MALARIA ELIMINATION PROJECT

Cambodia Malaria Elimination Project Quarterly Progress Report - Year 5, Quarter 2 January - March 2021

Submission Date: 29th April 2021

Contract Number: AID-442-C-17-00001 Contract Period: October 26, 2016 to October 25, 2021 COR: Rida Slot Alternate COR: Saad El-Din Hussein

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

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

1 TABLE OF CONTENTS 1. Acronyms...... 3

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...... 8 2.3 Objective 3: Strengthen national malaria surveillance systems and M&E appropriate for malaria elimination and control activities ...... 11 a. 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 . 13 Procurement ...... 18 Financial Management...... 18 Human Resource Management...... 19 3. Resolving challenges from FY21 Quarter 1 ...... 19 b. ANNEX 1 CSO FY21 Q2 RESULTS TABLES...... 22 d. ANNEX 2 LABORATORY QUALITY ASSESSMENT/MICROSCOPY TRAINING TABLES ...... 25

2 1. ACRONYMS

3K , and Koh Kong Provinces ACT Artemisinin-based Combination Therapies AHEAD Action for Health Development (CSO in Cambodia) AOP Annual Operational Plan API Annual Parasite Index ASMQ Artesunate + Mefloquine BCC Behavior change communication BKN Bakan BTB Battambang CHAI Clinton Health Access Initiative CMEP Cambodia Malaria Elimination Project CNM Cambodia National Malaria Center COP Chief of Party COVID-19 2019 novel coronavirus CSO Civil Society Organization DOT Directly-observed therapy DSWGE District Special Working Group for Malaria Elimination EDAT Early Diagnosis and Treatment FY21 Fiscal Year 2021 G6PD Glucose 6 Phosphate Dehydrogenase Hb Hemoglobin HC, HF Health Centre, Health Facility HH Household IDQA Internal Data Quality Assessment IEC Information, Education and Communication IP2 Intensification Plan 2 ITN Insecticide-Treated Net KRK Krakor LLIN/LLIHN Long Lasting Insecticidal Net/Hammock Net M&E Monitoring and Evaluation MIS Management Information System MMP Mobile and Migrant Populations MMW Mobile Malaria Worker MoH Ministry of Health MRS Maung Russey NTG National Treatment Guidelines OD/ODMS Operational Health District/OD Malaria Supervisor ODTL OD Team Leader P.f. Plasmodium falciparum PFDA Partner For Development in Action (CSO in Cambodia) PHD/PMS Provincial Health Department/Provincial Malaria Supervisor PKV Phnom Kravanh PLN Pailin PMI President’s Malaria Initiative PP Private Provider PPM Private Public Mix PQ Primaquine PSI Population Services International PST Pursat PSWGME Provincial Special Working Group Malaria Elimination P.v. Plasmodium vivax

3 Q1 Quarter 1 Q2 Quarter 2 Q3 Quarter 3 QA Quality Assurance QC Quality Control RDT Rapid Diagnostic Tests RH Referral Hospital SBCC Social and Behavior Change Communication SPL Sampov Loun SPM Sampov Meas STA Senior Technical Advisor TMK Thmar Koul UNOPS United Nations Office for Project Services URC University Research Co., LLC USAID United States Agency for International Development VMW Village Malaria Worker WHO World Health Organization

4 1. INTRODUCTION The United States Agency for International Development (USAID)|President’s Malaria Initiative (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: 2. Develop a scalable, evidence-based elimination model in Sampov Loun (SPL) operational district (OD) and support its dissemination and replication for malaria elimination in Cambodia. 3. Support scale-up of high-quality malaria control and prevention interventions in five to eight ODs, where gaps in coverage or quality exist. 4. Strengthen national malaria surveillance systems and monitoring and evaluation (M&E) appropriate for malaria elimination and control activities. 5. Build capacity of malaria program to manage, intensify, and sustain malaria control and elimination efforts particularly at the OD level. Figure 1. CMEP Summary of Activity Progress (Jan.-Mar. 2021)

CMEP conducted the following key activities in Fiscal Year 2021 (FY21) Quarter 2 (Q2): ▪ 34,709 of suspected cases were tested with 147 positive cases confirmed and all cases received appropriate treatment according to the National Treatment Guidelines (NTG). ▪ In the seven CMEP elimination ODs in Battambang (BTB), Pailin (PLN) and Pursat (PST) provinces, there were was one Plasmodium falciparum1 (P.f.)/mixed case in Q2. There was a total of 17 Plasmodium vivax (P.v.) cases in Q2. 17/17 (100%) of the P.v. species cases were notified within 1 day, 17/17 (100%) were investigated within 3 days, and 16/17 (94%) responded to within 7 days. In the partial elimination ODs, Phnom Kravanh (PKV) and Krakor (KRK), there was one P.f./mix case in Q2. ▪ During Q2, since the deployment of G6PD quantitative test in late January 2021, in total 112 P.v. cases were diagnosed and treated in CMEP BTB, PLN, PST and ‘3k’ provinces. 58 of these with normal G6PD completed 14 days’ PQ treatment and follow up (see page 7 for full details of the P.v radical cure results in Q2).

1 The one Pf case was detected in in Krakor OD and was classified as LC (Local Cambodia)

1 ▪ In Q2, CMEP response to malaria cases in Pursat ODs continued and included monitoring daily/weekly cases, intensified services at all points of care, and the continued setup and support of touchpoint/peer educator volunteers. Out of the 33 touch points/peer volunteers who performed as Mobile Malaria Workers (MMWs), regular mapping helped in identifying new hotspots and closing the existing ones that no longer qualified as hotspots. In Q2, there were 8 touch points volunteers and 5 peer educator volunteers in KRK, and 10 touch points volunteers and 10 peer educators in PKV. ▪ During Q2, there were some mass distribution activities for long lasting insecticidal nest (LLINs) and long lasting insecticidal hammock nets (LLIHNs) in only Sampov Meas (SPM) OD as most of the mass distribution activities had been finalized by end of FY 21 Quarter 1 (Q1). In SPM OD in Q2, a total of 1,782 insecticide treated nets (ITNs) were distributed. ▪ In the 7 elimination ODs, CMEP deployed ITNs as buffer stock to Health Facilities (HFs) and Village Malaria Workers (VMWs) in Q2. Through VMW outreach activities, the total ITN distribution was 2,311 to local residents and 1,546 ITNs to farms. ▪ In the 2 transitional ODs, 800 ITNs were deployed as buffer stock to HF and VMW levels, 1,422 ITNs were distributed to local residents and 0 ITNs to farms. ▪ CMEP supported CNM technical units to conduct 35 planned supervision visits (target = 41). ▪ In Q2, 75% of malaria suspected patients who visited Private Providers (PPs) were referred to public health facilities in the 7 elimination ODs. 65% of private providers attended the PP meetings. In the 2 transitional ODs, 33% suspected patients were referred from PPs to public health facilities. None of the PP meetings took place in these 2 ODs.

FY 21 Q2 CMEP PITT Progress against each performance indicator (PITT table) is presented in the file attached. TABLE.xlsx 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 2. Sustain universal long-lasting insecticidal net (LLIN) coverage: Mass distribution: There was some final mass distribution activities in Q2 for the elimination ODs. 1,782 ITNs (1,284 LLINs and 498 LLIHNs) were distributed as part of the mass campaign in SPM ODs (all other mass distribution in elimination ODs was completed in Q1). Ensure continuous distribution of LLINs: In line with the updated list of villages for ITN distribution, CMEP’s target for continuous LLIN distribution was 240 villages in the 7 elimination ODs [Act. 1.2.3]. In the elimination ODs, CMEP deployed 2,193 ITNs as buffer stock to HFs/VMWs in Q2 (10,610 planned). CMEP will further deploy ITNs in FY21 Quarter 3 using United States Government purchased ITNs. CMEP distributed 2,311 ITNs (10,985 planned) to target populations during outreach and response activities [Act. 1.2.5] and another 1,546 ITNs were distributed to mobile and migrant populations (MMPs) at big farms and MMP locations (the increased actual for this activity was due to increased outreach work by Civil Society Organizations in some of the elimination ODs) [Act. 1.2.5.a]. Overall, Q2 achieved versus target is lower due to the mass campaign in fiscal year 2020 Quarter 4 and FY21 Q1 based on new CNM guidance of targeting villages with Annual Parasite Index (API) >= 5. Net top up and malaria education to households: In the 7 elimination ODs, VMWs conducted 2,557 visits (target = 2,292) to households/farms for net use monitoring, net top-up and health education [Act. 1.2.6]. Visits to household (HH) members’/farm workers included health

