases were enrolled in the system and 54 of the cases have travel history information (see Figure 2 for a table of case classification and OD case distribution maps for Q3). Further analysis showed that cases (59%) were imported from Pursat, 1 case (2%) from Thailand and the remaining 21 cases (39%) from other provinces in Cambodia. There were no local cases (L1, L2, L3) for P.f/Mix identified in this quarter in the 7 elimination ODs. Figure 2. Map of case classification for 7 ODs and reported malaria cases by origin (Apr-Jun 2020) Battambang Mong Russei Pailin Sampov Luon Sampov Meas Bakan Species L1 L2 L3 L4 Imported Unclassified L1 L2 L3 L4 Imported Unclassified L1 L2 L3 L4 Imported Unclassified L1 L2 L3 L4 Imported Unclassified L1 L2 L3 L4 Imported Unclassified L1 L2 L3 L4 Imported Unclassified Pv 8124 1 0 0008 0 0 0013 0 1 0001 0 0 000120 0 2024 0 0 PM 0010 4 0 0000 0 0 0000 0 0 0000 0 0 0000 0 0 0000 0 0 Pf 0000 0 0 00000 0 00000 0 0000 0 0 0000 0 0 0000 0 0 Mix 0000 0 0 0000 0 0 0000 0 0 0000 0 0 0000 0 0 0000 0 0

1 Activity 1,1.1. was completed in Year 1 and Year 2 is not applicable to the FY20 Q3 reporting period

Out of 55 positive malaria cases reported in FY20 Q3, zero (0%) were P.f/mixed, 50 (91 %) were P.v, and 5 cases were P. malariae (9%). Figure 3 provides the cases breakdown for Q3 and the cases trend since January 2017. Figure 3. Number of confirmed malaria cases in 7 ODs per species in Apr 2017-Jun 2020 (source MIS/PMIS)

Due to there being zero P.f/mixed cases in Q3, it was not necessary to conduct any 28 day follow up for persons through reminder messages (via the mHealth application) or for transfer to response teams [Act. 1.3.3]. Figure 4 summarizes the implementation of DOT for confirmed cases in the 7 CMEP elimination ODs. Figure 4. Implementation of DOT in 7 ODs per species

In FY20 Q3, zero patients were hospitalized for second line treatment in the 7 elimination ODs [Act. 1.3.6]. CMEP provided case management training during which the emphasis was given to Single Low Dose Primaquine (SLDPQ) and during regular visits to VMWs and HFs. However, as there were zero P.f/mixed cases diagnosed in the 7 ODs in Q3, there were no eligible patients for SLDPQ. CNM Pharmacy, Lab and Diagnosis and Treatment units completed 9 supervision visits in the elimination ODs (7 planned) during FY20 Q3 [Act. 1.3.10]. Task 4. Malaria case reporting, investigation, and response In 7 ODs, in Q3, 54 out of 55 cases (98%) were notified within 1 day via the SMS Day-0 mHealth system, 53 cases (96%) were investigated within 3 days, and for 52 (95%) the response was provided within 7 days [Act.1.4.1-1.4.3]. All HFs/VMWs followed the established 1-3-7 surveillance practice. For response within 7 days, 3 cases out of the 55 cases (5%) were not responded to or were responded to later than 7 days, mainly due to patient unavailability at home or the household level. [Act.1.4.1-1.4.3]. Task 5. Strengthen case management, reporting, and response to all malaria cases in the private sector CMEP proposed and got approval for PPs not to test or treat, thus the previous indicator has been removed from this quarter but the referral and supervision indicator is still being tracked and reported. In Q3, there were 127 malaria suspected patients referred from PPs to public health facilities in the elimination ODs and 98% of PPs (190/193) attended the PP meetings [Act. 1.5.3]. PPs who were absent from quarterly meetings were either busy with other tasks or did not consider the meetings relevant as they realize PPs are no longer able to

5 test or treat. Those PPs who were absent received data collection visits from PHD/OD and from CMEP staff to ensure all PPs were continuing to provide health education and referrals for suspected malaria patients for all target populations. Semesterly supervision visits were also conducted to provide technical feedback on referrals and to improve SBCC initiatives. 112 PP visits were accomplished during supervision visits in Q3 [Act. 1.5.4]. 3 supervision visits (target=5) from CNM’s PPM unit were conducted in Q3. [Act. 1.5.6]. However, in the future there are potential challenges around PPs getting licensed from PHDs (it has been notified in future that the licence to PPs will not be issued from PHD, rather it would be done at the Provincial Governors office). This might pose challenges for strict monitoring by PHDs to PPs. Task 6: Build capacity and strengthen systems to manage elimination activities Supporting VMW monthly meetings: Monthly meetings were discontinued temporarily due to COVID-19 in Q3, however reports were collected through individual visits and VMWs visited HFs to submit reports and replenish stocks. Visits were held during the fourth weeks of April, May and June. In Q3 for the 7 ODs, 808 reports (80%) were submitted on time and the rest were collected later against the target of 1,008. Only those reports that were collected within the due date were reported in the system, however the remaining which missed the deadline were still collected and eventually 100% of the reports were collected by month end. During CMEP monitoring visits, VMWs were advised on the importance of submitting reports on time (either by visiting HFs for collection or by handing to HF staff when they visit the VMWs’ location). Because VMWs monthly meetings are still suspended due to COVID-19, VMWs are required to visit the HFs to submit reports and collect the drugs and tests. This practice will continue until further notice from CNM [Act. 1.6.2]. Integrated supervision from ODs to HFs: 104 supervision visits were conducted to 104 HFs in the 7 elimination ODs using the CNM supervision checklist (target=104) [Act. 1.6.3]. Data verification on total tests, total confirmed cases and total treated cases was performed during the visits. Stock monitoring: CMEP continued to provide monthly RDT and ASMQ, PQ stock status reports to CNM and all partners including UNOPS, and updates from all HFs in the 7 target ODs. Overall, stocks of tests and drugs in CMEP areas were secured for the period of April- June 2020; there were no stockouts and the few places that did, were identified and potential stockout were immediately fixed. HFs provide stock status to CNM through the monthly report via tablets. In addition to stock availability, CMEP monitoring visits and monthly reports highlighted the stock status and expiration dates of all tests and drugs. The storage facilities for G6PD RDT has been provided by the national program to all selected facilities which expired in July 2020. CMEP also monitors the stocks availability while advising on cold chain management and monitoring. There were no reallocation of drugs between elimination ODs during Q3. CMEP staff also visited key HCs, reviewed the stock levels and verified the consumption against the allocation. Visit to selected VMW’s from CNM VMW Unit: There was 4 visits from CNM VMW Unit conducted in elimination ODs in Q3 (target=0, the target was brought forward from the previous quarter) [Act. 1.6.6]. District Special Working Group for Malaria Elimination: 2 meetings were conducted in Q3 in the elimination ODs. Other scheduled meetings that were suspended in Q2 due to the COVID-19 situation were completed in Q3. These meetings enabled particpants to recieve updated information on the malaria situation and access to knowledge sharing. Provincial Special Working Group for Malaria Elimination There were zero PSWGE meetings in Q3 (planned=1) due to postponement to Q4 [Act. 1.6.8].

