Quarterly Performance Report from January 01, 2018 to March 31, 2018

Home , Bokpyin Township, Palaw, Palaw Township, Ramree Township

DEFEAT MALARIA

Defeat Malaria Quarterly Performance Report From January 01, 2018 to March 31, 2018

Submission Date: April 30, 2018

Agreement Number: AID-482-A-16-00003 Agreement Period: August 15, 2016 to August 14, 2021 AOR Name: Dr. Monti Feliciano

Submitted by: May Aung Lin, Chief of Party University of Research Co., LLC. Room 602, 6th Floor, Shwe Than Lwin Condominium New University Ave. Rd., Bahan Township Yangon, Myanmar Email: [email protected]

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

Table of Contents List of Tables ------ii List of Figures ------iii ACRONYMS AND ABBREVIATIONS ------iv Executive Summary ------6 Defeat Malaria Goal and Objectives ------7 Summary of Key Achievements (October – December 2017) ------9 Interventions and Achievements on Core Areas of Strategic Focus ------11 1. Achieving and sustaining scale of proven interventions through community and private sector engagement ------11 2. Use of strategic information to adapt to changing epidemiology ------21 3. Initiating malaria elimination approaches in three pilot townships in Southern Rakhine State - 23 4. Improving Myanmar’s capacity to collect and use information ------28 5. Building capacity and health systems strengthening ------31 6. Strengthening capacity of the NMCP and Ethnic Health Organizations (EHOs) ------35 Challenges ------40 Annexes ------42 Annex 1 – Case Finding and Management ------42 Annex 2 – Active case detection by mobile team ------45 Annex 3 – Monthly meeting ------47 Annex 4 – Supervision and monitoring ------48 Annex 5 – Reporting status of VMWs/PPs ------49 Annex 6 – Clinical audit ------50 Annex 7 – Stock out monitoring at the time of monitoring visits ------51 Annex 8 – Capacity building ------53 Annex 9 – BCC ------55 Annex 10 – Advocacy meeting ------57 Annex 11 – Performance Indicators ------58

List of Tables Table 1: Project area coverage as of March 31, 2018 ...... 8 Table 2: Summary of case finding and management by approach (From January 2018 to March 2018) .... 12 Table 3: State/Region wise summary of case finding and management (From January 2018 to March 2018) ...... 12 Table 4: Summary of DOT (from October to December 2017) ...... 13 Table 5: LLIN distribution at village-level (from January 2018 to March 2018) ...... 17 Table 6: LLIN distribution at worksites (from January 2018 to March 2018) ...... 18 Table 7: Monitoring of LLIN coverage and utilization (from January 2018 to March 2018) ...... 19 Table 8: Appropriate action plans based on epidemiological situations ...... 22 Table 9: Conducting Malaria Elimination Advocacy Meeting at Township Level ...... 25 Table 10: Micro-stratification of Toungup Township using 2017 Data ...... 25 Table 11: Micro-stratification of Ramree Township using 2017 Data ...... 26 Table 12: Capacity Building Training for Malaria Elimination in Three Pilot Townships ...... 27 Table 13: Summary of activities of QI Director from January 2018 to March 2018 ...... 33 Table 14: Findings and recommendations during admin and logistics team visit ...... 40 Table 16: Summary of Case Finding and Management by Township (from January 2018 to March 2018) – Mobile Team Approach ...... 42 Table 17: Summary of Case Finding and Management by Township (from January 2018 to March 2018) – VMW Approach ...... 43 Table 18: Summary of Case Finding and Management by Township (from January 2018 to March 2018) – Private Provider Approach ...... 44 Table 19: Summary of active case detection in project villages and work sites (from January 2018 to March 2018) ...... 45 Table 20: Summary of active case detection in non-project villages and work sites (from January 2018 to March 2018) ...... 46 Table 21: Summary of VMW/PP monthly meeting (from January 2018 to March 2018) ...... 47 Table 22: Summary of supervision and monitoring visits to VMWs/PPs (from January 2018 to March 2018) ...... 48 Table 23: Reporting status of VMWs/PPs (from January 2018 to March 2018) ...... 49 Table 24: Summary of clinical audit (from January 2018 to March 2018) ...... 50 Table 25: Summary of stock out monitoring at the time of monitoring visits and on-site data collection (from January 2018 to March 2018) ...... 51 Table 26: Summary of stock out monitoring at monthly meeting (from January 2018 to March 2018) .... 52 Table 27: Number of VMWs/PPs trained on case management (from January 2018 to March 2018) ...... 53 Table 28: Number of VMWs/PPs trained on diagnosis (from January 2018 to March 2018) ...... 54 Table 29: Number of people reached through Individual Interpersonal communication and Group Health Talks by Mobile Team, VMWs and PPs (from January 2018 to March 2018) ...... 55 Table 30: Number of people reached through individual interpersonal communication (IPC) and Group Health Talks by Private Providers only (from January 2018 to March 2018) ...... 56 Table 31: Advocacy meetings with private company (from January 2018 to March 2018) ...... 57 Table 32: Performance Indicators Tracking Table (from January 2018 to March 2018) ...... 58

List of Figures Figure 1: Map showing coverage of Defeat Malaria ...... 8 Figure 2: Reporting status (from January 2018 to March 2018) ...... 14 Figure 3: Number of people disaggregated by gender, reached through IPC by VMWs/PPs (From January to March 2018) ...... 16 Figure 4: PPM Officer and VMW met with forest goer at Thet Kar Ya Village, Myawaddy Township ...... 20 Figure 5: Progress of hsRDT study (From October 2017 to March 2018) ...... 21 Figure 6: Malaria case classification calculator ...... 27 Figure 7: M & E Director explained about M & E Guidelines and Data Flow Mechanism at Data Quality Assurance training ...... 28 Figure 8: Pilot testing of updated RDQA tools with the inclusion of one more area about use of data for decision making ...... 29 Figure 9: Map of Sinphyutaing Village with 3 positive cases location in the village ...... 30 Figure 10: Participants who attended PMI Thematic Workshop ...... 34 Figure 11: Defeat Malaria Dashboard ...... 35 Figure 12: Overall result of knowledge assessment on CBI to enhance Malaria Control in 3 States and Region ...... 36 Figure 13: Overall result of knowledge assessment on CTS (Training Skill Course) in 3 States and Region ...... 36 Figure 14: Pre and post knowledge assessment in both Malaria Technical and Training Skill in Kayin and Rakhine State and Tanintharyi Region ...... 37 Figure 15: Coaching RDT practice at ICMV training in Launglon Township ...... 37 Figure 16: Assessing RDT testing of VMW at Pinlenar village during supervision visit ...... 38 Figure 18: State Coordinator, URC handed over 17 laptops to State VBDC Officer, Rakhine ...... 38 Figure 19: NMCP staff with new laptops provided by Defeat Malaria ...... 39

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ACRONYMS AND ABBREVIATIONS ABER Annual Blood Examination Rate ACD Active Case Detection ACT Artemisinin-based combination therapy AMR Antimicrobial resistance ANC Antenatal care API Annual Parasite Incidence ARC American Refugee Committee ASTMH American Society of Tropical Medicine and Hygiene BCC Behavior Change Communication BHS Basic Health Staff BMA Burma Medical Association BPHWT Back Pack Health Worker Team CBI Community Based Intervention CBO Community Based Organizations CDC Communicable Disease Control CPI Community Partners International CTS Clinical Skill Trainings DOT Directly observed treatment DQO Data Quality Officer EID Emerging infectious diseases EMMP Environmental Monitoring and Mitigation Plan GMS Greater Mekong Sub-region ICMV Integrated Community Malaria Volunteer IEC Information, education and communication INGO International Non-governmental Organizations IPC Interpersonal communication IRS Indoor Residual Spray ITN Insecticide treated net KBC Karen Baptist Convention KDHW Karen Development and Health Welfare KNU Karen National Union LDHF Low Dose High Frequency LLIN Long lasting insecticidal nets LMIS Logistics Management Information System LQAS Lot Quality Assurance System M&E Monitoring and Evaluation MECC Malaria Elimination Coordination Committee MHAA Myanmar Health Assistant Association MMP Migrants and mobile populations MNMA Myanmar Nurse and Midwife Association MOP Malaria Operations Planning NGO Non-governmental Organizations NMCP National Malaria Control Program NSA Non-State Actors NTG National Malaria Treatment Guidelines ODK Open Data Kit PCR Polymerase Chain Reaction PMI President’s Malaria Initiative PP Private Providers

PPM Public Private Mix QAQC Quality Assurance/Quality Control QI Quality Improvement RDQA Routine Data Quality Assessment RDT Rapid diagnostic tests RHC Rural Health Centers SOP Standard operating procedures TPR Test Positivity Rate TSG Technical Strategic Group USAID United States Agency for International Development USG United State Government VBDC Vector Borne Disease Control VBS Village Based Stratification VHW Village Health Workers VMW Village malaria workers WHO World Health Organization

Executive Summary Myanmar’s National Malaria Control Program (NMCP) reported 79,654 malaria cases and 31 malaria deaths in 2017 as preliminary data. This marks a decline of 83% in cases and 92% in deaths from 2012 to 2017 However, the malaria burden in Myanmar remains the highest among the six countries of the Greater Mekong Sub-region (GMS), accounting for about 51% of the total.1 Significant challenges interfere with the implementation of a malaria control program, including weak health services in remote areas with high transmission, limited resources and manpower to expand and maintain quality malaria services, internal and cross-border migrations, and evidence of spreading artemisinin resistance along the border areas (especially the Thai-Myanmar border). Under the leadership of the national program, local and international organizations including the United States Agency for International Development (USAID) have collaborated to identify gaps and implement solutions to address these challenges. The Defeat Malaria Activity, funded by the U.S. President’s Malaria Initiative (PMI) and USAID, runs from 15th August 2016 to 14th August 2021 and is implemented by University Research Co., LLC (URC), in partnership with American Refugee Committee (ARC), Jhpiego and Duke University, Global Health Institute. Defeat Malaria also involves local partner organizations to deliver needed malaria services while contributing to local capacity building efforts, including the Myanmar Health Assistant Association (MHAA) and Myanmar Nurse and Midwife Association (MNMA). Defeat Malaria works with the NMCP to strengthen local health systems that are responsive and flexible and can respond appropriately to a changing malaria epidemiological situation and emerging threats, including multi-drug resistance and insecticide resistance. Defeat Malaria promotes sustainable approaches to support malaria control activities, including community empowerment in malaria control and prevention, evidence-based decision making, engagement of the private sector, and building on existing efforts to engage other agencies and sectors. Because of efforts of the NMCP and implementing partners, in all 17 townships of Rakhine State the malaria burden is decreasing from 123,814 cases reported in 2011 to 12,843 cases in 2017 (89% reduction). Thus, Defeat Malaria, in collaboration with the NMCP, initiated malaria elimination approaches in three pilot townships: Munaung, Ramree and Toungup townships beginning in January 2018. Second Quarter of Project Year 2 (January - March 2018) Key Highlights include:  Increased geographical coverage with case finding and management covering 31 townships with 1,310,697 people residing in 2,318 villages.  4,368 long lasting insecticidal nets (LLINs) distributed to vulnerable populations (638 pregnant women, 4,230 migrants and 2,570 people from villages and worksites)  38,045 people were tested, 621 cases were detected and 99.2% of positive cases were treated according to National Malaria Treatment Guidelines. In Quarter 2, refresher trainings on case finding and management and elimination concepts were conducted, targeting village malaria workers (VMWs)/Private Providers (PPs) and Basic Health

1 2015 Annual Report of National Malaria Control Program

Staff (BHS). The trained VMWs/PPs received rapid diagnostic tests (RDTs), antimalarial drugs, and patient registers. The VMWs/PPs and mobile teams provided case detection and management services in targeted areas. In areas where possible, directly observed treatment (DOT) was provided by VMWs to positive cases. DOT monitoring and confirmation was done by checking directly with patients to see if treatment was provided by a VMW or not, according to standard operating procedures (SOPs). Interpersonal communication was provided to those 15 years and above who tested positive for malaria. Group health talks were also provided in communities reaching 7,300 people. Project staff are continuously implementing Routine Data Quality Assessments (RDQAs) at different levels to strengthen Defeat Malaria data quality improvement systems for achieving better health care outcomes. In January 2018, with permission from the Core Technical Strategic Group (TSG), a group led by the NMCP to manage malaria activities, Defeat Malaria started implementing malaria elimination activities in three pilot townships in Southern Rakhine State: Toungup, Ramree, and Munaung. In these three townships, preparation activities like advocacy meetings, development of forms and formats for documentation and monitoring, trainings have been conducted. All suspected cases were tested and all positive cases were treated according to National Treatment Guideline in these three townships. In low transmission villages of these three townships, case investigation will start next quarter, whereas foci investigation is planned to start in the last quarter of this year after completion of the preparation phase, including training of local staff. Universal coverage of case detection and treatment services and prevention methods were also provided in a few villages with high transmission areas in these three townships. In March 2018, the PMI Malaria Operation Plan (MOP) team visited Defeat Malaria townships in Kayin State to observe malaria control activities and meet the State Health Director and other NMCP government officials in Hpa-An Township. The MOP team comprised the Chief Entomologist and Medical Epidemiologist from the Centers for Disease Control and Prevention (CDC), Atlanta, and USAID’s Senior Public Health Advisor, Regional Malaria Advisor and Senior Malaria Advisor. To exchange information on activities implemented by different malaria partners, share lessons learned, and address common challenges, a PMI Thematic Workshop was organized in Nay Pyi Taw from March 19-20, 2018. More than 60 participants from the NMCP, implementing partners and stakeholders attended, presented, and discussed issues under three main topics: malaria surveillance and elimination, case management, and vector control. Defeat Malaria Goal and Objectives The overall goal of the Defeat Malaria Activity is to reduce the malaria burden and control artemisinin-resistant malaria in targeted areas, thereby contributing to the long-term national goal of eliminating malaria in Myanmar. This will be achieved by expanding coverage of community- based prevention and case management services, prioritizing highly endemic and hard-to-reach areas, mobile and migrant populations, and non-state actor areas. Defeat Malaria strengthens the capacity of local partners to effectively lead, manage and implement interventions towards the goal of malaria elimination. The project is also strengthening the malaria surveillance system to

better inform and target interventions, and to monitor progress. Defeat Malaria engages communities and promotes the involvement of the private sector. Defeat Malaria works with the NMCP and key partners to achieve the following objectives: Objective 1: Achieve and maintain universal coverage of at-risk populations with proven vector control and case management interventions, while promoting the testing of new tools and approaches. Objective 2: Strengthen the malaria surveillance system to comprehensively monitor progress and inform the deployment and targeting of appropriate responses and strategies. Objective 3: Enhance technical and operational capacity of the NMCP and other health service providers at all levels of service provision. Objective 4: Promote the involvement of communities, private healthcare providers, private companies and state- owned enterprises in malaria control and elimination initiatives. Defeat Malaria currently covers two States (Rakhine in the west and Kayin in the south-east) and one Region (Tanintharyi in the south-east) of Myanmar. Rakhine State has the highest malaria burden in Figure 1: Map showing coverage of Defeat Malaria Myanmar (NSP, 2016-2020) and has deep forested mountain ranges. Dawna Mountain Range in Kayin State extends southward, merging with the northern part of Tanintharyi Hill. Deeply forested areas provide favourable conditions for mosquitoes’ receptivity and contribute to a high prevalence of malaria. In addition, the difficult terrain is a significant barrier to access health services in these remote areas. Table 1 provides a summary of villages and populations covered by Defeat Malaria as of March 2018. Table 1: Project area coverage as of March 31, 2018 Total Total Total % of State & Region Covered Covered Total Population Covered Population Townships Villages Population Covered Tanintharyi 10 586 1,408,401 307,013 21.8% Northern Rakhine 10 548 1,108,828 435,639 39.3% Southern Rakhine 7 1,001 740,797 442,205 59.7% Kayin 4 183 1,297,935 125,840 9.7% Total 31 2,318 4,555,961 1,310,697 28.8% As shown in Table 1, as of FY18 Q2 total covered townships are 31. Activities in Hpa-pun and Kyainseikgyi Townships, where ARC operates, stopped in January 2018 as activities were no longer allowed by the Karen Department of Health and Welfare (KDHW) and Karen National