2 education for malaria prevention/LLIN use. There were 2 monitoring and supervision visits conducted from CNM ITN Unit to elimination ODs in Q2 (target = 2) [Act. 1.2.7]. Task 3. Ensure Early Diagnosis and Treatment (EDAT) and follow up: In the 7 elimination ODs, CMEP activities covered 432 points of care in Q2 (107 public health facilities, 308 VMWs, and 17 MMWs) [Act. 1.2.1]. 18,274 of 18,274 (100%) suspected malaria cases received a parasitological test. 61% of individuals were tested by VMWs and 39% by HFs (this shows that VMWs are continuing to increase their share of testing compared to previous quarters). Out of all the individuals tested there were zero P.f./mixed cases and 17 P.v. cases were confirmed positive. All 17 P.v. cases were enrolled in the system and 16 of the cases have travel history information (see Figure 2 for a table of case classification and OD case distribution maps for Q1). Further analysis showed there were 8 cases (47%) imported from Pursat, 0 case (0%) from and 0 cases (0%) from other provinces in Cambodia. There were 1 local cases (L1) for P.v. identified in this quarter in the 7 elimination ODs. Figure 2. Map of case classification for 5 ODs that reported malaria cases by origin (Jan-Mar 2021)

Out of 17 positive malaria cases reported in FY21 Q2, 0 (0%) were P.f./mixed and 17 (100 %) were P.v. Figure 3 provides the cases breakdown for Q2 and the cases trend since April 2017. Figure 3. Number of confirmed malaria cases in 7 ODs per species in Apr. 2017-Mar. 2021 (source Management Information System/PMIS)

3 Due to zero P.f./mixed cases in Q2, it was not necessary to conduct any 28 day follow up [Act. 1.3.3]. Figure 4 summarizes the implementation of directly observed therapy (DOT) for confirmed cases in the 7 elimination ODs. Figure 4. Implementation of DOT in 7 ODs per species during FY21 Q2

In FY21 Q2, zero patients were hospitalized for second line treatment in the 7 elimination ODs [Act. 1.3.6]. CMEP provided case management training during Year 4 where it was emphasized to administer Single Low Dose Primaquine. This was also done during refresher training and regular visits to VMWs and HFs. Since there were no P.f. cases, no Single Low Dose Primaquine was administered. Case Management: 177 health staff in CMEP areas were provided with ‘cascade’ surveillance training courses for the updated case investigation form in Q2 in PST, BTB and PLN. And 4 supervision visits were made by the pharmacy and lab/D&T units in the elimination ODs (7 planned) during Q2 [Act. 1.3.10]. Task 4. Malaria case reporting, investigation, and response In 7 ODs in Q2, 17 out of 17 cases (100%) were notified within 1 day via the SMS Day-0 mHealth system, 17 cases (100%) were investigated within 3 days, and for 16 (94%) 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, 1 case out of the 17 cases (6%) were not responded to due to patient unavailability at their home [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 received approval from PMI for PPs not to test or treat as per the PRAKAS in 2018, thus the previous indicator has been removed from this quarter but the referral and supervision indicator is still being tracked and reported. In Q2, there were 123 (75%) malaria suspected patients referred from PPs to public health facilities where then tested and treated in the elimination ODs, and 60% of PPs (94/156) attended the PP meetings [Act. 1.5.3]. PPs who were absent from quarterly meetings were either busy with other tasks or did not consider the meetings relevant as they realize PPs are no longer able to test or treat, and lack of motivation among the PPs is also seen as one of the major factors. 6 monthly supervision visits were also conducted to provide technical feedback on referrals and to improve social and behavior change communication (SBCC) initiatives. 149 PP visits were accomplished during supervision visits in Q2 [Act. 1.5.4]. 2 supervision visits (target = 2) from CNM’s Private Public Mix (PPM) unit were conducted in Q2 [Act. 1.5.5]. Task 6: Build capacity and strengthen systems to manage elimination activities Supporting VMW monthly meetings: Monthly meetings continued in Q2 to support capacity

4 building of VMWs. Meetings were held during the fourth week of January, February, and March. In Q2 for the 7 ODs, in total, 822 VMWs attended meetings versus 822 planned [Act 1.6.1]. In January and February, actual VMW meetings were held, however due to the emerging COVID situation in March meetings were not held, the data for March is the number of reports submitted by VMWs to HFs. Integrated supervision from ODs to HFs: 103 supervision visits were conducted to 107 HFs in the 7 elimination ODs using the CNM checklist (target = 101) [Act. 1.6.3]. Data verification on total tests, total confirmed cases and total treated cases was performed during the visits. Stock monitoring: Stocks of tests and drugs in CMEP areas were secured for the period of January-March 2021. CMEP continued to provide CNM and all partners (including United Nations Office for Project Services, UNOPS) with monthly stock status reports for rapid diagnostic tests (RDT), artemisinin-based combination therapies (ACT), and Artesunate Melfoquine (ASMQ). Updates from all health centers (HCs) in the 7 elimination target ODs were included. No actual stockouts were reported and HFs that did identify any potential stockout were quickly fixed. No reallocation of drugs occurred between elimination ODs during Q2. CMEP staff also visited key HCs and monitored the stock levels verifying the consumption against the allocation. Visit to selected VMW’s from CNM VMW Unit: There were 4 visits from CNM VMW Unit conducted in elimination ODs in Q2 (Target=6) [Act. 1.6.6]. District Special Working Group for Malaria Elimination (DSWGE): 4 meetings were conducted in Q2 in the elimination ODs (target = 0). Due to the 2019 novel coronavirus (COVID-19) situation, Bakan OD conducted an additional meeting in Q2 because a new administrative district was established in the OD (Talo Saenchey). These DSWGE meetings enabled participants to receive updated information on potential gaps, tested cases, and frequency of testing in elimination settings. Provincial Special Working Group for Malaria Elimination (PSWGME) There was 1 PSWGME meeting held in Q2 in SPM OD (planned = 3) [Act. 1.6.8]. One other planned meeting in Q2 in PLN was cancelled following the Governors’ advice due to the emerging COVID situation in Cambodia. Task 7. Social and Behavior Change Communication (SBCC) for malaria elimination In the 7 elimination ODs, 18,274 individuals tested for malaria received interpersonal communication for malaria education (target= 13,823). This was over target mainly due to VMWs/HFs increasing testing and increased Civil Society Organization (CSO) activity [Act. 1.7.1]. In addition to malaria patients, malaria messages were provided to 17,209 people from high-risk groups during case response activities within the village and farms [Act. 1.7.2]. CNM Health Education Unit made 2 visits in Q2 in the elimination ODs (planned = 1) [Act. 1.7.3]. Task 8. Support civil society organizations (CSO) to complement malaria elimination activities: Despite the COVID-19 challenges in FY21 Q2, Action for Health and Development (AHEAD) was still able to carry out all activities in its 5 ODs and was able to work well with CMEP, OD teams, HCs, community level persons, OD staff, VMWs/MMWs and contact point staff. AHEAD also worked with local authorities and volunteers to identify hot spot areas, map MMP locations and identify suspected malaria patients for referring to VMWs/MMWs or HFs for testing and treatment. To ensure the effectiveness of referral cases reaching delivery points, AHEAD staff and contact points carried out extensive follow ups through phone calls or meetings (respecting all COVID-19 guidelines) with the relevant persons. AHEAD regularly followed up on the malaria situation in their ODs, and met OD/Provincial Health Department

5 (PHD) counterparts to discuss progress, challenges and ways forward. Targets were mainly achieved and some over achieved; for example, MMPs reached by campaigns (1,250 target versus 1,586 result), ITNs distribution to MMPs (1,110 target versus 1,887 result), hot spots mapping (48 target versus 77 result), and referring suspected malaria patients (189 target versus 240 result). Please see the full results in Annex 1, Table 1. In Q2, Partner for Development in Action (PFDA) continued to implement its activities in its 2 elimination ODs in PST Province, Bakan (BKN) and SPM. PFDA worked collaboratively with 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 COVID-19 restrictions and some flooding, PFDA was able to implement activities as planned. PFDA organized 12 health education campaigns in the two ODs which reached 302 MMPs and high risk residents, and also distributed 122 ITNs to MMPs and local residents in the remote target areas. PFDA engaged local authorities and village volunteers to map 12 hot spots. PFDA’s contact points were able to identify 78 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 met with OD/PHDs to share its implementation and progress. In Q2, most of the targets were achieved. Results are provided in Annex 1, Table 2. Quarterly meeting and field monitoring visits were planned for 24-26 March 2021 to discuss the progress (planned versus achieved), challenges, lessons learned and identifying solutions to address gaps. However, due to announcements of suspension of meetings by BTB and PST provincial halls on 15th March 2021, the meeting/visits were postponed. Considering the current COVID-19 situation, a virtual meeting may be held with the 2 CSOs in order to ensure they are on track and CMEP are able to provide any necessary support. Task 9. Conduct operational research in the context of malaria elimination CMEP did not have any ongoing operational research during Q2. On 25th February, CMEP team joined the national research network meeting convened by CNM and World Health Organization (WHO) to update on studies/pilots being conducted, and planned in Cambodia/region under the malaria program. Task 10. Refine existing malaria elimination tools, Standard Operating Procedures, and guidelines CMEP team actively engaged with CNM, WHO and other partners to update and refine the malaria elimination surveillance manual, guidelines, SOPs, checklists, forms and other tools. Incorporation of P.v. malaria into comprehensive surveillance is a great achievement adding to the efforts being made for P.f. malaria to similarly ensure every P.v. case is timely notified, investigated/classified and responded to. However, foci investigation and response for P.v. case has not yet been introduced in general country implementation while CNM is suggesting CMEP to start piloting foci investigation and management for L1 P.v. cases. Task 11. Expanded 5 ODs in 3K provinces of Kampot, Kep and Koh Kong CMEP continues to provide technical assistance to the 5 elimination ODs, mainly around the 1-3-7 approach, case based surveillance and quality service delivery. The three CMEP Technical Officers regularly attended provincial and OD meetings and provided malaria health functionaries timely support and advice for areas of improvement. CMEP teams took the opportunity to strengthen malaria case management and specifically the country scale-up of P.v. radical treatment with quantitative G6PD testing to ensure that all necessary tools are set up, regular quality control (QC) is checked, P.v. & mix patients who are eligible for G6PD check suitably tested and PQ treatment provided for those having normal G6PD and hemoglobin (Hb) level as per guidelines. On-the-job training has been conducted and every

