ARM3 QUARTERLY REPORT OCTOBER 1 – DECEMBER 31, 2012 ______

FISCAL YEAR 2013, QUARTER 1 PROGRAM YEAR 2

During a reality show organized by ARM3, a woman from Pobe Commune (Oueme/Plateau) shares her knowledge on the importance of preventing malaria during pregnancy.

January 30, 2013

This report was produced for the United States Agency for International Development (USAID) by Medical Care Development International (MCDI).

ARM3 Accelerating the Reduction of Malaria Morbidity and Mortality Program

Quarterly Report: October 1, 2012 to December 31, 2012 Fiscal Year 2013 Program Year 2

Submitted to: Dr. Emile Bongo, USAID Agreement Officer Representative (AOR), USAID/Benin Dr. Milton Amayun, Family Health Team Leader, USAID/Benin Ms. Anne Busaka, Senior Acquisition and Assistance Specialist, USAID/Benin

ARM3, Accelerating the Reduction of Malaria Morbidity and Mortality Program (ARM3), is funded by the United States Agency for International Development (USAID), under Cooperative Agreement AID-680-A-11-00001. ARM3 is managed by Medical Care Development International (MCDI) as the prime, in collaboration with sub-grantees Africare, Johns Hopkins University – Center for Communications Program (JHU-CCP) and Management Sciences for Health (MSH). The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or of the United States Government. Table of Contents Table of Contents ...... 1 List of Acronyms ...... 1 Acknowledgements ...... 4 Executive Summary ...... 5 Introduction...... 8 Final Phase of Start-Up Activities ...... 8 Achievements ...... 8 Result 1: Implementation of malaria prevention interventions in support of the National Malaria Strategy improved...... 10 Sub-Result 1.1: IPTp Uptake Increased ...... 10 Achievements ...... 10 Results ...... 11 Sub-Result 1.2: Supply and Use of LLINs Increased ...... 11 Achievements ...... 11 Results ...... 14 Result 2: Malaria diagnosis and treatment activities in support of the National Malaria Strategy improved 14 Sub-Result 2.1: Diagnostic Capacity and Use of Testing Improved ...... 14 Achievements ...... 15 Results ...... 16 Sub-Result 2.2: Case Management of Uncomplicated and Severe Malaria Improved ...... 16 Achievements ...... 17 Results ...... 23 Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened ...... 26 Sub-Result 3.1: MOH/NMCP Capacity to Deliver and Manage Quality Malaria Treatment and Control Interventions Improved .. 26 Achievements ...... 26 Results ...... 28 Sub-Result 3.2: Capacity to Collect, Manage and Use Malaria Health Information for M&E and Surveillance Improved ...... 28 Achievements ...... 28 Results ...... 30 Sub-Result 3.3: Capacity in Commodities and Supply Chain Management Improved ...... 30 Achievements ...... 30 Cross Sectional Activities ...... 38 Behavior Change Communication (BCC) ...... 38

Achievements ...... 38 Performance Improvement Approach ...... 44 Achievements ...... 45 Program Management ...... 47 Home Office Backstopping and Reporting...... 47 Achievements ...... 47 Major Challenges (per ARM3 sub-result): ...... 49 Major Activities Planned for next quarter (Jan – Mar): ...... 50 Financial Summary ...... 51 ANNEX 1: OTSS Data – Rounds 8 & 9 (Groups A, B, C, D) vs. Round 10 (Groups A, B, C, D) ...... 52 ANNEX 2: Key findings and recommendations from post-IMCI training follow up ...... 68 ANNEX 3: Mini Caravan Quotes ...... 70 ANNEX 4: SF 425 ...... 71 ANNEX 5: Quarterly Financial Report ...... 72 List of Acronyms

AAA/3A Akpro Misserte – Avrankou – Adjarra ABC Analysis of stock value, turnover, and volume ABD Adjohoun – Bonou -- Dangbo ABFC Association Béninoise de Femmes Chanteuses ACPB Association des Cliniques Privées du Bénin ACT Artemisinin Combination Therapy AIRS Abt’s Indoor Residual Spraying Program AL Artemether + Lumefantrin AMCES Association des Œuvres Médicales Privées Confessionnelles et Sociales ANC Antenatal Clinic AOR Agreement Officer Representative ARM3 Accelerating the Reduction of Malaria Morbidity and Mortality Program (ARM3) AS-AQ Artesunate-Amodiaquine BASICS Basic Support for Institutionalizing Child Survival BCC Behavioral Change Communication BDHS Benin Demographic and Health Survey CAFE Stock Management Software Company CAME Centrale d’Achat des Médicaments Essentiels (Central Medical Stores) CAR Charge de l’administration et des ressources CCM Community Case Management CDC Centers for Disease Control and Prevention CEBAC-STP Coalition des Entreprises Béninoises et Associations Privées Contre le SIDA, la Tuberculose, et le Paludisme CHD Centre Hospitalier Départemental CHW Community Health Workers CNHU Centre National Hospitalier Universitaire CoGeS Comité de Gestion COP Chief of Party DDMS Disease Data Management System DDS Direction Départmentale de Santé DHS Demographic Health Survey DIEM Direction de l’Infrastructure de l’Equipement et de la Maintenance DPMED Direction de la Pharmacie, des Médicaments et de l’Exploration Diagnostique DPP Direction de la Programmation et de la Prospective DRZ Dépôt Répartiteurs de zone DSME Direction de la Santé de la Mère et de l’Enfant EEZS Equipe d’encadrement de zone sanitaire EOP Emergency Order Point ETAT Emergency Triage, Assessment and Treatment EUVS End Use Verification Survey FO Field Office FSS Faculté des Sciences de la Santé--Université d’Abomey Calavi GFATM Global Fund to Fight AIDS, Tuberculosis, and Malaria GHI Global Health Initiative GOB Government of Benin HMIS Health Management Information System HO Home Office HOMEL Hôpital de la Mère et de l’Enfant de Littoral HW Health Workers ICCM Integrated Community Case Management IMaD Improving Malaria Diagnostics INMES Institut National Médico-Social INSAE Institut National de la Statistique et de l’Analyse Economique

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IPTp Intermittent Preventive Treatment for Pregnant Women IRS Indoor Residual Spraying IRSP Institut Régional de Santé Publique IVCC Innovative Vector Control Consortium JHU-CCP Johns Hopkins University – Center for Communication Programs KPI Key Performance Indicator LDP Leadership Development Program LIAT Logistic Indicator Assessment Tool LLIN Long Lasting Insecticide-Treated Nets LMIS Logistical Management Information System LOP Length of Project MCDI Medical Care Development International MCZS Médicin Chef de Zone Sanitaire M&E Monitoring & Evaluation MEDISTOCK Commodities Management Program MIS Malaria Indicator Survey MMAC Malaria Microscopy Accreditation Course MMRT Malaria Microscopy Refresher Training MNCH Maternal, Neonatal and Child Health MOH Ministry of Health MOU Memorandum of Understanding MOP Malaria Operational Plan MSH Management Sciences for Health NGO Non-Government Organization NMCP National Malaria Control Program ORTB Office de Radio et Telévision Béninoise OTSS Outreach Training Support and Supervision PAK Pobe – Adja Ouere -- Ketou PAS Porto Novo – Aguegues – Seme-Kpodji PI Performance Improvement PISAF Project Intégré de Santé Familiale PITA Plan Intégrée de Travail Annuel PMEP Performance Monitoring and Evaluation Plan PMI President’s Malaria Initiative PNLP Programme National de Lutte contre le Paludisme PY Program Year QA/QC Quality Assurance/Quality Control RBM Roll Back Malaria RDT Rapid Diagnostic Test RFA Request for Applications RMIS Routine Malaria Information System ROBS Réseau des ONG Béninoises de Santé SAGE Stock Management Software SAKIF Sakete/Ifagni SAM Senior Alignment Meeting SCM Supply Chain Management SGSI Service de gestion du Système d’Information SNIGS Système National d’Information et de Gestion Sanitaire SOP Standard Operating Procedures SP Sulfadoxine-pyrimethamine STTA Short Term Technical Assistance SWOT Strengths, Weaknesses, Opportunities and Threats TWG Technical Working Group UAC University of Abomey – Calavi UAM United Against Malaria UNICEF United Nations Children’s Fund

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USAID United Stated Agency for International Development WHO World Health Organization WOM Warehouse Operation Management WG Working Group

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Acknowledgements

ARM3 wishes to thank everyone who helped create this document as well as various technical and financial partners for providing constant support to Benin in the fight against malaria, including the National Malaria Control Program as well as our private sector partners: Coalition des Entreprises Béninoises et Associations Privées Contre le SIDA, la Tuberculose, et le Paludisme (CEBAC-STP); Association des Œuvres Médicales Privées Confessionnelles et Sociales (AMCES); Réseau des ONG Beninoise de Santé (ROBS); and Association des Cliniques Privées du Bénin (ACPB). In addition, we would like to acknowledge the USAID Benin Mission for their constant guidance and financial support in the implementation of the ARM3 Project.

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Executive Summary

ARM 3 Results Sub-Results Key Achievements

 Opened the ARM3 Field Office in Parakou  Held orientation of Parakou staff in Abomey and Cotonou offices  Recruited a consultant to assist with M&E activities  Recruited and hired a MEDISTOCK advisor  MCDI recruited and posted a Case Management/Team Leader Final Phase of Start-Up Activities and Field M&E Coordinator for the Parakou Field Office  MSH recruited and posted a Field Supply Chain Officer and Case Management and Performance Improvement Manager for the Parakou Field Office  Change in Africare’s project management organogram and support in the project  Prepared a draft MOU and received a funding request from 1.1 IPTp uptake Faculté des Sciences de la Santé (FSS) increased  Currently developing a training of trainers (ToT) manual in interpersonal communication  ARM3, Coalition des Entreprises Béninoises et Associations 1. Implementation of Privées Contre le SIDA, la Tuberculose, et le Paludisme malaria prevention (CEBAC-STP) and the National Malaria Control Program programs in support of (NMCP) worked with a consultant to develop the LLIN the National Malaria distribution plan for the 100,000 nets arriving in January 2013 1.2 Supply and use of Strategy improved  Participated in a workshop to re-define the guidelines for routine LLINs increased distribution of long-lasting insecticide-treated nets (LLIN) to include the private sector and schools  Revised and resubmitted a request to Peace Corps for the recruitment of a volunteer to assist with the bed net distribution program  Supported the NMCP in organizing a workshop to develop guidelines for RDT use at government and private health 2.1 Diagnostic capacity facilities and use of diagnostic  Analyzed and published results from Outreach Training and testing improved Support Supervision (OTSS) (Round 10)  Conducted OTSS (Round 11) in 47 facilities (32 public and 15 private)  Advocated for the adaptation of World Health Organization (WHO) recommendations to include IPTp administration until birth 2. Malaria diagnosis  Reviewed Malaria Case Management Guidelines and treatment activities  Supervised 45 health care providers (21 from Adjarra- in support of the Avrankou-Akpro-Missérété, Covè-Ouinhi-Zagnanado, Ouidah- national malaria Kpomassè-Tori-Bossito health zones (HZs) and some private strategy improved 2.2 Case management health centers of Cotonou and 24 from Kalalé-Nikki-Pèrèrè and of uncomplicated and Banikoara HZs) that were trained in the integrated management severe malaria of childhood illnesses (IMCI) in the last two quarters improved  Carried out integrated supportive supervision visits of health facilities in the health departments of Donga-Atacora, Atlantique-Littoral, Borgou-Alibori and Zou-Collines  Trained 35 practitioners in Emergency Triage, Assessment, and Treatment (ETAT) of severe malaria from 8 hospitals. Four new hospitals were added from the Atlantique-Littoral  Discussions held with MCH Directorate to implement Quality 5 | P a g e

Assurance (QA) process using the collaborative approach  Submitted to USAID an integrated Community Case Management (iCCM) proposal to integrate iCCM activities within ARM3 3.1 NMCP’s technical capacity to plan, design,  Organized, supported and held the first M&E Technical manage, and coordinate Working Group (TWG) meeting in year 2 a comprehensive  Supported the NMCP in organizing the Plan Intégré de Travail malaria control program Annuel (PITA) enhanced  Facilitated the preparation of one Routine Malaria Information System Newsletter (Number 7, July-September edition) and published and distributed Number 6 3.2 MOH capacity to  Provided technical support to the NMCP in providing an update collect, manage and on the following databases: LMIS, RMIS, MEDISTOCK, HMIS, use malaria health PILP (GFATM), and Palu Alafia (GFATM), as well as the EUV information for surveys monitoring, evaluation  Designed and proposed to the NMCP a tool for the 3. National health and surveillance implementation of the data quality verification process system’s capacity to improved  Carried out a nationwide data collection effort in order to input deliver and manage into the annual report and to make improvements to the quality malaria completeness and reliability of data treatment and control  Developed and validated a supply chain management interventions supervision tool with the NMCP strengthened  Carried out integrated supportive supervision visits to health care providers in health facilities across the six health departments that constitute the Benin health care system  Trained trainers on the Logistics Management Information 3.3 MOH capacity in System (LMIS), supportive supervision tools, and terms of commodities and supply reference (TOR) for supportive supervision at the intermediate chain management level improved  Briefed hospital and CHD Administrative managers on the LMIS  Presented End Use Verification (EUV) survey findings to health departmental pharmacists and financial administrators and zonal hospital financial administrators  Updated and validated malaria commodities LMIS tools with the NMCP; developed malaria commodities LMIS standard operating procedures (SOP) manual  Organized several mass media activities: aired 2 TV commercials: one on IPTp and one on LLINs; aired multiple radio broadcasts from 4 local radio stations on malaria prevention and promotion of ACTs; and aired 3 reality radio talk shows on malaria prevention during pregnancy  Distributed flyers on IPTp, ACTs and LLINs to all health centers in the Atlantique-Littoral department as memory aids for patients Cross Sectional  In support of community health workers’ activities, the ARM3 Activities BCC Manager participated in a 2-day workshop to adapt Africare training modules and in a separate workshop on the role of local NGOs  Organized a one-day mini caravan covering the Allada-Toffo-ZE health zone whereby key behaviors such as the use of long- lasting insecticide nets (LLINs) and Sulphadoxine- Pyrimehamine (SP) for IPTp and exclusive use of ACTs were promoted

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 Published a request for proposal for interested NGOs to oversee BCC activities in the health zones of Atlantique and Oueme-Plateau: short-listed 16 NGOs and selected 8 finalists; held orientation for selected NGOs; and conducted training of selected NGOs  MSH engaged a local consultant to conduct STTA in support of the development of the collaborative improvement approach  Assisted DDS and HZ of Oueme-Plateau and Atlantique-Littoral in the preparation of Strategic and Malaria Operational Plans  Finalized/signed MOUs with hospitals in 12 health zones  MCDI’s home office (HO) completed and submitted the second annual work plan and budget to USAID/Benin  MCDI’s HO supported the field office (FO) in the preparation of ARM3’s Year 1 performance report Program Management  The HO supported the FO in the process of procuring Activities microscopes  The MCDI HO provided short-term technical assistance by hiring a consultant to develop a LLIN distribution plan to be carried out with their private sector partner, CEBAC-STP

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Introduction

Accelerating the Reduction of Malaria Morbidity and Mortality Program (ARM3) in Benin is funded by the United States Agency for International Development (USAID). The ARM3 consortium, led by Medical Care Development International (MCDI) as the prime recipient, includes sub-grantees Africare, Johns Hopkins University – Center for Communication Programs (JHU-CCP), and Management Sciences for Health (MSH). The ARM3 consortium works in partnership with the Benin Ministry of Health’s National Malaria Control Program (NMCP), to implement the five year (October 1, 2011 to September 30, 2016) ARM3 malaria control program. In collaboration with USAID/Benin’s President’s Malaria Initiative (PMI), ARM3 seeks to assist the Government of Benin (GOB) in improving malaria health outcomes in accordance with the NMCP’s guidelines and standards. The primary objective of ARM3 is to help the Government of Benin achieve the PMI target of reducing malaria-associated mortality by 70%, compared to pre-initiative levels in Benin. In support of this PMI objective, the ARM3 program’s specific goal is to increase coverage and use of key life-saving malaria interventions in support of Benin’s NMCP Strategy. ARM3 will also complement and expand the efforts of other donors (for example the Global Fund to Fight AIDS, TB, and Malaria (GFATM), and private sector organizations) to reach the NMCP’s goal of eliminating malaria as a public health problem in Benin by 2030. ARM3 major results are as follows: Result 1: Implementation of malaria prevention interventions in support of the National Malaria Strategy improved. Result 2: Malaria diagnosis and treatment activities in support of the National Malaria Strategy improved. Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened. This report (October 1, 2012 – December 31, 2012) details the program activities completed and key indicators corresponding to the results and sub-results described in the ARM3 Annual Work Plan and Monitoring and Evaluation Plan. It also presents the key activities planned for the quarter January – March 2013.

Final Phase of Start-Up Activities Achievements Finalized the preparations for the opening of the Parakou office The ARM3 Parakou Field Office opened for business on the 3rd of December 2012 with five of the seven staff (Field Office Team Leader, Case Management Coordinator, Supply Chain Coordinator, M&E Coordinator, and Driver) managing the office starting on that date. Africare has identified a candidate to fill the position of Field BCC Coordinator, the only remaining professional staff to be assigned to the Parakou office. MCDI will also hire a second Driver. The Chief of Party (COP) and Supply Chain Manager travelled to Parakou to conduct a two-day orientation for the new employees and to determine the required equipment for the office. Two vehicles from former USAID-supported projects (one received from the BASICS Project and one refurbished vehicle from World Education International) have been assigned to the Parakou office.