Union (KNU) Brigade-5. Despite this, overall coverage of Defeat Malaria beneficiaries increased to around 1,310,697 people from 2,318 villages. Malaria services are reaching beneficiaries through a larger network of 1,864 VMWs/PPs and township mobile teams due to the initiation of malaria elimination approaches and aim of universal coverage in Munaung, Ramree and Toungup Townships in Southern Rakhine State. In addition, ARC took over activities from programs that are ending in 52 villages in Kawkareik, Bokpyin and Tanintharyi townships after discussion with the Tanintharyi NMCP and implementing partners such as KDHW and Community Partners International (CPI). Many people living in Northern Rakhine State are affected by conflict that started in August 2017. However, activities are still being implemented in two townships (Buthidaung and Rathedaung) by MHAA. Summary of Key Achievements (January 2018 to March 2018)  Training activities - In targeted townships, refresher trainings were conducted for 1,079 VMWs and PPs on malaria case diagnostics and management.  38,045 people were tested for malaria through VMWs, private providers and mobile outreach teams.  621 positive cases were detected and, among them, 7 cases were referred to hospitals. 609 out of 614 treated cases (99.2%) were in line with National Treatment Guidelines.  Under the DOT strategy, enrollment of positive cases increased to 80% (497 DOT cases among 621 positive cases) and almost all (99.8%) enrolled DOT cases completed the treatment course.  Interpersonal communication – Defeat Malaria reached 38,566 people (18,345 males, 20,221 females) through interpersonal communication (IPC) including 5,292 migrants. 517 group health talks were conducted reaching 7,300 people (3,332 males and 3,968 females) including 1,576 migrants in targeted areas.  A total of 4,368 LLINs were distributed in 7 villages and 19 worksites, including 638 pregnant women through 41 sub-centers for pregnant women attending ante-natal clinics, and to positive patients.  With the lead of Defeat Malaria Central Technical Team, capacity building of 16 project staff on reorientation and updates was refreshed at central level to ensure provision of quality malaria services and malaria information.

Interventions and Achievements on Core Areas of Strategic Focus This section covers the following topics: (1) Achieving and sustaining scale of proven interventions through community and private sector engagement (2) Adapting to changing epidemiology based on strategic information (3) Initiating malaria elimination approaches in three pilot townships in Southern Rakhine State (4) Improving Myanmar’s capacity to collect and use information (5) Building capacity and strengthening health systems (6) Strengthening capacity of the National Malaria Control Program and Ethnic Health Organizations (EHOs) 1. Achieving and sustaining scale of proven interventions through community and private sector engagement 1.1 Advocacy meetings to promote Defeat Malaria and private sector engagement Advocacy meetings (details in Annex 10) were conducted in Dawei Township with private companies and work site representatives. A total of 17 participants attended. 1.2 Capacity building of VMWs/PPs in malaria diagnosis and case management To provide quality malaria health care services to targeted communities, trainings were continued for VMWs and PPs. A total of 1,024 VMWs and 61 PPs received a 4-day training on malaria diagnosis and case management, how to conduct IPC, stock management, and data collection and reporting (details in Annex 8). 1.3 Distribution of commodities to all project townships and villages From January to March 2018, 22,500 RDTs and 4,587 ACTs were distributed from the central warehouse (in Yangon) to commodity storage sites to facilitate continuous uninterrupted treatment services for targeted communities. From those township level storage sites, commodities (39,386 RDTs and 3,065 ACTs) were delivered to respective sub-stocks for service delivery points i.e., VMWs/PPs during VMW monthly meetings and monitoring and supervision visits, as necessary. 1.4 Ensure early diagnosis and appropriate treatment through different approaches Different approaches such as community-based malaria diagnosis and treatment through VMWs, mobile teams by Defeat Malaria staff, and private sector engagement were used to rapidly expand coverage of malaria case finding and management among at-risk populations including migrants and mobile populations (MMPs) and pregnant women (see Tables 2 and 3). 38,045 people were tested and 621 cases were positive (313 P. falciparum, 295 P. vivax and 13 mixed). The Test Positivity Rate (TPR) was 1.63%. 614 positive cases (98.9%) were treated. Among cases treated, 99.2% were treated according to NTG. Please see Annex 1 for more details.

Table 2: Summary of case finding and management by approach (From January to March 2018) Total Approach Tested Pf Pv Mix TPR% Positive Mobile Teams 5,628 35 22 13 0 0.62% VMWs 29,171 525 264 250 11 1.80% PPs 3,246 61 27 32 2 1.88% Total 38,045 621 313 295 13 1.63%

Table 3: State/Region wise summary of case finding and management (From January to March 2018) Total State / Region Tested Pf Pv Mix TPR% Positive Tanintharyi Region 10,498 119 32 86 1 1.13% S. Rakhine State 12,118 102 84 17 1 0.84% N. Rakhine State 12,088 318 194 113 11 2.63% Kayin 3,341 82 3 79 0 2.45% Total 38,045 621 313 295 13 1.63%

1.5 Active Case Detection (ACD) Defeat Malaria teams conducted special mobile activities through active case detection (ACD) in 58 project villages and 76 non-project villages in 19 townships. From January to March 2018, mobile teams tested 5,628 in project and non-project villages and only found 35 positive cases (22 Pf, 13 Pv, and 0 mixed). In non-project villages, 26 positive cases (20 Pf, 6 Pv, and 0 mixed) were found among 2,521 tested, while 9 (2 Pf, 7 Pv, and 0 mixed) were found among 3,107 tested in project villages. The TPR in non-project villages was 1.03% while only 0.29% in project villages. For more detail, please see Annex 2. 1.6 Directly Observed Treatment (DOT) During this reporting period, 313 P. falciparum cases were detected, 255 (81.5%) were enrolled in DOT and all 255 (100%) cases completed DOT. Thirteen (13) mixed infection cases were detected, 12 (92.3%) were enrolled in DOT and all 12 (100%) cases completed DOT. On the move to malaria elimination, it will be important to ensure patients are taking the full course of Primaquine to prevent relapse of P. vivax infection. In this reporting period, 295 P. vivax cases were detected, 230 (77.6%) of them enrolled in DOT and 229 (99.6%) cases completed DOT. Overall, 80% of the 621 total positive cases were enrolled in DOT and only one positive case did not complete the full course of ACTs under VMW observation.

Table 4: Summary of DOT (from October to December 2017)

Pf Pv Mixed Total Total Positive Cases 313 295 13 621 255 230 Total positive enrolment in DOT (%) 12 (92.3%) 497 (80%) (81.5%) (77.6%) Completed DOT 255 229 12 496 % completed DOT among total positive 81.5% 77.6% 92.3% 79.9% cases % completed DOT among enrolment 100% 99.6% 100% 99.8%

1.7 VMW monthly meetings Even though some VMWs/PPs were not able to attend monthly meetings due to remoteness, busy with other jobs and/or lack of interest, Defeat Malaria Township Teams conducted VMW/PP monthly meetings with 94.6% of VMWs/PPs participating from January to March 2018 to monitor reporting performance (timeliness and completeness), data collection and verification of data, replenish materials and drugs and polish capacity of VMWs towards NTGs. Please see details in Annex 3. If a VMW/PP was absent from the monthly meeting and failed to report, project staff coordinated to find out why. 1.8 Supervision and monitoring As supportive supervisory visits improve the capacity and effectiveness of VMWs/PPs and facilitate on-site data verification, monthly performance and achievements of VMWs/PPs at village level were continuously monitored by respective township staff ensuring on time completeness and correct reporting, case detection activities, correct prescription of identified malaria cases, ensuring adequacy of stock supplies, treatment adherence through appropriate practice of DOT, and preventive practices. Based on the monitoring results, supervision visits were scheduled based on prioritized needs to provide support, on-the-job training, and motivation of VMWs/PPs. In this reporting period, 794 supervision visits (198 visits in Tanintharyi Region, 305 visits in Southern Rakhine State, 204 visits in Northern Rakhine State, and 87 visits in Kayin State) were conducted by township project staff following supervision protocols using standardized checklists at VMW/PPs’ villages (Details in Annex 4). In Buthidaung and Maungdaw townships in Northern Rakhine State, supervision visits could not be conducted due to security reasons. 1.9 Reporting status: improve data management capacity In addition to supervisory visits, VMW/PP activities are monitored through attendance at monthly meetings. If a VMW/PP missed two consecutive meetings, the field team would visit them in their village to discuss why they missed the meeting and if they were interested to continue case management activities. If they did not wish to continue, replacements were recruited (in this quarter, 93 replacements were made). Performance of VMWs/PPs is closely monitored through

blood examination rate, clinical audits, DOT completeness, data completeness and accuracy, and prevention activities performed. These were monitored through regular review of their activity reports. Reporting proficiency of VMWs/PPs was 97.8% despite challenges for reporting from conflict affected areas in Northern Rakhine State. Timely submission of reports steadily increased throughout the quarter with 99.6% (1,282/1,287) submitted on time in January, 99.5% (1,401/1,408) in February, and 100% (1,457/1,457) in March. Please see Annex 5 for details.

1,400 1,368 1,362 1,357 1,201 1,196 1,160 1,155 1,149 1,200 1,147

1,000

800

600 482 481 481

400

200

- Tanintharyi Total Southern Rakhine Total Northern Rakhine Total Kayin Total

Total cumulative # Of VMWs/PPs have to submit the report Total reported number (On time report + Late report) Total Timely reported number

Figure 2: Reporting status (from January to March 2018) 1.10 Clinical audit on treatment of positive cases according to National Malaria Treatment Guidelines (NTGs) Quality of health service provision by VMWs/PPs was ensured through initial and refresher trainings emphasizing treatment of malaria cases in line with NTGs. Safety of patients and quality of malaria health care services were continuously monitored through clinical audits at monthly meetings and regularly supervised by township Defeat Malaria staff. In this reporting period, 609 out of 614 treated cases (99.2%) were treated according to NTGs (see Annex 6). VMWs who were not following NTGs received supervision and were encouraged to use job aids at the time of treatment provision. They received additional messaging stressing the importance

of following the NTGs. If a patient was detected, these VMWs were also encouraged to call field teams to consult on treatment protocols. 1.11 Monitoring stock out of RDTs and first line antimalarials (ACT) To ensure continuous quality malaria services to communities, Defeat Malaria regularly monitors stock outs of commodities, including RDTs and first line antimalarials (ACTs), at service delivery points by checking commodity balances of VMWs/PPs at monthly meetings and during monitoring visits. A stock out is defined as a service delivery point experiencing a shortage of stock or availability of expired commodities for a week or longer during last 3 months. To prevent stock outs, regular replenishment of RDTs and ACTs is provided during monthly meetings and monitoring visits. From January to March 2018, VMWs/PPs received monitoring 4,732 times (4,369 times for VMWs and 363 times for PPs) during either monthly meetings or monitoring visits. Among them, 26 VMWs faced RDT stock outs and 5 VMWs experienced ACT stock outs problems during January 2018; all were from Buthidaung Township due to communication gaps between VMWs and MHAA because of ongoing conflicts and MHAA was unable to provide supervision visits. However, because of proper supervision and immediate replenishment, none faced stock-outs again in February or March 2018. The rest did not experience RDT/ACT stock outs (see in Annex 7) throughout this quarter. 1.12 Strengthen Behavior Change Communication (BCC) Under the guidance of the Regional Technical Director, Defeat Malaria produced the following information, education and communication (IEC) materials in FY18Q2: 1. Factsheets a. Defeat Malaria Factsheet (2017) b. Factsheet about Defeat Malaria in Kayin State 2. Posters used in advocacy meetings for malaria elimination a. To encourage taking blood test within 24 hours after onset of fever b. To announce Defeat Malaria will start malaria elimination activities in three townships of Southern Rakhine State 3. Billboards to increase community awareness for better participation in malaria elimination activities in Munaung, Ramree and Toungup Townships 4. Success story: “Transforming Lives – Defeat Malaria Forest Goers’ Kit” 5. Biweekly reports on a. Epidemiological assessment trip to Ah Naing Village, Tanintharyi Region b. Environmental Modification in War Taw Village, Tanintharyi Region c. Malaria database training with NMCP, Northern Rakhine State

Moreover, Defeat Malaria utilized several communication channels to achieve good coverage of the most vulnerable communities, including IPC (as the main mechanism for malaria BCC among

key affected communities), updating project and activity status on the project’s Facebook page, and distribution of printed materials (e.g., posters and information leaflets). IPC VMWs and PPs conduct IPC activities during case finding and management activities to share malaria preventive messages with at-risk populations and promote LLIN use and care. From January to March 2018, 38,566 people (52.4% female), including 5,292 migrants, were reached by IPC in villages and worksites (including 3,282 people (48.7% females) reached by private providers). Figure 2 and Annex 9 show the total number of people, disaggregated by sex, reached through IPC with malaria preventive messages. Additionally, group health talks were conducted to share malaria preventive messages and increase utilization of LLINs while mobile teams performed case finding and management and before LLIN distribution. In this reporting period, 517 group health talks were held in Defeat Malaria villages and work sites, reaching 7,300 people (54.4% females), 1,576 of whom were migrants. Health education sessions were also organized at worksites to share malaria preventive knowledge with MMPs. From January 2018 to March 2018, 116 health education sessions were conducted at 47 worksites and 1,368 migrants (820 males and 548 females) received malaria preventive messages.