6 treated case has been regularly followed up and monitored. 20 HF staff of the selected HFs for P.v radical treatment (14 in Kampot, 1 in Kep and 5 in Koh Kong) received on-the job training from CMEP TOs on P.v radical treatment, especially on setting up tools and practicing G6PD testing, both for regular QC and using the real blood for practice testing. The training on P.v radical treatment provided by CNM as cascade training was conducted since Nov 2020, the challenge was that the tools were just provided in February 2021, and therefore, most of the trained staff almost all of them did not retain and remember the procedures of using the G6PD testing and application of the buffer and reading values. The coaching/on-the-job training provided by CMEP teams helped the successful startup of P.v radical treatment in the 3K provinces and are monitoring regularly. CMEP monitoring visits, online meetings and email/phone communications also help in assessing gaps and providing feedback for further improvement. The Technical Officers conduct daily and weekly case tracking from both HFs and VMWs, and assisting 1-3-7 activities for every P.f./mix malaria case. In Q2, there were in total 5,016 cases tested and 22 confirmed malaria cases in the three provinces (1 P.f. and 21 P.v.). Among these, Kampot tested 3,926 and confirmed 15 in which there were 14 P.v. and 1 P.f. (0 L1, 1 LC and 0 imported case); Kep tested 291 and confirmed 0; and Koh Kong tested 799 and confirmed 7 cases (all P.v.). The Technical Officers at Kampot, Kep and Koh Kong provinces attended the District Malaria Elimination Committee meetings in January and February. However, due to the emerging COVID situation, they were not able to attend in March. Summary of P.v. Radical Cure progress in Q2 During Q2, since the deployment of G6PD quantitative test in late January 2021, 112 P.v. cases were diagnosed and treated in CMEP BTB, PLN, PST and 3k provinces. Amongst the 112 cases only 85 were able to be tested for G6PD status (the other 27 cases not tested include 17 forest goers detected by MMWs at work sites in PKV & KRK ODs who found it hard to visit the HFs to get tested for G6PD, 3 patients were underweight, 1 relapsed patient having deficient G6PD from previous test, 1 patient refused to test G6PD, and 5 patients were not tested due to late set up of G6PD quantitative testing tools in Krakor OD, Kampot and Koh Kong provinces). Out of the 85 tested G6PD, 60 cases confirmed normal G6PD, 23 were deficient and 2 were invalid (patient with value of Hb <9, with the result of G6PD as normal). 58/60 of the G6PD normal patients were then enrolled and received 14 days PQ treatment. Out of the 60 normal G6PD, 2 female patients were accidently tested and were found G6PD normal but were not treated with PQ (1 pregnant woman tested in MRS OD and 1 breastfeeding woman tested in KRK OD) {as per testing & treatment national guidance and protocol, pregnant women and breastfeeding mothers are not to be tested and treated} All of the rest of the 58 cases completed 14 days’ PQ treatment and regular follow up was conducted and there was no side effect nor adverse reaction recorded. Annex 3 provides the detailed summary of P.v. radical cure results in all 6 provinces of Battambang, Pailin, Pursat, Kampot, Kep and Koh Kong for FY21 Q2. There were no P.v. radical cure training in Q2, i.e. for the P.v. quantitative SD Biosensor G6PD test (this training was conducted in Q1 in PST, BTB and Koh Kong where a total of 200 persons were trained). The scale up of P.v. radical cure with quantitative testing to the whole country (including CMEP areas) commenced in January 2021 with the aim of all ODs being able to implement it in March. However, it was necessary to coach and follow up QA/QC around quantitative testing in many HFs and on the job training which was successfully undertaken by CMEP technical and field team in all 6 provinces.

7 2.2 Objective 2: Support scale-up of high quality malaria control and prevention interventions in five to eight ODs, where gaps in coverage or quality exist Task 2. Ensure universal coverage with LLINs Mass distribution: There was no mass distribution activity in Q2 for the transitional ODs, all was completed by the end of Q1. Continuous LLIN distribution and top up monitoring: CMEP continued to deploy ITNs to villages. 800 (21%) ITNs were deployed as buffer stock at the HC and VMW level (3,838 planned). During Q2, CMEP distributed 1,422 ITNs (38% of 3,763 planned) to target populations during outreach and response activities from January to March 2021 [Act. 2.2.5]. MMWs distributed zero ITNs at big farms and MMP locations in Q2 (against 185 targeted) [ Act. 2.2.6]. The lower figures for deployment and distribution in transitional ODs in Q2 was due to the significant mass distribution event in fiscal year 2020 quarter 4 and FY21 Q1, and the target revision based on new CNM guidance for targeting villages with API >= 5. VMWs conducted outreach visits to households and farms to monitor ITN distribution along with providing SBCC activities and EDAT services when required. 1,359 visits were accomplished against 1,356 planned [Act. 2.2.7]. 8,262 malaria education sessions were provided for interpersonal communication [Act. 2.2.8]. Task 3. Ensure EDAT and follow up Provide ongoing support in malaria diagnosis and treatment: CMEP activities covered 276 Point of Care in Q2 for its 2 transitional ODs (19 HFs, 182 VMWs and 42 MMWs) [Act. 2.3.1]. In the 2 transitional ODs, 16,435 individuals were tested, 130 were confirmed with malaria and all of these cases (100%) were treated in Q2 (Figure 5 shows the confirmed malaria cases from 2018 to 2020). Among the 130 confirmed cases, 1 case (0.8%) was P.f./mixed and 129 cases (99.2%) were P.v. In Q2, there were no severe malaria cases in the transitional ODs [Act. 2.3.4]. Figure 5. Confirmed malaria cases in 2 transitional ODs (April 2018 to March 2021)

Table 1 provides a breakdown of the confirmed malaria cases by species in the 2 transitional ODs (see Figure 6). Table 1. Breakdown of confirmed malaria cases by species in 2 ODs

