PMI/ARM3 9TH QUARTERLY REPORT OCTOBER 1 – DECEMBER 31, 2013 ______

FISCAL YEAR 2014, QUARTER 1 PROGRAM YEAR 3

FEBRUARY 2014

PMI/ARM3 Accelerating the Reduction of Malaria Morbidity and Mortality Program

9th Quarterly Report: October 1, 2013 to December 31, 2013 Fiscal Year 2014 Program Year 3

Submitted to: Dr. Emile Bongo, Agreement Officer Representative (AOR), USAID/ Family Health Team Leader, USAID/Benin

Cover photo: Meeting of CHWs (Credit: Ghislaine Djidjoho)

PMI/ARM3, Accelerating the Reduction of Malaria Morbidity and Mortality Program (ARM3), is funded by the United States Agency for International Development (USAID), under Cooperative Agreement

AID-680-A-11-00001. ARM3 is managed by Medical Care Development International (MCDI) as the prime, in collaboration with sub-grantees Africare, Johns Hopkins University – Center for Communications Program (JHU-CCP) and Management Sciences for Health (MSH). The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or of the United States Government.

Contents List of Acronyms ...... 5 Acknowledgements ...... 7 Executive Summary ...... 8 Introduction...... 12 Result 1: Implementation of Malaria Prevention Programs in Support of the National Malaria Strategy Improved ...... 13 Sub-Result 1.1: Implementation of Malaria Prevention Programs in Support of the National Malaria Strategy Improved ...... 13 Sub-result 1.1a: IPTp Uptake Increased ...... 13 Achievements ...... 13 Sub-result 1.1.b: Upgrade Skills of Health Workers (Public and Private Sectors) through Pre- service and In-service Training ...... 14 Achievements ...... 14 Results ...... 16 Sub-Result 1.2: Supply and Use of LLINs Increased ...... 16 Achievements ...... 16 Results ...... 22 Result 2: Malaria Diagnosis and Treatment Activities in Support of the National Malaria Strategy Improved ...... 22 Sub-Result 2.1: Diagnostic Capacity and Use of Testing Improved ...... 22 Achievements ...... 22 Results ...... 23 Sub-Result 2.2: Case Management of Uncomplicated and Severe Malaria Improved ...... 23 Sub-result 2.2.a: Upgrade Skills of Health Workers on Clinical Management ...... 23 Achievements ...... 23 Sub-result 2.2.b: Implementation of the Performance Improvement Approach (PI) in Participating HZs and Hospitals ...... 26 Achievements ...... 26 Results ...... 27 Sub-Result 2.3: Integrated Community Case Management (iCCM) Improved ...... 28 Achievements ...... 28 Result 3: The National Health System’s Capacity to Deliver and Manage Quality Malaria Treatment and Control Interventions Strengthened ...... 33 Sub-result 3.1: The NMCP’s Technical Capacity to Plan, Design, Manage, and Coordinate a Comprehensive Malaria Control Program Enhanced ...... 33 Achievements ...... 33 Results ...... 35 Sub-Result 3.2: Capacity to Collect, Manage and Use Malaria Health Information for M&E and

Surveillance Improved ...... 35 Achievements ...... 35 Results ...... 39 Sub-Result 3.3: Capacity in Commodities and Supply Chain Management Improved ...... 39 Achievements ...... 40 Results ...... 42 Result 4: Cross Sectional Activities ...... 43 Achievements ...... 43 Program Management ...... 48 Field Office ...... 48 Home Office Backstopping and Reporting ...... 48 Major Challenges (per ARM3 sub-result): ...... 49 Major Activities Planned for Next Quarter (Year 3, Jan-Mar): ...... 50 Financial Summary ...... 51 Annex 1: Cumulative Financial Report ...... 53 Annex 2: SF 424 ...... 54

List of Acronyms ABFC Association Béninoise de Femme Chanteuses ACT Artemisinin Combination Therapy AL Artemether + Lumefantrin AMCES Association des Œuvres Médicales Privées Confessionnelles et Sociales ANC Antenatal Care APBC Association of Private Clinics of Benin ARM3 Accelerating the Reduction of Malaria Morbidity and Mortality Program (ARM3) BASICS Basic Support for Institutionalizing Child Survival BCC Behavioral Change Communication BOA Bank of Africa CA Collaborative Approach CAME Centrale d’Achat des Médicaments Essentiels (Central Medical Stores) CTB Coopération Technique Belge CCIB Chambers of Commerce and Industry of Benin CCM Clinical Case Management CDC Centers for Disease Control and Prevention CEBAC-STP Coalition des Entreprises Béninoises et Associations Privées Contre le SIDA, la Tuberculose, et le Paludisme CHW Community Health Workers/Relais Communautaire CIM Chambre Interdépartemental des Métiers/ Interdepartmental Trades Chambers CIP Interpersonnel communication CM Case Management CNHU Centre National Hospitalier et Universitaire de COP Chief of Party CTB Coopération Technique Belge CUGO University Clinic of Gynecology and Obstetrics DDS Direction Départementale de la Santé/Health Department DHS Demographic Health Survey DNSP Direction Nationale de la Santé Publique DRZ Dépôt Répartiteurs de zone (Health Zone Depots) DSIO Directorate of Nursing and Midwifery DSME Direction de la Santé de la Mère et de l’Enfant/Directorate of Maternal and Child Health ENTASE National School of Senior Technicians in Health and Epidemiological Surveillance EPI Expanded Program on Immunization ETAT Emergency Triage, Assessment and Treatment EUVS End Use Verification Survey F CFA French Central African Franc FM-UP Faculty of Medicine – University of FO Field Office FSS Faculté des Sciences GFATM Global Fund to Fight AIDS, Tuberculosis, and Malaria GOB Government of Benin GPRS Standard Phone Network GSM Global Service for Mobile Communication HC Health Centers HFS Health Facility Survey HIV Human Immunodeficiency Virus HMIS Health Management Information System HO Home Office HZ Health Zone iCCM Integrated Community Case Management