Task 7. Social and Behavior Change Communication (SBCC) for malaria elimination In the 7 elimination ODs, 14,904 individuals tested for malaria received interpersonal communication for malaria education (target=12,234, was over target mainly due to VMWs/HFs increasing their number of tests and increased CSO activity) [Act. 1.7.1]. In addition to malaria patients, malaria messages have been provided to 22,030 people (8,672 sessions were carried out at SPL, BTB, TMK, MRS, PLN, SPM, and BKN ODs) from high- risk groups during case response activities within the village and farms [Act. 1.7.2]. At the farms, VMWs organized small group education sessions to deliver key malaria messages. As a result, 2,270 MMPs were reached at farms with malaria outreach educational activities. CNM Health Education Unit made 5 visits in Q3 in the elimination ODs (planned=7) [Act. 1.7.3]. Task 8. Support civil society organizations (CSOs/CBOs) to complement malaria elimination activities: AHEAD continues to carry out activities succesfully in all of its 5 ODs and continues to work well with CMEP, OD teams, HCs, community level, OD counterpart staff, VMWs/MMWs and contact point staff. AHEAD also worked with local authorities and volunteers to identify hot spot areas, map MMP locations and identified suspected malaria patients for referring to VMWs/MMWs and HFs for testing and treatment. To ensure the effectiveness of referral cases reaching the service delivery points, AHEAD staff and contact points have carried out follow ups through phone calls and face to face meetings with the relevant persons. Importantly, AHEAD regularly follows up on the malaria situation in its areas and meets OD/PHD counterparts to discuss progress, challenges and to help them engage in the implementation. Considering COVID-19 pandemic challenges, AHEAD was able to carry out their activities as usual on the whole, and the majority of the activities were implemented well with satisfactory results. However, the activities were split into 2 events ensuring that the participants were not more than 20 in one event. Most of the targets were achieved and some over achieved; for example MMPs reached by campaigns (2,500 target versus 3,253 result), ITNs distribution to MMPs (2,410 target versus 3,783 result) and referring suspected malaria patients (189 target versus 357 result). Please see the results comparing target and actuals in Annex 1, Table 1. In Q3, PFDA continued to implement its activities in 2 elimination ODs in Pursat Province (BKN and SPM). PFDA has continued working collaboratively with SPM and BKN OD counterparts, CMEP OD teams, HF staff, VMWs, local authorities and contact points to implement the assigned tasks to support the malaria elimination in the two ODs. Despite the emerging COVID-19 situation, PFDA was able to implement the activities as planned, however, the activities were split into 2 events ensuring that the participants were not more than 20 in one event. Due to good collaboration at all levels, PFDA successfully organized 24 health education campaigns in the two ODs which reached 709 MMPs and high risk residents, and also distributed 1,368 ITNs to MMPs and local residents in the remote target areas. PFDA engaged local authorities and village volunteers to map 24 hot spots. PFDA’s contact points were able to identify 39 suspected malaria patients who were referred to VMWs/MMWs and HFs for testing and treatment (100% of referred patients reached the points of care as required). PFDA has continued to meet with OD/PHDs to share its activity implementation and progress. In Q3, most of the targets were achieved or over achieved. Results are provided in Annex 1, Table 2. As part of sub-grantee capacity building, technical support provision and implementation monitoring, CMEP teams at the OD level have worked collectively with both CSOs to undertake monthly field visits, to organize monthly meetings regulary to discuss activity planning, results, challenges, lessons learned and to seek improvement. Additionally, quarterly meetings with CSOs were routinely organised by CMEP PNP staff. For Q3, CSOs visits were

7 conducted on 22nd and 24th June 2020 (the quarterly meetings were actually conducted on 25th June 2020 in Pursat Province). The meeting purpose was to review the Q3 progress of the two CSOs, note any challegnces and discuss future activity implementation. The two CSOs accomplished good results in Q3 even though they faced some challenges including COVID- 19. It was suggested and advised to the CSOs to continue updating and mapping hotspots in consideration with areas where the cases have not been reported on for the last few months. It was also suggested to coordinate with ODs staff and CMEP on the Intensificatiom Plan. Task 9. Conduct operational research in the context of malaria elimination During FY2020 Q3, the final technical report of the study on performance of highly sensitive Rapid Diagnostic Tests (‘hsRDTs’) was prepared. The study has been conducted since November 2018 by CNM, CMEP, IPC and relevant PHDs/ODs/ HFs’staff of Battambang, Pailin and Pursat provinces to evaluate the use of hsRDTs versus conventional RDTs (‘cRDTs’), compared with a Polymerase Chain Reaction (PCR) as the gold standard in reactive case detection, to identify additional malaria infections amongst the at risk population especially asymptomatic people. Field activities and data collection were completed by 31st March 2020. In brief, the preliminary finding highlighted that hsRDTs were not sensitive in the detection of P. falciparum infection in asymptomatic individuals with low parasitemia. Conversely, use of hsRDT tests in the symptomatic (index) population showed good efficacy of these diagnostic tools when parasitemia was sufficient. No false positives were found when testing P. vivax positive individuals with hsRDT. As a secondary objective, the study identified a higher risk among co-workers of index cases. This supports the focal nature of malaria transmission areas away from their residence and likely associated with travel to forest areas. Consequently, interventions targeting those persons could further be evaluated and strategies could be proposed around that higher risk factor. The final report is expected to be ready in July 2020 for submission to the Cambodia National Ethics Committee for Health Research (NECHR) and the CDC IRB. Final dissemination of the study results to all stakeholders in Cambodia is planned for FY2020 Q4. Task 10. Refine existing malaria elimination tools, SOPs, and guidelines The kick-off P.f elimination in 2 ODs of PKV and KRK in Pursat province started from April 2020 and involved scaled up application of malaria elimination tools, specifically the 1-3-7 forms have been introduced/trained to OD & HF staff and VMWs/MMWs. The implementation is ongoing. Interestingly, foci investigation within 7-14 days showed good progress where field implementers (PHD, OD, HF, and CMEP teams) are actively engaging in full 1-3-7 approaches. Task 11. Expanded 5 ODs CMEP has been providing ‘technical assistance only’ on the elimination model for the 5 ‘Expanded’ ODs in Koh Kong, Kampot and Kep provinces, starting within CMEP FY2020. During FY20 Q3, CMEP deployed Technical Officers (TOs) for each of the 3 provinces. At these 3 expanded provinces CMEP regularly facilitates: • Daily and weekly case tracking from both HF and VMW, and assisting 1-3-7 activities for every P.f/Mix malaria case. In Q3, there were in total 4,575 tested cases and 56 confirmed malaria cases in the 3 provinces (2 P.f and 54 P.v). Among these, Kampot tested 3,325 and confirmed 38 in which were 36 P.v and 2 P.f (1 L1 and 1 L4); Kep tested 151 and confirmed 2 (both P.v); and Koh Kong tested 1,099 and confirmed 16 cases (all P.v). • With support from CMEP PNP team, the CMEP team directly lead the foci investigation on P.f L1 in Koh Kong and Kampot while providing on the job training