Figure 6. Monthly malaria cases in Kravanh and Krakor ODs

8 Outreach activities: Amongst all the confirmed P.v. malaria cases, 46 (35.7%) were in PKV, and 83 (64.3%) were in KRK ODs. Although there were changes in the number of cases compared to the last two quarters, the general areas of concern remain the same; most of the cases were notified from villages near the forest areas. For example, one village Kbal Teahen reported 14 P.v. cases and Bam Nak reported 9 cases in Q2 both from Cheutom HC in KRK. Forest interventions CMEP continues implementing the intensification plan phase 2 (IP2), focusing on increasing malaria services for forest workers in PKV and KRK ODs where population movements into the forest areas is still active. In Q2, 33 MMWs were available for implementing IP2 in these 2 ODs (20 in PKV and 13 in KRK, 2 MMWs in KRK OD were removed in Q1 due to almost zero malaria cases in their assigned locations). The MMWs (either ‘touch points’ or ‘peer volunteers’) have been regularly monitored by HF/OD and CMEP staff. MMWs conduct malaria testing for forest workers/goers, provide treatment for confirmed cases, provide health education via interpersonal communication, and distribute ITNs and SBCC materials. The MMWs regularly joined monthly meetings with VMWs (under the same catchment areas of relevant HFs). Results showed that during Q2, the 33 MMWs conducted 328 site visits and interacted with forest goers and tested suspected malaria patients. Of the 4,409 suspected patients tested, 28 (9 in PKV & 19 in KRK ODs) were malaria positive (all P.v.) and all the 28 patients received treatment as per NTGs. 420 LLIHNs were distributed and 3,535 health education sessions were conducted. Also, 29 forest packs (only in PKV) and 707 bottles 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 also engaged in additional work such as timely notifying every detected case to the relevant HF, applying 3 days DOT for all P.f./mix patients and assisting in reactive case detection, foci investigation and management. During Q2, there was one P.f. case detected in KRK OD in February but its active foci was identified in the IP2 area of PKV OD. The foci was investigated and is currently being managed through weekly AFS by the existing MMWs. Capacity building on P.v. radical cure: There was no quantitative G6PD testing training for HFs conducted in Q2 (the training was completed in Q1). However, CMEP technical team did provide some on the job training for HFs that requested it. CNM supervision: In FY21 Q2 there was 2 planned supervision visits from the CNM pharmacy and lab units to the transitional ODs (target=2)[Act. 2.3.10]. Task 4. Strengthen case management and reporting in the private sector: Private Providers: There were two PP quarterly meetings in the transitional ODs in Q2 (target = 2). In Q2, there were 23/61, 38% malaria suspected patients referred from PPs to public health facilities in the transitional ODs (target = 75%) [Act. 2.4.5a]. Supervision visits: During Q2, there was 2 supervision visits to PPs by CNM PPM Unit against 2 planned [Act. 2.4.5]. Task 5. Build capacity and strengthen systems to manage malaria control activities: CMEP Support to VMWs/MMWs: In total, 592 (304 in KRK and 288 in PKV) VMWs/MMWs (target 527) attended monthly meetings from Jan. to Feb. 2021 (112%) [Act 2.5.1]. During these meetings, VMWs reported information on malaria cases; received RDTs/ACTs from health center staff; and received on the job training for case management, SBCC, case

9 registration/reporting, and ITN monitoring/top-up reports. VMWs also shared challenges which included difficulties with DOT completion among MMPs and forest-related workers, poor road conditions, long distances to travel and some demands of topping up ITNs among the residents. Due to the emerging COVID situation in March, the VMW meetings had to be suspended in KRK and PKV ODs. In March 2021, a total of 170/170 reports (100%) were received from VMWs [Act 2.5.2]. Integrated supervision from OD to HFs [Act. 2.5.3]: 17 (81%) of supervisory visits were accomplished during Q2 (target = 21). Due to COVID restrictions and changing priorities, 4 visits could not be completed. Build capacity and strengthen systems to manage malaria commodities: CMEP continued to provide support in stock monitoring and management to the transitional ODs during Q2. CMEP used the Management Information System (MIS) to validate report and assess gaps and inform relevant authorities on stock status. There were 3 reallocations of drugs and tests between HFs and VMWs in the transitional ODs during Q2 [Act. 2.5.4]. ACT distribution (all 9 ODs) ACT and/or RDT stock status were reported for 9 ODs in Q2. Table 2 provides a summary of ACT and RDT stock monitoring in all CMEP ODs (for ASMQ - 100+200 mg/6 tablets). Table 2. FY21 Q2 ACT and RDT stock monitoring in all ODs Operational # of HFs ACT RDT District monitored Potential Stock Out Potential Stock Out SPM 39 0 0 2 0 BKN 33 0 0 1 1 PKV 30 0 0 0 0 KRK 27 0 0 0 0 PLN 24 0 0 3 5 BTB 90 0 0 0 1 SPL 33 0 0 2 0 TMK 57 0 0 0 1 MRS 42 0 0 0 0 Total 375 0 0 8 8 CMEP ODs continued to carefully monitor potential stock outs in Q2 to avoid having any complete stock outs of ACTs & RDTs. For ACT’s, there were no stock outs in Q2, and for the RDT’s, although there were very few HFs in SPM, BKN, PLN, SPL &TMK that reported with stock outs, these were mainly due to the HF staff not entering the stock data completely into the MIS in Q2, and the requests were not timely made to ODs drug store. CMEP followed up and now the stocks have been replenished. Visits to selected VMWs from CNM VMW Unit: In Q2, there were 0 supervision visits due to COVID restrictions by the VMW unit in the transitional ODs (planned=2) [Act. 2.5.6]. Provincial Special Working Group for Malaria Elimination [Act. 2.5.7]:There were no PSWGE meetings in Q2 in the transitional ODs. Task 6. Strengthen behavioral change communication (BCC) interventions for intensified malaria control Interpersonal Communication to tested malaria cases and high-risk groups: In Q2, 16,435 (target 15,500) suspected malaria patients were tested and received interpersonal communication through VMWs, MMWs and HCs [Act. 2.6.1]. In addition to malaria patients, malaria messages were provided to 4,776 people from high risk groups, including 185 MMPs who received messages from 18 peer educators and 15 touch points (target = 4650) [Act. 2.6.2].

10 Task 7. Support civil society and community-based organizations to implement activities Provide support to selected CSO partners and Implement sub-grant activities [Act. 2.7.2]: In Q2, PFDA continued to demonstrate good progress towards implementing activities and engaging stakeholders as planned. The mapped sites in PFDA locations showed considerable progress in reaching out to the MMPs in remote locations in forest areas and in farms. PFDA continued to maintain a good relationship with the OD Malaria Supervisor (ODMS) and OD/HF staff to ensure their activities were well coordinated. They participated in provincial and OD meetings and provided continuous information on their activities and challenges. Close coordination with VMWs/MMWs and contact points helped in organizing health education campaigns and screening high risk populations. With the COVID situation worsening in Q2, PFDA was still able to organize 30 health educational campaigns and reached out to 734 MMPs including forest goers/workers. PFDA distributed 684 ITNs to MMPs. PFDA staff mapped 30 MMPs settlements/locations and identified 634 suspected malaria patients who were referred to VMWs/MMWs/HFs (all of these referred reached the malaria service providers). PFDA always engages with the PKV and KRK OD counterparts regarding project activities implementation and regularly meets with them to share results, challenges and to find solutions to immediately address any issues. The detailed targets versus results for key activities implemented are provided in Annex 1, Table 3. Task 8. Operational research- CMEP FY21 Q2 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: CMEP continued to contribute to the updating of the surveillance manual in Q2. Through discussions with CNM and partners, P.v. case indicators were added into the MIS system. M&E forms were updated to incorporate P.v. case investigation along with P.f. case investigation and as initiate the new form to be piloted in CMEP locations [ Act. 3.1.1]. Support consistent use of the harmonized forms by providers: In Q2, CMEP continued to support the use of case based surveillance forms with HFs and VMWs. During monitoring visits and spot checks at HFs, CMEP staff checked the availability of forms being used by HF staff. When required forms were not observed, CMEP staff made sure that they would be provided. Gaps identified during the visits were typically around case/case history not being properly documented. Capacity building was provided to help HF staff to correctly use the forms and document cases [Act. 3.1.2]. Overall, during Q2, 91.7% of providers submitted surveillance data on time (99.8% from HFs and 89.0% from VMWs). Figure 7 provides submission percentages since FY 2020 Q1. Figure 7. Percentage of HFs, VMWs/MMWs in target transitional ODs submitting surveillance data on time per national guidelines (since FY 2020 Quarter 2)

11 Task 2. Provide technical assistance on data management and use Conduct Internal Data Quality Assessment (IDQA) at OD and selected HFs by ODMS/PMS and CMEP [Act. 3.2.2]: The CMEP FY20 IDQA was conducted in FY21 Q1 at one elimination and one transitional OD (SPM and PKV ODs). Manual and information system indicator data sources were checked/verified The findings were good overall for the 4 CMEP indicators selected for the exercise. The IDQA report was accepted by USAID on 12th March 2021. Provide Technical Assistance to CNM on village-based stratification and facilitate use of stratification tools [Act. 3.2.3]: Analysis of villages with high cases were regularly informed to CNM during the planning meeting and making plans for mass distribution. CMEP on an ongoing basis during CNM meetings provided village information based on ‘no risk,’ ‘low,’‘medium,’ ‘high,’and ‘highest.’ Provide Technical Assistance to CNM on data visualization and outbreak module development for MIS CMEP has regularly supported HFs on data visualization and has encouraged the preparation and presentation of available data in a visual map format (this included Kep, Kampot and Koh Kong HFs). The CMEP OD quarterly bulletin also regularly highlights the OD malaria cases and trends in case reduction [Act. 3.2.4]. CNM supervision [Act. 3.2.5]: During Q2, several visits were conducted by the CNM technical units to CMEP target areas, and overall, 85% of the planned visits were achieved. Table 3 summarizes these visits. The visits not undertaken were due to COVID restrictions starting from March 2021 and the unavailability of vehicles for travel purposes Table 3. Summary of CNM Technical Unit visits in FY21 Q2