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Recruitment of ARM3 Staff Departure of the M&E Manager, Edouard Balagoun: At the end of the M&E Manager’s one year contract in November 2012, he notified MCDI that he would be resigning from his position with ARM3. As a result, MCDI immediately began soliciting interest from potential candidates.

MCDI vetted over 15 candidates and interviewed the two most qualified. While both were viable candidates, only one, Dr. Fortune DAGNON, was immediately available. MCDI engaged Dr. Dagnon in a short term consultancy to assist with critical M&E activities - preparation of the 2013 PITA, editing of the latest issue of Palu-Info bulletin, organizing the M&E TWG meeting; and producing the data needed to compile quarterly and annual reports. Due to Dr. Dagnon’s exceptional performance, MCDI decided to seek USAID approval to fill the key ARM3 M&E position.

Hiring of the MEDISTOCK Programmer: In order to continue the work begun by PISAF with the introduction of MEDISTOCK as a means for managing drug stocks at the health zone depots (DRZ), ARM3 identified improvements to the reporting formats that would be useful to the DRZ managers. Not all 34 health zones were using MEDISTOCK at the end of the PISAF project; in order to make the modifications to the MEDISTOCK software and ensure that all DRZ managers are fully versed in the use of the software, ARM3 engaged a software developer, Mr. Valentin Tosse, in a one year contract. This will allow sufficient time to make the necessary modifications and to ensure that all HZ managers are able to use and manipulate the software. The following table presents newly recruited staff that joined the ARM3 project during the quarter October – December 2012 by name, job title, institutional affiliation, start date, and office location.

Personnel engaged in Q5

Name Job Title Partner Status/Date Began Location V. Tosse Supply chain IT MCDI November 22, 2012 Cotonou coordinator/ MEDISTOCK programmer P. Assogba Supply Chain Coordinator MSH December 1, 2012 Parakou E. Kifffouly Case Management and MSH December 1, 2012 Parakou Performance Improvement Coordinator A Wakil M&E Coordinator MCDI December 1, 2012 Parakou Dr. Lola Field Team Leader and MCDI December 1 ,21012 Parakou Gandaho Case Management Coordinator

Change in Africare’s project management organogram and support in the project Africare has restructured its organogram and made subsequent changes in roles and responsibilities, thus Dr. Yasmine Ibrahim, formerly Africare-Benin’s Program Manager, was designated as Africare's ARM3 Liaison Officer/GF Manager dedicating 100% of her time to ARM3 beginning November 5, 2012. Dr. Josette Vignon, Africare’s Country Director, is charged (20% level of effort) with coordinating and overseeing Africare's overall effort on ARM3, providing technical, grant management and managerial support and feedback and assuming the role of Africare's primary point of contact.

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Result 1: Implementation of malaria prevention interventions in support of the National Malaria Strategy improved

ARM3 will scale-up prevention efforts through the expansion of IPTp and improved coverage of LLINs through the social marketing of LLINs in the private sector (supported by IEC/BCC activities). The two sub-results are: Sub-Result 1 (IPTp increased) and Sub-Result 2 (supply and use of LLINs increased). Sub-Result 1.1: IPTp Uptake Increased Results from the 2012 Demographic and Health Survey (DHS) show that only 22.8% of pregnant women had received two doses of sulphadoxine – pyrimethamine (SP) in 2011. In support of PMI’s Malaria in Pregnancy (MIP) objectives, ARM3 will improve IPT uptake. To achieve this result, ARM3 is pursuing interventions that include upgrading the skills of government and private health sector workers both through pre-service curricula modifications at the major training institutions, INMES and the medical faculty, and in-service training. Additionally, ARM3 is working to provide improved supervision and support to health workers to follow case management and prevention guidelines (including IPTp, in the context of focused-antenatal care (ANC), severe malaria, and clinical IMCI. Finally, ARM3 is continuing the review/implementation of Behavior Change Communication (BCC) campaigns to promote IPTp and early care seeking behavior in addition to improving skills of government health providers on patient counseling. Achievements

Faculté des Sciences de la Santé (FSS) The ARM3 Case Management Officer and FSS staff met on several occasions with the objective of deciding upon the content to be included in a future memorandum of understanding (MOU) between the parties. The MOU will define the roles and responsibilities of the FSS, NMCP, and ARM3 as well as the technical and/or material support to be utilized under this collaboration including the method of application, use, and justification. The responsibilities agreed upon by the FSS include: (1) preparing and submitting an implementation plan for capacity building of the teaching faculty in malaria case management; (2) implementing the activities outlined in the aforementioned plan; (3) engaging instructors from relevant departments to participate in the NMCP Technical Working Groups (TWG) and encouraging the regular participation of at least one staff in the case management technical working group (CMTWG); (4) ensuring the participation of FSS instructors in NMCP training sessions and in the review of new directives and training manuals for in-service training organized by the NMCP; and (5) submitting a report on activities carried out to the NMCP and ARM3 at the end of each semester. The FSS would like to improve the skills of doctors, nurses, and other professional staff in the area of malaria diagnosis using microscopy. In order to improve their teaching laboratories, the FSS managers have requested that ARM3 purchase 15 microscopes as part of the collaboration between ARM3 and the FSS. MCDI’s Home Office is in the process of soliciting quotes for this equipment. ARM3 plans to deliver the equipment next quarter.

Curriculum conception on interpersonal communication To train health care providers on how to provide quality client counseling, ARM3 is currently developing a training of trainers (ToT) manual in interpersonal communication. The local consultant recruited by JHU- CCP to develop the manual is currently reworking the document based on feedback received from the JHU-CCP team. The first draft of the manual will be submitted to the ARM3 team for internal review.

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Results Indicator Baseline LOP Target PY2/Q1 Results Source/Comments Result 1: Implementation of malaria prevention programs in support of the National Strategy improved Sub-result 1.1: IPTp uptake increased 1) Percentage of women Women who receive 3.0% who have completed a two or more doses of 22.8% (total) pregnancy in the last two SP during their last DHS report , May Source years who received two or pregnancy within the 24% (Urban) 2012 DHS, more doses of IPTp during last two years will 21.9% (Rural) 2006 that pregnancy reach 85% Proportion of women 1.a) Proportion of women 28.1% attending antenatal RMIS results are from attending antenatal clinics clinics who receive PY12/Q4 who receive IPTp2 under Source 36.8% IPTp2 under direct (July-Sept 2012) direct observation of a RMIS observation by a health health worker 2011 worker will reach 85% Health zone training reports 0 PY2 Target: 476

21) Number of health health professionals Activity will begin workers trained in IPTp Source from 12 health zones None this quarter after health zones using USG funds ARM3 (re)trained in IPTp receive 1st advance Records using USG funds under their MOU (Program Year 2)

Sub-Result 1.2: Supply and Use of LLINs Increased In support of this sub-result, ARM3’s innovative approaches to scaling- up interventions for impact is the inclusion of in-country private and non-governmental partners to support specific interventions. The consortium believes that efforts to scale up malaria control in the public sector are certainly critical and necessary, but probably insufficient to achieve the ambitious goals sought by the NMCP and USAID without increasing access to quality services through the private sector, non-governmental organizations (NGOs), and the active participation of community organizations.

ARM3 recognizes that social marketing is a strategy to promote changes in ideas, attitudes, and behavior and that it is based on the traditional marketing mix: product, place, price and promotion. ARM3 is using a target subsidy approach that will permit employees of CEBAC-STP member companies to purchase nets at a subsidized price and to do so through an installment payment mechanism that may include having the installment payments deducted from their paychecks over time. The social marketing concept under consideration will permit CEBAC-STP members to utilize the proceeds generated through the sale to support complementary activities to include household LLIN monitoring BCC campaigns that focus on health promoting behaviors. Achievements Coalition des Entreprises Béninoises et Association Privées Contre le SIDA, la Tuberculose et le Paludisme (CEBAC-STP)

Advocacy and awareness of the health committees From November 5 - 10 2012, two teams made up of ARM3 and CEBAC-STP personnel visited CEBAC- STP member companies throughout the country with the objective of meeting with their business leaders

11 | P a g e and receiving their support and active involvement in the social marketing of LLINs to their employees at a subsidized rate. By the end of each visit the following were achieved:  Advocacy towards the managing directors of the companies;  The members of the health committees and focal points were informed about the project and their commitment solidified;  A registration form for taking a census of staff members was distributed;  Estimates on the number of nets that the company could manage were obtained; and  The 36 companies that would take part in the social marketing of LLINs were identified. Developing a social marketing plan With the support of a LLIN distribution planning consultant, a social marketing plan with the strategy, tools and the timing of the sale of LLINs in the private sector initially developed by MCDI was finalized. For 10 days in December, Mr. Alain DAUDRUMEZ led a mission to support the project and CEBAC-STP in the elaboration of a plan to manage the 100,000 nets arriving in January 2013. Specifically, the objectives of the consultancy were:  To support the ARM3 team, the NMCP and CEBAC-STP in developing a logistics and distribution plan for receiving, transporting, storing and distributing a total of 40,000 LLINs to the employees of CEBAC-STP member organizations during the first round;  To assess, in collaboration with the CEBAC-STP ARM3-Malaria Committee, the need for financial resources, if any, to implement the distribution plan;  To assist the Committee in finalizing plans for a system of employee payment for LLINs, the management of funds generated from these payments as well as the use of such resources for related follow-up, i.e. LLIN monitoring and repair, BCC materials, etc.;  To recommend appropriate LLIN control systems, procedures and tools to ensure proper tracking and accountability of LLIN distribution and repair;  To recommend a plan for the logistics of LLIN repair and maintenance every six months after their distribution;  To liaise with the ARM3 Communication Specialist to ensure optimal BCC approaches for CEBAC-STP employees in relation to the distribution of LLIN; and  To support the Committee in developing a draft plan for a further distribution of 60,000 LLINs to take place a few months after the first distribution. By the end of the consultancy, the main results achieved were:  Reaching consensus on the order in which the companies would carry out the process;  The quantities of LLINs to provide each company;  A map for the loading and delivery of the nets;  Planning for the temporary storage and transport of the nets;  A micro distribution plan for the first phase of 40,000 nets to be distributed;  A distribution strategy developed;  Tools for monitoring and supervision (sheets, statements) of the delivery and for tracking the reception of the nets by the end user;  A timeline for the distribution for the first phase; and  Initial planning of a waste (packaging) disposal plan.

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Orientation of private sector health committee members A local consultant has been hired to develop the content of the training manual that will be used to orient health committee members within the private sector as part of the initiative on malaria prevention and care in the work place. The report will be available the second week of January 2013. Participation in expanding the scope of routine distribution Workshop to update the guidelines for routine distribution of LLINs From November 26 to 30 2012, ARM3 supported the NMCP in the organization of a workshop to update the guidelines for the routine distribution of LLINs. Present at this workshop were different actors and partners in malaria control in Benin as well as representatives of the CEBAC-STP and the Ministry of Primary and Kindergarten Education. The objective was to update the guidelines for the continuous distribution of nets provided by the Ministry of Health (MOH). At the end of the workshop, the national strategy had been revised to introduce distribution through primary schools as well as the private sector via private clinics to benefit students and employees. This would be in addition to distributing nets to public facilities’ maternity wards and during vaccination campaigns. The main recommendations of the workshop were:  Extend the routine distribution of LLINs to other private health centers (NMCP)  Ensure that the DDS and MCZS (Health Zone Chief Medical Officer) supply the prenatal kits, respecting the officially agreed upon contents and cost;  Write to the Administrators of private clinics to solicit their commitment to follow the guidelines of routine distribution of LLINs; and  Evaluate the strategy of providing prenatal kits via public and private clinics.  Update the MCH daily tracking registers to delineate IPTp1 and IPTp2. Partnership with Peace Corps/Benin ARM3 has requested assistance from Peace Corps/Benin to assign a Peace Corps Volunteer (PCV) to provide support to the NMCP in the distribution of LLINs. The PCV will work with the ARM3 Private Sector Manager and Behavior Change Communications Manager to support the NMCP’s goal of working with the private sector in the fight against malaria. The PCV will be responsible for the following activities:

 Prepare the terms of reference for training staff in the private sector;  Prepare training materials;  Develop report of activities carried out;  Prepare monthly and quarterly schedule of activities;  Monitor implementation of activities;  Track sales of LLINs in the private sector;  Monitor the data collection of health facilities in the private sector;  Support the consortium in its efforts to design and implement a small grants mechanism to local NGOs for the implementation of the community BCC activities in the health zones;  Work with consortium partners to ensure that they are providing patient data to the MOH health information system;  Work with consortium partners to identify personnel from the private sector to participate in MOH training programs, i.e. laboratory technician training, IMCI, ETAT, etc.;  Work to introduce health zone team supervision of the private sector facilities to ensure compliance to the new directives for malaria case management;  Work with private providers to improve pregnant women’s compliance to IPTp;  Oversee the implementation of the social marketing of LLINs with the consortium partners; and

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 Work closely with the ARM3 BCC Manager to promote correct and consistent use of LLINs and their repairs with private sector partners.

ARM3 anticipates finalizing the recruitment and posting of the PCV in the next quarter.

Results Indicator Baseline LOP Target PY2/Q1 Results Source/Comments Result 1: Implementation of malaria prevention programs in support of the National Strategy improved Sub-result 1.2: Supply and use of ITNs increased

Proportion of pregnant 20% 75.5% (total) 2) Percent of pregnant women who slept under women who slept under an an ITN the previous DHS report, May 2012 Source 73.9% (Urban) ITN the previous night night in intervention DHS, 76.5% (Rural) areas will reach 85% 2006 Proportion of children 20% under five who slept 71% (total) 3) Percent of children under under an ITN the five who slept under an ITN Source DHS report, May 2012 previous night in the 70.5% (Urban) the previous night DHS, intervention areas will 71.3% (Rural) 2006 reach 85% Proportion of 25% households with a 79.8% (total) 4) Percent of households pregnant woman and/or with a pregnant woman Source children under five that 78.2% (Urban) DHS report, May 2012 and/or children under five DHS, own at least one ITN 81% (Rural) that own at least one ITN 2006 will reach more than 90% Distribute 100,000 CEBAC-STP reports / 4.a) Number of LLINs LLINs through social ARM3 program distributed through social marketing among reports marketing among employees -- employees and 0 and dependents of CEBAC- dependents of CEBAC- LLINs expected to STP member organizations STP member arrive 01/28/2013 organizations Please note: ARM3 is not responsible for mass distribution of LLINs

Result 2: Malaria diagnosis and treatment activities in support of the National Malaria Strategy improved

ARM3 supports improved case management of both severe and uncomplicated malaria and improved diagnosis of malaria through use of microscopy and RDTs. Result 2 consists of two sub-results: Sub- Result 2.1 (diagnostics capacity and use of testing improved) and Sub-Result 2.2 (case management of uncomplicated and severe malaria improved). Sub-Result 2.1: Diagnostic Capacity and Use of Testing Improved ARM3 assists the NMCP in enhancing capability and utilization of quality malaria diagnostic services via the implementation of enhanced supportive supervision at government health facilities. Prior to ARM3, MCDI implemented a supportive supervision program throughout the country through the IMaD program.

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Achievements

Validation of the training manuals for RDT use in Health Facilities See comments below in section 2.2 Develop Guidelines for RDT use at the Community Level ARM3 supported the NMCP in organizing a workshop to develop guidelines for RDT use at government and private health facilities. It also supported a workshop to review existing documents and develop others for community case management of malaria using RDTs to confirm suspected cases. The resulting training manuals for RDT use at the community level are currently awaiting approval by the MOH. MCDI provided ARM3 with draft versions of the RDT training materials recently finalized by WHO and will support the translation of these materials in January 2013.

In November 2012, in partnership with the NMCP, ARM3 organized a validation workshop to review the participants’ and trainers’ documents designed to train community health workers (CHW) in the use of rapid diagnostics tests (RDTs). Two of the NMCP’s key partners, who are principal recipients of the GFATM projects, Africare and CRS, had included the costs for training CHWs in RDT use in their applications to receive further funding from the Global Fund making the need for training materials even more pressing.

The RDT training manual was based on the existing training materials for malaria case management by CHWs. In a week long workshop in Abomey in May 2012, a group of 17 participants drafted both a participant’s and trainer’s manual. The one day validation workshop was intended to review and make final recommendations on the completeness and accuracy of the manuals before putting them to use.

The participants were assigned to two groups, each group responsible for reviewing one of the manuals. The trainer’s manual received relatively few comments and observations whereas the participant’s manual had extensive comments and corrections throughout the document. Unfortunately, the time allotted did not permit the participant’s manual to be completely updated. As a result, the participants were not able to validate both documents.

Outreach Training Support and Supervision (OTSS) Round 10 data entry and analysis completed The implementation of the 10th round of the national malaria Quality Assurance/Quality Control (QA/QC) plan through OTSS was successfully completed during the quarter July - September 2012. However, OTSS Round 10 data entry and analysis was completed during the quarter October – December 2012. Round 10 was carried out by12 supervisory teams (laboratory and clinician supervisors) that visited a total of 118 health facilities (102 public and 16 private). Private facilities included 9 AMCES, 2 CEBAC- STP, 2 ACPB and 3 other private organizations (Centre de Sante Ahmadiya, CS Clinique Cooperative Calavi and Hospital El Fateh). Annex 1 presents the findings of OTSS round 10. Outreach Training Support and Supervision (OTSS) Round 11 Implementation of the third quarterly formative supervision of the latest 47 health facilities including 14 private (7 AMCES, 2 CEBAC-STP, 2 ACPB and CS Ahmadiyya Clinic Cooperative Calavi, Al Fateh Hospital) and 33 public health facilities with labs was carried out in December 2012. Only 46 facilities were supervised as the Hospital Louis Pasteur (ACPB member) refused to participate. This supervision was conducted in 31 health zones by 10 of the 12 supervisory teams. OTSS Round 11 data entry and analysis will be completed and a report will be prepared during the quarter January – March 2013.