to field staff. In Q3, 1 foci investigation was conduted in Kampot starting from 5th May with support from both CNM and CMEP. The foci was classified as V0R0, thankfully there was not a single P.f case within the last 12 months in the concerned villages and mosquito collection did not capture any malaria vectors. • Meetings and field visits were jointly conducted by CNM, CMEP and others (donors and CSO partners). On 9-10th June 2020, CNM deputy director (Dr. Soley) and CMEP COP & STA met PHD/OD team of Kep and Kampot to (i) review progress of P.f elimination and (ii) discuss the possibility of introducing P.v radical treatment. A similar meeting was conducted with Koh Kong PHD/OD team virtually via Zoom to discuss with the PHD director, PHD deputy director, PMS and ODMS. A joint visit to Koh Kong by WHO, UNOPS and local partners (PFD and CMEP) as well as Sre Ambel OD and HC was conducted on 22-24 June 2020 to learn about the cluster of P.f cases that the foci investigation was conducting since March 2020 with CMEP support. The visit could not actually reach the foci as road conditions were difficult. Summary of P.v Radical Cure progress in Q3 Up to the end of Q3, 29 P.v cases were identified in CMEP BTB and PLN OD areas for P.v radical cure treatment (6 were female and 1 was underweight). In Q3, 22 of the 29 were tested for G6PD, of which 20 resulted in a normal status of G6PD (2 were deficient and zero invalid). All 20 of the G6PD normal patients were then enrolled and received 14 days PQ treatment, 16 of these cases have so far completed 14 days follow up, 4 are ongoing and zero have dropped out. Annex 3 provides the summary of results in the Battambang and Pailin ODs for FY20 Q3. 2.2 Objective 2: Support scale-up of high quality malaria control and prevention interventions in five to eight ODs, where gaps in coverage or quality exist Task 1. Rapid Situational Analysis and Needs Assessment Report – This activity was already completed in Year 2. Task 2. Ensure universal coverage with LLINs Mass distribution: There was no mass distribution activity in FY20 Q3 for Objective 2, however there is a plan for mass distribution to be conducted in FY20 Q4. Continuous LLIN distribution and top up monitoring: CMEP continued to deploy ITNs to villages. 7,175 (163%) ITNs were deployed as buffer stock at the HC and VMW level (4,400 planned). During Q3, CMEP distributed 7,645 ITNs (201% of 3,800 planned) to target populations during outreach and response activities from April to June 2020. The actual result was higher than planned due to an increased need for ITNs and MMPs movement to the forest location. It was also due to frequent change of forest goers location to different sites [Act. 2.2.5]. MMWs distributed 184 ITNs at big farms and MMP locations in Q3 (against 160 targeted) [ Act. 2.2.6]. VMWs/MMWs conducted outreach visits to households and farms to top up ITNs using remaining nets from the previous deployment, along with providing SBCC activities and EDAT services when required. 1,382 visits were accomplished (474 planned) by VMWs to households and farms for ‘use monitoring’ and health education [Act. 2.2.7]. 8,476 individuals received malaria education through interpersonal communication. [Act. 2.2.8]. Task 3. Ensure EDAT and follow up Provide ongoing support in malaria diagnosis and treatment: CMEP activities covered 243 Point of Care units in Apr.-Jun. 2020 for its 2 transitional ODs (19 HFs and 182 VMWs and 42 MMWs). PPs are now excluded as they are not allowed to test and treat [Act. 2.3.1].

In the 2 transitional ODs, 17,512 individuals were tested, 285 were confirmed with malaria and all of these cases (100%) were treated in Q3 (Figure 5 shows the trend in confirmed malaria cases from 2018 to 2020). Among the 285 confirmed cases, 5 cases (2%) were P.f/mixed and 280 cases (98%) were P.v. Three-day DOT was provided by VMWs to 1 P.f/mixed case (20% of the total 5 VMW P.f/mix cases detected) and by HF staff for the other 4 cases [Act. 2.3.2]. During Q3, there were no severe malaria cases in the transitional ODs [Act. 2.3.4]. Figure 5. Confirmed malaria cases in 2 transitional ODs (January 2018 to Jun 2020)

Table 2 provides a breakdown of the confirmed malaria cases by species in the 2 transitional ODs (see Figure 6). Table 2. Breakdown of confirmed malaria cases by species in 2 ODs OD Name Species Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Pf 380 242 196 157 128 67 54 77 39 33 28 29 99 37 20 34 6 7 3 0 1 0 1 3 Kravanh Pv 928 853 740 669 644 545 517 415 365 323 331 320 480 290 222 252 170 135 93 71 54 37 44 52 Mix 26 7 1811 15 1011 6 2 4 4 8 4 1 3 1 2 1 1 0 0 0 0 0 Pf 73 81 47 47 48 26 25 16 9 8 9 19 46 15 6 3 7 6 3 1 0 0 1 0 Krakor Pv 246 308 205 231 216 165 195 137 120 130 119 144 218 132 108 165 109 91 77 69 60 50 44 53 Mix 11743224100 431211 00010000 Figure 6. Monthly malaria cases in Kravanh and Krakor ODs

Outreach activities: Amongst all confirmed malaria cases, 137 (48%) were in PKV, and 148 (52%) were in KRK ODs (see Figure 7 for maps showing village incidence in PKV and KRK ODs). Although there were some changes in the number of cases identified in individual villages, the general areas of concern remain the same, with most representing areas being near the forest. For 9 selected high incidence villages in PKV, there were 4 cases in April and 12 cases in June 2020. For 12 selected high incidence villages in KRK OD, there were 28 cases in April and 22 cases in June 2020. Figure 7. Village incidence in PKV and KRK ODs

Forest interventions The forest interventions have been managed along with an intensification plan (IP) introduced by CNM. The current intensification plan, ‘IP2’, implemented was focused on pro-actively increasing malaria service coverage for forest workers in PKV and KRK ODs where malarial transmission risk is higher due to population movement into the forest areas. In FY20 Q3, 39/42 MMWs were available for implementing IP2 for PKV and KRK ODs. The