Myawaddy 627 761 Kawkareik 421 591 Hpa-an 570 1089 Hlaingbwe 594 1095 Male Female Sittwe 379 615 Rathedaung 642 596 Ponnagyun 348 348 Pauktaw 434 463 Myebon 835 899 Mrauk-U 290 301 Minbya 180151 Kyauktaw 930 859 Buthidaung 921 362 Toungup 411 350 Thandwe 2335 2633 Ramree 732 649 Kyaukpyu 550 645 Gwa 906 983 Ann 1092 1171 Yebyu 258 308 Thayetchaung 241 336 Tanintharyi 641 717 Palaw 402 576 Myeik 421 627 Launglon 257 503 Kyunsu 676 763 Kawthoung 1240 1021 Dawei 385 335 Bokpyin 627 474 0 1000 2000 3000 4000 5000 6000 Figure 3: Number of people disaggregated by gender, reached through IPC by VMWs/PPs (From January to March 2018)

Distribution of printed materials Defeat Malaria distributed pamphlets and other IEC materials to share core malaria preventive messages to targeted populations during LLIN distribution and ACD. From January 2018 to March 2018, 13,765 pamphlets were distributed in covered areas. Facebook page Defeat Malaria is on Facebook (“Defeat Malaria Myanmar”) to test the ability to strengthen online communication and disseminate project achievements, reach local people and groups, and advocate for donor and stakeholder interest and investment in malaria elimination. The compelling Facebook content includes introduction of new IEC materials and program improvement tools such as Malaria Case Classification Calculator, storytelling pictures, short video clips and short articles/stories. The content of the Facebook page is updated weekly by project staff. 1.13 Optimize coverage and promote use of proven vector control interventions Mass Distribution of LLINs From January to March 2018, 253 LLINs were distributed in seven villages in Kawthoung, Hpa- an, Myawaddy and Thandwe based on the standard “2 persons per 1 LLIN”, thus providing protection for 2,570 people from 661 households. Both household and population coverage was 100%. Average population per LLIN is 2.02. Table 5 shows mass LLIN distribution/top-up at the village level by state/region. Table 5: LLIN distribution at village‐level (from January to March 2018)

Mass distribution Top-up Indicator Total Kawthoung Hpa-an Myawaddy Thandwe # of Villages 2 1 1 3 7 # of Households (HHs) present 181 105 152 223 661 # of HHs covered 181 105 152 223 661 # of Population present 469 526 734 841 2,570 # of Population covered 469 526 734 841 2,570 Total LLINs Distributed 205 295 426 349 1,275 % of HHs covered 100% 100% 100% 100% 100% % of Population covered 100% 100% 100% 100% 100%

Net Ownership (Pop per LLIN) 2.29 1.78 1.72 2.41 2.02

LLIN distribution to migrants and mobile populations in collaboration with employers Defeat Malaria seeks to prevent migrants from getting malaria through a focus on worksites by distributing and topping up LLINs. 19 worksites were covered during this reporting period and

2,455 LLINs were distributed to 4,230 MMPs (Table 6). All worksite households and populations were 100% covered with an average population per LLIN of 1.72. Table 6: LLIN distribution at worksites (from January to March 2018) Mass distribution Top up Indicator Grand Total Kawthoung Bokpyin Kawthoung

# of Worksites 13 3 3 19

# of Households (HHs) present 532 554 499 1,585

# of HHs covered 532 554 499 1,585

# of Population present 1,472 1,632 1,126 4,230

# of Population covered 1,472 1,632 1,126 4,230

Total LLINs Distributed 893 854 708 2,455

% of HHs covered 100% 100% 100% 100%

% of Population covered 100% 100% 100% 100%

Net Ownership (Pop per LLIN) 1.65 1.91 1.59 1.72

LLIN distribution to pregnant women during Antenatal Care (ANC) in high transmission areas To promote and increase utilization of LLINs among pregnant women through their distribution in antenatal care (ANC) services in high transmission areas, Defeat Malaria is working in collaboration with Township Health Departments and respective Rural Health Centers in 4 townships of Southern Rakhine State. LLINs were distributed to pregnant women through ANC facilities at 3 Rural Health Centers (RHC) in Ann Township and 2 RHCs in Toungup Township since the last quarter of FY 2017, but distribution in 1 RHC of Gwa and 1 RHC of Thandwe couldn’t commence until the second quarter of FY 2018. Recording and reporting forms and indicators required by the LLIN distribution to pregnant women SOP were developed and approved by USAID in July 2017. From January to March 2018, LLINs were distributed to 638 pregnant women at their first ANC visit at 41 sub-centres of 7 RHCs in four townships. Monitoring LLIN coverage and utilization From January to March 2018, LLIN monitoring was conducted in 330 Defeat Malaria villages. The CAP-Malaria and Defeat Malaria projects have been distributing LLINs in these villages since 2015. According to the LLIN Monitoring SOP, eligible respondents from 21 households in each village were interviewed by VMWs/PPs with an LLIN monitoring data collection form to assess LLIN coverage and utilization in these villages. Monitoring data from VMWs/PPs was forwarded to Defeat Malaria township teams for analysis together with VMWs during monthly meetings. Coverage analysis

According to the Lot Quality Assurance System (LQAS) method, if ≥ 15 households of 21 interviewed own an adequate number of LLINs (i.e. at least 1 LLIN for 2.5 persons despite 2 persons per 1 LLIN in the SOP as teams don’t always distribute LLINs for children under 5 years as they sleep with their parents), that village is supposed to have more than 85% of households owning at least one LLIN for every two persons.

Utilization analysis LLIN use is estimated by the proportion of household members, among the 21 interviewed households, who slept under a LLIN the previous night. If the proportion falls below 80%, this is insufficient. If ≥ 15 households out of 21 interviewed are below 80%, this village is not at an acceptable level (more than 70% of at-risk population at that village slept under LLIN the last night). For more details of results, please refer to Table 7. Table 7: Monitoring of LLIN coverage and utilization (from January to March 2018)

# Townships Total no. LLIN ownership LLIN utilization of villages No. of No. of villages No. of No. of villages assessed villages at not at villages at not at acceptable acceptable level acceptable acceptable level level and can’t be level and can’t be interpreted interpreted 1 Bokpyin 9 0 9 5 4 2 Dawei 19 12 7 12 7 3 Kawthoung 18 2 16 7 11 4 Kyunsu 11 4 7 4 7 5 Launglon 5 2 3 2 3 6 Myeik 7 7 0 7 0 7 Palaw 15 8 7 10 5 8 Tanintharyi 8 3 5 8 0 9 Thayetchaung 11 10 1 6 5 10 Yebyu 8 5 3 2 6 Tanintharyi Total 111 53 58 63 48 11 Ann 62 33 29 54 8 12 Kyaukpyu 48 24 24 45 3 13 Ramree 44 25 19 42 2 14 Toungup 31 27 4 23 8 Southern Rakhine 185 109 76 164 21 Total 15 Hlaingbwe 5 3 2 2 3 16 Kawkareik 1 1 0 0 1 17 Myawaddy 5 2 3 3 2 Kayin Total 11 6 5 5 6 Grand Total 307 168 139 232 75 Even though LLIN monitoring was conducted in 330 villages, results of 23 villages could not be interpreted because those villages were composed of less than 21 households as teams didn’t

know prior the basic information of those villages. According to findings, about half (45.3%) of total assessed villages were not at an acceptable level of LLIN coverage and one fourth (24.4%) of villages were not at an acceptable level of utilization. Villages at an unacceptable level of coverage will be included in LLIN top-up distribution in FY18 Q3. BCC campaigns (individual and group health talks) with a focus on the importance and use of LLINs will follow to increase utilization among the community. 1.14 Implementation and assessment of acceptability and utilization of forest goers’ package (Activity: 1.2.7) Forest Goers, usually missed by malaria services due to hard-to-reach locations and physical inaccessibility, and prolonged rooted behaviour such as sleeping without bed nets in the forest or without clothes when it’s hot, were targeted for distribution of 514 malaria prevention kits in Dawei Township in September 2017, and 449 kits to other areas (168 kits in Palaw, 49 kits in Kyunsu, and 232 kits in Myawaddy) in November 2017. This pilot is assessing acceptability and utilization of distributed forest goer kits and items including LLIN, long thick clothes, mosquito repellent (Odomos) and a health education Figure 4: PPM Officer and VMW met with forest goer at Thet pamphlet. Kar Ya Village, Myawaddy Township The Public Private Mix Officer (PPM Officer) visited 2 villages in Myawaddy and 3 villages in Dawei in March 2018 to monitor reporting practices of VMWs and data entry methods of Data Assistants, and conducted pilot testing by questionnaire to assess acceptability and utilization of kits 6 months after distribution . A field survey determining use and acceptability of the forest goer kits using a questionnaire and qualitative discussions will start in next quarter with collecting data from all 9 targeted villages in Dawei Township where forest goers constitute more than 10% of the population, followed-by data entry, data transcribing and translation of qualitative data, data verification, analysis and report development. Based on the findings, Defeat Malaria will update the contents of the forest goer kit according to acceptability by different areas.

1.15 Operational research to pilot new tools and approaches to reduce malaria transmission (Activity: 1.5.1) Progress of Evaluation of the performance of a hsRDT versus cRDT compared with Polymerase Chain Reaction (PCR) in Rakhine State On the move towards malaria elimination, better, cost-effective and more accurate diagnostic tools with an increased capacity to detect low density malaria infections are important. Starting in October 2017, Defeat Malaria has been implementing operational research on the “Evaluation of the performance of a hsRDT versus cRDT compared with PCR as the gold standard, in reactive case detection of malaria infections in Rakhine State”. Blood samples are being collected from a target of 50 index cases and 1,980 contacts by cRDT, hsRDT and dried blood spots for further confirmatory test by PCR.

Figure 5: Progress of hsRDT study (From October 2017 to March 2018)

As of March 2018, blood samples have been collected from 32 index cases and 1,217 contacts. Confirmatory test by PCR will be run only after completion of data collection to control batch error bias. It is expected field survey activities will continue next quarter and data analysis and report writing will be done in FY 2018 Q4. 2. Use of strategic information to adapt to changing epidemiology 2.1 Malaria Operation Planning (MOP) Team visit to Kayin State The MOP team worked with Defeat Malaria to identity appropriate strategic actions based on local epidemiology and determine the future operational plan through observation of malaria control activities implemented by Defeat Malaria. The MOP Team visited Defeat Malaria Townships in Kayin State from March 15-18, 2018. The MOP team also met with the State Health Director and other NMCP officials in Hpa-an Township.

The team was composed of:  Mr. William Hawley, Chief, Entomology Branch, CDC, Atlanta, USA  Ms. Susan Youll, Senior Public Health Advisor, USAID, Washington D.C, USA  Dr. Feliciano Monti, Malaria Advisor  Dr. Jimee Hwang, Medical Epidemiologist, CDC, Atlanta, USA  Dr. David Sintasath, Regional Malaria Advisor, USAID, Bangkok On 15th March 2018, the team met with the Kayin State Social Minister, State Public Health Director and NMCP Official to discuss the purpose of the mission visit, the malaria situation in Kayin State and service gaps in Non-State Actor (NSA) controlled areas. The Social Minister suggested that USAID assists in covering other health sectors and establishing a referral laboratory for malaria microscopy quality improvement. The team had also meetings with two ethnic health organizations, the KDHW and the Karen Baptist Convention (KBC), to discuss cooperation and coordination in malaria health care services in Kayin State. Team suggested ARC and EHOs to find ways of collaboration with Defeat Malaria, for example, sub-granting or output based contracting services or receiving donation of malaria commodities from Defeat Malaria to implement malaria control activities. The MOP team went to Nan Kaw Tay Village from Kawkareik on 16th March 2018 and met with VMWs and villagers. The team observed community awareness towards malaria, provision of malaria services, coverage of malaria preventive measures, such as LLINs, and utilization and coordination between Defeat Malaria and implementing partners. The team also met with another ethnic health organization , Back Pack Health Worker Team (BPHWT), on 17th March 2018 to discuss BPHWT’s malaria control activities and their coverage in Kayin state and other areas of Myanmar. The team visited Chaung Sone Village in Myawaddy Township and monitored the Defeat Malaria VMW’s provision of malaria health care services.

2.2 LLIN distribution and case detection approach based on local epidemiology in elimination areas Using routine surveillance data of villages, URC annually assesses changing epidemiological situations at the end of the project year. LLIN distribution, case detection and treatment approaches in each elimination township are based on receptivity and vulnerability of the area. Table 8 breaks down elimination activities based on receptivity and vulnerability.

Table 8: Appropriate action plans based on epidemiological situations

Receptivity Vulnerability LLIN Case detection and (climate, (Parasite carrier – man distribution plan treatment approach topography, or vector, population abundance of migration.)

Township vector)

Very low, island, Very low because most Not required Early detection of all very few forested people travel abroad. imported cases and treatment areas Incomer migrants are also according to NTGs. from low vulnerability or Hospitalization of all positive Manaung non-receptive areas. cases should be considered. Different degrees Different degrees of Receptive and low Using elimination approaches of receptivity vulnerability. vulnerable areas. of malaria interventions. NO LLINs Receptive and high Universal access to case

Toungup vulnerable areas. detection and treatment. YES

2.3 Malaria Response in new work sites in Bokpyin Township, Tanintharyi Region According to URC’s Defeat Malaria Team in Palaw Township ), six people from Palaw Township travelled on 15th March 2018 to Special Zone 1 in Bokpyin Township to construct houses for migrant workers. Of these six people, five contracted malaria from the area (one developed fever on April 1, 2018 while the remaining three developed fever on April 2-3, within the incubation period). All five people returned from Special Zone 1 to Palaw to receive treatment. In Palaw, among the five people tested, four P. vivax cases were detected. The other was negative, but the patient is now in Palaw general hospital for non-malaria related symptoms. The area where they travelled to is highly receptive and vulnerable as all four people were infected within 2-3 days of arrival. Follow up action by Palaw Defeat Malaria (URC) Team Two of the four P. vivax patients live in Palaw town in a non-receptive area and DOT was provided by a Health Facilitator. Since it was a non-receptive area, there was no possibility of on-ward transmission. The remaining two P. vivax cases live in villages (Mi Chaung Thike and Lat Kuu), and a midwife and VMW performed reactive case detection in theses villages to detect other parasite reservoirs and educate villagers to sleep under an LLIN. The mobile team tested 49 people and 59 people at Mi Chaung Thike village and Lat Kuu village, respectively, but no positive cases were found. Points for future action at source of infection (Bokepyin Township) Defeat Malaria will discuss the activities with the Township Medical Officer (TMO) and ARC will begin implementing activities in the area. Defeat Malaria needs to determine the total migrant population in these sites, available malaria services in that area, and if there are none, determine a plan for providing services given the mobility pattern of migrants. LLIN distribution will also be considered. 3. Initiating malaria elimination approaches in three pilot townships in Southern Rakhine State With permission from the Core TSG , Defeat Malaria started implementing malaria elimination activities in accordance with the Year 2 work plan in three pilot townships in Southern Rakhine

State: Toungup, Ramree, and Munaung in January 2018. According to CAP-Malaria data, Ramree and Munaung Townships have a very low TPR and Annual Parassite Incidence (API) with an adequate Annual Blood Examination Rate (ABER) suggesting they’re appropriate areas to begin pilot malaria elimination activities. Unlike the other two townships, Toungup Township possesses a range of topography and malaria transmission heterogeneity. Moreover, the north borders the highly endemic Ann Township and the east borders the Rakhine mountain range. Elimination will be a challenge here and it was selected as a learning opportunity. During the initial stages of implementation, great emphasis was given to preparation of health system requirements and program aspects in line with the World Health Organization (WHO) Global Technical Strategy for Malaria Elimination. 3.1 Support NMCP to develop an elimination package Defeat Malaria, within its elimination strategy, developed a malaria elimination model for the NMCP in close collaboration with PMI, WHO, and other stakeholders. With involvement of the community, public, and private sectors, this model adjusts interventions based on local receptivity, vulnerability, and existing health services provision in the three townships. Basic health and hospital staff, volunteers, and general practitioners play a substantial role in the package of surveillance interventions after provision of training in three pilot townships.