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Results Indicator Baseline LOP Target PY2/Q1 Results Comments Result 2: Malaria diagnosis and treatment activities in support of the national malaria strategy improved Sub-result 2.1: Diagnostic capacity and use of diagnostic testing improved Results shown are for OTSS Round 10 (PY1 Q4)

The decrease from the baseline value in 5) Percent of targeted health overall proportion of centers that have the Proportion of health facilities with the following: 1) personnel 95.8% centers with the ability ability to perform trained in malaria to perform biological diagnostics for malaria diagnostics, 2) no stocks- Source diagnostics for malaria 83.7% can be attributed to the outs affecting malaria OTSS (either microscopy or increased number of diagnostics for 7 or more Round 7 rapid diagnostic testing) reported stock-outs of days, 3) a functional will be 85% materials affecting microscope (non-RDT malaria diagnosis. facilities only)

OTSS Round 11 data is being complied

Indicator describes OTSS facilities only Results shown are for OTSS Round 10 (PY1 Q4) 303 trainings On average, at least 1 On average, greater health worker from 165 lab trainings than 1 laboratory staff 22) Number of health each staff type 138 clinical member and greater PY1: workers trained in malaria (lab/clinic) per facility trainings than 1 clinical staff Average diagnostics (including per supervisory visit member were trained trainings microscopy/RDTs) and case trained in malaria Lab: 1.4 per health facility Lab: 1.4 management with USG diagnostics (including Clinical: 1.2 during OTSS Round Clinic: 1.3 funds microscopy/RDTs) and 10 case management with 118 facilities USG funds reporting for Target only includes PY2/Q1 facilities with labs

Will report against PY1 baseline

Sub-Result 2.2: Case Management of Uncomplicated and Severe Malaria Improved Upgrading the skills of health workers is critical to proper case management of severe and uncomplicated malaria. ARM3’s vision is to assure quality enhancement through developing/updating clinical case management guidelines and related tools, supporting the training of private and government health staff, and implementing a Performance Improvement Approach (PIA) in health zones and hospitals. An integral part of quality assurance requires an enhanced and integrated supervision approach which includes IPTp, malaria diagnostics, and clinical case management.

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Achievements Validation of training manuals for malaria in pregnant women: Participant’s and Facilitator’s Manual The validation of the training manuals that were updated in June 2012 was planned for October 2012. In early November, in a meeting between the NMCP and ARM3, it was agreed that the latest recommendations by the WHO about administering SP up until birth would be debated before proceeding with the finalization of the training manuals for pregnant women. Review of NMCP Malaria Case Management Guidelines The revision of training materials and tools to comply with the new malaria case management guidelines in Benin has been planned since February 2012 but scheduling problems have prevented ARM3 from assisting the NMCP in completing this task. To date,

1. Three documents on the original list have been revised and validated: Malaria Case Management for Non-qualified Health Agents - Trainee Manual; Malaria Case management for Non-qualified Health Agents - Trainer’s Guide; and Integrated Management of Childhood Illness Training Materials and Templates. 2. Two have been revised and are awaiting validation: Malaria Case Management for Pregnant Women -Trainee Manual; and Malaria Case Management for Pregnant Women -Trainer’s Guide 3. Four are yet to be reviewed: Complementary Training Manual for Qualified Health Workers in Pharmacovigilance, Use of RDTs, Management of Drugs, LLIN and Other Products - Trainee Manual; Complementary Training Manual for Qualified Health Workers in Pharmacovigilance, Use of RDTs, Management of Drugs, LLIN and Other Products - Trainer’s Guide; Malaria Case Management in Heath Facilities - Trainer’s Guide; and Malaria Case Management in Heath Facilities -Participant Manual.

ARM3 recognizes the importance of these documents in achieving malaria control targets, especially as we begin implementing training activities at the HZ level, and will therefore work diligently to quickly bring this to a close. ARM3 has restated its commitment to the NMCP in supporting, both financially and technically, the revision and validation of all remaining malaria case management guidelines. Revisions and validations will take place during the course of the second year. Supervision of IMCI trainees With financial support from the ARM3 project, from November 5 – 10, 2012, a team composed of the Maternal and Child Health Division of the Benin MOH (DSME) and ARM3, carried out a follow up visit to the 24 health workers that were trained in clinical IMCI from May 21 to June 1, 2012 in the Kalalé-Nikki- Pèrèrè Health Zone and Banikoara Health Zone. Since four of the 24 health workers were trained as IMCI supervisors and triage staff, the follow up supervision targeted only 20 of the health workers.

From 19 to 24 November 2012, a similar post IMCI training follow up supervision was carried out for the health zones of Adjarra-Avrankou-Akpro-Missérété, Covè-Ouinhi-Zagnanado, Ouidah-Kpomassè-Tori- Bossito and some private health centers of Cotonou for 21 health care providers that were trained from 16 to 27 July 2012.

The objectives of the two follow up visits were to:

 Strengthen the skills acquired during revised IMCI training and improve health worker performance to better implement IMCI according to revised IMCI guidelines  Identify problems encountered by health providers in the integrated management of cases

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 Gather information on the conditions that influence implementation of IMCI  Identify the most efficient health care providers and promote them to serve as resource persons and support IMCI supervision in health zones

During the support supervision, the team followed the following steps:

 Observed health workers while managing cases and conducted interviews with care givers to assess their satisfaction  Reviewed records of cases managed since return from IMCI training  Evaluated the environment in which the health workers are practicing IMCI  Held a wrap-up session with the health team in the facilities that were supervised

For detailed information on the findings and recommendations, refer to Annex 3.

Integrated supervision Profiting from the supply chain division’s organization of a follow up visit to the EUVS sites throughout the country, four case management teams joined the Supply Chain Management (SCM) teams to visit health centers in four departments: Atacora-Donga, Borgou-Aliobori, Zou-Collines and Atlantique-Litoral. The supervision teams met with the Chief Medical Officers of each health zone to present the terms of reference. The teams used the NMCP integrated supervision guide to collect data. At each facility, the supervisors shared the terms of reference of the mission with the head of the health facility and midwife while explaining the purpose and objectives focusing on formative supervision. This approach consists of observing practitioners, noting their methods and pointing out areas for improvement. At the end of the visit, the supervisors held feedback sessions with on-site management teams to present the findings and discuss strategies to resolve identified issues. It is important to note that the figures presented herein are not statistically significant and only give a general idea vis a vis these indicators. The tables presented are not to be misinterpreted as representative of all health zones nor departments visited. The sample size was quite small for each department. Four to eight sites were visited.

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Confirmed diagnosis by RDT

100%

80%

60% 100% 40% 82%

48% 44% 20%

0% Zou-Collines Atacora-Donga Borgou-Alibori Atlantique-Littoral

% patients with fever or antecedent fever tested with RDT

Analysis According to national malaria management guidelines revised in November 2011, treating a patient with ACTs should only occur once there is a confirmed positive diagnosis using RDTs and/or microscopy. As part of this supervision, only health centers without labs were visited. After consulting patient records, 100% of cases diagnosed with malaria in the health facilities visited in the Atacora-Donga department were confirmed with a positive RDT. Similarly, in the health facilities in the Zou-Collines, 82% of malaria diagnoses were confirmed via a positive RDT before treatment. In Borgou-Alibori and Atlantic Littoral only 48% and 44% respectively of the cases diagnosed as malaria were confirmed by RDT. In Zou-Collines, the gap observed may be explained by two problems: shortages of RDTs and the lack of control guidelines by some caregivers who continue to diagnose malaria in children less than 5 years without biological confirmation. During the feedback sessions, health officers were briefed on the current guidelines and recommendations were made about stock management so as to avoid RDT stock outs.

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Cases tested positive and treated with ACTs

100% 90% 80% 70% 60% 50% 98% 100% 97% 99% 40% 30% 20% 10% 0% Zou-Collines Atacora-Donga Borgou-Alibori Atlantique-Littoral % of cases tested positive with RDT and treated with ACTs

Analysis Combination therapy employing artemisinin (ASAQ and AL) based drugs is currently the treatment recommended by the NMCP for uncomplicated malaria. The graph above shows that in the majority of cases, ACTs are used to treat uncomplicated malaria. This is very encouraging. However, in Zou-Collines we noted several cases of uncomplicated malaria for which treatment was not recorded, most often for patients over 5 years. The justification for this most frequently cited is related in part to the Government of Benin’s recently implemented policy, which offers ACTs free of charge to children under 5 and to pregnant women. Once patients were no longer eligible to continue benefitting from this policy were unfortunately either unwilling or unable to return to purchase ACTs. Cases tested negative and treated with ACT 100% 90% 80% 70% 61% 60% 50% 45% 40% 30% 20% 10% 0% 0% 0% Zou-Collines Atacora-Donga Borgou-Alibori Atlantique-Littoral % of cases with negative RDT and treated with ACTs

Analysis Despite the fact that current guidelines recommend treating only cases confirmed by a positive blood test the graph above shows that in Borgou-Alibori and Atlantique-Littoral almost half of the cases tested negative were nonetheless treated with ACTs. To stem this practice ARM3 in association with the health

20 | P a g e zone is providing funds for refresher training in case management under the new directives and will fund at least two supervisory visits to all health centers in the 12 targeted health zones of Atlantique Littoral and Oueme-Plateau. Cases not tested but treated by ACT

100% 90% 80% 70% 60% 60% 56% 50% 40% 30% 20% 20% 10% 0% 0% Zou-Collines Atacora-Donga Borgou-Alibori Atlantique-Littoral

% of cases treated with ACT but not tested

Analysis The figure above shows the percentage of cases treated as simple malaria with ACTs for which no test was performed. Again Borgou-Alibori and Atlantique-Littoral show the greatest tendency to not follow the new NMCP guidelines for treating simple malaria. The most common explanation given by health facility personnel was that there was a shortage of RDTs and a tendency to treat all fevers of children under five as malaria. Diagnostic confirmation was not required before treating cases of fever in children under 5 years prior to the treatment protocols in 2011, i.e. treatment was based on symptomatic diagnosis. This practice persists among some caregivers. ARM3 will work with the NMCP to set maximum and minimum levels for RDTS to be distributed to health zones rather than the current practice where each health zone requests whatever quantity they desire. Training of health providers to manage severe malaria - ETAT training (Sept. – Dec 2012) ARM3 sponsored a training program on ETAT of severe malaria which began in September with four hospitals (3 public and 1 private) in Oueme-Plateau and continued with the addition of four hospitals. To date, the ETAT training has covered a total of 47 health care providers at eight hospitals. The table below presents the hospitals and the personnel trained during the quarter. Thirty five more doctors and nurses have been trained.

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ETAT training Statut Poste # of participants Département NOMZS Oueme-Plateau SAKIF publique Hôpital de Zone d’Adjohoun 2 Oueme-Plateau PAK publique HZ Pobè 2 Oueme-Plateau SAKIF publique HZ Sakété 4 Oueme-Plateau PAS prive Polyclinique Le Bon Samaritain 6 Oueme-Plateau PAS prive Clinique Coopérative de Ouando 3 Alt-Lit AS prive Clinique ”Oasis” de Houègbo 4 Alt-Lit AS prive Clinique Coopérative d’Abomey Calavi 7 Atl-Lit AS prive Hôpital la Croix de Zinvié 7 Post-ETAT training follow-up A program to begin the post training follow up was proposed to the supervisors and facilitators of the ETAT training program for early December. Scheduling conflicts meant that those dates could not be retained and this activity will be rescheduled for early next quarter.

ETAT quality assurance process Discussions have begun with the MCH Directorate to implement a quality assurance process using the collaborative approach. The MCH has implemented this approach and wishes to continue the process with the newly added hospitals. The quality assurance (QA) process is designed to ensure that the case management of severe malaria adheres to certain performance metrics. Preparatory activities for integration of Community Case Management (CCM) in five former BASICS health zones In response to USAID Benin’s request, ARM3 submitted an integrated community case management (iCCM) technical and cost proposal to integrate iCCM activities within ARM3 in 5 Health Zones of North Benin. Funding for the first-year of CCM activities can be found by re-allocating ARM3’s budget lines for LLIN procurement (years 1 and 2) and financial support to the IRSP (years 1 and 2). Funding for subsequent years of the CCM activity will need to be discussed.

ARM3’s integrated CCM proposal includes the following:

1. Continue working in the 5 HZs with the majority of CHWs engaged through the BASICS contract. 2. The functional integration of CCM activities within ARM3 programming and especially with the latter’s community BCC activities: a. CHW’s in these 5 Health Zones will implement both CCM and community BCC activities, b. CHW’s will be directly supported and supervised by government staff in their neighboring health facilities, facilitating a continuum of care between them. Local NGOs will support this process but only as a transition measure, i.e. they will be phased out progressively. ARM3 will provide technical and financial assistance to both government health facilities and local NGOs. 3. The integration of the CCM activities within the organizational structure of ARM3: a. MCDI will integrate the CCM activities within the organizational structure of ARM3, especially at the Parakou and Cotonou offices, and will assign personnel in both locations to lead, support and supervise them.

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b. Parakou-based Africare ARM3 staff, initially allocated only to support community BCC activities, will also support the CCM activities. c. MSH will assign additional CCM-experienced staff to this activity.

During the quarter October – December 2012, following the establishment of the ARM3 Field Office in Parakou (northern Benin), ARM3 initiated activities that are possible without committing any financial resourses to iCCM while awaiting the Contracting Officer’s written approval. Activities that were carried out include:  An exercise to map the coverage and interventions of other partners in the five former BASICS Health Zones in order to identify gaps as well as avoid duplicate actions covered by other donors. ARM3 also contacted the Chief Medical Officers of each health zone for an update on CHWs and partners in their respective zones.

 Re-evaluated the funding for iCCM based on what costs are already being covered by other partners, in particular Africare and the Belgium cooperation (Coopération Technique Belge). This included verifying what costs budgeted for in the ARM3 proposal are already taken into account by other partners; i.e. payment of: monthly incentives to CHWs, costs associated with local transportation, food and other expenses to CHWs participating in monthly one day meetings; facilitation fees to staff at health facilities for one day monthly meetings, etc.

 Established initial contacts with the NGOs that were implementing iCCM activities under the former MSH/BASICS Project. While it would be preferable to contract with the five former BASICS NGOs, the NMCP has asked, citing reasons of transparency and open competition, that a new solicitation of interest be organized. MCDI, in collaboration with Africare, will draw up an announcement and submit it to the NMCP for their approval. Once approved, we will publish the announcement in local newspapers. ARM3 will insist that selection criteria include the requirement that the NGO has worked in the area on iCCM for which they are applying and possesses knowledge of USAID procedures.

 Based on ACT consumption data for the last 12 months from the BASICS database, ARM3 estimated the number of RDTs needed to comply with the NMCP’s new directives. ARM3, with assistance from USAID, will insist that the NMCP prioritizes supplying adequate amounts of RDTs to USAID health zones.

 ARM3 will pursue sustainable means to guarantee incentives for CHWs beyond the life of the project. ARM3 will build on the model developed by UNICEF involving the Mayor’s Office to take over these payments. We have already contacted the DSME who has indicated that they would like us to continue to observe the results of UNICEF’s efforts before continuing. Results

Indicator Baseline LOP Target PY2/Q1 Results Source/Comments Result 2: Malaria diagnosis and treatment activities in support of the national malaria strategy improved Sub-result 2.2: Case management of uncomplicated and severe malaria improved

36.7% (all 90% of suspected 79.7% (all ages) RMIS results are from 6) Percent of suspected ages) malaria cases will be FY12/Q4 malaria cases submitted to 17.5% < 5 tested via 82.3% < 5 (July-Sept 2012) laboratory testing 52.6% ≥ 5 microscopy/RDTs 76.9% ≥ 5

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Source RMIS FY11/Q4 93.9% (all ages) ≥ 95% of patients (all

ages) who tested 93.7% < 5 7) Percent of patients (all positive for malaria (via 94.0% ≥ 5 ages) who tested positive for microscopy or RDT) -- EUVS report, April malaria (via microscopy or will receive an effective Micro – all ages 2012 RDT) who received an anti- anti-malarial (ACT) 77.8% malarial RDT – all ages Micro only ≥ 85% 95.0% RDT only ≥ 95%

57.6% (all ages) < 35% of patients (all

ages) who tested 67.2% < 5 negative for malaria 8) Percent of patients (all 48.6% ≥ 5 (via microscopy or ages) who tested negative -- RDT) will receive an EUVS report, April for malaria (via microscopy Micro – all ages effective anti-malarial 2012 or RDT) who received an 40.1% (ACT) anti-malarial RDT – all ages

59.5% Micro only < 35%

RDT only < 45%

OTSS Round 9 PY1/Q3 (June) Supervisory visits will OTSS Round 11 OTSS Round 9 9) Percent of targeted health be conducted at 100% PY2/Q1 (December) 100% (N=46) facilities that received -- of targeted health OTSS Round 11 supervision facilities at least once One additional facility 100% (N=47) every 6 months was added during Round 10 and carried through henceforth. Percent of children <1% under-five with 10) Percent of children suspected malaria under-five with suspected Source (fever) in the last two malaria (fever) in the last DHS, 12.3% DHS report, May 2012 weeks who received two weeks who received 2006 treatment with ACTs in treatment with ACTs targeted areas will

increase to 85% ≥ 90% of mothers / 11) Percent of mothers / caretakers who sought caretakers who sought <1% treatment with the use treatment with the use of of ACTs for their ACTs for their under-five Source under-five children with 6.7% DHS report, May 2012 children with suspected DHS, suspected malaria malaria (fever) within 24 2006 (fever) within 24 hours hours of onset of their of onset of their symptoms symptoms 12) Number of schools of Develop, review, ARM3 program nursing and educational update and implement reports institutions that have -- with the MOH the 0 updated their malaria guidelines and training Draft MoU has been guidelines and curriculum curricula on malaria prepared and the FSS

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diagnosis and treatment has requested at a total of 4 schools of assistance procuring nursing and educational microscopes institutions (2 in PY2; 2 in PY3) Support training in clinical IMCI for 72 13) Number of newly hired newly hired health ARM3 training reports health workers trained in -- workers in the private No new trainees clinical IMCI sector to contribute to Total to date: 48 national scale-up of clinical IMCI ARM3 training reports

LOP running total: 15 trainers and 48 health professionals from 8 hospitals have Support refresher been trained in severe training and supervision malaria case to ensure appropriate management 21/50 management and 14) Number of hospitals that hospitals 4 total referral practices for Note: the original LOP received a refresher training provided severe malaria to the target was 55 for severe malaria case training 3 public remaining 29 hospitals hospitals. This value management by 1 private nationwide has been revised down PISAF 29 (total) to 29 as PISAF have 17 public already provided 12 private training for severe malaria case management to 21 hospitals. There are 5 hospitals of the proposed 55 that cannot be identified. Health zone training reports

Activity will begin when health zones 23) Number of health PY2 Target: 476 health receive 1st advance workers trained in case care professionals from under their MoU management with 12 health zones (PY2) -- None this quarter artemisinin-based (re)trained in case combination therapy (ACTs) management with The revised OTSS with USG funds ACTs using USG funds checklist which captures trainings in case management with ACTs will begin use during OTSS Round 12

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Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened

ARM3 addresses a number of serious weaknesses in the NMCP’s capabilities. Result 3 consists of three sub-results: Sub-Result 3.1: MOH/NMCP capacity to deliver and manage quality malaria treatment and control interventions improved; Sub-Result 3.2: Capacity to collect, manage and use malaria health information for M&E and surveillance improved; and Sub-Result 3.3: Capacity in commodities and supply chain management improved.