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IMCI Integrated Management of Childhood Illness INMES Institut National Médico-Social IPC Interpersonal Communication IPT Intermittent Preventative Treatment IPTp Intermittent Preventive Treatment for Pregnant Women IRSP Institute Régionale de la Santé Publique JHU-CCP Johns Hopkins University – Center for Communication Programs KGS Kandi--Segbana LDP Leadership Development Program LLIN Long Lasting Insecticide-Treated Nets LMIS Logistical Management Information System LMU Logistical Management Unit MCDI Medical Care Development International MCZS Médecin Coordinateur de Zone Sanitaire /Health Zone Physician Coordinator M&E Monitoring & Evaluation MEDISTOCK Commodities Management Program MIP Malaria in Pregnancy MOH Ministry of Health MOU Memorandum of Understanding MOP Malaria Operational Plan MSH Management Sciences for Health NGO Non-Governmental Organization NMCP National Malaria Control Program ODK Open Data Kit ORS Oral Rehydration Salts OTSS Outreach Training Support and Supervision PADNET Project to Advance the Durability of Long Lasting Insecticide-treated Net PI Performance Improvement PITA Integrated Annual Work Plan PMI President’s Malaria Initiative PPMRm The Procurement Planning and Monitoring Report for malaria QAT Quality Assurance Team RDT Rapid Diagnostic Test RMIS Routine Malaria Information System ROBS Réseau des ONG Béninoises de Santé/ Network of Beninese Heath NGOs SCC Supply Chain Coordinator SCM Supply Chain Management SMS Short Message Service SOBEMAP Port Authority SOP Standard Operating Procedures SP Sulfadoxine-Pyrimethamine STG Standard Treatment Guidelines TC Technical Coordinator TEA Total Estimated Amount TOT Training of Trainers TWG Technical Working Group USAID United States Agency for International Development WHO World Health Organization

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

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Executive Summary

ARM3 Results Sub-Results Key Achievements/Challenges

1. Implementation of 1.1 IPTp uptake • Provided technical assistance to NMCP in updating malaria in malaria prevention increased pregnancy training materials (facilitator guide and participant manual) programs in support • Signed MOUs with the Faculty of Medicine of the University of of the National Parakou (FM-UP) and National Training School for Senior Malaria Strategy Technicians in Public Health and Epidemiological Surveillance improved (ENATSE) to strengthen the capacity of the teachers and students in the fight against malaria • Conducted a briefing on the National Malaria Policy and Malaria Guidelines for INMES teachers who in turn disseminated its contents to this year’s graduating students • Organized two TOT workshops and trained 68 national trainers on interpersonal communication (IPC) • Followed-up on IPTp barrier study recommendations

1.2 Supply and use • Implemented a cross-sectional study to track LLINs distributed in of LLINs increased Phase 1 and assess for usage and current condition in a sample of 264 employees. • 85.5% (224/262) of respondents to the LLIN tracking study have used at least one LLIN in their households since the beginning of the campaign • Conducted Phase 2 distribution of 55,000 LLINs to 21 CEBAC-STP members • Conducted supervision in December 2013 to beneficiary companies to follow up on the status of the distribution to their employees and adherence to the distribution protocol • Conducted trainings for Peace Corps volunteers on malaria, behavior change, project design, M&E and reporting

2. Malaria diagnosis 2.1 Diagnostic • OTSS Round 13 involving the 118 Health Facilities was scheduled for and treatment capacity and use of December/January 2014 (this activity was postponed as ARM3 was activities in support diagnostic testing waiting for approval of the Y3 work plan) of the national improved malaria strategy 2.2 Case • Organized the first collaborative learning session for 12 hospitals improved management of following 3 months of implementation of the Emergency Triage, uncomplicated and Assessment, and Treatment (ETAT) approach for severe malaria severe malaria • Rate of adherence to ETAT standards increased from 73.5% to 86%, improved which has led to a reduction in child mortality during the first 24 hours of emergency care from 13.2% to 10.7% • Evaluated 13 new hospitals in the health zones (HZ) of , Kouandé, Tanguiéta and , and selected 11 hospitals for its enrollment in Phase 2 of ETAT • Conducted an evaluation of the implementation of MOUs with initial 25 HZs and 6 Direction Départementale de la Santé/Health Department (DDS) • Conducted an assessment of the Collaborative Approach and LDP implemented under the Quality Improvement Component

2.3. Integrated • Conducted a coordination meeting with projects and organizations community case intervening in , Kandi, , Djougou, and Bassila management • Conducted a meeting of iCCM-implementing partners involved at the improved community level in 5 HZs • Signed sub-agreements with 5 NGOs for 6 months (ending May

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2014) for follow-up of iCCM activities (ARM3 is requesting an extension for the implementation of iCCM until September 2014) • Provided technical assistance (TA) to the MOH/DNSP for the validation of new national standards and guidelines for implementation of iCCM in Benin • Conducted orientation workshop for the 5 local NGOs selected to support the implementation of iCCM • Conducted an assessment of CHW and their needs to re-initiate iCCM in the 5 HZs 1,117 CHW were identified. • Provided technical assistance to the DSME/NMCP on: o Development of new national standards and guidelines for implementation of iCCM o Review of training materials and CHW tools, and o Participate in the design of pre- test of tools • Conducted visits to regional CAME depots to assess level of inventory of iCCM drugs (RDTs, ACTs, Paracetamol, Amoxicillin, ORS and Zinc). CAME warehouses have sufficient stock availability and their directors are committed to support iCCM implementation • Conducted the feasibility testing on the use of the CommCare/ODK application as part of the SMS/GSM pilot project • Adopted the CommCare/ODK platform for the implementation of the SMS/GSM pilot project in 2 HZs • Updated reports in the iCCM database 3. National health 3.1 NMCP’s • ARM3 ability to support PITA activities was constrained due the system’s capacity to technical capacity to absence of an approved Year 3 work plan deliver and manage plan, design, • Case Management TWG meeting was held on October 30, 2013 quality malaria manage, and where participants discussed the new malaria case management treatment and coordinate a policy and made the following recommendations to the group: control interventions comprehensive o Participants will share contact information/documents and conduct follow-up between TWG meetings in order to ensure strengthened malaria control action on key issues program enhanced o Follow-up on BCC activities in order to improve IPTp coverage through Interpersonal Communication (IPC) • Reproduced a music video originally developed by the ‘Association Béninoise de Femmes Chanteuses (ABFC)’ at the request of the BCC TWG 3.2 MOH capacity to • Implemented the health facility survey in 60 health facilities in 12 collect, manage and . use malaria health • Assured supervisory support to surveyors during the HFS survey and information for cleaned databases. Descriptive data analysis is being conducted and monitoring, will be finished upon submission of the results of the reading of evaluation and malaria slides by the “Centre National Hospitalier et Universitaire de surveillance Cotonou (CNHU)” improved • Provided technical support to the NMCP in the analysis and preparation of data for the validation of the RMIS data collected from July – December 2013. • Provided technical assistance for the implementation of the LLIN tracking survey for the nets distributed to private sector companies associated with CEBAC-STP • Provided continued technical support to the NMCP in providing an update on the following databases: LMIS, RMIS, MEDISTOCK, HMIS, PILP GFATM, and Palu Alafia (GFATM-funded) • Ongoing collection of information for the development of the RMIS newsletter, Palu-Info

3.3 MOH capacity in • Collaborated with the NMCP in developing the draft malaria commodities and commodities management directives supply chain • Printed and distributed malaria commodities LMIS reporting tools