MMWs (designated as either ‘touch points’ or ‘peer volunteers’) have been monitored in the above 2 ODs. They contacted and encouraged forest goers/workers to conduct malaria testing, provided treatment for confirmed cases, provided health education via interpersonal communication, and distributed treated nets and SBCC materials. The MMWs regularly joined monthly meetings with VMWs (under the same catchment areas of relevant HFs). Results showed that, from April to June 2020, the 39/42 MMWs conducted 288 site visits and interacted with forest goers and tested 4,244 suspected malaria patients. Of the 4,244 suspected patients, 47 (1.2%) tested positive (all P.v) and all 47 patients received treatment as per NTGs. 1,494 LLIHNs were distributed (some forest goers already have nets from previous distribution events) and 3,658 health education sessions were conducted (which reached 5,277 forest workers). In addition, 1,021 forest packs and 774 botles of repellents were distributed to forest goers. P.f elimination has been implemented in the 2 ODs of PKV and KRK since April 2020. The MMWs established under IP2 have also been engaged for additional works such as notifying every detected cases to the relevant HC and the mobile app, applying 3 days DOT for all P.f/mix patients as well as assisting in Re-ACD, foci investigation and management. Capacity building: In Q3, there was no target for case management trainings in the transitional ODs. The 1-3-7 elimination activity including foci investigations management training were conducted for KRK (25 OD HF staff) and PKV (20 OD HF staff). CNM supervision: There were 0 supervision visits from the Laboratory unit of CNM to the transitional ODs due to conflicting priorities within CNM (target=2). There were no planned CNM Pharmacy Unit visits in Q3 to the transitional ODs [Act. 2.3.10]. Task 4. Strengthen case management and reporting in the private sector: Private Providers: The CMEP contract modification was approved in FY20 Q1, and resulted in PPs now formally being able to refer patients (CMEP supported to have a referral form for all the registered private providers under the PPM scheme). In Q3, there were 20 malaria suspected patients referred from PPs to public health facilities in the transitional ODs. 2 quarterly meetings (2 planned) were held in the 2 ODs [Act. 2.4.3]. 80% of PPs attended the PP meetings (51/64). The 51 PPs who attended the quarterly meetings (target=64) typically asked why PPs were not allowed to test/treat and when this situation shall change. Supervision visits: During Q3, there was no supervision visits to PPs by CNM PPM Unit as planned. [Act. 2.4.5]. Task 5. Build capacity and strengthen systems to manage malaria control activities: CMEP Support to VMWs/MMWs: In total, 637 (target=470) submitted monthly reports on time from Apr. to Jun. 2020 (136%) [Act. 2.5.1]. Only those reports that were collected within the due date were reported in the system, however the rest that missed the deadline were also collected. In total 100% of the reports were collected by every month end. During CMEP monitoring visits, it was shared to VMWs to submit reports on time, either by visiting the HFs or collection by HFs staff while visiting the VMWs location. Since the monthly meeting still has not been officially announced to be held, the VMWs are required to visit the HFs to submit reports and collect the drugs and tests. This practice will continue until further notification from CNM. During Q3, CMEP OD teams visited 10 absent VMWs to review progress and provide mentoring [Act. 2.5.2]. Integrated supervision from OD to HFs [Act. 2.5.3]: 18 (85%) of supervisory visits were accomplished during Q3 (target=21). This figure is similar to Q2, the reason provided for under

11 performing was due to conflicting priorities at OD level who were asked to monitor migrants moving from border areas into Pursat and rigorous monitoring due to COVID 19. Build capacity and strengthen systems to manage malaria commodities: CMEP provided support in stock monitoring and management to the nine target ODs during Q3. CMEP used the mHealth application (via laptops) [Act. 2.5.4-2.5.5] which automatically geotags facilities and locations to allow close monitoring of places visited. ACT distribution: ACT and/or RDT stock status were reported for 9 ODs in Q3. Table 3 provides a summary of ACT and RDT stock monitoring in all CMEP ODs. Table 3. Q3 ACT and RDT stock monitoring in all ODs Operational # of HFs ACT RDT District monitored Potential Stock Out Potential Stock Out SPL 10 0 0 0 0 BTB 28 0 0 0 0 PKV 8 0 0 0 0 KRK 8 0 0 0 0 TMK 18 0 0 0 0 MRS 15 0 0 0 0 PLN 6 0 0 0 0 BKN 11 0 0 0 0 SPM 12 0 0 0 0 Total 115 0 0 0 0 Visits to selected VMWs from CNM VMW Unit: In Q3, there were 0 visits from CNM’s VMW Unit to CMEP transitional areas (planned=0) [Act. 2.5.6]. Provincial Special Working Group for Malaria Elimination [Act. 2.5.7]: There were zero PSWGE meetings in Q3 (planned=1), due to conflicting priorities and has been postponed to Q4 [Act. 1.6.8]. Task 6. Strengthen BCC interventions for intensified malaria control IPC to tested malaria cases and high-risk groups: During Q3, 17,512 (target 9,000) suspected malaria patients were tested and received interpersonal communication through VMWs and HCs [Act. 2.6.1]. For the high risk groups in KRK and PKV ODs, 14 peer educators and 28 touch points provided health education sessions to 3,658 MMPs (target=2,000) [Act. 2.6.2]. Task 7. Support civil society and community-based organizations (CBOs) to implement Provide support to selected CSO partners & Implement sub-grant activities [Act. 2.7.2]: In PKV and KRK ODs, PFDA has played an important role in bringing malaria services to the forest goers/forest workers in the forest areas. PFDA has continued to implement the activities smoothly with good collaboration with PKV and KRK OD staff, HF staff, CMEP team, local authorities, VMWs/MMWs and contact points to execute health education campaigns to elevate malaria knowledge of the hard-to-reach populations. In Q3, PFDA organised 36 health educational campaigns which reached 934 MMPs including forest goers/workers and distributed 1,170 ITNs to MMPs. PFDA staff worked with local authorities and volunteers to map 36 MMP settlements/locations and identified 282 suspected malaria patients who were referred to VMWs/MMWs and HFs (all referred patients reached the service delivery points). PFDA always consults with PKV and KRK OD countertparts regarding all implementation activities and always keeps them engaged. In addition, PFDA regularly meets and shares results and challenges with them and discusses for improved implementation. Even though the challenges around COVID-19 restricted most of the activities, PFDA was still able to manage

12 and implement all activities within the quarter. The detailed targets versus results for key activities implemented in the two ODs are provided in Annex 1, Table 3. Task 8. Operational research- CMEP Q3 Operational Research activity is covered under Objective 1. 2.3 Objective 3: Strengthen national malaria surveillance systems and M&E appropriate for malaria elimination and control activities Task 1. Refine and harmonize M&E reporting forms and support consistent use by public and private healthcare providers Work with CNM and partners to harmonize M&E reporting forms: Technical supervision procedures continued to be revised for HF/RH/ODs in FY20 Q3 [Act. 3.1.1]. Support consistent use of the harmonized forms by providers: CMEP regularly ensures consistency of the forms (including recent visits/spot checks from key staff). OD teams were urged to always use the required correct forms [Act. 3.1.2]. Overall, during Q3, 91% of providers submitted surveillance data on time (100% from HFs and 89% from VMWs). Figure 8 provides submission percentages per OD since FY 2018 Q3. Figure 8. Percentage of HFs, VMWs/MMWs in target transitional ODs submitting surveillance data on time per national guidelines (since FY 2018 Q3)