Sub-Result 3.1: MOH/NMCP Capacity to Deliver and Manage Quality Malaria Treatment and Control Interventions Improved ARM3 plans to undertake activities to reinforce the capacity of the NMCP to manage malaria interventions. One of the primary methods includes the support and promotion of NMCP Technical Working Groups (M&E, supply chain, communications, and case management) to meet regularly and to assist in coordinating with other malaria implementing partners. Additionally, ARM3 will seek out other Malaria Control Partners operating in Benin to work to improve collaboration. Achievements Malaria Related Quarterly Technical Working Group (TWG) Meetings Monitoring and Evaluation TWG The Monitoring and Evaluation TWG meeting was held on November 27, 2012 at the NMCP offices. Fourteen participants from the MOH (NMCP, DDS, SGSI, and DPP), IRSP and partners (AFRICARE, and ARM3) attended. The following activities were carried out:  Evaluation of each section of the RMIS newsletter to identify topics that can be more reader- friendly;  Evaluation of the feasibility of disaggregating data for pregnant women on the PNLP form;  A review of the indicator labels; and  Potential solutions for improving the reporting of community-based malaria data. The participants suggested no new sections to the existing format of the report. It was proposed to modify the PNLP1 data form to disaggregate data about pregnant women from the column labeled >5 and pregnant women but no decision about its dissemination was made. The definitions of the 10 main indicators were reviewed and their descriptions improved. These indicators will be used to create a dashboard by ARM3 that will be used by the MOH/NMCP on a regular basis. MCDI HO is currently in the process of designing this dashboard which will be available for implementation in January. The PNLP1 data form has four indicators for community based information that are poorly reported on by the health centers at this time. PNLP2 forms are used exclusively for community data collection and will be distributed to Africare and CRS by the NMCP once the new disaggregated forms are developed. Africare has committed to improve the completeness of community-based data by assuring that health centers received the completed PNLP2 form. BCC TWG Meeting Due to the conflicting agenda at the NMCP, the BCC working group did not meet during this quarter. However, the BCC Manager attended other important meetings with NMCP partners that offered him a chance to work together and share experiences.

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The BCC Manager was invited to attend a meeting by the BCC network in Zou/Collines Department on October 12, 2012 involving all partners working on BCC. At this first meeting, he took the opportunity to share the project’s vision and expressed the need to have a representative regularly attend the BCC working group in Cotonou. His statement also goes along with a recommendation made by the BCC members during the first meeting in April 2012 suggesting to extend the BCC technical group membership to people coming from the departments and informed the participants about workshops that will be initiated by ARM3 in year two to reinforcing BCC staff’ skills in interpersonal communication and leadership in strategic communication. As of this quarter, all TWGs, including the Monitoring and Evaluation, Behavior Change Communication, Supply Change Management, and Case Management TWGs, have met at least once during the year, have agreed upon Scope of Works (SOWs), and are currently carrying them out. Technical and financial support of 2013 PITA design The 2013 Plan Intégré de Travail Annuel (PITA) elaboration workshop was held from December 4-6, 2012 in Porto Novo. The objectives were to assess the implementation of 2012 PITA and to develop the 2013 PITA. The PITA is an annual exercise that coordinates the activities of all MNCP partners by preparing an integrated annul work plan for all parties to work from. A total of 27 participants representing the major partners, CRS, Africare, ARM3, CREC, IRSP, Abt, FSS, national and regional NMCP representatives, were in attendance. ARM3 provided financial and technical support to the NMCP regarding the organization of the workshop. A consultant was provided by ARM3 for the PITA. His responsibilities were to provide quality support to the NMCP for the follow-up of 2012 PITA and to prepare the 2013 PITA. The following are key points regarding the 2012 PITA:  NMCP 2012 activities were implementation at a rate of 66%;  ARM 3 activities were implementation at nearly the same rate, 69%;  Not all of partners sent information about PITA implementation;  A new PITA template was designed and adopted; and  It was recommended that participants review the formulation of activities to simplify, consolidate and be more specific as well as sticking strictly to the objectives of the NMCP strategic plan. Summary of 2013 PITA planned activities N° Intervention areas Number of Proportion on total Total cost (in Proportion on total planned activities planned activities CFA millions) budget

1 LLIN 13 6.40% 2943 27%

2 IPT 7 3.45% 79 1%

3 DIAGNOSIS 17 8.37% 1,077 10%

4 TREATEMENT 26 12.81% 1,934 18%

5 MONITORING & EVALUATION 49 24.14% 886 8%

6 PROGRAM MANAGMENT 66 32.51% 3,020 28%

7 COMMUNICATION 13 6.40% 222 2%

8 RESEARCH 12 5.91% 763 7%

Total 203 100% 10,924 100%

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Results Indicator Baseline LOP Target PY2/Q1 Results Source/Comments Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened Sub-result 3.1: NMCP’s technical capacity to plan, design, manage and coordinate a comprehensive malaria control program enhanced The 4 NMCP technical working groups 15) The number of meetings (monitoring and held by the NMCP technical Case Mgmt – 0 evaluation, supply working groups (monitoring BCC – 0 ARM3 program -- chain, communications, and evaluation, supply SCM – 0 reports and case management) chain, communications, and M&E - 1 are meeting regularly as case management) planned (twice per year) The activities described in section 3.2 below also directly support Sub-Result 3.1.

Sub-Result 3.2: Capacity to Collect, Manage and Use Malaria Health Information for M&E and Surveillance Improved Successful program management requires timely and accurate data to make rational and informed decisions on policy and interventions. ARM3 plans on evaluating and strengthening each of the major information systems including the HMIS/RMIS (LogiSnigs & LogiHops), LMIS (Medistock), IRSP sentinel surveillance, OTSS, EUVS and other malaria-related systems. The objective is to ensure that each system is providing high quality and timely data for decision making and that barriers to information collection, management, and utilization are addressed. Achievements Routine Malaria Information System (RMIS) Support and Improvements In support of Sub-Result 3.2, ARM3 is preparing quarterly Routine Malaria Information System newsletters. The primary purpose of these newsletters is to keep stakeholders abreast of the current malaria epidemiological situation and malaria prevention activities. RMIS newsletter 7 (July – September 2012) was prepared this quarter and newsletter number 6 (April – June 2012) printed and distributed. With the objective of finalizing the third newsletter of 2012 (number 7) with data from the RMIS, a subset of the national health information system (SNIGS), the newsletter editorial committee met on December 26-28, 2012, in Porto Novo. A working group of 10 persons with members mainly from the NMCP and ARM3 produced this latest report. The participants specifically carried out the following: 1. Analyzed the completeness of Routine Malaria Information System (RMIS) data by HZ and Department for the period of July - September 2012; 2. Tested the internal validity of the data; 3. Agreed on data to be presented in the newsletter; 4. Agreed on the editorial content; 5. Agreed on the overall presentation of the report with regard to the comments made by readers and other key players; 6. Prepared the newsletter for printing; and 7. Approved the newsletter for publication.

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To facilitate workflow, preliminary presentations were made on the level of data transmission, the key indicators to be published in the bulletin. Three sub-groups were formed following the presentations: group 1 was responsible for the editorial section of the newsletter; group 2 for producing all tables and graphs, and group 3 analyzed indicators and organized the layout and formatting of the newsletter. In the plenary session, the draft bulletin was crafted based on the presentations, and it was then approved by the participants. Update of NMCP central data platform During the quarter, ARM3 provided technical support to the NMCP to provide an update on the following databases: LMIS, RMIS, MEDISTOCK, HMIS, Projet d’intensification de lutte contre le paludisme (PILP) (GFATM), and Palu Alafia (GFATM), as well as the EUV surveys. Data from different regions of the country were merged to detect outliers and errors within databases. In addition, this information should be made available to help NMCP coordination and other stakeholders for programmatic decision making. Implementation of verification process of data quality In December 2012, ARM3 designed and proposed to the NMCP a tool for the implementation of the verification process of data quality. This tool is based on the Global Fund on-site-data-verification tool. The NMCP is reviewing the tool and the supervision is planned for the quarter January – March 2013. On site data collection During the quarter, ARM3 carried out a nationwide data collection effort by visiting all 34 health zones in an effort to reach two objectives: (1) to have updated data for the USAID annual report; and (2) to improve the completeness and the reliability of data for decision making. Meetings with health zone coordinators and statisticians were held to explain the purpose of the active data collection, to assess the data collection process at each health zone office and to identify challenges. A questionnaire was used to collect data during the visits. The results indicated a slight improvement (65%) in data completeness. Some errors were identified in the databases but were promptly corrected and the data entry operators were cautioned again about the importance of checking their data for completeness and quality. The field visits did not allow time for visits to health facilities where inconsistencies and biases have been observed. This level of supervision is being planned. It was noted that the health zones do not promptly enter data that they have received, thereby missing the deadline for submission to the next level. Data entry errors are still common and some health centers are still not able to complete the forms correctly as the persons responsible for data entry do not understand the definitions and concepts. In conclusion this only produced a slight increase in the completeness, and while data quality is improving at the health zone, it is still troubling at the facilities level. It will take formative supervision of the data entry agents to significantly improve the quality. The health zone supervisory team will need to incorporate increased oversight of the data entry process into future planning for data quality improvement. Due to the unavailability of heath zone statisticians (who were committed to collecting data related to the census of private sector health facilities) and NMCP workers at the national and department levels,, the following activities are postponed for the quarter January – March 2013: training of staff and statisticians on LOGISNIGS; supervision of the health information systems; and evaluation of the strengths, weaknesses, and constraints to the collection, review, and prompt submission of quality data.

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Results Indicator Baseline LOP Target PY2/Q1 Results Source/Comments Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened Sub-result 3.2: MoH capacity to collect, manage and use malaria health information for monitoring, evaluation and surveillance improved ≥ 95% of targeted 16) Percent of targeted facilities reporting PY1/Q4Results RMIS results are facilities reporting through the through the RMIS 66.4% from FY12/Q4 Routine Malaria Information 37.8% and sentinel RMIS: (568 public (July-Sept 2012) System and sentinel surveillance sites and 91 private surveillance sites are Source are providing health facilities, out The IRSP has providing complete RMIS complete of 923 facilities) received funding but information on a regular and (FY11/Q4) information on a IRSP Sentinel have yet to timely basis for decision regular and timely Surveillance: 0% commence active making basis for decision (0of 5) data collection making

Sub-Result 3.3: Capacity in Commodities and Supply Chain Management Improved

The continuous availability of high quality malaria commodities is crucial to reduce malaria related morbidity and mortality in Benin. The main objective of ARM3’s supply chain management (SCM) component is to strengthen Benin’s SCM activities, including building the capacity and improving the performance of Benin Central Medical Store (CAME). ARM3 intends to work with CAME to improve governance practices, warehousing of drugs and financial information systems to improve their performance. ARM3 is supporting the NMCP and CAME in designing and implementing a well-designed Malaria Logistic Management Information System (LMIS) in order to reduce stock outs and overstock. The LMIS end goal is to track malaria commodities and make sure that the right product is available in the right quantity, in the right condition, at the right time, in the right place, and at the right cost. Achievements

LMIS Strengthening Developed and validated supply chain management supervision tool NMCP validated supportive supervision tools that will make it possible to collect logistics data at all levels and especially at the DRZ level. The aim of this tool is to: (1) collect annual logistics data and to have information that can help forecast malaria commodities; (2) identify issues in relation to malaria commodities management; (3) information storage conditions; and (4) track the number of health facilities receiving malaria commodities by DRZ. LMIS supportive supervision During the quarter October – December 2012, ARM3 made visits to all 34 Health Zone depots, 27 Health Zone Hospitals, and 6 Departmental Hospitals.

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Trained 9 data collectors; supervised 34 DRZ managers; 27 Zonal Hospital pharmacy managers; 6 Departmental Hospital Pharmacy managers; and 66 health centers.

From October 7-13, 2012, ARM3 supported the NMCP by organizing supportive supervision to 34 DRZ managers, 27 Zonal hospitals, 6 Departmental Hospitals, and 68 health centers. On October 4, 2012 the ARM3 SCM team organized a training session for the following supply chain data collectors at Direction de la Pharmacie du Medicament et des Explorations Diagnostic (DPMED):) 5 NMCP doctors at the departmental level; one pharmacist from DPMED; one lab technician from National Quality control lab; and 5 NMCP staff on the supply chain management component of the supportive supervision. The supervision methodology uses one DRZ manager per Department with excellent performance to participate in the supportive supervision. This allows them makes to share their knowledge with their colleagues. The methodology allows all DRZ managers to visit selected health structures in their health zone to be visited by supportive supervision. The supportive supervision was carried out by 9 teams of 3 people including one personal from CAME. This supervision revealed the following:  All DRZ reported delivery of malaria commodities to 804 public health structures, 25 confessional health centers and 43 private health centers, provides an estimate of quantities of malaria commodity tools to be printed and distributed;  This supportive supervision is the first that supported DRZ managers to visit health centers in their health zones;  The absence of supervision of health structures by DRZ managers makes it difficult for LMIS data quality control by DRZ manager; therefore, quantities reported by DRZ managers as quantities distributed to health facilities are not verified by DRZ managers as they are not integrated with health zone supervision;  Reporting rate of usage of malaria commodities is very low in all health departments;  A sizable amount of RDTs on the verge of expiring were identified in the SAKIF health zone, and further analysis showed that the DRZ manager had approximately 11,000 RDTs;  The exportation of MEDISTOCK data to MEDISTOCKWEB needs to be improved by DRZ managers in Oueme – Plateau;  Almost all pharmacy managers require training in malaria commodities; and  Storage conditions must be improved in all health departments. By the time ARM3 and NMCP tried to redistribute the overstocked RDTs found in SAKIF, the product had already expired. Therefore, the RDTs were withdrawn from the DRZ. Information and issues identified were presented to DRZ managers and Charge de l’Administration et des Ressources during the Training of Trainers of DRZ managers and the briefing of the CAR who serves as their supervisor. The information collected helped to share with the NMCP an approach of forecasting based on one year consumption and distribution data collected in all DRZ during the supportive supervision. This forecast makes it possible to identify AL 1x6 as the AL the most used by DRZ Managers followed by AL 2x6, AL3x6, and AL4x6. On the basis of this forecast it appears that there is no need to procure AL4x6 if the current consumption rate of AL 4x6 does not change.

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Training of trainers on redesigned Malaria LMIS (Trained 34 DRZ managers as trainers of Malaria commodities LMIS, trained 34 Charge de l’administration et des ressources (CARs) as supervisors of DRZ managers)

ARM3 organized two workshops in Grand Popo: (1) From November 26-28, 2012, 34 DRZ managers (7 women and 27 men) were trained as trainers of malaria commodities LMIS at zonal level. (2) From November 29 – 30, 2012, 34 Chefs de l’Administration et des Ressources (CAR) were trained as supervisors of malaria commodities LMIS trainers. After the malaria commodities LMIS system design done in September 2012 in Lokossa, the training of trainers was one of the very important steps in implementation of the newly redesigned malaria commodities LMIS. In support to NMCP, ARM3 trained 34 DRZ managers on the selected commodities inventory management using a max/min system. Trainers were trained on (1) malaria epidemiology; (2) malaria commodities LMIS SOP; (3) stock status assessment; (4) estimation of needed quantities to be ordered based on consumption data; and (5) storage best practices. During this first training session, the ARM3 SCM team presented some issues identified in the supply chain section of the EUVS April 2012 and October 2012 supportive supervision and by MEDISTOCK monitoring. These presentations made it possible for DRZ managers to identify issues and suggest solutions with deadlines for the implementation of these solutions. The participants of the training completed pre- and post-tests and the result was grouped according to the department where DRZs were located. ARM3 intends to disseminate best practices throughout Benin’s health departments by having DRZ managers currently employing best practices in malaria commodities LMIS visit other DRZ Managers in health departments that require performance improvements. The graph below demonstrates the pre-and post-test results: 10 9.2 8.4 9 7.9 7.8 7.3 7.3 7.2 8 6.6 7 5.7 6 5 5.4 5.2 5.3 5 4.2 4 Average 3 2 1 0

DEPARTEMENT

Average. PRE TEST Fig. 1: DRZ managers pre- and post-test results per health department, Average. malaria commodities LMIS TOT, Nov. 2012 POST TEST

This graph makes it possible to identify that all DRZ managers made some progress from pre- to post- test. The ideal result expected was 8/10 to be considered as an acceptable trainer. On this basis, all DRZ managers in Borgou–Alibori and Oueme–Plateau may be considered as acceptable malaria commodities LMIS trainers. The other health departments will need much more coaching from ARM3 and NMCP. It is important to note that only 11 (32%) participants knew the formula that is used to place orders.