3.2 Current situational analysis A situational analysis (receptivity, vulnerability, human behavior, operational, HR, existing surveillance system, etc.) was conducted and based on these findings, a Malaria Elimination Plan of Action draft document was developed and distributed to the PMI MOP Team, USAID and the NMCP. It will be finalized by the end of April 2018. 3.3 Review and revise recording and reporting tools Based on the WHO Framework on Malaria Elimination, required documentation were identified and Defeat Malaria developed : (1) Positive Case Register (2) Case Investigation Form, Foci Investigation Form, Response Record Form (3) Case Detection Monitoring Form which covers monitoring of reporting units, monthly reporting status, adequacy of blood testing, inclusiveness of all sectors in reporting and different case detection approaches (4) SOP on foci investigation and persistent transmission of malaria 3.4 Advocacy meetings with public / private / community sectors on malaria elimination and formation of Township Level Malaria Elimination Committee In the three townships, advocacy meetings were conducted for all sector engagement and their roles in malaria elimination (Table 9). During the advocacy meetings, Township Malaria Elimination Coordination Committees (MECC) were discussed including nomination of members and their roles and responsibilities. To create an enabling environment, formation of MECCs were proposed at township level to guide performance and coordinate among different sectors. The Township Administrator and Township Medical Officer will serve as the Chairman and

Secretariat of the MECC, respectively. The Township Level MECC in Toungup Township was officially formed on 12 March 2018 with 16 members led by local government administrative authorities with the involvement of all three sectors (public, private and community). In the remaining two townships, MECCs will be organized in April and May 2018. With the formation of the MECC, field operation support teams including five field staff from the NMCP and URC, have a platform to provide timely support to township NMCP and Defeat Malaria teams. Table 9: Conducting Malaria Elimination Advocacy Meeting at Township Level

# Date Township Participants 1. 1 Feb 2018 Toungup 63 2. 24 March 2018 Ramree 44 3. 29 March 2018 Munaung 58

The first quarterly MECC meeting was on 27 March 2018 in Toungup Township with 17 participants, including MECC members. Discussion topics included distribution of RDTs and ACTs to general practitioners, reporting status of all reporting units and how to avoid nil reporting in an elimination setting. Quarterly MECC meetings were planned for Ramree and Munaung Townships, depending on availability of MECC members, in June and July 2018. 3.5 Strengthening the mHealth system for case notification In Munaung, Ramree, and Toungup, Defeat Malaria initiated an mHealth system to notify positive malaria cases via voice or short messaging service. Notifications are sent to responsible township- level staff. After receiving case notification by phone, township staff provide the unique patient ID number to the responsible Case Investigation Team for action. 3.6 Micro-stratification based on receptivity and transmission by using village-based data Ramree and Toungup have a low ABER, and a baseline assessment for village based micro- stratification was carried out using API regardless of ABER. Villages were stratified into (1) receptive but no current transmission and (2) receptive with current transmission. Receptive with current transmission were sub-stratified into low, moderate, and high transmission villages. Objectives, strategy and interventions were developed in accordance with characteristics of each stratum. Based on the current situational analysis, all village surveillance agents (BHS, midwives, etc.) will be encouraged to increase ABER by testing all suspected malaria cases in 2018. Table 10: Micro‐stratification of Toungup Township using 2017 Data

API ABER Total Remarks 0 > 0 - 5 > 5 - 20 > 20

0% 22 22 Not relevant because of zero ABER Not relevant because of inadequate > 0 - < 5 % 55 14 2 1 72 ABER

≥ 5 % 81 13 24 30 148 Adequate ABER

Total 158 27 26 31 242

Table 11: Micro‐stratification of Ramree Township using 2017 Data

API ABER Total Remarks 0 > 0 - 5 > 5 - 20 > 20

0% 8 8 Not relevant because of zero ABER Not relevant because of inadequate > 0 - < 5 % 33 1 0 0 34 ABER ≥ 5 % 168 12 2 0 182 Adequate ABER

Total 209 13 2 0 224

3.7 Introduction of Malaria Case Classification Calculator In elimination areas, it is necessary to classify all positive cases (whether imported or locally contracted) based on the incubation period, date of onset of fever, and travel history. Based on the case classification category appropriate responses will be conducted. However, the correct response time is required for effectiveness of control measures. To fill-up these gaps, Defeat Malaria developed and introduced a Malaria Case Classification Calculator for appropriate timing to respond. The calculator comprises for Pf and Pv species, with differing response times. Defeat Malaria’s Regional Technical Director led development of the calculator. This will be distributed to Vector Borne Disease Control (VBDC) and project staff in elimination townships in FY18 Q3 for better case investigation, classification and response.

Front of calculator Back of calculator

Figure 6: Malaria case classification calculator 3.8 Capacity building Defeat Malaria will conduct a series of malaria elimination capacity building trainings in the three townships. The training curriculum was developed based on provider category (see below) for basic health and hospital staff, NMCP staff, Defeat Malaria staff, and volunteers. Category A – for Medical Officer, Township Health Assistant, Health Assistant 1, Township Health Nurse, Health Assistant, Lady Health Visitor, and Public Health Supervisor Grade 1. Training will focus on basic malaria epidemiology to conduct case investigation, foci investigation and response. Category B – for Midwife and Public Health Supervisor Grade 2. Training will focus on details of case detection and treatment and certain concepts of basic malaria epidemiology to conduct case investigation if Category A staff are not able to conduct case investigation. Category C – for volunteers. Training will emphasize testing of all suspected malaria cases and treatment according to NTGs. In FY18Q2, one-day malaria elimination orientation trainings for township and station hospital staff were done as follows: Table 12: Capacity Building Training for Malaria Elimination in Three Pilot Townships

# Date Township Participants Remarks 1. 24 March 2018 Ramree 35 Township and Station Hospital Staffs 2. 27 March 2018 Toungup 54 Township and Station Hospital Staffs 3. 28 March 2018 Munaung 17 Township and Station Hospital Staffs

4. Improving Myanmar’s capacity to collect and use information 4.1 Capacity building of project staff on reorientation and updates to Monitoring and Evaluation (M&E) protocols at central level Data Quality Management training was provided to 12 Defeat Malaria staff at the Defeat Malaria Yangon Office from 21st to 23rd February 2018 by the central M & E team. The participants included a newly recruited Data Quality Officer from URC and ARC, Township Team Leaders and M & E focal staff from all partners (ARC, MHAA, MNMA and URC). The training promoted quality of data from service delivery points and Figure 7: M & E Director explained about M & E Guidelines and townships by provision of a data quality assurance Data Flow Mechanism at Data Quality Assurance training package to build capacity of newly recruited Data Quality Officers (DQOs) and data quality assurance focal staff in conducting routine data quality assessment, On-site Data Verification techniques, and provide an overview of Defeat Malaria objectives, indicators, guidelines, updated RDQA tools, forms and formats used for Defeat Malaria activities. 4.2 Multiplier trainings on reorientations and updates of M&E technique to outreach staff at township levels For initiation of pilot malaria elimination activities in Toungup, Ramree and Munaung and new expansion in Mrauk-U Township in Northern Rakhine State, all level of staff were newly recruited. A Defeat Malaria project orientation training was provided to 11 Medical Doctors, 5 Team Assistants and one Program Officer from Jhpiego at the Defeat Malaria Yangon Office from 12th to 16th March 2018. The objectives were: (1) To understand Defeat Malaria’s project design and strategies, work plans, M & E Guidelines and Procedures, Standard Operating Procedures, National Malaria Treatment Guidelines, Manual for Village Malaria Workers, Stock Management Guideline Manual, Staff Manual and Human Resource Guidelines, and Financial Guideline (2) To orient staff to standard forms and formats for application (3) To orient staff to the Defeat Malaria work plan and activities (4) To build capacity of M & E needs of newly recruited staff accountable for all reported township data 4.3 Management of Data Quality Provision of Routine Data Quality Assessments (Activity 2.1.5)

Quality of data is an essential foundation of surveillance, monitoring and evaluation. Defeat Malaria is always promoting data quality through capacity building to State/Region level focal staff (Data Quality Officer or M & E Officer for some partner organizations), orientation and refresher trainings on M & E for township staff (township team leader, team assistant and health facilitator), RDQA visits and On-site data verification conducted by central level and State/Region level, supervision visits of township level staff, and orientation, refresher trainings and post-training follow-up to VMWs/PPs. In this reporting period, RDQAs were conducted in 24 out of 30 (80%) Defeat Malaria townships, and on-site data verifications (including beneficiary interviews for their compliance on DOT) were conducted at 23 service delivery points by State/Region level staff (DQO and M & E Officers). The central M & E team conducted RDQA, on-site data verification and pilot testing of a new RDQA tool for continuous quality improvement at Figure 8: Pilot testing of updated RDQA tools with the inclusion of one Myeik and Kyunsu Townships in March more area about use of data for decision making 2018. The tool supports keeping records on data verification and feedback, consistency of dispatched stock quantity and received quantity of sub-stock cards, application of appropriate donor policy for branding, data verification needs, and data utilization for effective action. 4.4 Assessment on residual transmission areas in the focus of Sinphyutain Village of Dawei Township and appropriate response based on findings Most CAP-Malaria project villages showed a marked declination in API. But in some villages API was still high and residual malaria transmission was seen even after good coverage of malaria control. Sinphyutaing village showed a number of residual malaria positive cases, leading to an assessment in that village. Field assessment activities were done in November 2017.

Figure 9: Map of Sinphyutaing Village with 3 positive cases location in the village

Sinphyutaing is situated at the Myanmar-Thailand border, 75 miles from Dawei and 20 miles from the Myanmar-Thailand border gate. There are 128 households with a population of 502. It is on a plain with no thick forests around the village, but small ponds are present around and within the village. An. minimus and An. dirus were recorded during a 2013 Entomology survey. The test positivity rate reduced from 27.4% to 2.04% and API reduced from 227.69 to 10.86 per 1000 population from 2014-2017, respectively. Although malaria declined, locally contracted positive cases were still detected. Most of the population are forest goers and a few are MMPs. Throughout the night most people, including some children, work in forested areas to search for fish, bamboo shoots, mushrooms and hunting. About one-fourth of the village population migrates in and out every year. Immigrant groups from Kamahaw village (a malarious area) usually comes to harvest mountain rice fields near Sinphyutaing in November. Some people from Sinphyutaing also go to Kamahaw and War Taw to cut wood. An assessment of LLIN ownership and utilization was done for 83 households. A total of 272 LLINs were distributed in these 83 households with nearly 100% population coverage. Percentage of full protection by LLIN was only 58% of the population. Regarding treatment seeking behavior, most villagers consult either the midwife or volunteer. Sometimes self-treatment is also noticed at the onset of fever before consulting a midwife or volunteer. Previously, both Pv and Pf cases were seen, but Pv is now dominant with Pf rarely seen. Malaria patients from near-by villages also come for treatment in Sinphyutaing. Positives were found more among nearby villagers, leading to a mis-interpretation of the situation. In FY 2016, 25 positive cases were detected in Sinphyutaing, but only 6 cases stayed in the village while the remaining positive cases were from other villages with no health care services. Villagers still have misconceptions on causes and prevention methods for malaria.

Although local malaria transmission occurs in Sinphyutaing, these cases are very few with most coming from other malarious areas for treatment and most people agreed that malaria is more prevalent among forest goers (night time occupation). Among three positive cases detected, two were locally contracted and 1 was a migrant worker working on timber extraction at Kamahaw, a malarious area, in FY 2017. The NMCP midwife detected 13 positive cases including 1Pf and 12 Pv during 2017. A total of 9 cases were detected during the malaria season from June-August. In 2017, positive cases detected by the midwife were not investigated to differentiate between imported and locally contracted malaria cases. Two sets of data (NMCP and URC) were not yet compiled for analysis as a single set of data. Plan of action for the elimination of malaria transmission Based on the findings, the following activities will be carried out.  In 2018, both NMCP and URC data should be compiled before assessment by the end of this year. The midwife’s data of detected positive cases should incorporate geotag mapping for location of these cases.  All positive cases need a thorough history to know where the infection was contracted. (Patient address, travelling history, date of onset of fever). It is also necessary to differentiate between locally contracted malaria cases and imported malaria cases. Most of the cases are found among forest goers.  People coming from malarious areas, especially Kamahaw, for work in Sinphyutaing should be monitored for early detection of positive cases and prompt treatment to prevent on- ward transmission.  Encourage the community to keep and properly use LLINs. LLIN utilization rate is only 58%, mainly affected by the proportion of people who slept under a LLIN (only 78%). This is largely due to the nature of their work (working most of the night). Appropriate methods should be considered in groups like this including promoting use of repellent. 5. Building capacity and health systems strengthening 5.1 International meeting and training for Defeat Malaria Submission of abstracts to American Society of Tropical Medicine and Hygiene With the intention of continuous quality improvement and data utilization for program effectiveness and promoting efficiency, Defeat Malaria is reviewing all malaria service provision data. Recently, Defeat Malaria submitted 5 abstracts to the American Society of Tropical Medicine and Hygiene (ASTMH) for the 67th Annual Meeting. The submitted abstracts cover all components of Defeat Malaria objectives and which are: (1) Pursuing effective LLIN coverage and utilization in new areas of Northern Rakhine State, Myanmar [Recommended LLIN monitoring by observation of available bed-nets with enquiry of quality aspects of LLIN and participatory learning with communities for better action to achieve and maintain LLIN coverage and utilization targets.] (2) Village-based stratification in Myanmar for monitoring and to inform selection of malaria interventions [Suggesting simple ways to stratify using existing routine surveillance data