Q2 Planned Q2 Actual Percentage

ITN unit 4 4 100% Pharmacy unit 5 5 100% Laboratory unit 5 5 100% PPM unit 4 3 75% VMW unit 4 4 100% Health Education Unit 5 4 80% M&E unit 6 2 33% Epidemiology unit 8 8 100% Entomology NA NA Total 41 35 85%

Task 3. Support further development and implementation of electronic data reporting and use platform: CMEP and the CNM M&E team has been continuously monitoring malaria cases. This was done by regular visits to HFs and reviewing and validating data (i.e. checking the HF data with what was found in the CNM MIS). There has been a focus on Pursat for these visits as it is recognized the VMWs/MMWs in KRK and PKV report submission is not 100% due to the fear of COVID, they refrain visiting the health centers and replenishing their stock and submitting report. CMEP team along with HF staff in most cases have visited the VMWs/MMWs to collect reports. Findings and corrective actions were provided for each

12 OD/HF after the visit. The main challenges relate to mobile phones and tablets as many are reported to be broken or not functioning correctly. Often, VMWs use their own personal mobile phones until the procurement for new ones is completed. CMEP continues to work closely with CNM to procure the required mobile phones and tablets for all 6 provinces. Task 4. Strengthen capacity to conduct entomologic monitoring Conduct entomology training for OD and PHD staff [Act. 3.4.1.]: This activity ended in Year 4. However, CMEP is supporting the CNM entomology unit to undertake foci investigation. a. 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 Annual Operational Plan development [Act. 4.1.4.]: All the ODs have developed the Annual Operational Plan (AOP) in FY21 and it has been approved and duly signed. In Q2, there were 5 AOP review meetings carried out in the CMEP ODs (1 in January and 4 in March). Internal Competency Assessment course for malaria microscopists [Act. 4.1.7]: In Q2, there was no plan for conducting an Internal Competency Assessment course. CMEP is in conversation with CNM to identify referral labs in 6 provinces to restart conducting the course. Laboratory quality assurance [Act. 4.1.8]: During FY21 Q2, WHO and CNM organized 2 trainings related to laboratory quality assurance in Siem Reap (a) ‘Lab Microscopist and supervisory training’ in January – a lab staff attended from BTB rural hospital (RH) and PST RH; and b) ‘Refresher training for malaria microscopist’ in March – 2 lab staff attended from BTB RH, 1 from Krakor RH and 1 from PST RH. See Annex 2 for all Laboratory quality assurance results for Q2). Provide on the job training and mentoring by CNM units [Act. 4.1.9]: During supervision visits conducted by CNM, mentoring and supportive supervision and on the job trainings are regularly being provided. More emphasis was given on testing all fever cases and follow ups. Stock management was one of the concerns raised during CNM visits and CNM unit has provided regular on the job training during supervision visits. E-Payment [Act. 4.1.10]: The e-payment system is being implemented in all ODs except Thmar Koul (TMK) because there are no VMWs present at this OD. Task 2. Support CNM and MoH to develop and maintain a system for on-going technical and management capacity development Provide feedback to HFs/OD/PHD by CNM technical units during supervisions [Act. 4.2.1]: Despite the COVID situation, CNM teams were able to conduct 35 supervision visits in Q2. As part of the visits, CNM teams highlighted any issues that needed attention or intervention. Overall, CNM appreciated the work achieved in malaria case reduction in CMEP ODs. CMEP Central Progress Review [Act 4.2.2]. The first Year 5 Central Progress Review meeting was scheduled to be held in Q2 at the end of March in Pursat. However, due to the emerging COVID crisis and restrictions on meetings/gatherings, it was not possible to hold the meeting. CMEP will look at the possibility of conducting the meeting online in Q3.

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

13 Task 3: Improve malaria policies and guidelines [Act. 4.3.1]: CMEP, along with other partners, was extensively and actively involved in updating the surveillance manual. CMEP provided technical inputs and shared field experiences to feed into the revision process. CMEP teams together with CNM in early February 2021 attended the TOT training on the updated malaria surveillance and further provided cascade training during late February and early March 2021 to PHD, OD, and HF staff for their implementation and monitoring at the field. The updated surveillance for malaria elimination emphasizes better P.v. malaria case surveillance along with P.v. radical treatment for countrywide scale up in which the G6PD testing has shifted from qualitative test by RDT to quantitative test by G6PD analyzer (SD Biosensor) providing both status of G6PD and Hemoglobin level as the 2 critical elements for a decision on radical treatment with Primaquine. CNM SBCC strategy development [Act. 4.3.1]: In Q2, CMEP team joined the CNM’s SBCC technical working group meeting in March to discuss PSI/PHB's ‘Vision of Perfect’ workshop for malaria social and behavior change (SBC) activities. Discussions were held to validate the SBC activities & behavioral aspects, and project deliverables. As a result, the findings from 2 personal/target groups highlighted that the (i) day trip forest goers and (ii) long-term forest goers are potentially at high risk and contribute to malaria transmission, it was also learnt from IPC research about day time biting. These finding should be considered to refine the national malaria SBCC strategy. Project Management CMEP Phnom Penh team visited Kampot and Kep provinces and provided technical support - 4th to 6th Jan. – CMEP team visited 3 HCs, 2 VMWs and Kep provincial hospital in Kep province and visited 3 HCs and 1 VMW in . CMEP team along with the other ODs and PHDs functionaries observed that not all fever cases were tested, the testing rate is very low among VMWs, during monthly meeting VMWs often came with zero test reports, and since there was no malaria cases for a long time the VMWs changed over time leading to gaps in prescribing the correct drug. In Kep provincial hospital, CMEP team observed that there was no database system for patients’ profiles, and the lab staffs did not receive any training on G6PD testing, in fact the doctors attended the training but the actual work is done by lab staff. More attention needs to be given to stock management at HCs, and in some cases the date was not correct. CMEP team shared these findings to the PHD/OD and HF staff and provided a few corrective measures. CNM was also informed on these monitoring visits which were later visited by CNM to the provinces to highlight CMEP findings and actions proposed. CMEP team meeting internal program management meeting in Pursat on 12th & 13th Jan. – A 2-day meeting of the CMEP team was held in Pursat. These regular ongoing program management meetings are held to review the project activity status and make corrective actions and plans for the future. Highlights for Y4, Y5 Q1 status and performances, CPARS findings OD progress and the action plan for Y5 Q2 was discussed. In addition, reviewed and revisited the 2021 AOP for the 3K provinces with CNM guidance only for 10 months. The results of LLIN Durability Monitoring and plan for last assessment was discussed and shared. A session was provided regarding Y5 priorities and tasks, ITN continuous distribution for the 2 last quarters; financial spending and gaps; CMEP exit strategies/phase out plan and handing over activities/meetings with PHD/OD counterparts. Overall the meeting was very critical as the field team had more clarity on the priorities and next steps. CMEP team joined the VMW monthly meetings in Kampot and Kep (19th – 21st Jan.) the CMEP Team witnessed the 3 days of VMW monthly meetings in 4 HFs in Kampot province and 2 HFs in Kep province. 100% attendance was observed in the meetings, stocks were

14 replenished, and it was noted that the majority of the VMW villages did not have malaria cases for last 3 years, however they continue to work. Challenges were with smart phones as most of the VMWs reported about broken mobile phones and their functioning, (however, paper reporting was still functional and thus the HFs were able to get the reports on time). CMEP team then provided instructions to HF staff and VMWs on how to increase malaria testing with an updated criteria to reach optimal Annual Blood Examination Rate. The team also updated some additional tasks to be given to VMWs following the revised surveillance manual. Coaching/on-the job training to start P.v. radical treatment in Pursat: With late arrival of G6PD analyzer (SD Biosensor), test strips, control kits and other tools there was reluctance amongst HF staff to start the P.v. radical cure with G6PD quantitative tests in Pursat. The CMEP team spent the week from 3-6 February together with ODMS visiting selected HFs in the 4 ODs of Pursat to provided on-the-job training to implement P.v. radical treatment. The G6PD testing applying the SD Biosensor among HF staff were carried out, ensuring everyone understood all steps, including QC as an initial step. All relevant job-aids, recording book/forms were explained and applied as an example as well as instruction on proper storage of testing devices and consumables and monitoring of the temperature of the refrigerator (2-30 °C). The ODMS appreciated CMEP for their valuable support to make possible the start of G6PD quantitative testing process. Project progress review in TMK OD on 22nd Mar: – It was quite a challenge to undertake the project review during the COVID crisis, but with the assurance from the TMK OD Director and agreement from BTB Provincial Malaria Supervisor (PMS). The CMEP TMK team facilitated the meeting on 22nd Mar 2021 in Bovel District to review the progress of all activities as per the AOP for the past 6 months. The meeting highlighted the success and significant achievement that the project experienced and also talked about the challenges including TMK having no VMWs therefore the community work is carried out by VHSGs, yet the progress was still remarkable. COVID precaution measures were well set up and the meeting was chaired by the PMS and OD Director and facilitated by CMEP OD Team Leader (ODTL) where some 27 total participants from all health facilities and OD staff, CSO/AHEAD as well as CMEP OD team attended. Regular internal program monitoring via virtual meetings within CMEP– Under current crisis of COVID-19, CMEP teams has maintained monitoring processes remotely and via online communication. During the month of March, several ZOOM calls/meetings were organized, for instance (i) Monday/weekly PP/OD team meeting; (ii) MIS training provided by Phnom Penh IT/data staff with Phnom Peng and OD teams on 19th Mar.; (iii) ODTL meeting with Chief of Party (COP), Senior Technical Advisor (STA) and some Phnom Penh staff on 22nd and 24th Mar.; (iv) Instruction of presentation sharing during online meeting provided by IT specialist to Phnom Penh staff and ODTLs, etc. were conducted. The virtual call became more important during these crisis times when the Phnom Penh team were not able to conduct any monitoring visits to the field. CMEP Sub-grantee quarterly meetings: CMEP sub-grantee visit and quarterly meeting on 12th, 13th & 14th Jan. – The ongoing quarterly field visit was held for 3 days, CMEP, 2 sub-grantees staff and CMEP Phnom Penh team accompanied the team to the field location and later participated in the quarterly meeting. Some 21 participants attended the meeting. The 2 sub-grantees shared their progress, challenges and next plans, the partners highlighted that most of their activities overachieved the targets even though they faced some challenges during COVID-19 and during flooding period. Feedback from the field visit was shared by CMEP sub-grant coordinator followed by clarification and agreement on the next steps. The sub-grantees plan to hand over activities and