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management • Provided technical support to CAME’s warehouse design improved • Coached malaria commodities DRZ managers to collect consumption data • Prepared implementation of MEDISTOCK V4+ at CAME’s warehouses • Supported NMCP in organizing EUVS in the Mono/Couffo health department • Produced EUV summary report and shared it with USAID Cross Sectional Behavioral Change • ARM3 conducted a workshop with 10 radio stations supporting BCC Activities Communication programs to review achievements and challenges (BCC) • Initiated the malaria prevention campaign “Let’s make the mosquito’s life impossible” through community fairs • Supported the NMCP and local authorities in the response to the high under-five mortality due to malaria in the Bembereke-Sinende HZ by disseminating malaria prevention messages through radios and interpersonal communication in schools and the community fairs. • Aired the TV spot on malaria prevention which was broadcast 30 times between November-December on ORTB TV • Continued distribution of printed materials including fliers to health centers, partners, and at community events in Cotonou, , and Parakou • Barrier study recommendations incorporated in BCC materials and Year 3 work plan

Quality • Drafted a manual on quality control/assurance as a reference for both Assurance/Quality the project staff and those involved in implementing the MOUs. This Improvement document reviews processes and standards incorporating quality assurance activities into all the ARM3 components. Non-Governmental • Oversaw the close-out of activities of the 18 NGOs supporting Organizations community BCC on September 30, 2013 and conducted a final evaluation of the NGOs Program Field Office • Field staff worked on and submitted an initial Year 3 work plan in Management October Activities • Prepared response to USAID/MOP team comments on year 3 work plan • Produced a revised year 3 work plan based on comments from USAID/MOP review committee • Adjusted program activities following the “de-scoping”/Partial Termination letter from USAID Home Office • MCDI: backstopping and o Worked with the field office in developing the work plan for reporting Year 3 o Developed Year 2 Annual Report o Prepared response to Partial Termination letter from the RAO received on December 24, 2013 o Conducted coordination meetings and conferences with ARM3 partners regarding Partial Termination and Year 3 work plan o Worked with FO on the revised Year 3 work plan o Coordinated the fielding of Dr. Luis Benavente to provide short term assistance for ARM3 o Developed the TOR coordinated the recruitment of an IT consultant for the assessment of the CommCare platform • Africare: o Africare HO contributed to the finalization of a set of documents (including ARM3’s Year 2 annual report, Africare revised Year 3 work plan and budget) and submitted them to

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MCDI • JHU-CCP: o JHU-CCP HO contributed to the finalization of a set of documents (including ARM3’s Year 2 annual report, JHU- CCP revised Year 3 work plan and budget) and submitted them to MCDI o Submitted the revised version of the literary review: “Barriers to the LLIN and IPTp Use in Benin” • MSH: o MSH HO contributed to the finalization of a set of documents (including ARM3’s Year 2 annual report, MSH revised Year 3 work plan and budget) and submitted them to MCDI o Developed LDP and CI approach reports Human Resources • Developed TOR and recruited iCCM consultant • Africare hired an accountant for the Parakou field office responsible for supporting the local NGOs in finance management for community- based activities. He took up his duties on October 7, 2013 in Africare’s Parakou office • Promoted the Parakou accountant to project finance and administrative officer following the depart of our Cotonou based finance officer • Recruited and trained an accountant for the Parakou office

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Introduction Accelerating the Reduction of Malaria Morbidity and Mortality Program (ARM3) in Benin is funded by the United States Agency for International Development (USAID). The ARM3 consortium, led by Medical Care Development International (MCDI) as the prime recipient, includes sub-grantees Africare, Johns Hopkins University – Center for Communication Programs (JHU-CCP), and Management Sciences for Health (MSH). The ARM3 consortium works in partnership with the Benin Ministry of Health’s National Malaria Control Program (NMCP), to implement the five year (October 1, 2011 to September 30, 2016) ARM3 malaria control program. In collaboration with USAID/Benin’s President’s Malaria Initiative (PMI), ARM3 seeks to assist the Government of Benin (GOB) in improving malaria health outcomes in accordance with the NMCP’s guidelines and standards. The primary objective of ARM3 is to help the GOB achieve the PMI target of reducing malaria-associated mortality by 70%, compared to pre-initiative levels in Benin. In support of this PMI objective, the ARM3 program’s specific goal is to increase coverage and use of key life- saving malaria interventions in support of Benin’s NMCP Strategy. ARM3 seeks to complement and leverage the efforts of other donors (for example the Coopération Technique Belge (CTB), Global Fund to Fight AIDS, TB, and Malaria (GFATM), UNICEF, WHO and private sector organizations) to reach the NMCP’s goal of eliminating malaria as a public health problem in Benin by 2030. ARM3’s major results are as follows: Result 1: Implementation of malaria prevention programs in support of the National Malaria Strategy improved. Result 2: Malaria diagnosis and treatment activities in support of the National Malaria Strategy improved. Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened. The project was launched on October 1, 2011 and is currently in its third year of implementation. This ARM3 9th Quarterly Report (October 1, 2013 to December 31, 2013) details the program activities completed and key indicators corresponding to the results and sub-results described in the ARM3 Annual Work Plan and Monitoring and Evaluation (M&E) Plan. Activities under each sub-result have been aligned to the revised version of the Year 2 work plan modified in July 2013.

During this reporting period, the focus of the project was on the development of the Year 3 work plan, which was sent to USAID in October of 2013. Following this submission, USAID/PMI replied with comments from the MOP team. While preparing these comments, MCDI received unofficial notification of a “de-scoping”/Partial Termination directive requesting the reduction of $10,000,000 to ARM3’s budget as well as changes to the activities programed for Years 3 through 5. Consequently, the Year 3 work plan and budget submitted in October was never approved. On December 24 2013, ARM3 received an official Partial Termination request from the Agreements Officer (AO). In the absence of an approved work plan ARM3 conducted activities approved under the Agreement Modification of July 2013 during the 1st Quarter of Year 3. MCDI notified its partners of USAID’s Partial Termination directive and suggested appropriate course of action to prepare a response. Partial Termination suggested changes will result in a $ 10 million reduction in the ARM3 total estimated amount (TEA). A summary of the Partial Termination Letter is included in Annex 3.