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During a second training session 34 CARs (9 women and 25 men) were trained on (1) malaria commodities LMIS SOP; (2) their roles and responsibilities as DRZ supervisors; (3) stock status assessment; and (4) results of supportive supervision, supply chain section of EUV, and issues identified during MEDISTOCK implementation. This second training session helped to identify issues and possible solutions with regard to the roles and responsibilities of DRZ managers. During this activity participants constructed a final problem identification tree per health department and per health zone. ARM3 will support the NMCP in problem solving and monitoring by ARM3 supply chain coordinators and NMCP-supported doctors at the departmental level. In order to have a proper system in place the ARM3 SCM team intends to coach DRZ managers during the training of users, scheduled to take place during the last week of January 2013. ARM3 supported the NMCP to identify with CARs’ needs in the training of users of the new LMIS data collection tools, and on that basis the training strategies were defined. The training of users will be carried out by a team composed by DRZ managers and supervised by CARs, Health Zone Coordinators, doctors, and ARM3 supply chain coordinators. Presented EUVS Findings to 6 Departmental pharmacists, 6 Departmental financial administrators, 6 departmental financial administrators, and 26 Zonal Hospital financial administrators As recommended in the EUVS report, during the training on the new malaria commodities LMIS, ARM3 supported the NMCP by debriefing 44 people (37 men and 7 women) involved in malaria commodities management at Health Departments, Zonal Hospitals, and Departmental Hospitals.

The EUV Survey found that drug availability may be adversely affected by the financial decision that the health zone makes in regards to how to allocate their funds when placing orders. They may have insufficient funds to purchase commodities up to the maximum suggested limit or they may invest in drugs that produce a better “profit” for the health center without regard to which drugs are of a higher public health benefit, hence the negative impact of financial considerations to drugs management and avoidance of stock out of malaria medications.

Updated and validated malaria commodities LMIS tools by NMCP ARM3 updated the newly redesigned malaria LMIS tools for all levels of the health pyramid. These tools are intended to help DRZ managers, Departmental Hospitals, Health centers and Zonal hospitals, and community health workers to report on the status of malaria commodities. NMCP validated the malaria commodities LMIS tool that will be used by health structures in Benin to report logistics data: (1) stock on hand; (2) consumption; and (3) loss and adjustment.

These tools will be printed and distributed to users during the training of malaria commodities LMIS that will take place during the next quarter. The malaria commodities LMIS tools will be distributed to: (1) 34 DRZs; (2) 6 Departmental Hospitals; (3) the National University Hospital; (4) 27 Zonal Hospitals; and (5) 900 health centers. Developed malaria commodities LMIS Manual of Standard Operating Procedures (SOP) Malaria commodities LMIS SOP manuals have been drafted and shared with the NMCP. This manual will make it possible for all LMIS users to have information on the Malaria commodities LMIS and to have clear view of the Malaria commodities LMIS. The newly redesigned Malaria commodities LMIS parameters are as follows:

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Table 1: Inventory levels by facility

Emergency Review Type of Facility Order Point Mimimum1 Maximum2 period (EOP) Health centers (including community 1 month 2 weeks 1 month 2 months health workers), Zonal hospitals

DRZ, CHD, CNHU 1 month 1 month 2 months 3 months

CAME 3 months 3 months 6 months 9 months

Fig.2: Malaria commodities LMIS

1 Below this inventory level, the facility is at risk of being out of stock.

2 At this inventory level the facility may experience over stock and/or expiration. 34 | P a g e

Received DRZ stock status

The NMCP received stock status reports from 25 DRZ managers. An analysis of these reports can be found in the table below: Table 2: 25 DRZ stock status analysis # of DRZ # of DRZ # of DRZ # of DRZ # of DRZ INN Unit Stocked Stocked < EOP < Min < Stock> out EOP stock< Min stock< Max Max Artemether+ Blister Lumefantrine 6 tb 20mg/120 mg 7 3 4 5 4 AL 20mg/120 mg Blister Comm 6 tb 3 1 1 Blister AL 20mg/120 mg 12 tb 3 4 4 3 9 Blister AL 20mg/120 mg 18 cp 4 7 2 4 6 Blister AL 20mg/120 mg 24 cp 5 3 6 4 4 Sulfadoxine + Pyriméthamine tb (500mg/ 25mg) 4 5 2 1 10 RDT test 3 7 7 4 2

This analysis of DRZ stock status, alongside the CAME stock status, allowed for the following further analysis: Table 3: Major findings and recommendations N° Findings Action recommended 1 CAME had less than 3 Order AL1x6 in order to have 9 months of stock on hand at CAME months of AL 1x6 on hand 2 Products (AL and RDT) over NMCP to redistribute the over stock to DRZ in need in order to avoid stocked expiration. 3 All CAME stocks are not NMCP to call for a meeting with CAME to explain the need to have correctly stored according to Max/Min applied by all health structures including CAME in order to Max/Min inventory system avoid stock out of product like AL 4x6 and AL 3x6in CAME Natitingou and Parakou and over stock at CAME Cotonou. 4 CAME was positioned to be USAID to help NMCP to procure some SP in emergency in order to stocked out of SP for IPTp have 9 months of stock according to Malaria commodities LMIS 5 RDT quantities in stock < USAID to help NMP to procure some RDT in emergency in order to EOP have 9 months in stock.

Table 4: Analysis of CAME malaria commodities stock status N° Malaria commodity Number of month of Recommendation stock on hand 1 AL 1x6 (procured by NMCP Stock out 1. NMCP to order AL 1x6 2. NMCP 35 | P a g e

and stake holder) 2 AL 1x6 (procured by CRS) 0, 5 month 1. CRS and Africare to order AL 1x6 3 AL 1x6 (procured by Africare) 0,3 month 4 AL 2x6 8 months NA 5 AL 3x6 17 months 1. NMCP to use some of AL 3x6 to reconstitute AL 1x6 in order to avoid expiration of AL 3x6 in stock 6 AL 4 x6 21 months 1. NMCP to use some of AL 4x6 to reconstitute AL 1x6 in order to avoid expiration of some AL 4x6 7 Artesunate 25 mg + (29,950 tablets) 1. NMCP and CAME to inform Amodiaquine 67,5 mg facilities that some Artesunate 25 mg + Amodiaquine 67,5 mg are available. 8 Artesunate 50 mg + 17 months 1. NMCP and CAME to inform Amodiaquine 135 mg facilities that some Artesunate 50 mg + Amodiaquine 135 mg are available 9 Artesunate 100 mg + 1. NMCP and CAME to inform Amodiaquine 270 mg blister facilities that some Artesunate 20 months of 6 tablets 100 mg + Amodiaquine 270 mg blister of 6 tablets are available 10 Artesunate 100 mg + (16,200 tablets) 1. NMCP and CAME to inform Amodiaquine 270 mg blister facilities that some Artesunate of 3 tablets 100 mg + Amodiaquine 270 mg blister of 6 tablets are available 11 Sulfadoxine 500 mg / 1 month 1. NMCP to order SP for IPTp in pyrimethamine 25 mg boxes order to avoid stock out. 12 RDT 1 month 1. NMCP to order RDT to avoid stock out.

As presented in Table 1(Inventory levels by category of facility), it will be important that the NMCP reorder malaria commodities in order to have the maximum level of stock--9 months’ worth--on hand. By using these parameters at all levels, the NMCP and CAME will be able to avoid stock shortages and/or over stock or expiration of supplies.

The quantity of RDTs available at the end of December 2012 does not take in account the USAID/PMI procured RDTs that are due to be delivered in January 2013. As the CAME stores in Natitingou and Parakou are under stocked, we would recommend that USAID, NMCP, CAME and ARM3 hold a meeting to reach an agreement on the malaria commodities LMIS strategy going forward so as to avoid this and other possible expiry scenarios.

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Results Indicator Baseline LOP Target PY2/Q1 Results Source/Comments Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened Sub-result 3.3: MoH capacity in commodities and supply chain management improved The national malaria Available LMIS commodity supply reports Quarterly chain is functioning 17) Number of quarterly and reports: 0 with an LMIS that Expected quarterly annual reports generated by -- regularly provides reports for PY2: 4 the LMIS per year Annual quarterly and annual reports: 0 reports (4 quarterly Expected annual and 1 annual reports) reports PY2: 1 ≥85% of government health facilities have ACTs available for 80.3% 18) Percent of government treatment of EUVS April, 2012 health facilities with ACTs uncomplicated malaria 90.6% Source available for treatment of for patients of any age Sample size is limited RMIS uncomplicated malaria at any point in time to scope of EUVS (FY11/Q4) covered by project- supported EUV surveys 77.3% 18.a) Percent of health ≥85% of health RMIS facilities reporting no stock- Source facilities report no 88.1% (PY12/Q4) outs of ACTs RMIS stock-outs of ACTs (FY11/Q4) ARM3 program reports Complete (100%) implementation of NB: Indicator 19) Percent of facilities in reforms initiated in reformulated for compliance with CAME 0% CAME so as to 0% reforms place within reforms improved governance CAME in lieu of and transparency of its CAME reforms operations implemented by other facilities. Will begin reporting next quarter. Results from the ARM3 program EUVS are analyzed 20) Percent of facilities that Results reports and used to identify submit an action plan in pending management and 0% response to the End-Use EUVS Restitution to the operational issues in Verification Survey report health zones has yet to the commodity supply occur chain system

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Cross Sectional Activities

Behavior Change Communication (BCC) Achievements This quarter was marked by the launch of several BCC activities in the field reaching Atlantique/Littoral,Oueme/Plateau and Zou/Colline. During this period, ARM3 was able to activate several key communication channels to amplify messages expected to stimulate behavior change in malaria prevention and care management. The communication channels included the following: Mass Media Broadcast of TV spots and educational music video on malaria on National Television. A TV spot with David Djigla, a Beninese national league soccer player, and a music video providing malaria prevention messages were broadcasted by ORTB (Office de Radio et de Télévision Béninoise) in October and November 2012. By including a soccer star in the video, we expect to reach more men with a message which, to date, has mostly targeted pregnant women and children under five. The use of this medium was carefully chosen because according to the 2006 DHS, 35.6% of men regularly watch television in Benin. ARM3 plans to rebroadcast the same video during the African Cup of Nations in South Africa in January and February 2013. The music video was originally developed by the Association Béninoise de Femmes Chanteuses (ABFC) and approved by the National Malaria Control Program. The video content talks about malaria prevention by promoting the use of insecticide treated nets and SP treatment during pregnancy, discouraging self- medication, and compliance with malaria treatment. In collaboration with the ABFC and NMCP, and after evaluating the pertinence and relevance of this tool given the current malaria context in Benin, the ARM3 team decided to re-broadcast the music video and adding branding that says “Rediffusé avec le financement de l’USAID.” Two other new TV spots have also been developed with the involvement of BCC NMCP partners. The first spot talks about SP for IPTp and the second is about insecticide treated net use. The two TV spots have been shown to the ARM3 staff and will be presented to the communication working group before being pretested. Development and broadcast of radio programs Due to the difficult terrain in Benin and the low literacy rate, radio was selected as the most effective medium for reaching the general public, especially women and pregnant women. ARM3 has developed two radio programs: a radio magazine and a reality radio talk show. The choice was made because of the popularity of these types of programs among listeners. The radio magazines contain ten topics: 1. Malaria, what is it? 2. Consequences of malaria on pregnant women and the fetus; 3. Preventing malaria among pregnant woman; 4. Simple malaria with a child; 5. Severe case of malaria among children; 6. Importance of malaria diagnostic/TDR; 7. Managing child malaria cases with ACT; 8. Care at home for children with malaria; 9. Mosquito nets in the fight against malaria; and 10. Managing ITN.

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To ensure appropriate, accurate and consistent message content for the radio programs, ARM3 provided a guide document to the radio stations and at the same time negotiated with the Atlantique and Littoral health departments for health providers to participate in the programs as guest experts to answer questions raised by the audience. ARM3 provided technical support in the production of all radio programs including monitoring and supervision of recording, editing, and airing. In October and November 2012, Radio Tokpa, which has the largest reach in Littoral and Atlantique departments, broadcasted 10 topic programs, two per week, Wednesday and Thursday, both in French and in Fon. This program was extended until January 2013. Following the memorandum of understanding signed between ARM3 and health zones last December, ARM3 extended its communication capacity reach to two local radios located in Ouiddah and Allada in Atlantique department. Radio Kpasse is expected to reach people in the health zones of Ouiddah, Kpomasse and Toffo, whereas Radio la Voix de Lama will reach people in Allada, Tofo and Ze health zones. Note that with the rising number of radio ownership in Benin, the choice of the two radio stations was made after consulting the health zone medical coordinators who are aware of the potential of each station in their catchment area.

Three reality radio talk shows produced and aired and Atchakpodji has become a women’s radio talk show The first one took place in Pobe commune in Oueme Plateau Department and was facilitated by Radio FM de Pobe under the ARM3 team’s close supervision. The second was held in the commune of Djida in the arrondissement of Ouengbegam, in Zou and Collines department in partnership with Radio Royal Women attending Atchkpodji in Didjan Commune, in Zou/Collines Department. FM. The last one took place in Ze, Allada commune, Atlantique department with Radio Immaculée Conception. Shows were hosted by a journalist and health providers, and recorded in a common area open to a walk-in public, which most notably included a large attendance of women who were either pregnant or with children under five. Women were enthusiastic about the live recording and the fact that they would be heard by many other people. The main topic addressed during the three shows was malaria prevention during pregnancy. The participants responded to the journalist’s questions and the health providers’ guidance by raising their concerns and sharing their experiences, and they were urged to take the messages back home to share with peers and husbands. One of the questions asked to women during the Djidja radio reality show (on 11/30/ 2012) was “What do you do when your mosquito net has holes”? One woman stood up and responded: “I will take my mosquito net to the health center and ask the health worker what I should do now that my mosquito net has holes.” Many women did not have a better answer - illustrating the low level of knowledge about net management and prompting a response from the health worker to clarify how nets can and should be repaired by their owners.

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Important figures such as opinion leaders, kings and religious leaders were used to reinforce messages during the radio show. In Ze commune, a well-respected king was given few minutes on air to encourage people to adopt promoted behaviors. The ARM3 team intends to continue to seek the support of opinion leaders in different areas to join the project’s effort in the action against malaria in Benin. After the programs were recorded, people were informed about the days and time of broadcast. Radio FM de Pobe, Radio Royal FM and Radio Immaculée Conception broadcasted the recorded program twice. .

IEC Materials The literature review conducted by ARM3 last year helped to identify effective IEC materials produced by the National Malaria Control Program that can be used by programs in Benin. Flyers were among those materials that the team identified as having appropriate and accurate messages. ARM3 reproduced three flyers on SP for IPTp, ITN, and ACT. The aim is to make them available in the health centers so that clients who are coming in for any The King of Ze speaks during a reality program in Allada prompting people to consultation (for any reason) can adopt preventive behaviors to reduce the malaria burden. Sitting to his right take them home and learn more is Dr. Guidi Etienne, the medical health zone officer. about malaria prevention and management. Table 1: Distribution of message cards as of December 31, 2012 Flyers Quantity Distributed LLINs 33,100 SP 40,000 ACT 33,100

In addition to the flyers, ARM3 produced banners used for two purposes: (1) to be used during community events and (2) to brand any activity sponsored by ARM3 in compliance with USAID regulations.

Banner on SP and LLIN use used during community events 40 | P a g e

Banner on ACT used during community events

Supporting community health workers’ activities in the field Aware of the importance of community health workers’ role in changing behaviors at the community level, ARM3’s BCC manager attended 1) the 2-day workshop in Lokossa to adapt Africare training modules; 2) a workshop with selected NGOs where a presentation on communication and community engagement and the role of NGOs was made on December 13, 2012 in Porto Novo. He also involved community health workers in community events sponsored by ARM3, including radio reality show recordings and rallies. For instance, on November 29 during the Ze community event, community health workers were introduced to the audience by the health zone medical officer who urged the public to encourage and praise them for their work. In addition, discussions took place with Africare and CRS on the distribution of IEC material to the community health workers in Littoral.

Reaching People to promote malaria prevention through a caravan in Benin Community event on November 28 2012: a caravan for social mobilization was organized to educate people and seek the support of opinion leaders in the Ze health zone.

Initiating Contacts Taking into consideration the low health indicators in malaria preventive interventions, the Atlantique and Littoral Health department director suggested holding a social mobilization event aimed to promote behavior change in the Ze health zone. According to Dr. Didier Agbozognigbe, the Allada- Tofa-Ze medical health coordinator, only 18% of children under five and 31% of pregnant women sleep under mosquito nets. Also, the SP intake was reported to be less than 30%. For Dr. Etienne Guidi, the Ze medical officer, people have a tendency to sell the nets when they collect them at the health centers. Other problems raised were the widespread belief that malaria is caused by Participants attending Ze health zone community mobilization. food and exposure to sun and the low use of laboratory tests to confirm cases of malaria within the local hospital, which now has new equipment and trained staff.