and API data and its use in monitoring progress and providing strategic information to target appropriate interventions for different strata.] (3) Assessment of residual malaria transmission in Letpan village, Southern Rakhine State, Myanmar [Letpan village classified as a residual non-active foci and identified forest goers as a risk group suggesting active surveillance for fever cases among returning forest goers and strengthening measures to prevent man-vector contact among forest goers.] (4) Improving adherence to National Malaria Treatment Guideline by Village Malaria Workers in selected townships through a Low-Dose, High-Frequency training approach [Suggesting Low Dose High Frequency (LDHF) was appropriate for capacity building of VMWs in general, but in some circumstances, it might need materials in local languages and with culturally appropriate illustrations] (5) Assessment of malaria services offered by private providers in rural, under-served areas of Tanintharyi Region, Myanmar [Highlighting private providers from rural, under-served areas should be appropriately trained, supported for malaria service provision, encouraged to engage in a timely referral mechanism and case reporting, and receive information on Myanmar’s national malaria treatment policy] Attending Prince Mahidol Award Conference (PMAC) 2018 Five Defeat Malaria staff attended the Prince Mahidol Award Conference 2018 with the theme “Making the world safe from the threats of emerging infectious diseases (EIDs)” from January 29 to February 3, 2018. From this conference, key drivers of EIDs and antimicrobial resistance (AMR), and appropriate public health responses for EIDs and AMR were well understood. A Bangkok statement on “A call to action on making the world safe from the threats of EID” was also noted. According to malaria related posters, agricultural pesticide exposure was found as a risk factor for malaria incidence with anopheles resistant to permethrin based insecticide (Renti Mahkota, 2018). Another study related to elimination concluded that malaria elimination in the Asia Pacific region is an achievable goal with benefits outweighing the costs (Rima Shretta, 2018. Investing in malaria elimination in Bangladesh, Indonesia, and Papua New Guinea). 5.2 Quality Assurance/Quality Improvement (QA/QI) Visit of QA/QI Consultant and recruitment of Quality Improvement Director A new staff was hired in the position of QI Director for a period of one year, starting from 14th March 2018. He will work with community, field teams and central level staff to rapidly assess and prioritize problem areas in quality improvement aspect and then develop and implement solutions. He will also conduct and facilitate trainings related to quality improvement and will institutionalize QI tools for continuous improvement of malaria integrated health services with a focus on cost- effectiveness and sustainability. The QI Director worked with Dr. Jessica Oyugi, who was hired as QA/QI Consultant for a duration of one month from 6th March to 6th April 2018, to develop quality improvement concepts, prioritize gaps and develop targeted improvement interventions. The Consultant presented concepts and approaches to integrate quality improvement in Defeat Malaria activities.

Key concepts and methods in Quality Improvement include Plan, Do, Study, Act (PDSA) cycles, fishbone analyses to brainstorm and measure (test changes, document, learn, spread). The QI consultant advised Defeat Malaria to document corrective actions with a QI plan and publish quality changes for both beneficiaries and donors and integrate QI in monthly meetings with VMWs and ensure VMWs are part of the QI process, e.g. identifying gaps, test changes, share learning. Potential gaps in prevention such as BCC may use QI concepts to further improve advocacy and IPC to ensure retention of messages among beneficiaries and promote use of LLINs in elimination settings. Visit of QI Director to Northern Rakhine State On 29th March 2018, the QI Director visited Chilepin Village in Sittwe Township together with the Field Coordinator to observe VMW activities. For field staff, he presented Defeat Malaria’s Environmental Monitoring and Mitigation Plan (EMMP) and documentation of environmental compliance activities. Ten project staff (9 males and 1 female) attended. On 30th March 2018, the QI Director together with the Sub-grant Manager facilitated VMW training in Buthedaung Township in Northern Rakhine State. 33 VMWs (32 males and 1 female) attended the training and discussed challenges and problems faced in the community and possible solutions. Table 13: Summary of activities of QI Director from January 2018 to March 2018

Problem/Gap Activity Whom, When & Status/Result Where Field staff not aware of QI director presented on QI Director and Region QI director will present Defeat Malaria EMMP EMMP in Sittwe office on and State Leads, trainings EMMP in semi-annual submitted to USAID 29 Mar in field offices and meeting, State/Region and observation at service Township Leads to delivery points disseminate and monitor environmental compliance People in the target QI Director discussed the Defeat Malaria Discuss the issue with communities are taking issue with VMWs in management, BCC team Chief of Party, to discuss substandard or Buthedaung and QI Director, FY2, with other stakeholders counterfeit drugs* Dissemination of Yangon office and field working on malaria information in the sites community Reduced community trust VMW suggested in Defeat Malaria Discuss the issue with in VMWs and people do meeting that Defeat management, Chief of Party, to discuss not listen health Malaria staff to be with State/Region and with sub-grantees: MHAA education messages* them when they face the Township Leads, FY2, and MNMA problem field sites 5.3 Participate in relevant Technical Strategic Group (TSG) meeting and support quarterly PMI partners’ meeting The Core TSG meeting was conducted on 12 January 2018 at the WHO Office. Main discussion points included malaria elimination, technical consultation on malaria elimination interventions at

33 the township level, and Defeat Malaria’s plan for pilot elimination activities in 3 townships of Rakhine State presented by URC’s Regional Technical Director. Topics included the role of local authorities, international non-governmental organizations (INGO), community based organizations (CBO) and the volunteer network in malaria elimination. The Core TSG agreed that Defeat Malaria could start implementation of malaria elimination activities in three pilot townships of Toungup, Ramree, and Munaung in Southern Rakhine State. 5.4 President’s Malaria Initiative (PMI) Thematic Workshop To exchange information on activities implemented by different malaria partners, share lessons learned and address common challenges, a PMI Thematic Workshop was organized in Nay Pyi Taw from March 19-20, 2018. The NMCP and more than 20 malaria implementing partners such as WHO, UN organizations, CDC, Defeat Malaria partners, GF-PR (UNOPS, STC), Ethnic Health Organizations (BPHW), national Figure 10: Participants who attended PMI Thematic Workshop and international NGOs presented on three main thematic topics: malaria surveillance and elimination, case management and vector control. For surveillance, Defeat Malaria’s Technical and Program Management Coordinator presented updates on pilot malaria elimination activities in collaboration with the NMCP in Munaung, Ramree and Toungup Townships. For case management, Defeat Malaria’s M&E Advisor provided progress updates on the “Evaluation of the performance of a hsRDT versus cRDT, compared with PCR as the gold standard, in Reactive Case Detection of Malaria Infections in Rakhine State.” Defeat Malaria’s M&E Director delivered a presentation on the “Formative Assessment of Residual Malaria Cases in Letpan Village, Toungup Township” during the Vector Control session. A total of 84 participants ( 47 male and 37 female) attended the 2-day workshop. 5.5 GIS Capacity building of central and township level staff After two batches of GIS trainings for 52 Defeat Malaria staff from central, State/Region and township level, organized in the last quarter of 2017, Defeat Malaria applied GIS to map project areas and malaria epidemiology. Shape file and base files are kept ready for regular updating and all township teams are utilizing these maps for data utilization and visualization. Drop-out of some Township Team Leaders could be a challenge for generating updated malaria situation maps and area expansion. Currently, State/ Region staff and central level staff are supporting updated maps for the townships in need. 5.6 Improved surveillance through mHealth Development of Defeat Malaria Dashboard A Defeat Malaria Dashboard was developed by the mHealth and Research Officer together with the Central M&E Team using Tableau for better visualization and internal monitoring. The

dashboard is web-based and is published at the Defeat Malaria domain: defeatmalariamyanmar.org. The dashboard consists of the project summary, goal and objectives, project coverage and progress updates. Unique usernames and passwords will be provided to each department within Defeat Malaria to access the dashboard after finalization. The dashboard will be updated monthly.

Figure 11: Defeat Malaria Dashboard

Development of a mobile device-based supervision tool using Open Data Kit (ODK) To capture location of project villages and malaria case settlements, GPS coordinates are essential. Currently, Defeat Malaria is using ODK to develop a mobile phone-based supervision checklist for use by project staff to capture GPS coordinates and support supervision visits. Use of the ODK mobile application is being piloted in the hsRDT survey by survey teams for capturing index house locations as well as 10 nearby households. 6. Strengthening capacity of the NMCP and Ethnic Health Organizations (EHOs) 6.1 Develop General Trainers identified from NMCP from Project States and regions on Malaria Technical and Training skill course In collaboration with the NMCP, Jhpiego and URC conducted a five-day General Trainer workshop in February 2018. 18 General Trainers per state/regions were targeted for a total of 56 General Trainers (18 from Kayin and Rakhine State, and 20 from Tanintharyi Region) (please see Annex-9). Participants were equipped with the concepts of community participation and community ownership through identification of community structures and community resources. Additional topics for integrated community malaria volunteers (i.e., TB, HIV, etc.) and their roles, updates on accurate diagnostic skills, prescription of drugs and management of illness, how to ensure proper recording and reporting of community data, and how to properly store drugs and commodities at community level. Participants are now competent trainers able to conduct cascade trainings effectively and efficiently, particularly for VMWs. As a component of the workshop, pre- and post-knowledge and skills assessments were administered to ensure participants achieve the required level of skills and knowledge. The knowledge questionnaires and skills checklist were designed to enhance the understanding of the

Community Based Intervention (CBI) approach and to improve skills on history taking, physical examination, RDT testing and treatment. Action plans for subsequent training for volunteers were developed on the last day of workshop. Figure 10 shows average scores (%) of General Trainers’ on CBI to enhance Malaria Control increased to 92%, 94% and 84% in Rahkine, Kayin and Tanintharyi, respectively.

Pre & Post test Average scores (%) of Knowledge assessment on CBI to enhance Malaria Control

92% 94% 100% 84% 72% 80% 67% 66%

60% pretest posttest 40%

20%

0% Rakhine Kayin Tanintharyi

Figure 12: Overall result of knowledge assessment on CBI to enhance Malaria Control in 3 States and Region

Pre & Post Test Average scores (%) of Knowledge Assessment on Training skill course

77% 77% 75% 80% 57% 60% 49% 60% pre test 40% post test 20%

0% Rakhine Kayin Tanintharyi

Figure 13: Overall result of knowledge assessment on CTS (Training Skill Course) in 3 States and Region Figure 11 shows average scores (%) of Training Skills increased to 75-77% on the post-test. Data were collected as a percentage based on questions that are answered correctly.

Total Average percentage of knowledge in Malaria technical and Training Skill Kayin Malaria Technical skill 100% 80% Tanintharyi Training Skill 60% Kayin Training Skill 40% 20% pre 0% post Tanintharyi Malaria Rakhine Malaria Technical Technical skill skill

Rakhine Training Skill

Figure 14: Pre and post knowledge assessment in both Malaria Technical and Training Skill in Kayin and Rakhine State and Tanintharyi Region Only one participant passed the training skills pre-test. About 62-67% of participants passed the post test. 33-38% of participants gave incorrect answers on competency based training skills, coaching skills and audio visual aids. This may be due to unclear questions. 6.2 On-site trainings In collaboration with the NMCP, new on-site trainings for Integrated Community Malaria Volunteers (ICMVs) were conducted in two sessions in Kyauphyu Township (Rakhine State). One in Launglon Township (Tanintharyi Region) as a first dose and in Myawaddy township (Kayin State) as a second dose followed by a training done by the NMCP in February and March 2018. 140 VMWs received technical updates on clinical diagnosis and management of malaria, how to fill the forms, how to conduct BCC, and how to perform RDT testing using different teaching aids, including Figure 15: Coaching RDT practice at ICMV case studies and group exercises. training in Launglon Township Jhpiego facilitated a Village Malaria Workers (VMW) training with URC in Dawei and Kanpauk in Launglon Township, Tanintharyi Region and in Pauktaw, Rakhine state. With ARC, Jhpiego facilitated a VHW training in Hlaingbwe, Hpa-an and Kawkareik townships in Kayin State.

6.3 Conduct joint support supervision with project staff/BHS In FY18Q2, Jhpiego participated in joint supportive supervision visits led by the URC Monitoring and Evaluation Team and Field Operations Team to Khay Taw village in Sittwe, Rakhine State and by ARC team to Hlaingbwe, Kayin State to assess data and stock and assist in performing RDQAs. Jhpiego also participated in supportive supervision visits with NMCP staff in 6 villages in Kyaukphyu township after ICMV training. Jhpiego joined the Quarterly ICMV meeting in Kyaukphyu to support report collection from VMWs and stock management. During the meetings and supportive supervision visits Figure 16: Assessing RDT testing of VMW at Pinlenar volunteers received quick technical updates on village during supervision visit the importance of RDT testing and community health education. Individual assessments of on-the-job performance were done through role play, checking monthly reports, and giving individual feedback. 6.4 Strengthen malaria surveillance system, improve data management capacity at all levels Access database management training To strengthen surveillance and data management of NMCP staff in Rakhine State, central NMCP trainers (Field Officer and Surveillance M&E Officer) provided Access database training to 48 participants in Sittwe from January 9-10, 2018. Training comprised the Access database, data validation techniques, results monitoring and how to report monthly data through google drive. The State VBDC Officer encouraged all partners to install and perform data entry using Access starting in 2018. However, NMCP trainers indicated the need to Figure 17: State Coordinator, URC handed over 17 overcome some errors for partner data compilation laptops to State VBDC Officer, Rakhine and implementing partners should use their own for now. Access database training was also provided to 18 VBDC staff from Kayin State by central NMCP trainers in Hpa-an Township from 28-Mar-2018 to 01-Apr-2018. Eight Dell Core i7 laptops were provided for use by malaria focal staff from all 7 townships and the State VBDC Officer. Provision of new laptops for better surveillance and data management

To replace poor functioning laptops and support new laptops for focal NMCP staff of all townships of Rakhine State, 17 Dell, Intel Core i7 laptops were provided by Defeat Malaria. The State Public Health Director, State VBDC Officer and NMCP staff expressed their gratitude Figure 18: NMCP staff with new laptops provided by Defeat Malaria and satisfaction to PMI and URC Defeat Malaria. For Kayin State, 8 Dell Core i7 laptops were provided for use by malaria focal staff from all 7 townships and one for the State VBDC Officer. 6.4 Technical support to VBDC team in Indoor Residual Spray (IRS) activity Defeat Malaria’s Team Assistant from Kyauktaw Township provided on-the-job trainings and assisted the Sittwe VBDC team to conduct IRS through field supervision of activities conducted by the Sittwe VBDC Team in Ohn Taw Chay Camp in Sittwe Township from 8th to 10th February 2018.