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PMI/ARM3 9TH QUARTERLY REPORT OCTOBER 1 – DECEMBER 31, 2013

Result 1: Implementation of Malaria Prevention Programs in Support of the National Malaria Strategy Improved

ARM3 has been scaling-up prevention efforts through the expansion of intermittent preventative treatment for pregnant women (IPTp) and improved coverage of long-lasting insecticide-treated nets (LLINs) through social marketing of LLINs in the private sector and behavior change communication/ (BCC) activities; the two sub-results are: Sub-Result 1 (IPTp increased); and Sub-Result 2 (supply and use of LLINs increased). Sub-Result 1.1: Implementation of Malaria Prevention Programs in Support of the National Malaria Strategy Improved Results from the 2012 Demographic and Health Survey (DHS) show that only 22.8% of pregnant women had received two doses of Sulfadoxine-Pyrimethamine (SP) in 2011. In support of the PMI Malaria in Pregnancy (MIP) objectives, ARM3 seeks to improve IPTp uptake. To achieve this result, ARM3 is pursuing interventions that include upgrading the skills of government and private health sector workers both through pre-service curricula modifications and through supervision and support to health workers to follow case management and prevention guidelines. Additionally, ARM3 is continuing the review/implementation of BCC campaigns to promote IPTp, LLIN use and early care seeking behavior in addition to improving skills of government health providers on patient counseling using the recommendations of the IPTp barriers study. ARM3 is also working with private sector health facilities by providing training in malaria case management and diagnostic guidelines and by supporting the implementation of MIP activities, including the uptake of IPTp, the distribution of LLINs and the timely reporting of the results through the Routine Malaria Information System (RMIS).

Sub-result 1.1a: IPTp Uptake Increased

Achievements IPTp Training Finalize Malaria in Pregnancy (MIP) Training Materials During the reporting period, ARM3 provided technical assistance to the NMCP in updating of training materials for maternity health care workers providing Antenatal Care (ANC). The training materials, which include a manual for participants and facilitator's guide, have been revised to focus on IPTp administration and to include World Health Organization (WHO) guidelines. These documents have been sent to the NMCP and will be printed and distributed pending the Minister of Health’s signature.

Women's Reaction to the SP Shortage According to the Routine Malaria Information System, Sulfadoxine-Pyrimethamine (SP) intake increased to 38% despite SP shortages, which were noticeable in many health structures throughout the country. When asked about women’s behavior during the shortage in her clinic, Ms. Abdou Barira, from the Banikani health center, responded: “Eight (8)out of 10 women who are receiving a prescription for SP, are obtaining it from local pharmacies, returning with the medication and taking it under the a health provider’s supervision”. ARM3’s BCC activities are successfully convincing beneficiaries of the importance of SP. Not only will women look for SP elsewhere, but they will also take it as prescribed.

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Sub-result 1.1.b: Upgrade Skills of Health Workers (Public and Private Sectors) through Pre-service and In-service Training Achievements Support the Faculté des Sciences (FSS) and Institut National Medico-Sociale (INMES) in their Efforts to Incorporate Malaria Subject Matter into Pre-service Curricula The NMCP collaborated with ARM3 to hold a briefing on National Policy and Malaria Guidelines for the INMES teachers, from October 28-29, 2013. The purpose of this briefing was to prepare them to disseminate this document and content to their students. Nine (9) teachers were trained (66% women). The strongest four teachers were selected to facilitate a session on day two of the training for 51 nursing students and midwives (60% women) on the use and application of the above mentioned policy and guidelines.

Photo 1 (left): Representatives from INMES and the NMCP along with ARM3’s COP at the opening ceremony of the briefing session for teachers Photo 2: Midwives and nurses participating in the 2nd day of the training.

This session was supported with additional training materials from the WHO, the contents of which presented different scenarios related to the management of severe malaria. Pre- and post-test evaluations were conducted; see Graph 1. Graph 1: Pre- and Post-Test Results by Students at INMES Attending the Severe Malaria Briefing Provided by the NMCP, WHO, ARM3, and INMES

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When compared, the results of the evaluations demonstrate that while no participant scored higher than 10 out of 20 on the pre-test, approximately 70% of participants had answered more than 50% of the questions correctly.

Collaboration with Health Schools in Parakou On October 24, 2013, ARM3, in collaboration with the NMCP, signed MOUs with two northern health training schools including the Faculty of Medicine of the University of Parakou (FM-UP), and the National Training School for Senior Technicians in Public Health and Epidemiological Surveillance (ENATSE). The objective of the MOUs is to strengthen the capacities of these institutions to better train students to support the implementation of the MOH's national malaria policies and guidelines; to manage statistical data, conduct operations research and to make information based decisions.

Photo 3 (left): Signature of the MOU between FM-U, NMCP and ARM3 Photo 4: Signing of MOU with the Director of ENATSE TOT in Interpersonal Communication ARM3 organized two training of trainer’s (TOT) workshops on Interpersonal Communication (IPC) this quarter. The first took place in Grand Popo from November 26-29, and the second was held in Parakou from December 9-13, 2013. Sixty-eight (68) participants, including medical doctors, birth attendants, nurses and social workers, benefited from the training. The course covered: i) client centered approaches; ii) adult learning techniques; iii) the behavioral change process; iv) interpersonal communication (IPC) skills; and v) the use of BCC/IEC materials. IPC Photo 5: Bed net demonstration during IPC TOT theories were communicated through workshop in Grand-Popo presentations, demonstrations, role-playing, field visits; a participant’s manual was distributed. At the end of the session, participants provided suggestions for additional content to be considered for the subsequent training scheduled to take place in the next quarter. There, trainers will conduct “cascade” training of health workers.

During the IPC TOT training, it became apparent that the poor treatment of pregnant women by health providers remains a serious problem. ARM3 will respond to this problem through revised training materials and media programs.

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Results

Indicator Baseline LOP Target PY3/Q1 Results Source/Comments

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

Sub-result 1.1: IPTp uptake increased

1) Percentage of women 3.0% Women who receive 22.8% (total) DHS report, May who have completed a two or more doses of 2012 pregnancy in the last two SP during their last years who received two or Source pregnancy within the 24% (Urban) more doses of IPTp during last two years will that pregnancy DHS, reach 85% 21.9% (Rural) 2006

1.a) Proportion of women 28.1% Proportion of women 38.3 % RMIS result from attending antenatal clinics attending antenatal PY2/Q4 who receive IPTp2 under Source clinics who receive (Jul-Sep 2013) direct observation of a RMIS, IPTp2 under direct health worker 2011 observation by a 1 RMIS result from health worker will 15.7 % PY3/Q1 (Oct-Dec reach 85% 2013) 2. Number of health 0 PY3 Target: 840 Year 3 work plan workers trained in IPTp health professionals and budget not using USG funds Source from 34 HZs (re) 68 trainers of approved trainers on IPC ARM3 trained in IPTp using Records USG funds

Sub-Result 1.2: Supply and Use of LLINs Increased In support of this sub-result, ARM3 is using innovative approaches framed around public-private partnerships. The consortium believes that efforts to scale up malaria control in the public sector are critical but probably insufficient to achieve the ambitious goals sought by the NMCP and USAID unless access to quality services is increased through the private sector, NGOs and participation of community organizations. ARM3 is using a target subsidy approach that permits employees of the Beninese Business and Private Association Coalition against AIDS, Tuberculosis, and Malaria (CEBAC-STP) member companies to purchase LLINs at a subsidized price and to do so through an installment payment mechanism that may include deductions from paychecks over time. Proceeds generated from the sale of 100,000 LLINs will permit CEBAC-STP member companies to support complementary activities, including malaria prevention and promotion of specific health behaviors. During Phase 1 of the distribution, completed in Year 2, 44,000 LLINs were distributed benefiting more than 110,000 private sector workers and their families. Achievements For the current reporting period, ARM3 is providing an update on its activities related to the tracking and monitoring of LLINs distributed during Phase 1 of the LLIN distribution campaign and an update on the Phase 2 distribution, which was launched December 21, 2013.