15 tools/information with OD/PHD counterparts, is scheduled to be discussed in next quarterly meeting scheduled sometime in April 2021 due to the suspension of the meeting that was supposed to be held in March 2021. Meetings with USAID (including Contracting Officer’s Representative and PMI-USAID): USAID/Cambodia Partners Virtual Meeting (January 12th, 2021) – The virtual meeting was attended by COP and some 100 participants were on this meeting. The meeting began with a briefing from the US Ambassador on his experience visiting the project sites and USAID future plans in Cambodia, followed by the update from the mission. The US Ambassador visits that he made in November last year were shared to all and his learning on malaria RDT testing was specifically mentioned. USAID/PMI - Virtual meeting 18th February – The virtual meeting was attended by PMI HQ and Cambodia PMI staff along with CMEP staff. The discussion was on LLIN durability round 3 report and retrospective net brand type reporting. The proposed action was that CMEP team shall provide a basic breakdown of the nets type from Round 2 to Round 3 to PMI team and in the Final Round, CMEP team will capture the breakdown of the remaining net types. MOP 22 meeting on 24th Mar: – CMEP Phnom Penh team (COP, STA, M&E/SI, plus SPTA) and URC HQ (Dr. Hala/Vice president) joined virtual meeting on 24th Mar. together with PMI members including the COR and team in Phnom Penh and in the US. The meeting was facilitated by COR (Dr. Rida), and CMEP COP (Sharon) presented CMEP project status and performance to date. A few questions raised by PMI team on low percentage of 1-3-7 foci investigation in other provinces apart from CMEP, capacity of PHD/OD on entomological monitoring and foci investigation, challenges/missing on P.v. radical treatment for female patients, and implementation of TDA & IPTF in CMEP location were convincingly responded by CMEP COP. CMEP and CNM Meeting: (including virtual meetings) Joint CMEP-CNM teams visited to Koh Kong on 26th to 28th Jan.- CNM technical and MIS staff, CMEP COP, STA and 3 Technical Officers in the 3K provinces visited 4 HCs, in 2 ODs (Smach Meanchey and Sre Ambel) of . It was observed that overall malaria cases had drastically decreased both at HF and at VMW (zero P.f. case since mid- 2020). All the visited HFs showed malaria testing was very low, some stock outs of RDT were found and also some expired items were also observed. The team observed that the tablets at visited HFs were very old, broken and unusable. Equipped smart phones at visited VMWs are not available anymore. There are many ITNs with expiry dates by 2014 and 2017 in store at the HC but not recorded. CMEP and CNM team held a meeting with Koh Kong PHD director, the PMS, Smach Meacnhey OD director and the ODMS to brief them on the gaps and actions to be taken. The COP highlighted that the malaria testing and treatment, supply and stock monitoring, capacity of HF staff and VMW, future engagement with VMW, MIS and supply of electronic devices, concerns on funding support by field implementers were still not satisfactory and needs attention by OD and provincial officials. CNM Surveillance TOT Training in Kg. Speu (4th – 6th Feb. & 8th –10th Feb.) – CMEP joined 3-day course on malaria surveillance TOT conducted in Kampong Speu. The trainings were funded from the Global Fund RAI3E grant. The participants were from CNM, PHD, OD and RH teams as well as staff from implementing partners. Two separate training courses were organized for 12 provinces in Cambodia. The agenda for this surveillance TOT included (i) Surveillance principles and indicators; (ii) Malaria situation in Cambodia; (iii) Malaria

16 elimination strategies; (iv) Case notification, classification, Re-ACD, Foci investigation and response management; (v) Last mile to P.f. elimination; and (vi) MIS upgrading. P.v. radical treatment meeting on 12th Mar. 2021 (virtual meeting) – CMEP team participated in the virtual meeting on P.v. radical treatment, coordinated by Professor Lek Dysoley, CNM Deputy Director, together with 35 participants from CNM, WHO, PMI, CMEP, PMS, Population Services International (PSI), Clinton Health Access Initiative (CHAI), CRS and HSD. The meeting covered topics on (i) summary of pilot P.v. radical treatment implemented from Nov. 2019 – Dec. 2020 in 4 provinces of BTB, PLN, Kg Speu and Kg Chhnang using G6PD qualitative test via RDT; (ii) Country scale up of P.v. radical treatment using G6PD quantitative test via SD Biosensor- progress along with February 2021 data; (iii) CNM Quality Assurance (QA)/QC plan on G6PD testing; and (iv) Supervision checklist and upcoming supervision plans. The meeting continued discussing field staff capacity, equipment/supply of materials and tools, VMW case referral, MIS applications, etc. It was noted that the radical cure interventions were well managed and treatment provided as per SOP, there were a few cases of exclusion and also referred cases from VMWs not reaching the HFs for G6PD testing and radical treatment . CNM agreed to observe the situation and were willing to revisit the treatment guidelines . Annual Malaria Conference - CNM annual conference in Kg Speu (24th Feb.) – CMEP team (COP, STA and SBCC specialist) attended the annual conference of CNM 2020-2021, conducted in Kg Speu Town. The conference was chaired by the Minister of Health (Professor Mam Bunheng), and WHO representative and Kg Speu Provincial Governor. There were 55 participants directly joined in the session while other 20 provinces joined online along with several donors and implementing partners. The conference highlights were (i) Progress of 2020 and target for 2021 of the 3 CNM programs (Malaria, Dengue and Deworming); (ii) Last miles’ approaches for P.f. elimination; (iii) P.v. radical treatment- country scale up; (iv) Process of elimination certification; and (v) RAI2E & RAI3E of Global Fund. Meetings with CNM and Other Partners CNM meeting to monitor supply management - CNM Commodity Supply Coordination Meetings (virtual) on 11th Feb. 2021 and 12 Mar. 2021 CMEP participated along with CNM, UNOPS and other partners to review and assess the stock status and supply of malaria commodities. Challenges raised included late update of stock status, over stock due to less cases, lower stock/potential stock out/out of stock of some items at OD level after monthly allocation to HFs and VMWs, expired items to be collected and cleaned from the record, and errors with MIS reporting on negative balances. Follow up actions were discussed. CNM research network meeting (25th Feb.) – CMEP attended the meeting of malaria research network. 18 participants from CNM, WHO, Naval Medical Research Unit-2 , MORU, CHAI, CMEP, PSI, UCSF and AHEAD attended. The meeting involved discussion of 4 studies: (i) NAMRU on malaria screening of Cambodia-UN peacekeepers ; (ii) UCSF/BITE on planned study on other preventive tools (treated cloths and repellents); (iii) MORU on efficacy of Artemeter Lumefantrine (AL) for prophylaxis among forest goers and (iv) PSI presenting about performance and safety of point of care G6PD activity assay being conducted in Kg Speu. The second half was used for the reviewing of the surveillance manual and going through the changes made, it was agreed to have a separate meeting with CNM to finalize the surveillance manual given that there were still a few issues that needed to be addressed. Village Stratification 2020 virtual meeting on 10th Mar. 2021 – CMEP team joined the virtual meeting with CNM and partners on village stratification for malaria risk. Highlights