Task 2. Provide technical assistance on data management and use Conduct IDQA at OD and selected HFs by ODMS/PMS and CMEP [Act. 3.2.2]: The CMEP FY19 IDQA was previously conducted in FY20 Q1 at one elimination and one transitional OD and was approved in Q3. Provide TA to CNM on village-based stratification and facilitate use of stratification tools [Act. 3.2.3]: Initial maps have been completed, and various parameters required for spatial analysis and stratification have been collected. CMEP has also analysed village wise data in PKV OD and developed initial maps and identified 13 villages that were reporting high prevelance of malaria cases. Provide TA to CNM on data visualization and outbreak module development for MIS The distribution of the CMEP OD Bulletins for FY18/FY19/FY20 has contributed to TA to CNM on data visualization. The bulletins provide useful visual representations of OD cases and species and are also provided in the local language [Act. 3.2.4]. CNM supervision [Act. 3.2.5]: During Q3, several visits were conducted by CNM technical units to CMEP target areas, and overall, 87% of the planned visits were achieved. Table 4 summarizes these visits. Table 4. Summary of CNM Technical Unit visits in FY20 Q3 Q3 Planned Q3 Actual Percentage ITN unit 5 5 100% Pharmacy unit 5 5 100% Laboratory unit 5 4 80% PPM unit 5 3 60% VMW unit 4 4 100%

Health Education Unit 5 7 140% M&E unit 5 4 60% Epidemiology unit 5 2 40% Entomology 0 0 100% Total 39 34 87% Task 3. Support further development and implementation of electronic data reporting and use platform CMEP continues to monitor and follow up on the use of smartphones designated to VMWs and tablets designated to HF/OD staff that provide notification and reporting of malaria cases and stock status of malaria commodities. Kravanh and Krakor reported major issues with mobile phones and tablets being old and unused, CNM instructed CMEP to procur mobile phones for VMWs and tablets for HFs. The process is under consideration. Task 4. Strengthen capacity to conduct entomologic monitoring Conduct entomology training for OD and PHD staff [Act. 3.4.1.]: The LLIN Durability Monitoring ‘Round 3’ survey commenced on 25th June in BTB and KRK ODs. A refresher training event for the enumerators was held in Pursat on 24th June. Data was collected using an electronic survey on tablet devices. The results of the survey will be available during FY20 Q4. The retention of the nets has reached 50 percent, more details will be provided in the report. 2.4 Objective 4: Build capacity of Ministry of Health (MOH) to manage, intensify, and sustain malaria control and elimination efforts particularly at the OD level Task 1. Develop and implement a plan to strengthen technical and management capacity at National, PHD and OD levels2 OD AOP development [Act. 4.1.4.]: All AOP meetings were completed in Q2 except Pailin. Internal Competency Assessment (ICA) course for malaria microscopists [Act. 4.1.7]: The activity was completed in Year 3. Laboratory quality assurance [Act. 4.1.8]: From April to June 2020, the CMEP Lab Supervisor conducted Lab QA supervision and monitoring visits with the BTB/Pailin PLS’s to the HFs labs of 5 elimination ODs (BTB, SPL, TMK, MRS, and PLN). See Annex 2 for the results. According to the current policy of Operational Manual for QA of malaria diagnosis that was organized by WHO and CNM from 11-14 June 2019, microscope services are managed only at RHs (District/Provincial levels) and are not required for HCs. Nevertheless, QA for RDT is required at all POCs. CMEP capacity building and regular interaction with lab units have proven remarkable progress, for example the BTB lab was able to detect P.m/P.k species. This has been with the effort of regular quality assurance work within the project. Provide on the job training and mentoring by CNM units [Act. 4.1.9]: During supervison visits conducted by CNM, mentoring and supportive supervision, on the job trainings are regularly being provided. E-Payment [Act. 4.1.10]: The e-payment system is used to pay per diems, transportation and other allowances through mobile payments. Up to FY20 Q3, CMEP has now implemented E- payments to all VMWs in 8 ODs except VSHG’s in THK because there is no monthly meeting. Task 2. Support CNM and MOH to develop and maintain a system for on-going technical and management capacity development

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

Provide feedback to HFs/OD/PHD by CNM technical units during supervisions [Act. 4.2.1]: During 33 supervision visits, technical sessions were held with the participation of CMEP, CNM, OD, PHD staff at ODs in Q3 (aligned with the supervision schedule). The feedback was mainly related to retaining VMWs as per planned targets, and in case there is any VMW scale down, this needs to be intimated to CNM. During VMW selection, ODs were asked to keep CNM in the loop. Non registered PPs should ideally not participate in CMEP activities. More accurate reporting, especially stock management should be ensured by HFs/ODs. CMEP progress review [Act. 4.2.2.]: The CMEP Central Progress review meeting which was postponed in Q2 was held on 13th June in Pursat. CNM staff and other partners attended, and progress for CMEP was presented and discussed. A few suggestions from CNM highlighted on regular outreach activities conducted by MMWs in KRK and KRV. Other highlights were to continue case based surveillance and reporting in the MIS system. P.v radical cure scale up, orientation and preparation will commence in Year 5 Q1, per diem for MMWs and transportation cost to be re-visited and raincoats provided during outreach activities is seen as a motivating factor for MMWs. Task 3: Improve malaria policies and guidelines [Act. 4.3.1]: CMEP technical team has actively engaged with CNM, WHO, CHAI and others in reviewing tools (manual, SOP, form, checklist, and other training materials) for P.v radical treatment cure scaling up and planning. Recent discussions on quantitative G6PD tests and review of SOPs and other training materials shall be undertaken in Q4. CNM SBCC strategy development [Act. 4.3.1]: Referring to the SBCC strategy and increasing behavior change materials, 5 items of IEC materails were finalized and printed (9,000 ITN forest posters, 250 Sub-grantee referral books, 500 malaria flipcharts, 436 PPM referral slips and 720 Malaria record books for VMWs). These will be distributed in Q4. Project Management CMEP Field Visits: CMEP DCOP visited Samlot at Otatong areas on 29th April 2020 to investigate 4 reported P.v cases. It was found that 2 cases were underage children (they had accompanied their parents to forest areas and they did not carry nets). Both were treated with ASMQ. The other 2 patients were G6PD normal and PQ was administered. CMEP COP and STA conducted a joint visit with CNM and WHO to Battamabang and Pailin on 5th May. The team and ODMS staff visited 2 HCs in PLN OD (Psar Prum and Krachab). The team checked the register book on P.v radical treatment and discussed this with HF staff. The team presented the CNM supportive supervision checklist and asked HF staff together with ODMS to review and understand the tool themselves and fill it with required figures/data under direct guidance from CNM, WHO and CMEP. P.m samples were collected by CNM for further investigation (P.m patients were treated as P.f patients). P.k malaria in Samlot district, BTB OD: On 26-27th May, CMEP COP and STA and BTB OD team with CNM team and IPC team worked with BTB PHD, BTB OD, 2 HCs to discuss a field survey on the emerging P.k malaria cases in Samlot district. The survey was lead and managed by CNM, technically supported by IPC, and CMEP facilitated and coordinated the field activities. The recently reported P.m cases from BTB OD were confirmed as P. Knowlesi (P.k) and the dissemintation of the survey shall be undertaken in Q4. CNM and CMEP visit to Pailin: On 26th May 2020, COP, STA and CNM visited Pailin Krachab HC to discuss the bordering villages to Battambang that have potential risk of P.k. The HF