6.5 Capacity building of EHOs Defeat Malaria’s Senior Operations Director facilitated a one-day refresher training for 100 volunteers (Male – 37, Female – 63) from BPHWT at Mae Sot on 29th January 2018 to update malaria technical skills and introduce malaria elimination concepts 6.6 Capacity building on Logistics Management Information System (LMIS)

Monitoring visits of Admin and Logistics team to Northern Rakhine State A monitoring and supervision team consisting of a Senior Admin & Logistics Coordinator and Admin Officer from Defeat Malaria HQ visited 7 townships in Northern Rakhine State from 4th to 8th March 2018 to assess the LMIS system not only at state/regional level but also township level by checking stock, inventory and vehicle logs.

Findings and recommendations

Table 14: Findings and recommendations during admin and logistics team visit

# Findings Recommendations 1 Stock Management - Teams didn’t check ground - Ground stock checking should be done stock regularly. monthly. - Even though stock reports were - Revised stock reports should be submitted revised and submitted to Field timely to Central Logistics Team. Admin, they were not reported to Central Logistics Team. - Discrepancies were found in the - Stock balance between stock cards and in balance of stock between stock hands of VMWs should be verified monthly. cards and in hands of VMWs. - Unsystematic arrangement of - Arrangement of stock card, drugs and stock card, drugs and equipment equipment should be taken care in accordance with batch number and expiry dates. - There was no record for balance - Balance of damaged drugs should be of damaged drugs. recorded.

2 Vehicle log - Spare parts were not available - Regular assessment on availability of spare parts should be done.

3 Ethics Hotline - All townships have ethics hotline - System should be maintained. posters.

4 File management - All files such as procurement, - System should be maintained. administration and finance were arranged properly.

Monitoring visits of IT officer For better communication and project management, IT officer visits to sub offices in Northern Rakhine (Sittwe and Minbya) from 6th to 9th April 2018 and Tanintharyi (Dawei and Myeik) 27th to 31st March to setup the new wireless network for internet and Local Area Network (LAN) and install Konica Minolta Color printers together by training project staff to be able to utilize.

Challenges  Temporary interruption of activities in Maungdaw and Buthidaung villages due to conflict – Defeat Malaria targeted villages in Buthiduang and Maungdaw Townships were severely affected by conflict. Starting from the early weeks of October 2016 and last weeks of August 2017, unstable security conditions occurred in Northern Rakhine State causing

interruption of Defeat Malaria field activities. In a Coordination Committee meeting, the TMO stated INGOs are not allowed to do field visit activities at village level in Buthidaung and Maungdaw. MHAA is waiting for the permission letter (approval) from the Rakhine State Coordination Committee to implement field activities at village level. Phone accessibility is not possible for contact and volunteers have left villages (mainly in Maungdaw). MHAA maintains regular contact with the Township Health Department and BHS and conducts monthly meetings with BHS and Volunteers at the RHC Level. Continuous follow up is done for approval from the Coordination Committee to conduct field visits.  Difficulty in finding malaria cases – Due to aggressive and universal coverage of prevention and case management by all implementing partners, malaria incidence has reduced in most geographical areas. This led to low detection of positive malaria cases. Most of the new expansion villages have a low malaria caseload. Through negotiation and collaboration with State/Regional Health Departments and VBDC, Defeat Malaria will work beyond target areas and continue to practice a village-based strategy and introduce intensified case finding activities. In areas where malaria prevalence is low or zero, it is necessary to adapt to the changing epidemiology and utilize appropriate approaches. In these areas, sustaining no malaria status and reducing low malaria transmission to zero malaria transmission can be recorded as impact of the project. Thus, the surveillance system needs to be strengthened to maintain the objectives even it is costlier.  In three elimination townships, advocacy meetings for malaria elimination were held at township level. In Toungup and Munaung Townships, meetings were successfully conducted. In Ramree Township, the meetings was postponed due to unforeseen activities of key government sector staff who couldn’t attend. Next quarter, a meeting will be arranged to explain their contribution to the mission of elimination.  Delay in Procuring ACTs and RDTs – under the USAID DELIVER Project, ACT procurement took 6 months for delivery. Under USAID GHSP-PSM, ACT procurement takes 9 months. (CPIR requested date for ACT 15-May-2017, actual arrival date 15 February 2018). Some temporary ACT mobilization was made from other partners to prevent stock out. Commodity Procurement Information Request for RDT was done on 15 May 2017 and RDTs have not yet arrived. Defeat Malaria is facing stock outs due to area expansion and elimination activities.  Per discussion between ARC’s Defeat Malaria Project Manager and the Karen National Union (KNU) Brigade-5, the KNU focal point of Hpa-Pun Township confirmed that they won’t conduct Defeat Malaria activities. Thus, ARC stopped activities in Hpa-pun and Kyainseikgyi Townships in January 2018. The MOP team had a meeting with the KDHW on March 15, 2018 and discussed future cooperation in malaria health services.

Annexes Annex 1 – Case Finding and Management Table 15: Summary of Case Finding and Management by Township (from January to March 2018) – Mobile Team Approach

# Township Tested Total Positive Pf Pv Mixed TPR% 1 Bokpyin (ARC) 20 4 0 4 0 20.00% 2 Dawei (URC) 326 0 0 0 0 0.0% 3 Kawthoung (ARC) 111 0 0 0 0 0.0% 4 Kyunsu (URC) 281 2 0 2 0 0.7% 5 Launglon (URC) 210 0 0 0 0 0.0% 6 Myeik (URC) 151 0 0 0 0 0.0% 7 Palaw (URC) 326 3 0 3 0 0.9% 8 Tanintharyi (ARC) 112 0 0 0 0 0.0% 9 Thayetchaung (URC) 112 0 0 0 0 0.0% 10 Yebyu (URC) 31 0 0 0 0 0.0% Tanintharyi Total 1,568 9 0 9 0 0.6% 11 Ann (URC) 2,054 18 18 0 0 0.9% 12 Gwa (MNMA) 221 0 0 0 0 0.0% 13 Kyuakpyu (URC) 0 0 0 0 0 - 14 Munaung (URC) 0 0 0 0 0 - 15 Ramree (URC) 0 0 0 0 0 - 16 Thandwe (MNMA) 559 0 0 0 0 0.0% 17 Toungup (URC) 32 0 0 0 0 0.0% Southern Rakhine Total 2,866 18 18 0 0 0.6% 18 Buthidaung (MHAA) 0 0 0 0 0 - 19 Kyauktaw (URC) 400 3 0 3 0 0.8% 20 Maungdaw (MHAA) 0 0 0 0 0 - 21 Minbya (URC) 65 3 3 0 0 4.6% 22 Mrauk-U (URC) 0 0 0 0 0 - 23 Myebon (URC) 174 1 1 0 0 0.6% 24 Pauktaw (URC) 0 0 0 0 0 - 25 Ponnagyun (URC) 0 0 0 0 0 - 26 Rathedaung (MHAA) 135 0 0 0 0 0.0% 27 Sittwe (URC) 0 0 0 0 0 - Northern Rakhine Total 774 7 4 3 0 0.9% 28 Hlaingbwe (ARC) 184 0 0 0 0 0.0% 29 Hpa-an (ARC) 0 0 0 0 0 - 30 Kawkareik (ARC) 0 0 0 0 0 - 31 Myawaddy (ARC) 236 1 0 1 0 0.4% Kayin Total 420 1 0 1 0 0.2% Defeat Malaria Total (Mobile) 5,628 35 22 13 0 0.6%

Table 16: Summary of Case Finding and Management by Township (from January to March 2018) – VMW Approach

# Township Tested Total Positive Pf Pv Mixed TPR% 1 Bokpyin (ARC) 571 13 2 11 0 2.28% 2 Dawei (URC) 462 14 0 14 0 3.0% 3 Kawthoung (ARC) 1,112 1 0 1 0 0.1% 4 Kyunsu (URC) 1,200 15 4 11 0 1.3% 5 Launglon (URC) 602 1 0 1 0 0.2% 6 Myeik (URC) 568 0 0 0 0 0.0% 7 Palaw (URC) 658 20 10 10 0 3.0% 8 Tanintharyi (ARC) 1,214 25 8 17 0 2.1% 9 Thayetchaung (URC) 302 1 0 1 0 0.3% 10 Yebyu (URC) 731 0 0 0 0 0.0% Tanintharyi Total 7,420 90 24 66 0 1.2% 11 Ann (URC) 1,496 38 28 10 0 2.5% 12 Gwa (MNMA) 958 8 7 1 0 0.8% 13 Kyuakpyu (URC) 697 0 0 0 0 0.0% 14 Munaung (URC) 0 0 0 0 0 - 15 Ramree (URC) 1,617 2 0 2 0 0.1% 16 Thandwe (MNMA) 2,744 8 8 0 0 0.3% 17 Toungup (URC) 982 12 9 2 1 1.2% Southern Rakhine Total 8,494 68 52 15 1 0.8% 18 Buthidaung (MHAA) 1,582 100 40 54 6 6.3% 19 Kyauktaw (URC) 2,471 93 76 17 0 3.8% 20 Maungdaw (MHAA) 0 0 0 0 0 - 21 Minbya (URC) 458 44 31 10 3 9.6% 22 Mrauk-U (URC) 328 24 18 6 0 7.3% 23 Myebon (URC) 1,758 22 10 12 0 1.3% 24 Pauktaw (URC) 979 1 1 0 0 0.1% 25 Ponnagyun (URC) 844 15 8 7 0 1.8% 26 Rathedaung (MHAA) 957 1 0 0 1 0.1% 27 Sittwe (URC) 1,083 3 1 2 0 0.3% Northern Rakhine Total 10,460 303 185 108 10 2.9% 28 Hlaingbwe (ARC) 517 5 0 5 0 1.0% 29 Hpa-an (ARC) 837 8 2 6 0 1.0% 30 Kawkareik (ARC) 830 7 0 7 0 0.8% 31 Myawaddy (ARC) 517 5 0 5 0 1.0% Kayin Total 2,797 64 3 61 0 2.3% Defeat Malaria Total (VMW) 29,171 525 264 250 11 1.8%

Table 17: Summary of Case Finding and Management by Township (from January to March 2018) – Private Provider Approach

# Township Tested Total Positive Pf Pv Mixed TPR% 1 Bokpyin (ARC) 122 2 1 1 0 1.64% 2 Dawei (URC) 29 0 0 0 0 0.0% 3 Kawthoung (ARC) 423 5 3 2 0 1.2% 4 Kyunsu (URC) 291 0 0 0 0 0.0% 5 Launglon (URC) 0 0 0 0 0 - 6 Myeik (URC) 257 1 0 1 0 0.4% 7 Palaw (URC) 192 6 4 1 1 3.1% 8 Tanintharyi (ARC) 0 0 0 0 0 - 9 Thayetchaung (URC) 196 6 0 6 0 3.1% 10 Yebyu (URC) 0 0 0 0 0 - Tanintharyi Total 1,510 20 8 11 1 1.3% 11 Ann (URC) 339 12 11 1 0 3.5% 12 Gwa (MNMA) 0 0 0 0 0 - 13 Kyuakpyu (URC) 143 1 0 1 0 0.7% 14 Munaung (URC) 0 0 0 0 0 - 15 Ramree (URC) 158 0 0 0 0 0.0% 16 Thandwe (MNMA) 0 0 0 0 0 - 17 Toungup (URC) 118 3 3 0 0 2.5% Southern Rakhine Total 758 16 14 2 0 2.1% 18 Buthidaung (MHAA) 0 0 0 0 0 - 19 Kyauktaw (URC) 81 0 0 0 0 0.0% 20 Maungdaw (MHAA) 0 0 0 0 0 - 21 Minbya (URC) 0 0 0 0 0 - 22 Mrauk-U (URC) 62 3 1 1 1 4.8% 23 Myebon (URC) 218 2 2 0 0 0.9% 24 Pauktaw (URC) 332 1 0 1 0 0.3% 25 Ponnagyun (URC) 161 2 2 0 0 1.2% 26 Rathedaung (MHAA) 0 0 0 0 0 - 27 Sittwe (URC) 0 0 0 0 0 - Northern Rakhine Total 854 8 5 2 1 0.9% 28 Hlaingbwe (ARC) 0 0 0 0 0 - 29 Hpa-an (ARC) 58 1 0 1 0 1.7% 30 Kawkareik (ARC) 10 0 0 0 0 0.0% 31 Myawaddy (ARC) 56 16 0 16 0 28.6% Kayin Total 124 17 0 17 0 13.7% Defeat Malaria Total (Private 3,246 61 27 32 2 1.9% Provider)

Annex 2 – Active case detection by mobile team Table 18: Summary of active case detection in project villages and work sites (from January to March 2018)

# Total Total Test Villages/ Coverag P Mixe Tota # Township populatio Teste Pf Positivit worksit e v d l n d y Rate es 1 Bokpyin 2 562 2 0.36% 0 0 0 0 0.00% 2 Dawei 3 749 326 43.52% 0 0 0 0 0.00% 3 Kawthoung 3 276 111 40.22% 0 0 0 0 0.00% 4 Kyunsu 4 1,979 281 14.20% 0 2 0 2 0.71% 5 Launglon 3 1,185 210 17.72% 0 0 0 0 0.00% 6 Myeik 3 519 151 29.09% 0 0 0 0 0.00% 7 Palaw 5 1,002 252 25.15% 0 1 0 1 0.40% 8 Thayetchaung 3 974 112 11.50% 0 0 0 0 0.00% 9 Yebyu 1 142 31 21.83% 0 0 0 0 0.00% Tanintharyi Total 27 7,388 1476 19.98% 0 3 0 3 0.20% 10 Ann 5 1,250 228 18.24% 2 0 0 2 0.88% 11 Gwa 5 1,209 216 17.87% 0 0 0 0 0.00% 12 Thandwe 10 1,066 554 51.97% 0 0 0 0 0.00% 13 Toungup 1 437 32 7.32% 0 0 0 0 0.00% Rakhine (South) 21 3,962 1030 26.00% 2 0 0 2 0.19% Total 14 Kyauktaw 5 984 242 24.59% 0 3 0 3 1.24% 15 Rathedaung 2 932 135 14.48% 0 0 0 0 0.00% Rakhine (North) 7 1,916 377 19.68% 0 3 0 3 0.80% Total 16 Myawaddy 3 2,910 224 7.70% 0 1 0 1 0.45% Kayin Total 3 2,910 224 7.70% 0 1 0 1 0.45% Grand Total 58 16,176 3,107 19.21% 2 7 0 9 0.29%

Table 19: Summary of active case detection in non‐project villages and work sites (from January to March 2018)