17 included: (i) Stratification - 5 levels: High Risk, Risk, Medium, Low and No Risk; (ii) Stratification application around 3 criteria at village level: Reported API, Forest coverage and Distance to the nearest HFs (in the meeting it was agreed to maintain VMWs in all villages with API>1/1,000, thus bringing the total to 2,249 active VMW villages). MIS Online training provided by CNM on 26th Mar. – CMEP staff joined a virtual training session on the updated CNM MIS including refreshing registration and monitoring P.v. radical treatment being applied by VMW and HFs. The training was provided by CNM and was attended by 27 participants from 3 CSOs and a number of PMS. The updated application is planned to launch after 26th March 2021. CNM urged all CSOs supporting the implementation to ensure availability and accuracy of data on P.v. radical treatment. Final review of surveillance manual for malaria elimination on 25th Mar. – There were a series of surveillance meetings held in the past 6 months, and after a long process the final draft version of the manual was circulated for final comments given that meetings could not be held due to the COVID crisis. CMEP team went over the entire manual and provided feedback and inputs related to Foci investigation, TDA and IPTF and the indicator section, reintroduction etc. CMEP team sent the document to Dr. Siv for further review and finalization. Procurement In FY21 Q2, procurement for tablets & mobile phones is still in process. CMEP is exploring various modalities to procure at the earliest. Given the COVID situation not much stocks are available with the current suppliers. CMEP has announced the procurement and is waiting for suppliers and vendor to send in the quotes. CMEP will follow its own procurement policy to procure these devices; it is expected to complete this process by Q3 to get 717 smartphones and 197 tablets. 2 Other procurements that are in the pipeline are the Banners, t-shirts, caps and masks for World Malaria Day and the COVID preventive supplies for VMWs and MMWs. Financial Management

18 Human Resource Management During FY21 Q2, CMEP had 68 staff on board. There were two vacant positions that were filled in Q2, a new OD Data Assistant for SPL OD in BTB province who joined and resigned in FY21 Q2, and an OD Team Leader Assistant in BKN OD. There were three staffs who resigned in FY21 Q2 (The OD Data Assistant in SPL OD, OD Team Leader Assistant in KRK OD, and Driver at PLN OD). The new OD Team Leader Assistant in Krakor OD in Pursat Province and Driver at PLN OD will join in FY21 Q3. Moreover, there are two staff who were promoted in FY21 Q2, namely the Admin and Finance Manager and the Senior Finance Officer based in the Phnom Penh Office. 3. RESOLVING CHALLENGES FROM FY21 QUARTER 1 P.v. investigation and radical treatment finally was layered into the surveillance manual after a long process of advocacy and technical meetings. The CNM and partners (CMEP, PMI, WHO, UNOPS and CHAI) met to discuss and deliberate on the SOP and the sections that need to go into the surveillance manual. The TOT was also completed and the trainers were asked to cascade the training at the respective partner field members. However due to the COVID situation one of CMEP provinces (Pursat) had to suspend the training and deferred it to be done when the situation improves. The final sign-off of on the surveillance manual is in process. CMEP has taken appropriate steps to follow up with provinces and ODs to ensure that the PPs attend quarterly meetings and also report on referrals, with the CMEP team regularly following up with PHD and OD officials (BTB and PLN province are doing well on this compared with PST). CMEP is making the effort to follow up with the PHD and ODs as to how to engage PPs in Pursat province but the challenges still remain of PPs being demotivated to do malaria work. CMEP has proposed earlier and needs to discuss with PMI and agree on some incentives to PPs to support referral services. With the COVID crisis still very much unpredictable and continuous, CMEP team is very concerned with the Year 5 activity implementation as it is the last year of the project and most of the activities are of utmost importance for the project phase out and closeout process. CMEP will keep monitoring the situation and will keep USAID/PMI updated and informed.

19 4. CHALLENGES AND ACTIONS TAKEN OR PROPOSED Even though the surveillance manual is almost finalized and in the process of getting approval by the ministry, there are still some questions that are unanswered around the TDA and IPTF implementation. These were previously only planned for the ‘last mile’ and now that it has been inserted into the surveillance manual, high endemic provinces like Pursat do not intend to carry out the TDA and IPTf intervention as per the agreement with PMI and CNM. However, if the surveillance manual is approved by default, the TDA and IPTf intervention still needs to be implemented. Another set of discussions are required between CMEP and CNM to get more clarity on the intervention that was agreed for the last mile but now has become universal. While administering the P.v. radical cure, the challenge that is faced by CMEP team and the health functionaries is the issue of G6PD value which determines a patient to be normal with >6 and deficient with <6. During the last two months, CMEP experienced and reported a high number of exclusion cases due to these threshold issues, and thus potentially exposing the patient for further transmission if not treated with 14 days PQ treatment. CMEP has raised this concern with WHO and CNM and feels if not addressed, the journey to P.v. elimination will be a challenge. Secondly it was also noted that when the VMWs refers P.v. patients to HFs for G6PD testing more than 30 to 50% of the cases did not reach the HFs thus there was concern patients were missing 14 days radical treatment and more could be exposed for further transmission (which was largely seen among forest goers and MMPs). CMEP has found that the issues with MMPs and forest goers is about distance and losing employment if they miss a single day of work. CMEP is considering to find an alternative and to incentivize the transport cost in discussion with CNM so that more left out cases can make it to the HFs for G6PD testing. Private Providers still continue to pose challenges around attending quarterly meetings and conducting referrals. CMEP team has been discussing with PHD and OD but no firm steps have been taken so far, and the issues is more around incentivizing PPs for referral services. Since this is a larger issue, CMEP team will be discussing with CNM and PMI to find an alternative. Due to the COVID crisis and a sharp spike in COVID cases, CSO activities are suspended including field visits and quarterly meetings which are a platform to review the progress of local partners. Additionally, as the project is nearing the project end date, the uncompleted activities will pose a challenge towards the phase out and hand over processes. CMEP team will be discussing with the ODMS and the 2 CSOs to find an alternative on completing the process smoothly. The timeline that was set up for the ODs merger and phase out from 3 ODs (BKN, SPL and TMK) post June 2021 was planned and agreed on the basis of a smooth transition but with the interruptions of COVID situation most of the planned activities (provincial meetings, district meetings, VMW meetings, supervision visits and specific activities for hand over process) are all on standby. Therefore, the timeline for phase out and exit needs to be re-planned as per the advisory and advice from the provincial authorities. CMEP team will discuss with provincial and OD authorities as to how best the transition could take place with minimum interruptions. There were concerns expressed from PHD and ODs around the VMWs and MMWs outreach and ongoing activities undertaken in their respective villages and locations. Due to the COVID surge and community transmission, the VMWs and MMWs are reluctant to visit HHs and also test suspected cases. It was noted that there has been some reduction of 7% to 8% in testing nationally. The reasons for non-testing and non-conducting of outreach activities is due to the absence of facemasks, hand sanitizers and gloves for VMWs and MMWs. The ODs officials,

20 the VMWs and MMWs have expressed their needs and concerns and to be provided with preventive supplies. CMEP team has discussed with PMI and is exploring and planning to procure facemasks, hand sanitizers and gloves for VMWs and MMWs in its 6 Provinces. The surge in COVID cases has put the CMEP provinces at a halt stage. Movements, travels, gatherings, meetings, events, schools, and public places have all been closed and suspended. This has led to many CMEP activities being suspended and withheld which poses obvious challenges around target achievements, project progress, Y5 activities completion, transition, phase out and exit. CMEP is somehow carrying out the malaria activities on case based monitoring and surveillance in the field with HFs staff and community network still with some resistance. CMEP will monitor the situation and keep USAID/PMI updated and informed. 5. PLANS FOR NEXT QUARTER AND UPCOMING EVENTS CMEP as part of the Year 5 work plan will implement the following in Q3, if the current COVID ban is lifted:

⮚ ITNs continuous distribution and monitoring. ⮚ Outreach activities by VMWs and MMWs. ⮚ Supervision visits by CNM, OD and HFs (partially suspended and rest) ⮚ Ensure follow up on P.v. radical cure treatment with quantitative G6PD testing. ⮚ Forest intervention as part of IP ongoing in KRK and PKV. ⮚ OD Team Leader and CMEP Phnom Penh staff quarterly meeting to review project performance and target tracking (virtually). ⮚ Training on Surveillance manual in Pursat in May, (tentative). ⮚ AOP review meeting with PHD, OD and CMEP staff, (tentative) ⮚ Central program review meeting with CNM and other key stakeholders, (tentative) ⮚ District and provincial special working group meeting(s), (tentative) ⮚ Sub grantee field monitoring and quarterly meeting; (tentative) ⮚ LLIN durability monitoring exercise to be conducted, (potentially to happen in May) ⮚ CMEP staff 6 months’ program review meeting and preparation and action plan for selected ODs phase out and merger, (potential to happen in May).