Chief mentioned that it would be useful to undertake screening with at risk populations using ‘PAN RDT’ as the conventional RDT cannot detect P.k. Sub-grant Oversight and Management, CMEP sub-grantee quarterly meeting: On 7 April 2020, CMEP PNP team, 9 CMEP ODTLs and 2 members from each CSO (AHEAD and PFDA) met in in Pursat. The meeting was to review the progress of activity implementation of the 2 CSOs in Y4 Q2 and orientating the grant shift from Fixed Amount Awards to simplified grants. On 5th June 2020, CMEP COP and STA accompanied CNM technical chief to visit Mol Chass village for a MMW and MMP/forest goers joint meeting. An interactive session was conducted between the CNM technical chief and MMWs/forest goers. Active and frequent outreach visits by MMWs was highlighted and encouraged the testing of all suspected cases, particularly forest goers/workers and those living or connecting with any malaria patients in the area. On 25 June 2020, CMEP PP and OD teams participated in the CSOs quarterly meeting with 2 sub-grantees (AHEAD and PFDA) in Pursat. The objective of the meeting was to review sub- grantee performance, progress, challenges, lessons learned, and to develop the next action plan. Meetings with USAID (including COR, PMI-USAID team): US Ambassador’s visit to CMEP PNP office: On 8th of April, The US Ambassador to Cambodia, Mr. Murphy Patrice with OPHE Director and his team visited the Cambodia Malaria Elimination Project office in Phnom Penh. CMEP COP/PNP team briefed the ambassador and team regarding CMEP’s goals, objectives, strategic interventions and activities as well as key achievements and successes. The Ambassador was very much appreciative to the CMEP team for welcoming him during COVID-19 crisis. CMEP-COR e-meetings: On April 1st, CMEP provided an update on COVID-19 situation and impact on activities as well as a risk assessment for CSO’s and partners (all activities progressing normally apart from those involving gatherings); the planned meeting between CMEP and CNM on possible integration of COVID activities was discussed; and the finalization of the contract modification for KRK amd PKV partial elimination was discussed. CMEP-COR e meeting: April 15th, CMEP provided an update on COVID-19 impact on activities (similar to April 1st e-meeting and plans for CMEP teleworking), along with the status of the April CMEP voucher, and an update on partial elimination planned activities in KRK/PKV ODs. CMEP-COR e meeting: April 22nd, CMEP provided an update on COVID-19 impact on activities (similar to April 15th e-meeting and further updates on CMEP teleworking); the progress/results of P.v radical cure treatment in CMEP ODs were provided along withan update on progress in 3 CMEP ‘expanded’ ODs. CMEP-COR e meeting: 13th May, CMEP provided an update on COVID-19 impact on activities (including progress to less restrictions for gatherings and hence recommencing of various meetings, including AOP reviews), and the remaining budget for Year 5 was discussed. CMEP-COR e meeting: 2nd June, CMEP provided an update on COVID-19 impact on activities (including that all staff returned to office since May 25th), and the progress of the Mid-term evaluation team was provided including discussions on the various data requests. CMEP-COR e meeting: 17th June, highlights of the CMEP Q3 success story on working successfully through the COVID-19 situation was provided to COR. The P. knowlesi survey progress was also discussed, and plans for the central review meeting on 23rd June were provided. Meetings with CNM and Other Partners:

CMEP - CNM –WHO Meeting: CNM proposed the meeting on 1st of April at CMEP office along with WHO to explore opportunity to integrate COVID-19 activities with malaria elimination efforts in CMEP catchment areas. CMEP shared the steps already taken to support the PHDs/ODs to continue malaria work and would also add COVID-19 health and hygiene messaging in meetings, practice social distancing and cleaning practices. WMD 2020: The usual physical event with public gathering was cancelled due to COVID-19, but messages for increased awareness were disseminated via radios, televisions and other formats. CMEP submitted pictures and captions of WMD to USAID and HQ with last years theme being the same for this year (“Zero malaria starts with me’’). CNM P.v radical cure meetings: 24 April 2020 via Zoom with partners including USAID/PMI. Agenda included a) Progress and challenges March 2020; b) Experience of HSD pilot in PKV; c) Supervision checklist; and d) Next steps. During the meeting, it was mentioned that the CMEP elimination provinces in the pilot study had performed extremely well. CMEP and CNM Meeting – On 29th April CMEP, CNM and WHO reviewed the CNM supervision checklist on P.v radical cure and planned a visit to BTB and Pailin province to test the checklist. It was discussed that once the checklist is tested it can be integrated into the overall CNM supervision checklist. CNM Virrual meeting - On 12th June 2020, zoom meeting was convened by CNM with 15 participants from CNM, WHO, USAID, CMEP, CHAI, PSI and others to review progress in May 2020 on P.v radical treatment implementation in 4 pilot provinces of Battambang & Pailin (CMEP), Kampong Chhnang (CHAI) and Kampong Speu (PSI). Discussions included possible ways to further scale up P.v radical treatment during 2020 and developing appropriate tools for all stakeholders. D&T working group meeting – On 15th May, CNM held a P.v radical cure D&T WG meeting. The meeting included a discussion of April 2020 data, supervision trip sharing, adverse event management, and G6PD quantitative tests procurement timeline. CMEP reported its 100% radical cure achievement with no adverse reactions. Virtual meeting with WHO - On 30th May, WHO and CMEP had a Zoom call to discuss aggressive interventions in Pursat (IP2). The items discussed included: 1) Basic IP2 activities; 2) Elimination: Case/Foci investigation; and 3) COVID: Migrant/MMP monitoring, Outbreak detection. CMEP shared the activities that have been undertaken in Pursat and in other elimination provinces, the major points that were shared was the foci investigation in Koh Kong and the protocol that was followed and the migrant workers tracking and assessing the movements into the forest areas. CNM Surveillance training: CMEP technical coordinator (Dr. Narann) on 12 May 2020 joined as facilitator in 1-day training on 1-3-7 malaria elimination surveillance to about 50 CNM staff together with WHO and CHAI. Key training topics were mainly malaria case real time notification, investigation, re-active case detection and foci investigation and response. All activity results are properly recorded in the MIS with regular rectification and analysis. IP2 meetings/activities: CMEP team (COP, DCOP, TO and PKV ODTL) attended IP2 e- meeting on 5th May 2020 (Dr. Siv chaired the meeting). It was decided to have 2 meetings per month with all partners on ensuring essential malaria services during the COVID situation. CNM-CMEP joint visit to expanded TA area: On 9th & 10th June 2020, CMEP COP, STA and CNM deputy director visited ‘expanded’ ODs Kep and Kampot for a meeting with respective PHDs and OD staff (Koh Kong team joined the meeting by Zoom). Objectives of the visit to the ‘expanded’ OD provinces included (i) discuss technical monitoring progress of 1-3-7, and (ii) exploring possibilities to implement P.v radical treatment. All 3 ODs appreciated