# Total Total Test Villages/ Covera Mixe # Township populatio Teste Pf Pv Total Positivi worksit ge d n d ty Rate es 1 Bokpyin 13 11,534 18 0.16% 0 4 0 4 22.22% 2 Palaw 2 311 74 23.79% 0 2 0 2 2.70% Tanintharyi Total 15 11,845 92 0.78% 0 6 0 6 6.52% 3 Ann 45 31,979 1,826 5.71% 16 0 0 16 0.88% 4 Gwa 2 - 5 - 0 0 0 0 0.00% 5 Thandwe 2 - 5 - 0 0 0 0 0.00% Southern Rakhine 49 31,979 1,836 5.74% 16 0 0 16 0.87% Total 6 Kyauktaw 5 742 158 21.29% 0 0 0 0 0.00% 7 Minbya 2 3,418 65 1.90% 3 0 0 3 4.62% 8 Myebon 1 450 174 38.67% 1 0 0 1 0.57% Northern Rakhine 8 4,610 397 8.61% 4 0 0 4 1.01% Total 9 Hlaingbwe 2 1,222 184 15.06% 0 0 0 0 0.00% 10 Myawaddy 2 991 12 1.21% 0 0 0 0 0.00% Kayin Total 4 2,213 196 8.86% 0 0 0 0 0.00% Grand Total 76 50,647 2,521 4.98% 20 6 0 26 1.03%

Annex 3 – Monthly meeting Table 20: Summary of VMW/PP monthly meeting (from January to March 2018)

% of VMWs/PPs VMW / PP Posts have Femal # Township Male Total attended the to attend the meeting e meeting 1 Bokpyin 126 18 97 115 91.3% 2 Dawei 63 12 50 62 98.4% 3 Kawthoung 157 85 52 137 87.3% 4 Kyunsu 160 38 121 159 99.4% 5 Launglon 88 12 69 81 92.0% 6 Myeik 90 6 81 87 96.7% 7 Palaw 117 30 82 112 95.7% 8 Tanintharyi 148 30 106 136 91.9% 9 Thayetchaung 76 10 65 75 98.7% 10 Yebyu 130 30 89 119 91.5% Tanintharyi Total 1,155 271 812 1,083 93.8% 11 Ann 183 111 54 165 90.2% 12 Gwa 195 80 109 189 96.9% 13 Kyaukpyu 150 114 33 147 98.0% 14 Ramree 264 170 79 249 94.3% 15 Thandwe 354 108 245 353 99.7% 16 Toungup 222 82 119 201 90.5% Southern Rakhine 1,368 665 639 1,304 95.3% Total 17 Buthidaung 150 92 12 104 69.3% 18 Kyauktaw 229 139 90 229 100.0% 19 Minbya 70 52 14 66 94.3% 20 Mrauk-U 78 49 25 74 94.9% 21 Myebon 165 83 79 162 98.2% 22 Pauktaw 126 73 52 125 99.2% 23 Ponnagyun 120 68 49 117 97.5% 24 Rathedaung 165 66 86 152 92.1% 25 Sittwe 96 14 79 93 96.9% Northern Rakhine 1,199 636 486 1,122 93.6% Total 26 Hlaingbwe 97 16 74 90 92.8% 27 Hpa-an 207 43 158 201 97.1% 28 Kawkareik 99 45 54 99 100.0% 29 Myawaddy 67 22 45 67 100.0% Kayin Total 470 126 331 457 97.2% Grand Total 4,192 1,698 2,268 3,966 94.6%

Annex 4 – Supervision and monitoring Table 21: Summary of supervision and monitoring visits to VMWs/PPs (from January to March 2018)

# of visits to Total # of VMWs and PPs # Township # of visits to PPs VMWs supervised 1 Bokpyin 17 3 20 2 Dawei 18 2 20 3 Kawthoung 31 3 34 4 Kyunsu 26 4 30 5 Launglon 14 0 14 6 Myeik 14 5 19 7 Palaw 14 7 21 8 Tanintharyi 28 0 28 9 Thayetchaung 5 2 7 10 Yebyu 5 0 5 Tanintharyi Total 172 26 198 11 Ann 36 8 44 12 Gwa 30 0 30 13 Kyaukpyu 58 8 66 14 Ramree 56 4 60 15 Thandwe 62 0 62 16 Toungup 36 7 43 Southern Rakhine Total 278 27 305 17 Kyauktaw 22 1 23 18 Minbya 12 0 12 19 Mrauk-U 15 2 17 20 Myebon 34 4 38 21 Pauktaw 22 8 30 22 Ponnagyun 21 6 27 23 Rathedaung 36 0 36 24 Sittwe 21 0 21 Northern Rakhine Total 183 21 204 25 Hlaingbwe 13 0 13 26 Hpa-an 35 0 35 27 Kawkareik 16 1 17 28 Myawaddy 22 0 22 Kayin Total 86 1 87 Grand Total 719 75 794

Annex 5 – Reporting status of VMWs/PPs Table 22: Reporting status of VMWs/PPs (from January to March 2018)

Total Number of % of On- cumulative # Number Of On-time % of time Report Of VMWs/PPs Report Reporti of # Township VMWs/PPs Reported (On submitted ng VMWs/PPs have to time report + by Status among submit the Late report) VMWs/PPs reported report 1 Bokpyin 129 125 123 96.9% 98.4% 2 Dawei 98 95 95 96.9% 100.0% 3 Kawthoung 157 151 150 96.2% 99.3% 4 Kyunsu 160 160 160 100.0% 100.0% 5 Launglon 88 84 84 95.5% 100.0% 6 Myeik 90 89 89 98.9% 100.0% 7 Palaw 117 117 117 100.0% 100.0% 8 Tanintharyi 151 139 139 92.1% 100.0% 9 Thayetchaung 76 75 75 98.7% 100.0% 10 Yebyu 130 125 123 96.2% 98.4% Tanintharyi Total 1,196 1,160 1,155 97.0% 99.6% 11 Ann 183 177 177 96.7% 100.0% 12 Gwa 195 195 195 100.0% 100.0% 13 Kyaukpyu 150 150 150 100.0% 100.0% 14 Ramree 264 253 253 95.8% 100.0% 15 Thandwe 354 354 354 100.0% 100.0% 16 Toungup 222 221 218 99.5% 98.6% Southern Rakhine 1,368 1,350 1,347 98.7% 99.8% Total 17 Buthidaung 150 107 107 71.3% 100.0% 18 Kyauktaw 229 229 229 100.0% 100.0% 19 Minbya 72 68 68 94.4% 100.0% 20 Mrauk-U 78 78 78 100.0% 100.0% 21 Myebon 165 164 164 99.4% 100.0% 22 Pauktaw 126 126 126 100.0% 100.0% 23 Ponnagyun 120 120 120 100.0% 100.0% 24 Rathedaung 165 161 159 97.6% 98.8% 25 Sittwe 96 96 96 100.0% 100.0% Northern Rakhine 1,201 1,149 1,147 95.7% 99.8% Total 26 Hlaingbwe 97 97 97 100.0% 100.0% 27 Hpa-an 219 218 218 99.5% 100.0% 28 Kawkareik 99 99 99 100.0% 100.0% 29 Myawaddy 67 67 67 100.0% 100.0% Kayin Total 482 481 481 99.8% 100.0% Grand Total 4,247 4,152 4,140 97.8% 99.7%

Annex 6 – Clinical audit Table 23: Summary of clinical audit (from January to March 2018)

% of Pf and Total Total Mixed Total positive % of Positive Total patients who Positive cases treated cases referred were cases treated cases # Township treated cases in treated found in according among in reporting according to reporting to NTG in positive reporting month National month reporting cases month Treatment month Guideline 1 Bokpyin 19 19 18 0 100.0% 94.7% 2 Dawei 14 14 14 0 100.0% 100.0% 3 Kawthoung 6 5 5 1 83.3% 100.0% 4 Kyunsu 17 17 16 0 100.0% 94.1% 5 Launglon 1 1 1 0 100.0% 100.0% 6 Myeik 1 1 1 0 100.0% 100.0% 7 Palaw 29 29 29 0 100.0% 100.0% 8 Tanintharyi 25 24 24 1 96.0% 100.0% 9 Thayetchaung 7 7 7 0 100.0% 100.0% 10 Yebyu 0 0 0 0 - - Tanintharyi Total 119 117 115 2 98.3% 98.3% 11 Ann 68 68 68 0 100.0% 100.0% 12 Gwa 8 8 8 0 100.0% 100.0% 13 Kyaukpyu 1 1 1 0 100.0% 100.0% 14 Ramree 2 2 2 0 100.0% 100.0% 15 Thandwe 8 7 7 1 87.5% 100.0% 16 Toungup 15 15 15 0 100.0% 100.0% Southern Rakhine Total 102 101 101 1 99.0% 100.0% 17 Buthidaung 100 100 100 0 100.0% 100.0% 18 Kyauktaw 96 95 95 1 99.0% 100.0% 19 Minbya 47 46 46 1 97.9% 100.0% 20 Mrauk-U 27 27 27 0 100.0% 100.0% 21 Myebon 25 25 24 0 100.0% 96.0% 22 Pauktaw 2 2 2 0 100.0% 100.0% 23 Ponnagyun 17 17 17 0 100.0% 100.0% 24 Rathedaung 1 1 1 0 100.0% 100.0% 25 Sittwe 3 3 3 0 100.0% 100.0% Northern Rakhine 318 316 315 2 99.4% 99.7% Total 26 Hlaingbwe 5 4 3 1 80.0% 75.0% 27 Hpa-an 9 9 9 0 100.0% 100.0% 28 Kawkareik 7 7 7 0 100.0% 100.0% 29 Myawaddy 61 60 59 1 98.4% 98.3% Kayin Total 82 80 78 2 97.6% 97.5% Grand Total 621 614 609 7 98.9% 99.2%

Annex 7 – Stock out monitoring at the time of monitoring visits Table 24: Summary of stock out monitoring at the time of monitoring visits and on‐site data collection (from January to March 2018)

Total # % of sites % of sites % of sites % of sites of VMW Total # of Total # Total # of Total # of Total # of which which which which with NO VMW with of PP with PP with # Township visited experienced experienced experienced experienced RDT NO ACT visited NO RDT NO ACT VMW NO RDT NO ACT NO RDT NO ACT stock stock out PP stock out stock out stock out stock out stock out stock out out 1 Bokpyin 17 17 100.0% 17 100.0% 3 3 100.0% 3 100.0% 2 Dawei 18 18 100.0% 18 100.0% 2 2 100.0% 2 100.0% 3 Kawthoung 31 31 100.0% 31 100.0% 3 3 100.0% 3 100.0% 4 Kyunsu 26 26 100.0% 26 100.0% 4 4 100.0% 4 100.0% 5 Launglon 14 14 100.0% 14 100.0% - - - - - 6 Myeik 14 14 100.0% 14 100.0% 5 5 100.0% 5 100.0% 7 Palaw 14 14 100.0% 14 100.0% 7 7 100.0% 7 100.0% 8 Tanintharyi 28 28 100.0% 28 100.0% - - - - - 9 Thayetchaung 5 5 100.0% 5 100.0% 2 2 100.0% 2 100.0% 10 Yebyu 5 5 100.0% 5 100.0% - - - - - Tanintharyi Total 172 172 100.0% 172 100.0% 26 26 100.0% 26 100.0% 11 Ann 36 36 100.0% 36 100.0% 8 8 100.0% 8 100.0% 12 Gwa 30 30 100.0% 30 100.0% - - - - - 13 Kyaukpyu 58 58 100.0% 58 100.0% 8 8 100.0% 8 100.0% 14 Ramree 57 57 100.0% 57 100.0% 3 3 100.0% 3 100.0% 15 Thandwe 62 62 100.0% 62 100.0% - - - - - 16 Toungup 36 36 100.0% 36 100.0% 7 7 100.0% 7 100.0% Rakhine (South) Total 279 279 100.0% 279 100.0% 26 26 100.0% 26 100.0% 17 Kyauktaw 22 22 100.0% 22 100.0% 1 1 100.0% 1 100.0% 18 Minbya 12 12 100.0% 12 100.0% - - - - - 19 Mrauk-U 15 15 100.0% 15 100.0% 2 2 100.0% 2 100.0% 20 Myebon 34 34 100.0% 34 100.0% 4 4 100.0% 4 100.0% 21 Pauktaw 23 23 100.0% 23 100.0% 8 8 100.0% 8 100.0% 22 Ponnagyun 24 24 100.0% 24 100.0% 6 6 100.0% 6 100.0% 23 Rathedaung 36 36 100.0% 36 100.0% - - - - - 24 Sittwe 21 21 100.0% 21 100.0% - - - - - Rakhine (North) Total 187 187 100.0% 187 100.0% 21 21 100.0% 21 100.0% 25 Hlaingbwe 13 13 100.0% 13 100.0% - - - - - 26 Hpa-an 35 35 100.0% 35 100.0% - - - - - 27 Kawkareik 16 16 100.0% 16 100.0% 1 1 100.0% 1 100.0% 28 Myawaddy 22 22 100.0% 22 100.0% - - - - - Kayin Total 86 86 100.0% 86 100.0% 1 1 100.0% 1 100.0% Grand Total 724 724 100.0% 724 100.0% 74 74 100.0% 74 100.0%

Table 25: Summary of stock out monitoring at monthly meeting (from January to March 2018)

Total # % of sites % of sites % of sites % of sites of VMW Total # of Total # Total # of Total # of Total # of which which which which with NO VMW with of PP with PP with # Township visited experienced experienced experienced experienced RDT NO ACT visited NO RDT NO ACT VMW NO RDT NO ACT NO RDT NO ACT stock stock out PP stock out stock out stock out stock out stock out stock out out 1 Bokpyin 103 103 100.0% 103 100.0% 12 12 100.0% 12 100.0% 2 Dawei 56 56 100.0% 56 100.0% 6 6 100.0% 6 100.0% 3 Kawthoung 126 126 100.0% 126 100.0% 11 11 100.0% 11 100.0% 4 Kyunsu 129 129 100.0% 129 100.0% 30 30 100.0% 30 100.0% 5 Launglon 81 81 100.0% 81 100.0% - - - - - 6 Myeik 69 69 100.0% 69 100.0% 18 18 100.0% 18 100.0% 7 Palaw 81 81 100.0% 81 100.0% 28 28 100.0% 28 100.0% 8 Tanintharyi 136 136 100.0% 136 100.0% - - - - - 9 Thayetchaung 58 58 100.0% 58 100.0% 17 17 100.0% 17 100.0% 10 Yebyu 119 119 100.0% 119 100.0% - - - - - Tanintharyi Total 958 958 100.0% 958 100.0% 122 122 100.0% 122 100.0% 11 Ann 137 137 100.0% 137 100.0% 28 28 100.0% 28 100.0% 12 Gwa 194 194 100.0% 194 100.0% - - - - - 13 Kyaukpyu 129 129 100.0% 129 100.0% 18 18 100.0% 18 100.0% 14 Ramree 238 238 100.0% 238 100.0% 11 11 100.0% 11 100.0% 15 Thandwe 352 352 100.0% 352 100.0% - - - - - 16 Toungup 177 177 100.0% 177 100.0% 24 24 100.0% 24 100.0% Rakhine (South) Total 1,227 1,227 100.0% 1,227 100.0% 81 81 100.0% 81 100.0% 17 Buthidaung 104 78 75.0% 99 95.2% - - - - - 18 Kyauktaw 197 197 100.0% 197 100.0% 6 6 100.0% 6 100.0% 19 Minbya 66 66 100.0% 66 100.0% - - - - - 20 Mrauk-U 62 62 100.0% 62 100.0% 12 12 100.0% 12 100.0% 21 Myebon 146 146 100.0% 146 100.0% 16 16 100.0% 16 100.0% 22 Pauktaw 95 95 100.0% 95 100.0% 30 30 100.0% 30 100.0% 23 Ponnagyun 96 96 100.0% 96 100.0% 14 14 100.0% 14 100.0% 24 Rathedaung 152 152 100.0% 152 100.0% - - - - - 25 Sittwe 93 93 100.0% 93 100.0% - - - - - Rakhine (North) Total 1,011 985 97.4% 1,006 99.5% 78 78 100.0% 78 100.0% 26 Hlaingbwe 90 90 100.0% 90 100.0% - - - - - 27 Hpa-an 201 201 100.0% 201 100.0% - - - - - 28 Kawkareik 97 97 100.0% 97 100.0% 2 2 100.0% 2 100.0% 29 Myawaddy 61 61 100.0% 61 100.0% 6 6 100.0% 6 100.0% Kayin Total 449 449 100.0% 449 100.0% 8 8 100.0% 8 100.0% Grand Total 3,645 3,619 99.3% 3,640 99.9% 289 289 100.0% 289 100.0%