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Under the leadership of the health department direction, ARM3 supported a social mobilization event on November 28, 2012. Other people involved were local health officials, mayoral representatives, civil society members, and several opinion leaders. ARM3 developed a pamphlet full of key messages urging recipients to speak loudly to their constituencies about malaria. A motorized car was used to mobilize people and disseminate messages about prevention, diagnosis and treatment. Health workers from Ze health zone took the lead in passing messages to the people covering three themes including prevention, diagnosis, and treatment. The Ze event was covered by the ORTB national TV station during the news hours twice after the event. The Kini Kini Promotion Agency was hired to shoot a 3 minute mini report, which was aired on four Benin television stations during the last two weeks in December 2012, including ORTB. For the first time, ARM3 addressed the problem of the distribution of chloroquine by local health providers. The increased resistance of the malaria parasite to chloroquine is widely known, and the WHO strongly discourages its use as it is no longer an effective medication. However, in Benin it appears that it is often taken because of its easy availability. This creates confusion when SP and ACT intake is recommended, as shown by people’s comments after the caravan, presented in Annex 3.

Implementation of BCC campaign Organized NGOs training curriculum and tools elaboration workshop Community mobilization activities are important for ensuring the involvement of target audiences in project implementation at all levels and for improving malaria services in health facilities. Selected local NGOs will be sub-granted to conduct community dialogue to promote key malaria-related practices and behaviors among community-based beneficiaries. In preparation for the training of these NGOs, Africare organized a two-day workshop from October 10 to 11, 2012 in Lokossa to review and update existing community mobilization tools currently in use by other partners and projects in the country. Participants included the NMCP, ARM3, Africare and other partners implementing community-based interventions in the country. During this workshop an NGO’s performance plan was developed and materials were reviewed including: training curricula and modules, monitoring and evaluation tools and forms and programmatic and financial reporting templates. Selection of Sub-grantees The tender for the recruitment of NGOs in Atlantique and Oueme- Plateau departments was launched by Africare on October 12, 2012. Thirty five (35) applications were received and analyzed by a review committee composed of Africare and MCDI staff based on the following criteria:  Be a legally established local NGO in Benin;  Be based in the target health zone with a functional field office in the target health zone for at least one year;  Demonstrate past performance of at least three-years and proven experience in Behavior Change Communication and community-based health related activities;  Have at least one-year proven experience in implementing malaria related activities;  Have a clear internal institutional organization with appropriate separation of administrative roles and responsibilities;  Have an organizational chart with qualified personnel;  Demonstrate a monitoring and evaluation system for the activities to be implemented; and  Demonstrate sound accounting and financial systems including internal controls.

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Twelve (12) NGOs were shortlisted and proceeded to the second phase consisting of an on-site visit and pre-award evaluation. The on-site visits were conducted from November 15 to 20, 2012 by a team composed of Africare, MCDI and the departmental NMCP staff. The interviews were based on Africare’s Sub Grantees Pre-Award Evaluation Form reviewed by MCDI. Issues such as legal status, office space, personnel and staffing, cash and banking, accounting system, audit, procurement, equipment and inventory were assessed and verified for each NGO. At the end of the exercise, eight (8) local NGOs, one per health zone were selected. After evaluating interview forms, the visiting teams proposed the selection of the following NGOs:

Health Districts Selected NGOs Porto Novo-Agugues-Seme Kpodji Autre Vie Adjohoun-Bonou-Dangbo Fondation Joseph The Worker Pobe-Adja Ouere-Ketou GADMIRE Sakete-Ifagni ASPAIF Ouidah-Kpomasse-Tori Bossito CERPADEC Abomey Calavi-So Ava La Vie Nouvelle Allada-Ze-Toffo OPESVAT Avrankou-Adjara-Akpro Misserete Jeunesse Ambition

Selected local NGOs orientation workshop The eight (8) selected NGOs’ directors and program managers were invited to a two-day orientation held in Porto-Novo from December 13 to 14, 2012. The agenda included review of the NGOs’ scope of work and responsibilities, performance framework, work plan, budget, and proposed agreement to be signed with Africare. Also present at this orientation session were: the NMCP, the Departmental Health Director and the targeted health zones’ coordination teams. The different documents of the project were reviewed by all twenty seven (27) workshop participants and consensus was reached on all of the documents. Selected local NGOs training on malaria and BCC approach The program managers and project animator of the eight (8) selected NGOs were trained in Ouidah on malaria prevention, treatment, and the NMCP/ARM3 BCC approach. They will in turn facilitate the community health workers’ (CHW) training in their respective health zones. One health worker was designated by each health zone coordinator to attend this three-day training and will support the NGO in the CHW training and supervision. Twenty one (21) participants, sixteen (16) from NGOs and five (5) health workers, were trained during the workshop held from December 20 to 22, 2012. It was facilitated by a local consultant.

Assisting local NGOs in implementing community engagement activities Africare will integrate gender equality into all ARM3 strategies and activities. It was discussed with the local NGOs during their orientation and training that community health workers should preferably be female; the sensitization sessions to be conducted on malaria by the community health workers will have as a primary audience mothers and pregnant women and thus contact with these groups is expected to be more comfortable if the CHWs are women. It is also important to emphasize that husbands play an important role in supporting their wives to adhere to practices and behaviors with respect to malaria prevention and treatment that they shall learn and adopt.

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Africare’s ARM3 staff based in the Abomey regional office participated in all meetings and activities of this office and also provided support to ARM3 staff in Cotonou, including the following:

 An informational show on malaria was given to an audience of mothers, pregnant women, and other caretakers of children under five years of age at Djidja and Pobè communes. This show took place in the presence of local authorities, the health zone coordination team, and other community leaders and was recorded and broadcast on local community radio on October 30, 2012 in Pobè and on November 30, 2012 in Djidja. In each commune, sixteen (16) women participated in an instructional game answering questions from the organizers. Prizes were given to participants who provided correct answers to questions.

Performance Improvement Approach Performance is defined as an achievement or an accomplishment in a given area and takes into account the improvement of quality in order to achieve the desired results. Performance level of the health system means access and use of services by those who need it; with adequate quality care and efficient use of resources by organizations that learn, adapt and improve for the future.

Performance Improvement (PI) is an approach that goes beyond assessment, planning and implementation activities to include advocacy support, research and obtaining resources for achieving results. The performance improvement model is developed in five stages:  The performance analysis: Identify gaps between actual and desired performance. It takes into account the current institutional context within which the organization, its mission, goals and strategies used.  Identification of root causes of deficiencies in relation to the desired performance. These root causes are identified after a detailed analysis which aims to highlight the root causes. Several methods are used such as "five whys", the fish bone diagram, the problem tree.  The selection of priority interventions: Aims to focus actions on the root causes, taking into account the commitment of stakeholders (providers, recipients) and their skills.  Implementation of selected intervention that follows a detailed planning of activities by the actors.  Monitoring and evaluating the activities and performance throughout the process and recognizing the performance achieved and reprogramming corrective actions if necessary.

The Improvement Collaborative is a collaborative learning model that enables teams to achieve breakthrough improvements in quality and cost reduction. In order to do so, a dynamic learning system is created, where teams from different sites collaborate to share and rapidly scale up strategies for improving the quality and efficiency of health services in a particular technical area.

The Leadership Development Program (LDP) is a six to eight month transformational process that empowers teams to apply proven practices in leadership and management to face real challenges and achieve measurable results. The LDP consists of six key elements: a Training of Facilitators Workshop, a Senior Alignment Meeting, four three-day workshops scheduled over a period of six months, two Collaborative Approach Learning Sessions, and a Results Presentation Meeting at the end of the process to assess results and select proven practices and operational successes to scale up and institutionalize into MOH policies, norms and standards.

The Leadership Development Program (LDP) Plus builds on the lessons of ten years of field experience in 40 countries of the LDP. The BASICS project in Benin applied an adapted version of the LDP in its work in 5 Health Zones. This new version of the LDP retains the process for empowering teams to face

44 | P a g e challenges and achieve results. And it adds new materials to improve country ownership, public health impact, scale-up, and government-civil society ownership.

It is assumed that the integration of LDP Plus and IC will create a synergistic effect that will strengthen the positive effects of both approaches. The LDP plus approach will be strengthened by its capacity to contribute to measurable health impact by incorporating the IC approach to focus on operational improvements in service delivery processes. And the IC approach will be strengthened by the LDP Plus in that LDP Plus will strengthen the capacity of managers and leaders to support the process of on-going service delivery components, to scale up proven practices and institutionalize them, thus ensuring sustainability.

Whatever the levels of intervention, the five stages of PIA described above consist of identifying gaps between current and desired performance, identifying the root causes, and selection of appropriate interventions. With regards to the implementation of priority interventions, several strategies can be used at the implementation level (central, intermediate, and hospitals EEZS). ARM3 in the implementation of the PIA offers the following strategies for different levels:  Central level: LDP  Intermediate: LDP  Health Zone: LDP + (LDP and collaborative)  National and departmental level hospitals: LDP + (LDP and collaborative)

Achievements

Quality Assurance/Quality Improvement MSH engaged the services of a consultant to develop an overview and plan for IC, review the MOUs, 3- year strategic plans and annual operational plans that ARM3 is developing alongside the DDS and HZs; review the progress made in the application of LDP and provided recommendations on how to integrate the application of the IC and LDP+ within the framework of implementing the MOUs; and develop criteria for the selection of the initial health zones and ensure appropriate implementation in Oueme-Plateau (OP) DDS and Atlantique – Littoral DDS. Under the leadership of MSH, ARM3 will focus on improving selected ARM3 indicators. Within the framework of the implementation of performance improvement approach of the health system on the level of the Health Zones (HZ) and hospitals, ARM3 started the process of Leadership and Development Program (LDP) training directed at the Health Zones (ZS), hospitals and Departmental Malaria Teams (DMT) of the departments of Ouémé-Plateau and Atlantic-Littoral. At the same time these same actors are elaborating / updating their three year strategic and annual operational plans. As part of the annual operational plan ARM3 staff is now introducing the collaborative approach for quality assurance at the facilities level. Collaborative Improvement As mentioned earlier, ARM3 developed a strategy document for the implementation of the collaborative approach with links to LDP. Management and training tools for the implementation of this approach have been updated with the technical support of the consultant and three resources persons that have implemented it in the Zou-Colline Health Department. The documents have been forwarded to the NMCP for approval. An orientation to the collaborative approach for the managers of the seven health zones in the Atlantique- Littoral and five health zones in the Oueme-Plateau Health Department was held in December 2012. A

45 | P a g e total of 32 participants (of which 15 were women) from the Atlantique-Littoral department and 46 (of whom 7 women) from the Ouémé-Plateau department participated. The purpose of the orientation was to seek to orient and advocate to the quality assurance approach proposed. During this orientation workshop, the planning for the Health Zones for the implementation of the approach during the next quarter was chosen. Leadership Development Program (LDP) activities The second workshop on the LDP for the 12 health zones constituting the Atlantic-Littoral (seven) and Ouémé-Plateau (five) departments could not be held as a result of the non-availability of the mains actors. It has been deferred to the beginning of the t January – March quarter and two successive workshops (2 and 3) will now be planned. The follow-up visits after the first LDP workshop to the participating teams by the LDP trainers took place during October and made it possible to appreciate that the majority of them had not carried out all the activities which were assigned to for period between the 1st and 2nd workshop. The reason evoked by the participants was lack of funds to carry out the activities assigned. Assist DDS and HZ of Oueme-Plateau and Atlantique-Litoral in preparation of Strategic and Malaria Operational Plans Throughout the October – December 2012 quarter, ARM3 worked closely with the health zones constituting the Oueme- Plateau (five HZs) and Atlantique-Littoral (seven HZs) Health Departments to finalize and validate their three-year malaria strategic and annul malaria operational plans with the full participation of the NMCP, respective DDS and ARM3. The Abomey-based ARM3 regional team organized a workshop for Oueme- Plateau DDS and five HZ staff to validate the annual plans that will serve as the basis of the partnership with the ARM3 project. The workshop was attended by During the validation of HZ plans and signature of MOU’s 18 (2 women) managers from the Ouémé Plateau health zones to identify the activities prioritized by the ARM3 interventions and for which funding was available and those that the health zones needed to seek other partners, such as CRS, Africare, community based funding, other international organizations, World Bank, etc. to carry out. In the Atlantique-Littoral DDS, ARM3 chose to work individually with each health zone to review and validate their strategic and annul plans. One major addition to the action plans has been the inclusion of the collaborative approach. The action plans developed were validated for the 12 HZs from Atlantique-Littoral and Ouémé-Plateau. The modification for the separation of roles and responsibilities between the DDs and the health zones for the collaborative approach are under preparation. Finalize Memoranda of Understanding with hospitals and health zones ARM3 signed MOUs with health zone Medical Coordinators and the Departmental Director of Health for Oueme-Plateau during an orientation meeting with the managers of the health zones – orientation covered how the HZs would be evaluated; financial reporting responsibilities; and activities reporting. In a 46 | P a g e two day workshop for the Atlantique-Littoral participants, the second day of their workshops covered a similar orientation. The DDS MoUs are deferred to January 2013.

Program Management

Home Office Backstopping and Reporting Achievements DDS Oueme-Plateau.

Second Annual Work Plan and Budget Preparation MCDI’s HO supported the FO in the preparation of the Second Annual Work Plan and budget and based on feedback received from the Mission, MCDI updated (to mirror Benin Mission’s operational plan) the second year work plan and resubmitted it to USAID/Benin.

Year 1 (October 1, 2011 to September 30, 2012) ARM3 Performance Report MCDI’s HO supported the FO in the preparation of the ARM3 Year 1 performance report that presented the achievements and challenges of the ARM3 during the first year (October 1, 2011 to September 30, 2012) of program implementation.

Procurement of Microscopes As part of ARM3’s strategy to improve FSS teaching laboratory and improve skills of pre-service training of students, MCDI’s HO supported the FO in initiating the process for procuring microscopes.

MCDI STTA Travelled to Benin MCDI engaged the services of Mr. Alain Daudrumez to provide short-term technical assistance (December 6 t- 20, 2012) to the ARM3 team by developing a LLIN distribution plan to be carried out along with member enterprises of our private sector partner, CEBAC-STP. Prior to the Consultant’s departure to Benin, the HO prepared and shared salient ARM3 project documents and forms that it adapted from MCDI’s experience in distributing LLINs in Equatorial Guinea. Materials developed for the Benin distribution exercise included the preponderance of the distribution planning tools and templates: the GIS, the geo-reference databases, etc; the HO also provided CEBAC-STP with several newly developed IEC materials for review during the planned workshop in January 2013. The HO coordinated with DELIVER, the Mission, and SIMTRAM to ensure that the port clearance of the LLINs and their warehousing would be properly organized.

OTSS Round 9 analysis: Home office completed the OTSS Round 9 analysis whose data were collected in June 2012. This round of OTSS collected data from 46 new health facilities and the subsequent analysis compared the results from these new health facilities to those previously collected during OTSS Round 8. The analysis essentially compared a group of health facilities that had been visited by OTSS supervisors on 4 separate occasions to a brand new group of facilities just entering the OTSS quality assurance program. A full report in addition to key findings can be found as an annex to the ARM3 Program Year 1 Annual Report.

Indicator Tables for ARM3 Program Year 1 Report: Home office helped compile the information included in the indicator tables for the recently submitted ARM3 annual report. The home office worked in

47 | P a g e close collaboration with the developer of the RMIS database to pull the relevant data for subsequent analysis and inclusion in the annual report. A number of recommendations for improving ARM3 M&E activities and the project’s PMP itself were able to be suggested for future implementation. For more information, please refer to the Remarks and Gap Analysis section of Annex 1 to the ARM3 Year 1 Annual Report.

M&E and PMP Dashboards: Home office has reached out to the ARM3 field office and the NMCP to collect the necessary information to build a set of dashboards. The first is designed to track ARM3 internal progress on achieving its goals/objectives laid out in the project’s PMP. A preliminary version has been created and sent to the field office for review and feedback. The second dashboard is meant to provide a means to track progress on the indicators selected to accompany the RMIS data stream.

An example of the PMP dashboard functionality is shown below.

IPTp2 1.1.2: Proportion of women attending antenatal clinics who receive IPT2 under direct observation by a health worker will reach 85% 1.1.1 Targets Measurements 100% Baseline 3.00% 90% Year 1 65% 22.80% 85% 80% 80% Year 2 75% Year 3 75% 70% 70% 65% Year 4 60% 49.20% Year 5 85% 50% 40% 28.10% 1.1.2 Targets Measurements 30% Baseline 28.10% 20% Year 1 65% 49.20% 10% Year 2 70% 0% Year 3 75% Baseline Year 1 Year 2 Year 3 Year 4 Year 5 Year 4 80% Year 5 85% Measurements Targets

1.1.3 Targets Measurements Baseline The data entry portion of the dashboard includes fields for indicator Year 1 0 0 Year 2 466 targets and year-to-year measurements both of which are linked to Year 3 0 corresponding graphs that bear the name of the indicator in question Year 4 0 and show annual progress against preset targets. Year 5 0

Meeting with ARM3 Consortium partners MCDI’s HO held individual meetings with ARM3 consortium members, Africare, JHU-CCP and MSH. The objective was to assess status of year 1 program implementation by the partners and bring to closure any pending deliverables.

With MSH, a time frame to finalize the consultancy report on linking the collaborative approach to the leadership development program and the pending EUVS report was reached. ARM3 has submitted to the Mission the French and English versions of the consultant’s report on the implementation of the collaborative approach in the Atlantic-Littoral and Oueme-Plateau health zones as a complement to our

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LDP program for quality assurance. MCDI worked closely with MSH in finalizing the EUVS report which MSH is currently in the process of copy editing for final publication.

With JHU-CCP, an agreement was reached on when to finalize the ARM3 BCC Strategy and literature review. The MCDI HO tapped into the vast experience of its Equatorial Guinea technical staff and provided extensive feedback in refining and finalizing the two documents – BCC strategy and literature review on barriers to IPTp.