CMEP technical support so far provided for 1-3-7 implementation, however issues with MIS (on notification) and tablets/smart phones (some being broken) were raised and CMEP agreed to assist with these where possible. Regarding P.v radical treatment, the 3 ODs expressed interest in this and agreed to start preparatory work (including checking HFs for cold chain facilities). CMEP central program review: On 23 June 2020, at Pursat, the CMEP central program review meeting was held to review last 6 months progress, challenges lessons learned, recommendations and ways forward. The meeting also discussed support required for the PHDs, ODs, HFs and others as well as CNM priorities for the upcoming years. The meeting was attended by 35 participants comprising of CNM team (director, deputy and technical chief), PHD Director, deputy, PMS, ODMS, CSOs and CMEP staff. The CNM Director Dr. Rekol opened the meeting with his speech in which he highlighted the achievements of CMEP elimination ODs, including drastic P.f reduction in Pursat and rollout of 1-3-7 work in the expanded ODs which could be a model for the whole country. Dr. Siv fron CNM provided a technical presentation which helped to further highlight CMEP’s progress in its 3 provinces. Meeting with IPC/Partners: CNM/WHO/IPC & CMEP (P.k discussion meeting). A meeting was held on 19th May with CNM, WHO and partners after P.k cases were found in Samlot district (BTB OD). 8 samples of Plasmodium Malariae (P.m) malaria cases, detected by Tasanh microscopy expert, were sent by CNM to IPC for PCR confirmation. The IPC provided results confirming 7 positive and 1 negative. Among 7 positive, 5 cases were mixed of P.k and P.v while 2 others are only P.k (both species P.k and P.m are not able to be detected by conventional RDT, only by microscope and PCR test). Regarding this new species, CNM, WHO, CMEP and IPC discussed to investigate further to learn and understand the case location and the situation if transmission occurs in the villages. CMEP along with CNM decided to organize a meeting with PMS/ODMS/HF requesting a quick cross sectional survey in 6 villages in 2 HCs in Samlot district. CNM & Partners meeting – 8th June CNM held a virtual meeting with all malaria partners to review the progress of malaria activities while focusing on hard to reach locations, challenges, and issues partners face during the implementation period. The meeting was chaired by Dr. Siv who provided a country malaria map with real time data highlighting the great progress in CMEP locations in drastically curtailing the P.f cases in Pursat. 29th June - Joint meeting on P.v radical treatment: CMEP Technical Coordinator joined with CNM, CHAI and WHO on 29th July reviewing the manual for P.v diagnosis and treatment (+radical cure), reviewing all job aids for G6PD testing both qualitative and quantitative tests, follow up check list as to how to follow up with patient by VMWs, as well as reviewing assessment tool for provincial hospitals in planning to expand to new provinces countrywide. 30th June – Call with CDC, Institute Pasteur in Cambodia IPC and CMEP: the hsRDT report was discussed at length and it is agreed that the hsRDT report shall be published and IPC is working on the manuscript. The final report of hsRDT requires approval which would be later disseminated by IPC. Procurement In FY20 Q3, CMEP transferred 1 motorbike to the PMI Vector Link Project (this was approved by USAID-PIM in February 2020). Financial Management

Human Resource Management At the end of FY20 Q3, CMEP has all 71 staff onboard. In Q3, all required CMEP vacant staff in Cambodia has been filled. 12 new staff joined in FY20 Q3 - 1) OD Team Leader Pailin, 2) OD Team Leader Bakan, 3) Technical Offier in Kep, 4) Techncial Officer in Kompot, 5) Technical Officer in Koh Kong, 6) OD Team Leader Assistant in KRK, 7) OD Team Leader Assistant in Pailin, 8) OD Team Leader Assistant in BTB, 9) BCC Specialist, 10) OD Data Assistant in TMK, 11) OD Data Assistant in SPL, and 12) Procurement Officer in Pnom Penh. Three staff resigned in Q3, (BCC Specialist,OD Team Leader in Bakan, and OD Data Assistant in TMK). The challenges of staff retention will still continue as the project approaches the last year and staff are potentially finding long term options. CMEP on an ongoing basis is doing recruitment to fill postions as they become vacant. 3. RESOLVING CHALLENGES FROM FY20 Q2 Reporting on PP referrals, as it had a few challenges of actual reporting and motivational issues were taken up in the last PPM quarterly meeting along with the ODMS and OD Director facilitating the session. It was reassured by the PP that they shall report on all the referred cases in the next quarterly meeting and also request ODMS to ask VMWs to follow up on the referred patients. The attendance in the quarterly meeting was better than the last quarter given that the clear guidance on CMEP expectations and the need and importance of PPs in malaria reduction was reemphasized. The refresher training of case based surveillance also was an add on and value addition to the overall knowledge of the Private Providers. The G6PD expiration issues was taken up at the national program meeting level where it was agreed that the HFs will try testing P.v cases and using as much as possible, and if there is any shortage in any other HFs, reallocation should be done at the earliest. CMEP team facilitated the session during monitoring visits to get the stock status and with the case trend was able to identify HFs which potentially might have a stock out. It was noted that none of the HFs shall have any stock out and very less remaining G6PD tests will be left unused. The national program reported that the next consignment shall be available by August 2020. The meetings that were suspended because of COVID-19 crisis has resumed gradually with some sanction and restrictions. PPM meetings, central level meetings, provincial and district special working group meetings, supervisions and monitoring were conducted in the Q3 reporting period. Since 18th March the VMW meeting has been suspended but it is given to understand that respective PHDs and ODs shall be making a decision whether to continue factoring in the COVID protocol. CMEP team resumed 100% work from office since May 2020. 4. CHALLENGES AND ACTIONS TAKEN OR PROPOSED The challenges and actions taken or proposed in this reporting period included: The issues pertaining to PPs still exists with the new decentralized structure in the Province that has been put in place, where all the department heads and authorities shall be under the line management of the Provincial Governor. In the provincial working group meeting it was shared by the PHDs Director that the PPs license shall no longer be given by health department, rather it will be now undertaken by the Governor’s office and thus PHDs shall have no authority on PPs work and involvement. In CMEP, the PHDs allowed only licensed PPs to engage and this helped to avoid misuse of drugs by PPs and testing and treatment of malaria PRAKAS enforced and strictly monitoring by PHDs. CMEP will continue working with the Provincial special working group and regularly highlight any issues emerging from PPs.