1 Results were affected by nation-wide SP stock out

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Tracking and Monitoring of LLINs Distributed in Phase 1 As part of the follow-up of the LLINs distributed in Phase 1, ARM3 implemented a cross sectional study to assess the number people who are in possession of at least one LLIN distributed by ARM3, evaluate if the family used the net the night before, and the current condition of the mosquito net.

Training of Data Collectors for LLIN Tracking Survey The training of investigators to assess the collection of data on LLINs distributed in Phase 1 was held in the ARM3 office in mid-December. Twenty-one (21) people participated in the training session (five facilitators and sixteen field investigators). Training was led by the members of the ARM3 M&E and private sector teams with technical support from the Project to Advance the Durability of Long Lasting Insecticide-treated Net (PADNET) technical team. During the first day of training, field investigators were briefed on the objectives and methodologies of the protocol. This was followed with a presentation of specific tools for the tracking of LLINs such as the questionnaires and the WHO assessment index tools for measuring holes in the nets. The first day ended with a simulation of the evaluation of the nets. During the second day, teams conducted a field test of the tools. Photo 6: Training of data field investigators in the The questionnaire and fieldwork procedures were LLIN tracking study protocol and tools adjusted based on the results of the field test. A plenary presentation of the results of the field test and adjustments were made at the end of the training.

Data Collection Data collection began for teams in and around Cotonou on December 18, 2013. Teams traveling to Porto-Novo, , Parakou, and Grand Popo began data collection December 19, 2013. Data collection lasted 7 days and was carried out by eight teams of two field investigators under the supervision of three ARM3 supervisors. Table 1 below shows the number of teams, area covered and number of interviews conducted by each team.

Table 1: Number of Interviews Conducted per Survey Team

Survey Area Covered Number of Team Interviews Team 1 Cotonou 1 36 Team 2 Cotonou 2 36 Team 3 Cotonou 3 36 Team 4 Cotonou 4 36 Team 5 Porto-Novo and Sèmè-Podji 36 Team 6 Lokossa 24 Team 7 Grand Popo 24 Team 8 Parakou and 36 Total 264

Employees were chosen randomly from a list of companies who participated in Phase 1 distribution and who employees had received one or more LLINs during this distribution campaign. All employees working within the company or private organization during the distribution campaign, who had received at least one net, were eligible.

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Individual interviews were conducted at the workplace (in each targeted company). Workplace interviews were followed with household visits, where questionnaire and LLIN verification tools were applied. Nets currently in use were assessed for holes using the WHO template. After seven days of field work, 264 participants from 21 companies were assessed. Some of the participants selected were absent and were replaced with the next person on the list. These substitutions were made to overcome the difficulties that the investigators found in cases where the families were absent or unavailable. Such substitutions adhered strictly to the sampling methodology. Supervision of Data Collection Dr. Fortune Dagnon, head of ARM3’s M&E department, Mr. Urbain Amegbedji, Private Sector Coordinator and Ms. Deborah Hangbe, a Peace Corps Response Volunteer, were all part of the supervisory teams. . The supervision was conducted to ensure effective implementation of the survey. Specific objectives were: i) to check if protocol was being followed by the surveyors; and ii) identify and address difficulties experienced by surveyors. In Grand Popo and in Porto-Novo the enterprises were located far from the city center and there were long distances between Photo 7: A surveyor from a private sector company workplaces and homes resulting in long travel assesses a net during a home visit time. In Lokossa and in Dassa teams had problems coordinating home visits and in some cases requested the support of the Chambre Interdépartmental des Métiers (CIM’s) to contact employees. Preliminary Results Twelve (12) employees from each of the twenty-two companies participating were interviewed. A total of 264 participants were chosen for the survey and 263 people agreed to participate. The majority of the interviewees were men 70.3% (n = 185) versus 29.7% women (n = 78). LLINs possession and use • 85.5% (224/262) of respondents confirmed use of an LLIN since the campaign • 48.3% (127/263) of respondents received 2 LLINs • 18.3%, 18.7% and 6% respectively purchased 1, 3 and 4 nets LLIN payment • 71.8% (n = 188) of respondents bought their nets for 1,000 French Central African Franc (F CFA) • 14.1% (n = 37) of the respondent’s employer paid for their net • 3.8% of employees received a grant of 500 F CFA from their employer • Approximately 10% said they paid more than 1,000 F CFA (between 1,200 - 2,500F CFA) Satisfaction of the quality of LLINs • 95.6% of respondents felt that the net was of good quality against 4.4% who felt that the net was of poor quality

Evaluation of the physical integrity of LLINs • The physical integrity of the net was tested in 85.2% (224/263) of the homes • 73.7% (165/224) of the nets evaluated had no holes • 20.5% of nets had between 1 and 4 holes (further data will be provided during the next quarter) • 5.8% of nets had more than 4 holes

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Graph 2: % of LLINs Utilizable per Period

Results showed high utilization by employees of some private companies such as La Farge where social marketing focused on malaria interventions has been implemented prior to the ARM3 distribution. The project will use the experience of La Farge and other companies with higher rates of utilization to influence CEBAC partners using ‘Positive Deviance’ approaches. Phase 2 Distribution of LLINs The Phase 2 distribution of LLINs to the private sector started in the reporting period with the development of distribution plans and trainings that were held for health committees involving 21 companies, including ten former companies (from Phase 1 Distribution) and eleven new companies. For the ten former companies, the distribution complemented and satisfied the requests for larger quantities of nets made during the Phase 1 distribution. During Phase 2, fifty-five thousand LLINs were distributed to companies for sale to workers at a cost of 1,000 F CFA per net. Of the 21 companies, more than half are comprised of small and medium enterprises grouped within particular Chambers of Commerce and Industry of Benin (CCIBs) and Interdepartmental Chamber of Tradesmen (CIM). ARM3 provided all recipient partners with monitoring tools to track the LLINs and to monitor funds generated through their sale.