With Africare, a consensus was reached to accelerate the implementation of community BCC activities.

Human Resources In the time that Dr. Thior has been with ARM3, MCDI has come to appreciate his considerable amount of skills and experience. By fostering a closer working relationship with the National Malaria Control Program (NMCP), Dr. Thior earned the NMCP Coordinator’s confidence. MCDI decided that Dr. Thior’s continued presence would strengthen and enhance all aspects of technical coordination and ensure the continued success of the project. He has been offered a key position in the ARM3 project, and MCDI is in the process of seeking approval of his candidature for the re-defined key position of Technical Coordinator. This key position replaces the key position of Case Management Officer. The incumbent in that key position completed his one year contract with ARM3 and his contract was not renewed.

Major Challenges (per ARM3 sub-result): Sub-Result 1.1: (IPTp uptake increased)

 Attempts to convene the Case Management TWG to discuss the WHO recommendations on IPTp administration until child birth were postponed due to unavailability of University staff. Sub-Result 1.2: (Supply and Use of LLINs Increased)

 The successful transfer of LLINs to private sector employees, without loss, theft and recovery of costs. Sub-Result 2.1 (Diagnostic Capacity and Use of Testing Improved)

 Introduction of RDT use at the community level  Adequate RDT management and use at the health facility level Sub-Result 2.2 (Case Management of Uncomplicated and Severe Malaria Improved)

 The rapid transfer of funds to HZs and implementation and effective activities planned by the 12 health zones in Oueme-Plateau and Atlantique – Littoral.  Strict monitoring of the activities of the 12 health zones Sub-Result 3.1 (Capacity to Deliver and Manage Quality Malaria Treatment and Control Interventions Improved)

 Adoption of new WHO guidelines recommending that SP for IPTp be administrated up until child birth Sub-Result 3.2 (Capacity to Collect, Manage and Use Malaria Health Information for M&E and Surveillance Improved)

 Increase the completeness of the database from 66 to 80% by the end of the second year of ARM3  Reduce the error rate from 24.8% to 5% by the end of the second year of ARM3 implementation 49 | P a g e

Sub-Result 3.3 (Capacity in Commodities and Supply Chain Management Improved)

 Reaching agreement on a utilization/distribution plan for the rational utilization of RDT  Developing a procurement plan that all partners buy into (UNICEF, Africare, CRS, NMCP, USAID)  Reduce the amount of drugs likely to expire in 2013 (more than 400,000 doses will begin expiring in April, June and September 2013) Cross Sectional Activities (Behavior Change Communication)

 BCC activities alone might not be sufficient to tackle and stop chloroquine use by Beninese people  From time to time we are informed that some health zones have suspended free distribution of LLINs. This was the case in Ze when the ARM3 BCC team was preparing the community event held on November 29, 2012.

Major Activities Planned for next quarter (Jan – Mar):

RESULT 1: Implementation of malaria preventions in support of the National Malaria Strategy improved  Continue to support radio programs  Continue airing TV spots with a local soccer player around the African Cup of Nations  Get the approval of two other new TV spots by the BCC working group  Present ARM3’s BCC strategy to the BCC working group for feedback  Support one social mobilization event in Oueme Plateau  Collaborate and contribute to the launch of the private sector event in Cotonou by providing orientation, preparing pamphlet, and producing T-shirts, banners  Organize training of trainers in interpersonal communication Support BCC working group’s activities  Conduct qualitative research on barriers to SP for IPTp  Distribute IEC materials  Secure contract with one local agency to develop BCC materials and tools

RESULT 2: Malaria Diagnosis and Treatment activities in support of the National Malaria Strategy improved  Make contacts with the Zou-Collines Health Department and present to them the objectives and strategies of ARM3  Workshop of elaboration/validation of the plans of ZC on the tools of follow-up-evaluation and financial management within the framework of MOU  Follow-up of the implementation of the activities retained in HZ’s plans and Zou-Collines Health Department  Training of trainers (training of qualified staff) on the collaborative approach  Installation of the management bodies (QAR) in the first health facilities selected for the collaborative approach  Data collection and calculation of basic indicators in the context of the implementation of collaborative  Monitoring the implementation of the activities identified in the work plans of the Oueme-Plateau Health Department  Validation of the plans and signature of the MOUs with Health Departments 50 | P a g e

Follow-up on the implementation of the activities retained in the HZ and the DDS’ plans Workshops 2 and 3 of Leadership and Development Program Post LDP workshop follow up Planning and follow up of related activities with DSME Planning and followed up of activities with NMCP: update, validation and multiplication of training documents followed by the starting of the training Training of 36 Bio Technologists (Atlantique – Littoral, Oueme-Plateau and Zou-Collines) Organization of workshop writing SOPs for malaria diagnosis Recruitment and training of 12 -14 new supervisors

RESULT 3: The national health system’s capacity to deliver and manage quality malaria treatment and control Train staff (ARM3, SNIGS, DDS, Health zones) on SGSI/RMIS and on LOGISNIGS maintenance Evaluate the strengths , weaknesses and constraints, to the collection , review and prompt submission of quality data Publish PALU INFO quarterly newsletters Conduct PITA Quarter 1 implementation review Support organization of monitoring and evaluation TWG meeting Organize 3 meetings for quarterly validation of RMIS data Monitor routine data quality assurance

51 | P a g e ANNEX 1: OTSS Data – Rounds 8 & 9 (Groups A, B, C, D) vs. Round 10 (Groups A, B, C, D)

All current health facilities enrolled in the OTSS supervision scheme (Groups A, B, C, D; N=118) are presented below following the prescribed indicators for OTSS in Benin. For each indicator, Groups A, B, C, and D from Rounds 8 & 9 are compared against the most recent, aggregate values (i.e. weighted averages, sums) of the health facilities comprising Groups A, B, C, and D from Round 10 (N=118). This is essentially an analysis of the first visit, under the ARM3 project, of all 118 Health Facilities (Rounds 8 & 9) against their second visit (Round 10). For the purposes of this report the Reference Group will represent those facilities from OTSS Rounds 8 & 9 while the Comparison Group will represent facilities from OTSS Round 10.

IMaD ARM3 Fiscal Year 2009 2010 2010 2010 2011 2011 2011 2012 2012 2012 Quarter 4 2 3 4 3 4 4 2 3 4 Round 1 2 3 4 5 6 7 8 9 10 1 36 (A) 24 (B) 13 (C) 46 (D) 2 36 (A) 24 (B) 13 (C) 46 (D) 3 36 (A) 24 (B) 13 (C) 4 36 (A) 23 (B) 13 (C) 5 36 (A) 23 (B) 13 (C) 6 36 (A) 23 (B) 7 36 (A) 23 (B)

8 36 (A) 23 (B) Visits by Health Facility Groups Facility Health by Visits 9 36 (A) Cumulative Sites by 36 60 60 60 72 72 72 72 46 118 Round

Health Facility Resources The resources available to a health facility significantly influence the ability of laboratory staff and clinicians to effectively complete their tasks. This section is intended to present a picture of the resources currently available to health facilities. The resources evaluated include those that are most important for malaria diagnostics. Effective and timely diagnosis of malaria is the most important factor leading to positive treatment outcomes. Positive outcomes are significantly hindered by misdiagnoses, delays, stock outs, and malfunctioning equipment (microscopes or RDTs).

Indicators FY12 Targets Report Against Reference Number and Percent of Functional Microscopes Group Percent of Health Facilities Experiencing Stock-outs Interrupting Malaria < 5% of those observed Microscopy Number and Percent of Health Facilities with Recommended SOPs & Bench Report Against Reference Aids Group Report Against Reference Number and Percent of Health Facilities using RDTs Group

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Table 1: Number and Percent of Functional Microscopes

Ratio of Functional Functional Non-functional Total Microscopes Microscopes (Average of Facilities Microscopes Microscopes Facility-Specific Ratios) Reference Group 231 113 344 73.4% 118 Comparison Group 219 120 339 69.5% 118

Findings:

Functional microscopes are vital to increasing volume of malaria microscopy completed and to ensure high quality of results. To monitor the level of functional microscopes, OTSS records the number of functional and broken microscopes which we can then be used to calculate a ratio of functional microscopes.

 There is a negative change in the ratio of functional microscopes between the Reference Group (73.4%) and the Comparison Groups (69.5%). Similarly, the overall proportion of non-functional microscopes recorded by the Baseline Group (32.8%) was lower than that recorded by the Comparison Groups (35.4%).

Interpretation and Recommendations:

 Among the facilities that are enrolled in OTSS, all were noted as having functional microscopes, however, there is still a large number of non-functional microscopes which, if they were functional, may provide increased capacity for microscopy and thus reduce turnaround time.  While facilities with a lab are a subset of the malaria diagnostic infrastructure in Benin, they play an important role in providing low cost, consistent confirmation of malaria diagnosis as well as allow for speciation and evaluation of severity of illness. For these reasons, additional support should be given to continue to improve the ratio of functional microscopes and scale of microscopy within Benin.

Table 2: Percent of Health Facilities Experiencing Stock-outs that Interrupted Microscopy

Percent of Health Facilities Experiencing Stock-outs that Interrupted Microscopy 10.0% 9.1% 9.0% 8.0% 7.0% 6.0% 4.9% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% Reference Group Comparison Group n=108 (Facilities Reporting) n=112 (Facilities Reporting)

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Findings:

 The rate of stock-outs interrupting malaria microscopy more than doubled from the Reference Group to the Comparison Group. The percent of facilities with stock-outs in both groups was relatively low. The stock-out rate of materials essential to conduct malaria microscopy was not able to reach the FY12 target of <5%.  Of note, 1 facility from the Reference Group reported a stock-out of microscopy slides, another facility reported a stock-out of lancets, 2 facilities reported a stock-out of Giemsa, and 3 facilities reported a stock-out of Methanol. In the Comparison Group there were no reported stock-outs of microscopy slides, lancets, or Giemsa, but 2 facilities reported a stock-out of Methanol.  The increase in reported stock-outs from the Reference Group to the Comparison Group is due to

increases in stock-out items such as: KH2PO4, Na2HPO4, pH paper, and Field Stains A & B.

Interpretation & Recommendations:  The procurement practices in place for microscopy supplies should be reviewed to ensure continuous stock of necessary items for malaria microscopy.  Supervisors conducting the OTSS supervision visits should reiterate that stock-outs should only be noted if they cause interruptions to the normal practice of malaria diagnostics. For instance, if a facility reports a stock-out of markers, the supervisor should follow-up to ensure that a stock-out of this sort did indeed cause disruptions/interruptions to malaria microscopy. If it did not then it should not be recorded as a stock-out.

Figure 1a: Percent of Health Facilities with Recommended Malaria Reference Materials (SOPs & Bench Aids)

Percent of Health Facilities Missing Recommended SOPs and Bench Aids 90.0% 85.2% 77.2% 80.0% 70.0% 58.0% 60.0% 50.0% 40.0% 30.3% 30.0% 20.0% 10.0% 0.0% % of Health Facilities Missing SOPs % of Health Facilities Missing Bench Aids n=114 | n=117 (Facilities Reporting) n=117 | n=118 (Facilities Reporting)

Reference Group Comparison Group

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Figure 1b: Percent of Health Facilities with Recommended Malaria Reference Materials (SOPs & Bench Aids) – Detail by type of SOP/Bench Aid

Percent of Facilities Missing SOPs & Bench Aids 97.4%

100.0% 91.2%

90.4%

89.7%

85.1% 82.9%

90.0% 81.2%

74.6%

74.4%

72.8% 71.1%

80.0% 71.1%

70.2%

69.3%

68.4% 68.4%

66.7%

63.2% 63.2% 63.2%

70.0% 61.5%

59.8%

58.1%

55.6%

54.7%

53.8%

52.1% 52.1%

60.0% 51.3%

50.4%

49.6%

47.4% 45.3%

50.0% 43.2%

35.6% 33.9%

40.0% 31.4%

28.0%

26.3%

24.6% 24.6%

23.7% 23.7% 30.0% 23.7% 20.0%

10.0%

0.0% 0.0% 0.0% 0.0% 0.0%

Reference Group Comparison Group

Figure 1c: Number of Health Facilities with Recommended Malaria Reference Materials (SOPs & Bench Aids) – Detail by type of SOP/Bench Aid

Number of Facilities Missing SOPs & Bench Aids 140

120 111

105

104

103

97 97

100 95

87

85

83

81 81

80 80 80

79

78

74 74 74

80 72

70

68

65

64

63

61 61

60

59

58

54 53

60 51

42

40

37 33

40 31

29 29

28 28 28

20

0 0 0 0 0

Reference Group Comparison Group

Total Facilities (Reference Group) N=118 Total Facilities (Comparison Group) N=118

Findings:

 Malaria laboratory standard operating procedures and bench aids are recommended to be present in every lab conducting diagnostic testing. They provide reference tools on a range of laboratory tasks to help support high quality diagnostics. This is particularly important during

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times of staff turnover or when diagnosticians are required to work across multiple diagnostics tests in addition to malaria microscopy and RDTs.  In every instance there were more SOPs and bench aids reported to be present in the Comparison Group when compared to the Reference Group. This may be due to the distribution of certain SOPs and bench aids to the facilities included in the OTSS supervision scheme.  It’s very clear that a large proportion of facilities included in the OTSS supervision scheme are lacking recommended SOPs.  Although figure 1.a shows that about 30% of facilities are missing Bench Aids, all health facilities enrolled in the OTSS quality assurance program (and even those that are not) have received the suite of Bench Aids distributed by the project during OTSS Rounds 8 & 9. There is an apparent issue with the manner in which these data are collected. Project staff are aware and will communicate the problem to the teams conducting the supervisory visits.

Interpretation & Recommendations:

 The IMaD project recommended that the recent bi-lateral agreement (ARM3 project) continue the distribution of the IMaD-produced bench aids and also utilize the OTSS data to quickly identify where bench aids should be delivered. Additionally, bench aids could be delivered by future diagnostic quality assurance visits.

Table 3: Number and Percent of Health Facilities using RDTs

Reference Group Comparison Group n % n % RDTs Used 81 68.6% 91 77.1% RDTs Used, but Out-of-Stock 8 6.8% 2 1.7% RDTs Not Used 25 21.2% 15 12.7% No Data/Unknown 4 3.4% 10 8.5% Total 118 100% 118 100%

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Figure 2: Proportion of Facilities using RDTs by RDT Status

Health Facilities by RDT Status 100.0% 90.0% 77.1% 80.0% 68.6% 70.0% 60.0% 50.0% 40.0% 30.0% 21.2% 20.0% 12.7% 6.8% 8.5% 10.0% 1.7% 3.4% 0.0% RDTs Used RDTs Used, but Out-of-Stock RDTs Not Used No Data

Reference Group Comparison Group n=118 (Facilities Reporting) n=118 (Facilities Reporting)

Findings:

 The proportion of RDT stock-outs, in facilities that otherwise use them for malaria diagnosis, has markedly declined when comparing the Comparison Group to the Reference Group.  Ten (10) additional facilities within the Comparison Group were recorded as using RDTs when compared to the Reference Group.

Interpretation and Recommendations:

 Consistent and reliable RDT stocks are critical in the continued improvement of malaria diagnostics and movement to ensure confirmation of suspected malaria cases. Chronic RDT stock-outs lead to multiple problems including unfamiliarity of RDT procedures and mistrust of test results. It is imperative that supply chain and funding mechanisms continue their support to ongoing national malaria objectives.

Training & Staffing Health facility personnel play a key role in implementing programs that are put in place to enhance the effectiveness of a health system. This section is intended to give an understanding of the personnel that are currently working throughout the health system. The information contained in this section can be used to identify facilities where on-the-job training will improve the quality of diagnoses.

Indicator FY12 Target Number of On-Site Trainings Conducted in Malaria Diagnostics 2 per OTSS visit per staff type Number of Staff Attending Formal Training During Previous Year Report Against Reference Group Average Number of Laboratory Staff Per Facility Report Against Reference Group

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Table 4: Number of Formal and Informal (On-site) Trainings Conducted in Malaria Diagnosis by Staff Type and Sex

Laboratory Technicians Health Workers/Clinicians Total Male Female Male Female Reference Group n=118 (Facilities Reporting) 123 48 76 92 339 Comparison Group 110 55 53 85 303 n=118 (Facilities Reporting)

Findings:

 The number of trained individuals from the Comparison Group is only slightly less than the number recorded within the Reference Group, 303 trainings versus 339 trainings, respectively.

Interpretation and Recommendations:

 Consistent (re)trainings create an environment of accountability and interest in professional development. The longer that OTSS visits are occuring at a facility the number of trainings should natually decrease as the quality of diagnostics improves. However, it is critical to continue onsite trainings to foster a professional enviroment. Additionally, it will limit back sliding and can focus on new employees who have not benefitted from previous trainings.

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Figure 3: Average Number of Laboratory Staff by Type

Average Number of Laboratory Staff by Type 6

5 4.45 4.35

4 3.30 3.10 3.00 2.91 3

2

1

0 Average Full-time Staff Average Full-time Malaria Staff Average Full-time Diagnostics Staff

Reference Group Comparison Group n=114 (Facilities Reporting) n=113 (Facilities Reporting)

Findings:

 There is essentially no difference in laboratory staff type between the Reference Group and the Comparison Group.  Full-time staff includes Biomedical Scientists, Laboratory Technicians, Laboratory Assistants, Students/Interns, and Nurses Aids.  Due to apparent limitations with data from the Comparison Group, it is not possible to calculate the average number of trainings given to clinical and laboratory staff.