Organizing meetings/workshops, monitoring visits of CSOs activities due to COVID-19 has progressed into a ‘new normal’ stage where all precautions to implement the project activities is becoming mandatory. Precautionary measures by social distancing, temperature checks, and use of protective supplies for all key stakeholders are now a regular feature. Challenges still remain as to how one holds themselves and others accountable to follow these norms. CMEP will follow the restrictions, precautions and all MoH guidelines related to COVID and ensure that the mass net distribution proposed by CNM in Q4 is well managed and implemented. Due to the G6PD expiration in July 2020, there still has not been any indication of the next batch of G6PD RDTs. If it does not arrive by August to the HFs, the pilot of P.v radical cure shall face challenges with P.v male patients not having access to radical treatment thus opening up possibility of transmission with relapsed cases and new infections. 5. PLANS FOR NEXT QUARTER AND UPCOMING EVENTS CMEP as part of the Year 4 Q4 work plan will implement the following:  Rigorous intensification plan implemented in KRK and PKV.  Implementation of the P.f elimination cased based surveillance in KRK and PKV.  Year 5 workplan and budget preparation, finalization and submission.  Continuation of P.v radical cure treatment in elimination ODs and recording.  AOP development and target finalization with ODs/PHDs along with CMEP OD staff.  Sub grantee quarterly meeting and report submission.  Initiate mass nets distribution as per CNM guidance in KRK and PKV.  Participate in ongoing zoom meeting with CNM on P.v radical cure and IP2.  Writing and finalizing the LLIN Durability report.  Finalizing the hsRDT manuscript and submission to PMI.  Review and provide input on the mid-term evaluation.  Central program review meeting of CMEP.

ANNEX 1 CSO FY20 Q3 RESULTS TABLES Table 1. AHEAD Results FY20 Q3 (BTB, PLN, SPL and TMK Elimination ODs) Indicators Target Actual Target explanation 1. # of health education campaigns Acheived over target because organized in high transmission Moung Ressey OD restarted villages 100 103 activities in Apr 2020. More MMPs needed malaria education provided. 2. # of mobile/migrant and new 2,500 3,253 Achieved over target due to settlers reached with BCC messages more new MMPs seeking work through IPC for corn harvesting and collection of cassava, resulting in more participation during campaign education. Screening of suspected cases during the campaign achieved a total of 1,399 persons (Male 675 and Female 724).

3. # of ITNs distributed to 2,410 3,783 Acheived over target to planned mobile/migrant population due to more new MMPs seeking work in seasonal collection of corn and cassava. 4. # of mobile/migrant settlements 100 138 Acheived over target due to mapped more new MMP settlements being identified. 5. # of suspected malaria patients 189 357 Achieved over target due to referred to VMWs/HFs more MMPs better understanding and being interested to undertake malaria testing. # or % of suspected refer reach to 183 357 Reached over to target plan due service VMW/MMW or HFs to more MMPs understanding of malaria prevention. 7.# of report any increased malaria 1 0 There was no increase of cases or outbreaks malaria cases in AHEAD targeted areas. 8.# of meeting organized with OD 5 5 (Conducted at Sampov Loun and PHD organized by CSOs OD) 9. # of government meeting attended 9 8 Did not reach target due to PHD by CSOs (Pro-TWGH meeting) not able to organize due to COVID-19 situation.

Table 2. PFDA Results FY20 Q3 (BKN and SPM Elimination ODs) Indicators Target Actual Target explanation 1. # of health education campaigns On target. organized in high transmission villages 24 24 2. # of mobile/migrant and new settlers 480 709 Over target due to more MMPs reached with BCC messages through coming to work in the target IPC areas. 3. # of ITNs distributed to 240 1,368 Achieved over target because mobile/migrant population ITNs not only distributed through health education campaigns, but also through net use monitoring conducted by PFDA’s contact points 4. # of mobile/migrant settlements 13 24 Achieved over target due to mapped new mobile populations being found in the old locations, and remapping in the old locations. 5. # of suspected malaria patients 12 39 Over target due to contact referred to VMWs/HFs points active in seeking out suspected malaria patients. There was a P.v positive case referred from Andong Tachuk to Releap Health Center. 12 39 Over target due to contact 6. # of suspected refer reach to points active in seeking out service VMW/MMW or HFs suspected malaria patients. 7.# of report any increased malaria 0 0 Malaria cases or outbreaks did cases or outbreaks not occur in targeted areas. 8. # of meeting organized with ODs, 0 0 Under target due to availability HCs and/or PHD by CSOs issues with OD counterpart staff (they were busy responding to

COVID-19). 9. # of government meeting attended 9 9 Achieved as planned. by CSOs (Pro-TWGH meeting)

Table 3. PFDA Results FY20 Q3 (KRK and PKV Transitional ODs) Indicators Target Actual Target explanation 1. # of health education campaigns Achieved target plan. organized in high transmission villages 36 36 2. # of mobile/migrant and new settlers 720 934 Over achieved planned due to reached with BCC messages through new MMPs . One P.v case was IPC found during campaign in Kravanh OD. 3. # of ITNs distributed to 360 1,170 Achieved over target because mobile/migrant population more MMPs were found during mapping and ITNs were not only distributed through health education campaign, but also through net use monitoring conducted by PFDA’s contact points. 4. # of mobile/migrant settlements 29 36 Over target (due to the new mapped mobile population found in the old location/remapping in the old locations). 5. # of suspected malaria patients 219 282 Over target due to contact points referred to VMWs/HFs being so active in seeking out suspected malaria patients. 6. # or % of suspected refer reach to 219 282 Over target due to contact points service VMW/MMW or HFs being so active in seeking suspected malaria patients. There was a P.v positive case which was referred from Chkea koh point to VMW in Kbal teahean village, KRK-OD. 7.# of reports of any increased malaria 2 0 No increased malaria situation cases or outbreaks to report. 8. # of meeting organized with ODs, 2 0 Counterparts had no time for HCs and/or PHD by CSOs meeting. They have been busy with responding to COVID-19. 9. # of government meeting attended 6 6 Government counterparts were by CSOs (Pro-TWGH meeting) busy responding to COVID-19

ANNEX 2 LAB QA/MICROSCOPY TRAINING TABLES Table 1: Slides crosscheck for Lab QA April - June 2020 in BTB and PLN Provinces HC Lab QA Lab QA Lab HC Lab result OD Name of HC result result result Positive Negative Negative Positive PLN RDTs malaria & RDTs G6PD Ou Chrar, - Good storage Krachab, and - Good performance Phnom Spong - Good quality follow up

RDTs malaria & RDTs G6PD

Kompong - Good storage

Lpov - Good performance BTB - Good quality follow up PV+PM 1, PM PV +PM1, Tasanh 16 16 5 PM 5 Sdao 14 0 14 0 BTB RH 15 PV 2 15 PV 2 SPL RH SPL 02 PV 1 02 PV 2 RDTs malaria & RDTs G6PD Bour, Trav - Good Storage Chou, Serei - Good Performance Mean Chey - Good quality follow up

TMK TMK RH 05 0 05 0 Bovel I RH 0 0 0 0 RDTs malaria & RDTs G6PD - Good storage Klang Meas, - Good performance - Good quality follow up

MRS MRS RH 06 PV 1 06 PV 1 RDTs malaria & RDTs G6PD - Good storage Prey Trolach, - Good performance Prek Chik - Good quality follow up

TOTAL 17 HFs 58 10 58 10 ACC- 100% 100% URACY

ANNEX 3 – PV Radical Cure Treatment Status Results of CMEP P.v Radical Cure in FY20 Q3 (in BTB and PLN ODs)

P.v radical cure data from April to June 2020

- Total P.v cases detected in Q3 = 29 cases - 6 cases are female: 4 in BTB OD and 2 in MRS OD - 1 case was low weight < 20kg) in BTB OD