Annex 8 – Capacity building Table 26: Number of VMWs/PPs trained on case management (from January to March 2018)

Village Malaria Workers Private Providers Grand # Township Total M F Sub-total M F Sub-total 1 Bokpyin 12 42 54 - 4 4 58 2 Dawei - 3 3 - 1 1 4 3 Kawthoung 23 17 40 2 1 3 43 4 Kyunsu 10 41 51 5 5 10 61 5 Launglon - 7 7 - - - 7 6 Myeik 2 19 21 - 6 6 27 7 Palaw 7 33 40 3 6 9 49 8 Tanintharyi 14 45 59 - - - 59 9 Thayetchaung 3 12 15 - 2 2 17 10 Yebyu 14 45 59 - - - 59 Tanintharyi Total 85 264 349 10 25 35 384 11 Ann 11 6 17 10 2 12 29 12 Gwa 25 35 60 - - - 60 13 Ramree 6 2 8 1 - 1 9 14 Thandwe 36 81 117 - - - 117 Southern Rakhine Total 78 124 202 11 2 13 215 15 Buthidaung 127 8 135 - - - 135 16 Kyauktaw 46 32 78 2 - 2 80 17 Pauktaw 17 15 32 8 2 10 42 18 Ponnagyun - 1 1 - - - 1 19 Rathedaung 29 36 65 - - - 65 20 Sittwe 1 6 7 - - - 7 Northern Rakhine 220 98 318 10 2 12 330 Total 21 Hlaingbwe 4 22 26 - - - 26 22 Hpa-an 13 52 65 - - - 65 23 Kawkareik 19 18 37 - - - 37 24 Myawaddy 5 16 21 1 - 1 22 Kayin Total 41 108 149 1 - 1 150 Grand Total 424 594 1,018 32 29 61 1,079

Table 27: Number of VMWs/PPs trained on diagnosis (from January to March 2018)

Annex 9 – BCC Table 28: Number of people reached through IPC and Group Health Talks by Mobile Team, VMWs and PPs (January to March 2018)

Individual IPC Group Health Talk # Township Migrants Session Migrants Male Female Total Male Female Total included s # included 1 Bokpyin 627 474 1,101 708 69 617 483 1,100 708 2 Dawei 385 335 720 57 0 0 0 0 0 3 Kawthoung 1,240 1,021 2,261 2,261 78 395 332 727 727 4 Kyunsu 676 763 1,439 106 0 0 0 0 0 5 Launglon 257 503 760 23 0 0 0 0 0 6 Myeik 421 627 1,048 97 0 0 0 0 0 7 Palaw 402 576 978 84 0 0 0 0 0 8 Tanintharyi 641 717 1,358 86 70 168 251 419 39 9 Thayetchaung 241 336 577 63 0 0 0 0 0 10 Yebyu 258 308 566 54 0 0 0 0 0 Tanintharyi Total 5,148 5,660 10,808 3,539 217 1,180 1,066 2,246 1,474 11 Ann 1,092 1,171 2,263 15 34 99 125 224 0 12 Gwa 906 983 1,889 97 5 113 208 321 7 13 Kyaukpyu 550 645 1,195 4 0 0 0 0 0 14 Ramree 732 649 1,381 19 0 0 0 0 0 15 Thandwe 2,335 2,633 4,968 299 12 340 364 704 0 16 Toungup 411 350 761 4 0 0 0 0 0 Southern Rakhine Total 6,026 6,431 12,457 438 51 552 697 1,249 7 17 Buthidaung 921 362 1,283 0 0 0 0 0 0 18 Kyauktaw 930 859 1,789 230 15 100 96 196 16 19 Minbya 180 151 331 117 3 56 33 89 0 20 Mrauk-U 290 301 591 43 3 18 2 20 0 21 Myebon 835 899 1,734 178 5 9 17 26 0 22 Pauktaw 434 463 897 117 7 33 52 85 26 23 Ponnagyun 348 348 696 81 3 9 17 26 5 24 Rathedaung 642 596 1,238 0 76 608 614 1,222 0 25 Sittwe 379 615 994 139 33 65 186 251 19 Northern Rakhine Total 4,959 4,594 9,553 905 145 898 1,017 1,915 66

Individual IPC Group Health Talk # Township Migrants Session Migrants Male Female Total Male Female Total included s # included 26 Hlaingbwe 594 1,095 1,689 70 0 0 0 0 0 27 Hpa-an 570 1,089 1,659 114 4 39 116 155 15 28 Kawkareik 421 591 1,012 45 98 571 1,018 1,589 13 29 Myawaddy 627 761 1,388 181 2 92 54 146 1 Kayin Total 2,212 3,536 5,748 410 104 702 1,188 1,890 29 Grand Total 18,345 20,221 38,566 5,292 517 3,332 3,968 7,300 1,576

Table 29: Number of people reached through IPC and Group Health Talks by Private Providers only (January to March 2018)

Individual IPC Group Health Talk # Township Migrants Session Migrants Male Female Total Male Female Total included s # included 1 Bokpyin 77 76 153 83 6 41 77 118 40 2 Dawei 23 12 35 1 0 0 0 0 0 3 Kawthoung 270 164 434 434 18 150 93 243 243 4 Kyunsu 133 143 276 18 0 0 0 0 0 5 Launglon 0 0 0 0 0 0 0 0 0 6 Myeik 119 201 320 17 0 0 0 0 0 7 Palaw 88 120 208 59 0 0 0 0 0 8 Tanintharyi 0 0 0 0 0 0 0 0 0 9 Thayetchaung 118 132 250 19 0 0 0 0 0 10 Yebyu 0 0 0 0 0 0 0 0 0 Tanintharyi Total 828 848 1,676 631 24 191 170 361 283 11 Ann 165 165 330 3 0 0 0 0 0 12 Gwa 0 0 0 0 0 0 0 0 0 13 Kyaukpyu 77 78 155 4 0 0 0 0 0 14 Ramree 56 68 124 0 0 0 0 0 0 15 Thandwe 0 0 0 0 0 0 0 0 0 16 Toungup 47 37 84 0 0 0 0 0 0 Southern Rakhine Total 345 348 693 7 0 0 0 0 0 17 Buthidaung 0 0 0 0 0 0 0 0 0 18 Kyauktaw 60 56 116 0 0 0 0 0 0

Individual IPC Group Health Talk # Township Migrants Session Migrants Male Female Total Male Female Total included s # included 20 Minbya 0 0 0 0 0 0 0 0 0 21 Mrauk-U 63 81 144 7 0 0 0 0 0 22 Myebon 71 72 143 35 2 3 7 10 0 23 Pauktaw 145 115 260 51 0 0 0 0 0 24 Ponnagyun 88 51 139 45 0 0 0 0 0 25 Rathedaung 0 0 0 0 0 0 0 0 0 26 Sittwe 0 0 0 0 0 0 0 0 0 Northern Rakhine Total 427 375 802 138 2 3 7 10 0 27 Hlaingbwe 0 0 0 0 0 0 0 0 0 28 Hpa-an 35 15 50 7 0 0 0 0 0 29 Kawkareik 7 7 14 1 1 9 9 18 0 31 Myawaddy 41 6 47 28 0 0 0 0 0 Kayin Total 83 28 111 36 1 9 9 18 0 Grand Total 1,683 1,599 3,282 812 27 203 186 389 283

Annex 10 – Advocacy meeting Table 30: Advocacy meetings with private company ( January to March 2018)

Date of Total # State/Region Township Place of meeting Male Female Advocacy Attendant 1 Tanintharyi Dawei 16-Feb-18 MCH Meeting Hall 15 2 17 Grand Total 15 2 17

Annex 11 – Performance Indicators Table 31: Performance Indicators Tracking Table (January to March 2018)

Actual Annual Target Indicators Frequency Baseline Achievements (FY2018)

IP 1: Annual Parasite Incidence (API) in Defeat Malaria villages Annual 8 (CAP-M FY15 N/A 5.5 progress report) IP 2: Annual Blood Examination Rate Annual 6% in 2015 (from N/A 7% National M&E Plan) IP 3: Percent of indigenous cases among cases investigated (in Quarterly 9% in 2015 (from NA 80% elimination areas) National M&E Plan) IP 4: Percent of active foci among foci investigated (in Quarterly N/A NA 80% elimination areas) IP 5: Proportion of villages with zero positive cases for at least Annually 18.5% (CAP-M N/A 23% last three consecutive years database) OC 1.1 % of households in targeted areas that own at least one Baseline and end NA NA insecticide treated net (ITN) line OC 1.2 % of households in targeted areas that own at least one 47% (in Rakhine), NA NA ITN for every two persons 60,2% (in Tanintharyi), 65.6% (in Kayin) - from CAP-M End line Household Surveys

OC 1.3 % of individuals in targeted areas who slept under ITN NA NA the previous night. (disaggregate by type of net, pregnant women, children under 5 OC 1.4 % of service delivery points which report no stock outs Quarterly Minimum 85% (from 99.5% ≥ 80% of RDTs lasting more than one week during the past 3 months CAP-M) (disaggregate by type of SDP)

Actual Annual Target Indicators Frequency Baseline Achievements (FY2018)

OC 1.5 % of service delivery points which report no stock outs Quarterly Minimum 85% (from 99.9% ≥ 80% of first line antimalarial medicines (ACT) lasting more than one CAP-M) week during the past 3 months (disaggregate by type of SDP) OC 1.6 % of patients found positive who received antimalarial Quarterly Minimum 95% (from 99.2% ≥ 95% treatment according to National Malaria Treatment Guidelines CAP-M FY15 progress report) OC 1.7 % of Malaria Positive cases with having completed the Quarterly 25% (from CAP-M 79.9% 50% treatment under DOT FY15 progress report) OP 1.1 Number of insecticide treated net purchased in any fiscal Quarterly 92,986 (From CAP-M 4,368 70,900 year with United State Government (USG) funds that were FY16 progress report) distributed in this quarter OP 1.2 Number of artemisinin-based combination therapy Quarterly NA 4,587 32,400 (ACT) treatments purchased in any fiscal year with USG funds that were distributed in this reported fiscal year (PMI required indicator) OP 1.3 Number of RDTs purchased in any fiscal year with USG Quarterly NA 22,500 465,000 funds that were distributed (PMI required indicator) OP 1.4 Number of individuals reached with malaria behavior Quarterly 514,333 (from CAP-M 38,566 100,000 change messages through interpersonal communication 5 year progress (individual talks) report) OP 1.5 Number of health workers trained in case management Month of training 5,155 (from CAP-M 5 1,079 1,500 VMWs/PPs with ACTs with USG funds (Disaggregated by male, female, and year progress report) profession) (PMI required indicator) OP 1.6 Number of health workers trained in malaria laboratory Month of training 5,443 (from CAP-M 5 1,079 1,500 VMWs/PPs diagnostics (rapid diagnostic tests (RDTs) or microscopy) with year progress report) USG funds (Disaggregated by male, female, and profession) (PMI required indicator)

Actual Annual Target Indicators Frequency Baseline Achievements (FY2018)

OP 1.7 % of VMWs/PPs in Defeat Malaria target areas received Annually N/A N/A ≥ 80% at least two supervisory visits per year OC 2.1 % of service delivery points in targeted areas report Monthly ≥ 80% (from CAP-M 5 97.8% ≥ 80% monthly data of malaria cases (disaggregate by type of SDP) year progress report)

OC 2.2 % of service delivery points in targeted areas report Monthly N/A 99.7% ≥ 80% monthly data of malaria cases on time (disaggregate by type of SDP) OC 2.3 % of positive cases notified within 24 hours in Monthly N/A NA 70% elimination targeted townships OC 2.4 Foci investigation rate Monthly N/A NA 60%

OC 2.5 Active focus response rate Monthly N/A NA 70%

OP 2.1 Number of townships that have developed and updated Annually N/A NA 33 Village Based Stratification (VBS) annually OP 2.2 Number entomological surveys conducted in persistent Semiannual N/A 0 3 transmission areas OP 3.1 % of targeted health services with Quality Annually N/A 0% 60% Assurance/Quality Control (QAQC) system received quarterly internal assessments of the QA system in collaboration with NHL/NMCP OP 3.2 Number of trainings on malaria technical skill and Quarterly by N/A 4 20 training facilitation skill supported by Defeat Malaria Jhpiego OP 3.3 Number of trainers developed through Defeat Malaria Quarterly by N/A 55 72 Jhpiego

Actual Annual Target Indicators Frequency Baseline Achievements (FY2018)

OP 3.4 Number of people trained through on-site training Quarterly by N/A 35 360 supported by USG program (Defeat Malaria) Jhpiego OP 3.5 Percentage of trainers supervised during trainings Quarterly by N/A 62.5% 50% Jhpiego OP 3.6 Percentage of master mentors retaining at least 80% of Quarterly by N/A 0% 80% of master mentors acquired skills and knowledge Jhpiego acquired skills and knowledge OP 3.7 Number of joint supervision visits to VMW for data Quarterly by N/A 6 6 quality assessments Jhpiego OP 4.1 Number of private companies and state-owned Annual N/A 0 60 enterprises involve in malaria activities OP 4.2 Number of health education sessions conducted in the Quarterly N/A 116 300 targeted areas with participation from collaborating companies and enterprises