Quality Assurance Proper equipment, well trained personnel and effective quality assurance systems are essential for a properly functioning health system. The purpose of this section is to present information on the quality of malaria diagnoses and the efficient use of resources. This information can help determine how quality-of- care can be increased through improved diagnoses and identifying ways through which resources can be utilized more effectively. Quality assurance activities are also important for the overall improvement of laboratory and clinical staff. These activities enable staff members to assess how well they are currently doing and to set goals for their future improvement.

Indicator FY12 Target Percent of Facilities Performing Malaria Microscopy Using Appropriate 90% of tasks correct Guidance Percent of Facilities Performing RDTs Using Appropriate Guidance 90% of tasks correct Percent of Facilities Complying with Results of Negative Tests 75% compliance Report Against Number and Percent of Facilities Performing Internal Quality Assurance Tasks Reference Group Percent of Health Facility Slides Read Correctly 100% agreement

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Figure 4: Percent of Facilities Performing Malaria Microscopy Using Appropriate Guidance

Percent of Facilities Performing Malaria Microscopy Tasks Using Appropriate Guidance 100.0% 88.2% 88.2% 87.4% 90.0% 86.5% 86.1% 87.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Slide Prep Avg Score Slide Reading Avg Score Combined Slide Prep/Reading Avg Scores n=111 | n=116 (Facilities Reporting) n=111 | n=114 (Facilities Reporting) n=110 | n=114 (Facilities Reporting)

Reference Group Comparison Group

Findings:

 Very little change, if any, can be seen in the performance of facilities between the Comparison Group and the Reference Group in conducting malaria microscopy tasks according to appropriate guidance.  Overall, the facilities within the Comparison Group were only 3 percentage points from the desired target of 90% of facilities performing malaria microscopy tasks using appropriate guidance.

Interpretation and Recommendations:

 Moving forward, the recommendation to conduct 4 quarterly visits for new facilities entering the quality assurance program and then transitioning them to biannual visits still stands. By scaling back the frequency of visits valuable resources may be conserved while still maintaining the progress already been made.

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Figure 5: Percent of Facilities Performing RDTs Using Appropriate Guidance

Percent of Facilities Performing RDT Tasks Using Appropriate Guidance 100.0% 88.4% 88.8% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Reference Group Comparison Group n=67 (Facilities Reporting) n=79 (Facilities Reporting)

Findings:

 As is apparent for malaria microscopy tasks, there is essentially no difference between the performance of facilities from the Comparison Group when compared to that of the Reference Group in conducting RDT tasks according to appropriate guidance (88.4% versus 88.8%, respectively).  Just over 1 percentage point separates the performance of the facilities within the Comparison Group from the desired target of 90% of facilities performing RDT tasks using appropriate guidance.

Interpretation and Recommendations:

 Historically, RDT observation scores remain flat across visits (varying between 80% to 90% performance levels according to appropriate guidance) which may be due to intermittent stock- outs of RDT supplies (i.e. if facility staff have irregular access to RDTs, their ability to master the recommended procedures may be impaired).  RDT availability and logistics management must continue to be addressed. Additionally, the RDT observation component of OTSS remains valuable as it supports the maintenance of RDT diagnostics.

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Figure 6: Percent of Facilities Complying with Results of Negative Tests

Prescriber Adherence to Negative Test Results 100.0%

90.0%

80.0% 74.0% 75.1% 74.6% 74.3% 70.0% 70.0% 66.1%

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0% RDT Adherence Blood Slide Adherence Overall Adherence n=83 | n=85 (Facilities Reporting) n=65 | n=65 (Facilities Reporting)

Reference Group Comparison Group

Table 5: Frequency and Percentage of Treatments Prescribed to Negative Tests

Coartem Total % Coartem Fansidar Total % Fansidar Quinine Total % Quinine Reference Group n=118 (Facilities Reporting) 113 62.1% 1 0.5% 68 37.4% Comparison Group n=118 (Facilities Reporting) 99 62.3% 0 0.0% 60 37.7%

Findings:

 The proportion of facilities that do not prescribe antimalarial drugs to patients with negative malaria tests is higher among the Comparison Groups (74.3% overall) when viewed against the Reference Group (70.0% overall).  The majority of patients with negative malaria tests (from both groups) who were prescribed anti-malarial drugs received Coartem. The proportion of patients with negative malaria tests receiving Quinine held relatively constant from one visit (Reference Group) to the next (Comparison Group).  Use of Fansidar to treat patients with negative malaria tests has reached 0%.  Overall prescriber adherence to negative malaria tests (i.e. no treatment is given) for the more recently visited facilities within the Comparison Group has essentially reached the FY12 target of 75% adherence.

Interpretation and Recommendations:

 Consistent trainings create an environment of accountability and interest in improving the quality of case management. The longer OTSS visits have occurred at facilities, significant improvement to case management has been observed. However, it is critical to continue onsite trainings to 62 | P a g e

continue to foster a professional enviroment looking to improve patient outcomes and prevent anti-malarial drug resistant strains of the disease. Additionally, while RDT stock-outs are likely to continue in the near future it is important to encourage physcians to trust diagnostic testing rather than reverting to unconfirmed/symptomatic malaria diagnosis.

Figure 7a: Number of Facilities Performing Internal Quality Assurance Tasks – Reference Group

Number of Facilities Performing IQA Tasks Reference Group 140

120 4 12 87 83 87 34 33 100 93 80

60

40

20 29 11 32 27 82 83 104 113 0 Positive pH Meter Slides Re- Slide Results Slide Re- Slide Box Species ID Parasite Control checked Recorded Reading Storage Counting Reference Group - Performing IQA Reference Group - Not Performing IQA Total Facilities (N=118)

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Figure 7b: Number of Facilities Performing Internal Quality Assurance Tasks – Comparison Group

Number of Facilities Performing IQA Tasks Comparison Group

140

120 2 2 88 24 26 100 84 79 93 80

60

40

20 29 28 31 91 88 111 113 9 0 Positive pH Meter Slides Re- Slide Results Slide Re- Slide Box Species ID Parasite Control checked Recorded Reading Storage Counting

Comparison Group - Performing IQA Comparison Group - Not Performing IQA

Total Facilities (N=118)

Figure 7c: Percent of Facilities Performing Internal Quality Assurance Tasks

Percent of Facilities Performing IQA Tasks

Reference Group vs. Comparison Group

95.8% 95.8%

100.0% 94.1%

90.0% 88.1% 77.1%

80.0% 74.6% 70.3% 70.0% 69.5% 60.0% 50.0%

40.0%

27.1%

26.3% 24.6%

30.0% 24.6%

23.7% 22.9%

20.0% 9.3% 10.0% 7.6% 0.0% Positive pH Meter Slides Re- Slide Results Slide Re- Slide Box Species ID Parasite Control checked Recorded Reading Storage Counting

Reference Group - Performing IQA Comparison Group - Performing IQA n=118 (Facilities Reporting) n=118 (Facilities Reporting)

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Findings:

 Among the facilities in the Comparison Group, slide re-reading, slide box storage, species identification, and parasite counting are four IQA tasks that are already in place by a majority of facilities, overall, however, the number of facilities not performing the suite of IQA tasks far outweighs those that do.  Small increases in the proportion of facilities performing slide re-reading, slide box storage, and species identification can be noted when comparing the more recently visited facilities from the Comparison Group to the Reference Group.

Interpretation and Recommendations:

 Many IQA tasks are still not being performed and additional supervision, encouragement, and provision of necessary support materials must be provided to ensure that uptake of IQA tasks occur and are maintained.

Figure 8a: Number of Facilities by Number of Cross-checked Malaria Slides

Number of Facilities from Reference and Comparison Groups by Number of Slides Cross-Checked 45 39 38 40 36 36 34 34 34 35 32 33 33 32 32 32 30 27 25 25 20 18 15 14 15 13 13 10 5 0 1 Slide Cross- 2 Slides Cross- 3 Slides Cross- 4 Slides Cross- 5 Slides Cross- 6 Slides Cross- 7 Slides Cross- 8 Slides Cross- 9 Slides Cross- 10 Slides Cross- checked checked checked checked checked checked checked checked checked checked

Reference Group (Group D | Visit 1) n=39 Comparison Group (Group D | Visit 2) n=38

Figure 8b: Percent of Health Facility Slides Read Correctly

Agreement, Sensitivity & Specificity for Blood Slide Cross-Checking 100.0% 96.7% 97.0% 97.3% 94.5% 95.0% 94.1%

90.0% 85.7% 85.0%

80.0%

75.0% % Agreement between Supervisors and Sensitivity Specificity Malaria Microscopists

Reference Group Comparison Group n=111 (Facilities Reporting) n=107 (Facilities Reporting)

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Findings:

 It was not anticipated that data would be collected for this indicator during the first round of OTSS visits, as it is the supervisor’s responsibility to introduce a slide re-checking program at the facility. However, some supervisors read a number of slides during their Round I visit. It is important to note that the number of slides read at these facilities was not standardized nor was it to be considered “slide validation”; rather it was classified as a slide re-checking exercise.  Thirty-two (32) facilities from Group D had the recommended 10 slides cross-checked by the supervisors during their second round of OTSS compared to 13 from the first visit. Thirty-nine (38) of the 46 facilities from the Group D had at least 1 slide cross-checked by the OTSS Supervisors during their second visit. All available values were taken into account when calculating agreement, sensitivity and specificity.  In each case (agreement, sensitivity and specificity) the more recently visited facilities from the Comparison Group performed better than the aggregate values recorded for the Reference Group. Most notably, is a nearly 10% increase (at the facility level) of laboratory staff to differentiate positive malaria slides from negative malaria slides (sensitivity).  Perfect agreement between laboratory recorded malaria results and supervisor re-read malaria results was not able to be reached. Just over 3 percentage points separated the more recently visited facilities within the Comparison Group from the FY12 target of 100%.

Interpretation and Recommendations:

 The data from OTSS supports the assertion that there is trustworthy microscopy available in Benin, although there is still room for improvement especially in the identification of positive cases (sensitivity).

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Figure 9: Health Facilities Enrolled in OTSS Quality Assurance Program

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ANNEX 2: Key findings and recommendations from post-IMCI training follow up

Kalalé-Nikki-Pèrèrè Health Zone and Banikoara Health Zone: Four days were assigned to the follow- up visit of 20 health workers. Three teams of supervisors were deployed to the four communes constituting the two health zones. In general, the supervising teams observed that:

 Proper tools (registers, counseling cards, and chart booklets) were available for IMCI  Most cases were managed by following IMCI procedures: (a) The success rate for the identification of general signs and evaluation of the main symptoms were at 100% and 95% respectively; (b) The comprehensive assessment of symptoms present occurred in 95% of cases; (c) Evaluation of anemia and nutritional occurred at 90% and 85% respectively;(d) The assessment of foods used is not systematic or done less well; (e) Assessment of immunization status and administration of vitamin A is well observed; (e) Only 35% of mothers knew the three rules for home care;  Assessment of maternal satisfaction: good views of mothers on the care their children received.  There is need for health workers to make efforts to appropriately complete medical records and forms – the percentage of the forms that were correctly completed in the four communes is as follows: 47% in Banikoara, 50% in Nikki, 69% in Kalele and 58% in Perere.  On their performance, (a) Two health workers scored over 85%; (b) 11 health care providers had a 50% or higher performance but less than 85%; (c) 5 scored between 30 to 50%; and (d) 2 scored below 30%.  Status of supplies and equipment: (a) Banikoara and Kalalé: weighing scales not available; (b) Pèrèrè-Nikki-Kalalé: a health facility in this health lacked IMCI registers; (c) 80% of providers do not have counseling cards; (d) Twelve of the twenty clinics did not have functional oral rehydration therapy corner; (e) Banikoara: five out of 10 providers have no have forms for monitoring dehydration; (f) four facilities had problems with preserving vaccines: Banikoara (1), Nikki (2) and Pèrèrè (1). (g) All health facilities do not vaccinate every day because of the vial policy including measles and BCG; (h) 8 health facilities in twenty are more than 30 minutes’ drive from the center of reference; (i) 18 out of 20 health facilities did not have all essential drugs for the implementation of IMCI particularly Artesunate-Amodiaquine, Artesunate suppository and RDT for private centers.

Adjarra-Avrankou-Akpro-Missérété, Covè-Ouinhi-Zagnanado, Ouidah-Kpomassè-Tori-Bossito Health Zones: Four days were devoted to the follow-up visit 21 of the 22 health workers. Three teams of supervisors were deployed to the ten municipalities. In general, the supervising teams observed that:

 Proper tools (registers, counseling cards, and chart booklets) were available for IMCI  Most cases were managed by following IMCI procedures: (a) The success rate for the identification of general signs and evaluation of the main symptoms were at 89% and 95% respectively; (b) The comprehensive assessment of symptoms present occurred in 72% of cases; (c) Evaluation of anemia and nutritional occurred at 89% and 67% respectively;(d) The assessment of foods used is not systematic or is done less well; (e) Assessment of immunization status and administration of vitamin A is done for over 83% of cases; (e) Only 23% of mothers knew the three rules for home care; and (f) 100% of mothers knew how to administer medications at the household level.  Assessment of maternal satisfaction: good views of mothers on the care their children received.  There is need for health workers to make efforts to appropriately complete medical records and forms – 32% of the forms that were sampled were completed correctly. 68 | P a g e

 On their performance, (a) One health workers scored over 85%; (b) 6 health care providers had a 50% or higher performance but less than 85%; (c) 5 scored between 30 to 50%; and (d) 8 scored below 30%.

 Status of supplies and equipment: (a) Out of 20 facilities, seven, five and nine did not have the following respectively, weighing scales, chronometer, and height scale. (b) 11 out of the 20 facilities did not have and Oral rehydration therapy corner; (c) Lack of potable water observed including forms for ORT and materials. (d) Problems of non-availability of refrigerators and conservation of vaccines were noted in five and two facilities respectively; (e) In three facilities all the antigens/vaccines were not available; (f) All health facilities do not vaccinate every day because of the vial policy including measles and BCG; (g) 20 out of 20 health facilities did not have all essential drugs for the implementation of IMCI particularly Artesunate-Amodiaquine, Artesunate suppository and RDT for private centers; and (h) 30% of the health facilities that were supervised had only 60% of their health workers trained in IMCI.

Recommendations: At the end of the two post IMCI training follow-up visits, the following recommendations were made: (a) Create an environment conducive for the implementation of IMCI in health facilities; (b) Reorganization of clinics as needed, to meet the IMCI guidelines; (c) Strengthening of health facilities by equipping them with appropriate equipment and materials needed for IMCI; (d) Ensure the continuous availability of essential drugs for IMCI; (e) Regularly supervise health workers trained in IMCI particularly the ones that were found to be underperforming: (f) Explore the possibility of providing private health facilities with RDTs; (g) Explore the possibility of vaccination of all children daily for all vaccines; (h) Integrate a few indicators of the implementation of IMCI in monitoring activities; (i) Rearrange available to accommodate for rooms for consultation, ORT corner immunization; (j) Equipping facilities with weighing scales; and (k) Solve the problem of availability of essential medicines.

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ANNEX 3: Mini Caravan Quotes

A motorcyclist, man, 60: “I am really shocked to hear today our own health workers telling us that chloroquine is bad. Are they not the ones who prescribed us this medication in the health center? I cannot believe that.” Sogbe Emiliene, female, 31, seller: “I came here because I was curious. What I have learned today is the use of two doses of SP and ACT. I should say that I have heard some of these messages through the community health worker. When I return home, I will tell my neighbors and friends about the importance of SP, ACT and the consequences of malaria on a pregnant woman. I have heard a message about choloroquine. For me, chloroquine is very effective because it is sold everywhere and our lawmakers know about it. Take a tour of Topka market and you will see. If you organizers of such events feel that chloroquine is not effective, go and tell our lawmakers. I wish you good luck.” Zinsou Ida, female, seller, 25: “I have come here after being attracted by the music. Today I have learned about the importance of SP. A friend explained that to me a while ago but I had not understood well. I am feeling confident that when I return home I will be able to talk to my friends about SP and ACT. I have heard a message about chloroquine. I used to take it before until my uncle dissuaded me to do so. Today, I know why it is not good anymore.” Gbedo Bernard, male, mechanic, 51: “I was passing by when I saw people and I decided to join. No one informed me about this event. It is the first time in my life I have heard about SP and ACT products. Something I have learned today and I can share with others is how to cover the mattress with a net and the use of SP and ACT. I heard also about chloroquine. I used to take it until a friend discouraged me after reading a document that the drug was no longer effective. I will encourage you guys to continue educating people throughout Benin because many people are ignorant. I was expecting to receive T- shirts, nets and drugs at the end of the event.” Marcellin Kpohazoun, male, motorcyclist, 35: “I was informed by la “Voix de la Vallée” Radio about this event. What I have learned today is the importance of intake of SP by pregnant women, the diagnosis to confirm malaria, and that malaria is not caused either by the sun nor food. In the past I have heard some of these messages through our local radio. When I return home, I will share with counterparts messages about the use of nets and attending prenatal care to get required SP doses. I have heard a message that chloroquine is no longer good. I used to take it but not anymore. My recommendation to the organizers of this event is to ensure that all health centers have access to the drugs you are promoting.” Alodji Noelie, pregnant woman, retailer, 28: “I have come to listen to the messages. I followed the motorized car to arrive here. What I have learned is the importance of attending prenatal care to get the two SP doses. Also I heard that in case of malaria, the best treatment is ACT. I have heard similar messages on radio and TV. Something I have learned and I am able to share with my counterparts is about sleeping under the net and reinforcing the idea that malaria is not caused by the sun but by mosquitoes. I have heard the message about chloroquine. However, I am convinced that chloroquine is not good. You said that SP is free, but myself I have already taken the first dose and I paid money for it. I want to confirm that it is not free. I will encourage you to do what you do. Before ending, as you have noted that I am pregnant, I have not received yet a free net but I use the one I bought. Regarding my children, none sleep under the net because the father has not bought for them.”

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