21 b. ANNEX 1 CSO FY21 Q2 RESULTS TABLES Table 1. AHEAD Results for FY21 Q2 (BTB, MRS, PLN, SPL and TMK elimination ODs) Indicators Target Actual Target explanation 1. # of health education campaigns Achieved target. organized in high transmission 50 50 villages 2. # of mobile/migrant and new Over-achieved target: Many new settlers reached with BCC messages MMPs came for harvesting corn and through interpersonal collecting cassava. 818 suspected communication 1,250 1,586 cases (M: 410, F:398) were screened during the Campaign. No positive cases found. 3. # of ITNs distributed to Over-achieved target: Many new mobile/migrant population MMPs came for harvesting corn and 1,110 1,887 collecting cassava. 1,887 ITNs distributed (LLIN: 912, LLIHN: 975) 4. # of mobile/migrant settlements Over-achieved target: Many new mapped settlers MMP came for seasonal 48 77 working. There were 60 existing and 17 new settlements. 5. # of suspected malaria patients Over-achieved target: MMPs referred to VMWs/HFs understood about benefit of seeking 189 240 malaria services on time. 6.# or % of suspected referred reach Over-achieved target: MMPs to service VMW/MMW or HFs understood about benefit of seeking 183 240 malaria services on time. 7.# of report of any increased N/A 0 0 malaria cases or outbreaks 8.# of meeting organized with OD N/A, this activity was postponed and PHD organized by CSOs 0 0 because of the COVID-19. 9. # of government meetings Achieved target. attended by CSOs (Pro-TWGH meeting) 9 9

22 Table 2. PFDA Results for FY21 Q2 (BKN and SPM elimination ODs) Indicators Targe Actua Target explanation t l 1. # of health education Achieved target campaigns organized in high 12 12 transmission villages 2. # of mobile/migrant and new Over-achieved target: A total of 302 settlers reached with BCC audients (M:115, F:187) attended the messages through interpersonal 300 302 campaign. There were 203 suspected communication patients (M:74, F:129) who received test during campaign. No positive cases found. 3. # of ITNs distributed to Over-achieved target: 256 of the MMP mobile/migrant population family members who haven’t received ITN 120 122 during the mass distribution campaign were found. A total of 122 INTs distributed (LLIN: 44 LLHIN: 78): 4. # of mobile/migrant Over-achieved target: A total of 10 maps settlements mapped were updated by GPS tool used to determine in old location before the education provided 6 12 to the newly discovered mobile population in Elimination-OD coverage. A total of 489 (M: 262, F:227) MMPs found in those sites 5. # of suspected malaria patients Over-achieved target: Many suspected referred to VMWs/HFs 39 78 patients were found by CP in this reporting period. All suspected cases were followed up 6.# of suspected referred reach to on the same day. All of them reached service VMW/MMW or HFs 39 78 VMWs/HFs. But no positive case was found . 7.# of report of any increased N/A malaria cases or outbreaks 0 0 8. # of meetings organized with N/A, this activity was postponed because of ODs, HCs and/or PHD by CSOs 1 0 the COVID-19. 9. # of government meetings Over-achieved as plan: PFDA joined Pro- attended by CSOs (Pro-TWGH 9 11 TWGH and quarterly meeting at OD level in meeting) SPM and Bakan ODs.

23 Table 3. PFDA Results for FY21 Q2 (KRK and PKV transitional ODs) Indicators Targe Actua Target explanation t l 1. # of health education Achieved target. campaigns organized in high 30 30 transmission villages 2. # of mobile/migrant and Over-achieved target: There were 468 suspected new settlers reached with patients (M:289, F:179) who received test during BCC messages through 680 734 campaign session. No positive cases found. interpersonal communication 3. # of ITNs distributed to Over-achieved target: 462 MMPs family’s members mobile/migrant population who haven’t received ITN during mass distribution 370 684 campaign were found. A total of 684 ITNs distributed (LLINs: 348, LLHINs: 336). 4. # of mobile/migrant Over-achieved the target: A total of 30 maps were settlements mapped updated by GPS tool used to determine in old location before the education provided to the newly discovered mobile population. In those mapped it was one new 18 30 mobile/migrant settlements that was scaled-up in PKV-OD. A total of 1,100 (M:620 males, F:480) of MMPs, stay and work in those sites and into the forests for their benefit. 5. # of suspected malaria Over-achieved target: Many suspected patients were patients referred to found by CP. 411 634 VMWs/HFs Over-achieved target: A total of 634 of referred 6. # or % of suspected patients were monitored. The PFDA field staff referred reached service to collaborated with CP to follow up with the patients (in VMW/MMW or HFs 411 634 person and phone) at the same day. There were 12 positive cases found with P.v. species. All of them got treated by VMW/MMW. 7.# of reports of any No abnormal case or outbreak in the Year 5 reporting increased malaria cases or period 1 - outbreaks 8. # of meeting organized N/A, this activity was postponed because of the with ODs, HCs and/or PHD COVID-19. 0 0 by CSOs 9. # of government meeting Under-achieved the target because of PKV-OD was attended by CSOs (Pro- busy with internal tasks. 6 5 TWGH meeting)

24 d. ANNEX 2 LABORATORY QUALITY ASSESSMENT/MICROSCOPY TRAINING TABLES Table 1: Slides crosscheck for Laboratory Quality Assessment (QA) Jan. – Mar. 2021 in BTB and PLN Provinces HC Lab HC Lab QA Lab QA Lab OD Name of HC result result result result Negative Positive Negative Positive

- Pailin OD has no lab QA supervision and monitoring in this quarter due to PLS not being comfortable to go to the field due to COVID .

SPL - Zero malaria blood slides because of no request SPL RH to do malaria diagnosis. Trang, RDTs malaria Sereimeanchey Correct Storage & Pechenda - - Perform test follow national guideline. HC Completed SD biosensor G6PD set up and have monthly internal quality control level 1 (low) and level 2 (high). TMK - Zero malaria blood slides because of no request to do malaria diagnosis. TMK RH - Completed SD biosensor G6PD set up and have monthly internal quality control level 1 (low) and level 2 (high).

Bovel, Klang RDTs malaria Meas, and - Correct Storage Beuong Pram - Perform test follow national guideline. HC BTB BTB RH 15 01 15 01 Tasanh HC 20 00 20 00 Beuongrun HC 13 01 13 01 Sdao HC 17 01 17 01 Completed SD biosensor G6PD set up and have monthly internal quality control level 1 (low) and level 2 (high). MRS OD MRS RH 06 00 06 00 RDTs malaria Prek Chick, - Correct Storage Prey Trolach - Perform test follow national guideline. Completed SD biosensor G6PD set up and have monthly internal quality control level 1 (low) and level 2 (high). 4 ODs 15 HFs 65 03 65 03

25 ANNEX 3 – P.v. Radical Cure Treatment Status Results of CMEP P.v. Radical Cure in FY21 Quarter 2 (in BTB, PST, PLN & ‘3K’ ODs) P.v. radical cure data from January to March 2021 (Q2, Year 5) # of G6PD test performed # of P.v. Radical cure Treatment (14-days PQ) Remark Total Name of Female P.v. On Drop OD patient Normal Deficiency Invalid Enrolled Complete cases going out

1 P.v. case was BTB 6 1 2 3 0 2 2 0 0 less than 20 kg 1 P.v. case was MRS 3 1 3 0 0 2 2 0 0 Pregnant TMK 0 0 0 0 0 0 0 0 0 SPL 0 0 0 0 0 0 0 0 0 PLN 1 0 1 0 0 1 1 0 0 1 P.v. case, had surgery two BKN 1 1 0 0 1 0 0 0 0 weeks ago. Only ASMQ for 3 days SPM 3 0 3 0 0 3 3 0 0 - 9 P.v. MMP detected by MMWs (TP) treat only ASMQ - 15 P.v. cases were G6PD deficiency - 1 case female normal G6PD but KRK 55 1 28 15 0 27 27 0 0 breast feeding treat only ASMQ for three days - 1 Patient refuse to transfer - 2 cases detected before test arrive to HC

- 8 P.v. MMP detected by MMWs - 1 Patient anemia (G6PD: 10.10; but Hb: 7.6) treated only 2 ASMQ and KRV 27 0 13 1 13 13 0 0 multivitamin - 2 P.v. cases under 20kg - 1 P.v. case patient relapse case with history of G6PD deficiency Kampo 0 0 0 0 0 0 0 0 0 t - In February some HF not Chhou clear how to 14 0 9 3 0 9 9 0 0 perform SD k Biosensor test, need of the job training

26 - 1 P.v. MMP detected by MMWs treat only ASMQ - 1 case female normal G6PD but just delivered treat only ASMQ for three days Kep 0 0 0 0 0 0 0 0 0

1 P.v. case found in February some Sre HF not clear how 2 0 1 0 0 1 1 0 0 to perform SD Ambel Biosensor test, need of the job training Total 112 4 60 23 2 58 58 0 0

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