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Table 2: List of Companies Participating in Phase 2 Distribution N° Organization Employees # LLITN bales Department Commune City Chambre de Commerce et d'Industrie 1420 1250 25 Borgou Parakou Parakou 1 du Benin (CCIB Borgou) Chambre Interdépartementale des 2500 2000 40 Borgou Parakou Parakou 2 Métiers (CIM Borgou) Chambre de Commerce et d'Industrie 560 1000 20 Atacora Natitingou Natitingou 3 du Benin (CCIB Atacora) Chambre de Commerce et d'Industrie 1650 2000 40 Cotonou Cotonou 4 du Benin (CCIB Atlantique) 5 SCB Lafarge 1350 1200 24 Plateau Ketou Onigbolo Société Béninoise de Manutentions 7150 5750 115 littoral Cotonou Cotonou 6 Portuaires (phase 2) 7 Port Autonome de Cotonou 584 1200 24 littoral Cotonou Cotonou Chambre Interdépartementale des 7870 10700 214 littoral Cotonou Cotonou 8 Métiers Atlantique-Littoral Société National de 9 Commercialisation des Produits 1100 2000 40 littoral Cotonou Cotonou Pétroliers (SONACOP) Conseil National des Chargeurs du 1600 3400 68 littoral Cotonou Cotonou 10 Benin (CNCB) Union Nationale des Pécheurs et littoral, Atlantique Cotonou, Cotonou, Ouidah 9450 8050 161 11 Maraichers du Benin phase 2 et Mono Grand-Popo Grand-Popo Chambre des Métiers COUFFO (CIM- 1350 2700 54 Couffo Aplahoue Azove 12 COUFFO) Chambre Interdépartementale des 1100 2200 44 Mono Lokossa Lokossa 13 Métiers du MONO Union Régionale Coopératives 14 Agricole Rurales (Chambre 1700 3400 68 Mono Lokossa Houin Agame d'Agriculture) Société Béninoise d'Energie 15 1550 2200 44 Ouémé Porto Novo Porto Novo Electrique 16 Chambre de Métier zou 1800 2500 50 Zou Abomey Abomey 17 Fludor 800 750 15 Zou Zogbodomey 18 SHB 300 400 8 Zou Bohicon 19 BOA 1450 500 10 Littoral Cotonou Cotonou 20 AZALAI Hôtel 250 400 8 Littoral Cotonou Cotonou Chambre de Commerce et d'Industrie 730 1400 28 Zou Abomey Abomey 21 du Benin (CCIB Zou) 46264 55000 1100

Supervision of the Phase 2 Distribution ARM3 team supervisory visits were conducted in late December 2013 in collaboration with representatives of CEBAC-STP. Supervision teams were able to visit 12 of the 21 companies that received LLINs to assess the level of implementation. The objectives were to verify: i) the actual receipt of LLINs in stores; ii) the conformity of the amounts sent and amounts received; iii) The LLIN storage conditions; iv) the availability of tools to support LLIN sales; v) the plan for the sale of LLINs; and vi) the resolution of any problems. Based on these supervisory visits, the main findings are: Photo 8: Private sector LLIN marketing to • All LLINs were received by the Chambers SONACOP employees • The storage conditions of the LLINs were satisfactory and LLINs were secure • A social marketing timeline existed in 75% of the companies visited • Tools and campaign materials were available and were being used • Managers reported being very satisfied with the partnership • A few companies started the transfer without waiting for the official launch • One company was distributing LLINs without collecting the net bags for disposal

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• Two companies did not document delivery of LLINs

Overall, the supervisory visits confirmed an effective start of the Phase 2 distribution of LLINs to private sector companies and have helped address minor implementation mistakes and correct them; for example, has been that net bags were not collected and properly stored awaiting collection for disposal.

Launch of Phase 2 Distribution The Phase 2 Distribution of the social marketing of LLINs to workers in the private sector was launched in a soccer game on December 21, 2013. Approximately three hundred athletes and spectators were present at the game. During halftime, officials from PMI/USAID, the representative of the NMCP, the Assistant Director of SOBEMAP, the President of CEBAC- STP and the ARM3 Chief of Party (COP) presented the objectives Photo 9 & 10: Launch of Phase 2 of LLIN distribution to private sector companies and the benefits of through a soccer match on December 21, 2013 malaria prevention for private sector businesses. Simultaneously, malaria prevention messages were disseminated through a vehicle which traveled throughout Cotonou. At the end of the soccer match, LLINs were distributed to the players of both of the teams, sharing with them and the spectators the importance of protecting themselves and their families against malaria. Partnership with Peace Corps

Training of Peace Corps Volunteers and Counterparts on Malaria From December 2-6, 2013, twelve Peace Corps volunteers and their twelve counterparts travelled to Parakou to attend a training workshop held at Hotel Central. The contents of the training included malaria, behavior change, project design, M&E and reporting. The training completed the pre-service training of Peace Corps Volunteers started in June 2013 in the . It was designed to enable volunteers and their counterparts to carry out effective activities against malaria at their places of assignment in collaboration with their respective communities. The 24 participants received an update of the current malaria situation in Benin as well as a presentation of the strategies and tools used to flight malaria at the community level. Participants also had an opportunity to practice behavior change framework design, project design and the use of malaria evaluation tools presented at the workshop. Training of Trainers on Malaria and BCC Campaigns From December 6-9, 2013, forty eight participants (twelve teams comprised by one volunteer/team and three of their host-country nationals (HCNS)-including one community counterpart and two students) met in Parakou at Hotel La Colombe to attend a training workshop on malaria and BCC campaigns in order to be trained as trainers for the implementation of campaign activities (and to overview the achievement of objectives and goals) to be held between December 2013 and May 2014. On the first day of training participants were trained in malaria topics such as parasitology, epidemiology, diagnosis, treatment, prevention, and behavior change. On the second day, participants were trained on: i) how to carry out small-scale bed net distributions as part of the Peace Corps activities in Benin; ii) carrying out behavior change campaigns; iii) how to conduct home visits

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and proper net hanging; iv) how to repair and care for LLINs; and v), how to conduct monitoring and evaluation surveys. Relating to BCC activities, participants received training on a variety of activities including bike tours, wall murals, school assemblies and income generation activities.

Results

Indicator Baseline LOP Target PY3/Q1 Results Source/Comments Result 1: Implementation of malaria prevention programs in support of the National Strategy improved Sub-result 1.2: Supply and use of LLINs increased 2) Percent of pregnant 20% Proportion of pregnant 75.5% (total) DHS report, May women who slept under women who slept 2012 an LLIN the previous Source under a LLIN the 73.9% (Urban) night DHS, previous night in 76.5% (Rural) 2006 intervention areas will reach 85%

3) Percent of children 20% Proportion of children 71% (total) DHS report, May under five who slept under five who slept 2012 under an LLIN the Source under a LLIN the 70.5% (Urban) previous night DHS, previous night in the 71.3% (Rural) 2006 intervention areas will reach 85% 4) Percent of households 25% Proportion of 79.8% (total) DHS report, May with a pregnant woman households with a 2012 and/or children under five Source pregnant woman 78.2% (Urban) that own at least one DHS, and/or children under 81% (Rural) LLIN 2006 five that own at least one LLIN will reach more than 90%

4.a) Number of LLINs Distribute 100,000 Total: CEBAC-STP reports distributed through social LLINs through social 55,000 LLINs ARM3 program marketing among marketing among delivered to 21 reports employees and employees and companies in dependents of CEBAC- dependents of Phase 2 STP member CEBAC-STP member organizations organizations Please note: ARM3 is not directly responsible for mass distribution of LLINs, and consequently has limited control over the LLIN related outcomes

Result 2: Malaria Diagnosis and Treatment Activities in Support of the National Malaria Strategy Improved ARM3 supports improved case management of both severe and uncomplicated malaria and improved diagnosis of malaria through use of microscopy and Rapid Diagnostic Tests (RDTs). Result 2 consists of two sub-results: Sub-Result 2.1 (diagnostics capacity and use of testing improved) and Sub-Result 2.2 (case management of uncomplicated and severe malaria improved). Sub-Result 2.1: Diagnostic Capacity and Use of Testing Improved Achievements Printing and Distribution of Standard Operating Procedures (SOP) Manuals for Laboratory Diagnosis of Malaria The SOP is awaiting the signature of the preface by the MOH before being published. Two hundred manuals will be reproduced and distributed to laboratories around the country next quarter.

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On-site Training and Supportive Supervision (OTSS) OTSS is the quality assurance platform supported by ARM3 to strengthen diagnostic capacity. OTSS Round 13 involving the 118 Health Facilities was scheduled for December/January 2014. However, this activity was postponed as ARM3 was waiting for approval of the Y3 work plan.

Results

PY3/ Q1 Result Indicator Baseline LOP Target PY3/Q1 Results Comments

Result 2: Malaria diagnosis and treatment activities in support of the national malaria strategy improved

Sub-result 2.1: Diagnostic capacity and use of diagnostic testing improved

5) Percent of targeted 95.8% Proportion of health PY2/Q3 results PY3/Q1: OTSS health centers that have centers with the ability from OTSS round 13, the following: 1) Source to perform biological Round 12 programmed for Q1 personnel trained in OTSS diagnostics for malaria 97.7% was postponed malaria diagnostics, 2) Round 7 (either microscopy or 1 Health Facility no stocks-outs affecting rapid diagnostic did not meet malaria diagnostics for 7 testing) will be 85% the indicator or more days, 3) a criteria functional microscope due to lack of (non-RDT facilities only) trained malaria diagnostic staff 22) Number of health PY1: On average, at least 1 PY2/Q3 results PY3/Q1: OTSS workers trained in Average health worker from from OTSS round 13, malaria diagnostics trainings each staff type Round 12 programmed for Q1 (including Lab: 1.4 (lab/clinic) per facility 12 new OTSS was postponed microscopy/RDTs) and Clinic: 1.3 per supervisory visit supervisors case management with trained in malaria trained USG funds diagnostics (including 12 former OTSS microscopy/RDTs) and supervisors re- case management with trained USG funds 117 trainings (41 lab trainings 76 clinical trainings) Lab Avg: 0.85 Clinical Avg: 1.58 48 facilities reporting for PY2/Q3

Sub-Result 2.2: Case Management of Uncomplicated and Severe Malaria Improved Sub-result 2.2.a: Upgrade Skills of Health Workers on Clinical Management Achievements Improvement of Severe Malaria Case Management First Collaborative Learning Session for the 12 ETAT Sites After 3 months of implementation of the ETAT approach, ARM3’s Dr. Akadiri conducted the first collaborative learning session during the 1st quarter of Year 3. This learning session included three

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representatives of each quality assurance team (QAT) from each of the 12 sites. The overall objective was to share the experience of the participants during the past 3 months of ETAT implementation. Some of the learning session activities included: • Review M&E indicators and their method of calculation • Present implementation challenges and their possible solutions • Evaluate the implementation of ETAT at each site • Identify and share best practices • Update database following presentations made by the participating hospitals • Develop a three-month action plan for each site The ETAT approach is being implemented in each of the 12 sites for each of the 5 indicators listed below. However, more involvement from all QAT members as well as support from hospital staff is needed. The administration and QAT members need to conduct on-site analysis of the challenges in implementation in order to identify solutions. Table 3: ETAT Indicators for the 1st Quarter of Year 3

No Baseline Introduction of ETAT Indicators Feb 13 Mar 13 April 13 July 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13

1 Proportion of children 0-59 2.9% 3.1% 4.4% 59% 71.4% 78% 87% 93.4% 93.7% months evaluated upon arrival (process Indicator) 2 Adherence Rate to ETAT 40% 0% 0% 56.3% 62.3% 73.5% 86% 76% 81% standards (process Indicator) 3 Case fatality rate during the first ND ND ND 13.8% 14.8% 13.2% 11.8% 11% 10.7% 24 hours in emergency (result Indicator) 4 Ratio of adherence to standards 45.3% 41% 41% 65.3% 66.5% 79.3% 85% 85% 83% of severe malaria case management (process Indicator) 5 Case fatality rate of severe 3.2% 2.9% 4.2% 4.1% 5.2% 2.6% 3% 3% 5% malaria (result Indicator)

From September to December 2013, the rate of adherence to ETAT standards increased from 73.5% to 86%, which has led to a reduction in child mortality during the first 24 hours of emergency care from 13.2% to 10.7% (Graph 3).

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Graph 3: Impact of the ETAT in the Reduction of Case Fatalities in Collaborating Hospitals, July – Dec 2013

Source: ARM3 monthly data verification visits

The rate of adherence to malaria case management standards for severe malaria has increased from 79.3% in September 2013 to 83% in December 2013, while the mortality rate due to severe malaria remained stable at about 5%.

Graph 4: Sever Malaria Case Fatalities in Collaborating Hospitals, ARM3 July-Dec 2013

Source: ARM3 monthly data verification visits

Evaluation of Hospitals to be Enrolled in Phase 2 of ETAT The scaling up of the ETAT approach was undertaken in the reporting period with the evaluation of 13 hospitals in the HZs of Bassila, Djougou, Kouandé, Tanguiéta and Natitingou. The evaluation covered the infrastructure as well as the human and technical resources available. These hospitals have a total of 45 skilled workers and 28 caregivers. In the Borgou/Alibori departments, the hospitals visited were located in Papané-Boko, Kandi, Banikoara and . The second group of hospitals has 38 skilled workers and 27 caregivers. In the , a newly opened children's hospital,

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Abbracio , was evaluated and had 5 agents and 5 qualified caregivers. The eligibility criteria for hospitals to enroll in the ETAT were: 1. A nationally recognized hospital (e.g., hospital area) 2. If not an area hospital, the requirements were: a) adequate infrastructure b) sufficient staff to ensure 24/7 operations c) high attendance of children under 5 years d) sufficient emergency equipment/materials required by ETAT (vacuum suction, O2 concentrator, quinine, injectable diazepam, injection probe, SG 10% and 5% Dextran, Adrenaline, infusion sets, syringes, catheters, etc.)

Upon completing the evaluation, 11 out of 13 hospitals proved to have adequate facilities, personnel and the minimum equipment to support emergencies; they were recommended for enrollment in the ETAT program. As of November 30, 2013 there are a total of 88 health workers in the 11 eligible hospitals that will be trained on ETAT and corresponding indicators. An additional two HZs, Lokossa and Aplahoué, will be evaluated in the coming quarter.

Sub-result 2.2.b: Implementation of the Performance Improvement Approach (PI) in Participating HZs and Hospitals

In Year 2, ARM3 provided financial and technical support to 25 HZs and 6 DDS through MOUs to support training and supervisory activities.

Achievements Health Department (DDS) and HZ Strategic Operational Plans Implementation The DDSs were not funded to hold quarterly MOU review meetings and to allow the DDS to supervise activities being conducted in the HZs. By the end of Quarter 8, the majority of the 25 HZs and 4 DDSs had submitted their final financial reports and were notified that no amendment or additional advances would be made until all reports were received. Follow-up actions to ensure the submission of financial reports from the remaining HZs were carried out during the quarter. Evaluation of MOU with HZs At the end of Year 2, ARM3 conducted the evaluation of the implementation of MOUs with the initial 25 HZs and 6 DDS by reviewing the MOU implementation as well as various tools in order to adjust them. The main results of this evaluation were: • HZs are able to develop their work plans • HZs are able to implement activities • HZs are able to report and are accountable for the management of funds provided

Improvements in the reporting and targeting of key indicators have been modified in the MOUs and will be signed in Year 3, with the 25 HZs participating in Year 2 and the 9 new HZs in Year 3, (an increase to 34 HZs).

Assessment of the LDP/Collaborative Approach All Collaborative Improvement activities have been suspended since the end of fiscal year 2013. USAID’s “de- scoping”/Partial Termination letter occasioned a reassessment of the extent to which ARM3 could continue to expend limited resources in support of the scaling-up of the Leadership Development Program (LDP) and the Collaborative Approach (CA). During the quarter, ARM3 received the assessment report conducted by Dr. Karki Mahamane regarding the evaluation of the LDP and CA, following seven months of implementation in twelve HZs and in 186 health facilities in the Atlantique/Littoral and Ouémé/Plateau departments, to document feedback and comments from health personnel on the impact of the CA on their work. After receiving feedback from USAID/Benin, the scope of work for the assessment was expanded to include a preliminary evaluation of the CA in targeted HZs as well as LDP (LDP continued until the end of Q4 and successfully; a shorter version of LDP concentrating on leadership qualities is under discussion for Year 3 for the other 22 HZs not previously targeted by LDP). Dr. Mahamane’s report on the evaluation of the LDP and CA will be sharedPage in 26the ofnext 55 reporting period.

Results

PY3/Q1 Indicator Baseline LOP Target Source/Comments Results

Result 2: Malaria diagnosis and treatment activities in support of the national malaria strategy improved

Sub-result 2.2: Case management of uncomplicated and severe malaria improved

6) Percent of suspected 36.7% 90% of suspected 78.8% (all RMIS results are from malaria cases submitted to (all ages) malaria cases will be ages)* PY2/Q4 laboratory testing 17.5% < tested via (July-Sept 2013) 5 microscopy/RDTs 80.1% < 5 52.6% ≥ 77.7% ≥ 55 *RMIS data for this 5 quarter has yet to be validated by the NMCP Source RMIS PY1/Q4 7) Percent of patients (all -- ≥ 95% of patients (all %87.2% all EUVS* report, Nov ages) who tested positive ages) who tested cases 2013 for malaria (via microscopy positive for malaria (via or RDT) who received an microscopy or RDT) will 87.4% < 5 (Mono/Couffo) anti-malarial receive an effective 86.9% > 5 anti-malarial (ACT) Micro-all ages 45.7% Micro only ≥ 85% RDT-all ages RDT only ≥ 95% 91.1% 8) Percent of patients (all -- < 35% of patients (all 2.5 % all ages EUVS* report, Nov ages) who tested negative ages) who tested 2013 for malaria (via microscopy negative for malaria (via 3.1% < 5 or RDT) who received an microscopy or RDT) will 2.1% > 5 (Mono/Couffo) anti-malarial receive an effective Micro all ages anti-malarial (ACT) 1.5% RDT all ages Micro only < 35% 2.7% RDT only < 45% 9) Percent of targeted -- Supervisory visits will No funding available for health facilities that be conducted at 100% HZ to carry out received supervision of targeted health supervision facilities at least once every 6 months 10) Percent of children <1% Percent of children 12.3% DHS report, May 2012 under-five with suspected under-five with malaria (fever) in the last Source suspected malaria two weeks who received DHS, (fever) in the last two treatment with ACTs 2006 weeks who received treatment with ACTs in targeted areas will increase to 85% 11) Percent of mothers / <1% ≥ 90% of mothers / 6.7% DHS report, May 2012 caretakers who sought caretakers who sought treatment with the use of Source treatment with the use ACTs for their under-five DHS, of ACTs for their under- children with suspected 2006 five children with malaria (fever) within 24 suspected malaria hours of onset of their (fever) within 24 hours symptoms of onset of their symptoms

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PY3/Q1 Indicator Baseline LOP Target Source/Comments Results

12) Number of schools of 0 Develop, review, 1 (ENTASE and MOUs signed with nursing and educational update and implement Facility of University of Parakou institutions that have with the MOH the Medicine) to adopt National updated their malaria guidelines and training University of Malaria Guidelines guidelines and curriculum curricula on malaria Parakou diagnosis and treatment at a total of 4 schools of nursing and educational institutions (2 in PY2; 2 in PY3) 13) Number of newly hired -- Support training in 0 ARM3 training reports health workers trained in clinical IMCI for 72 clinical IMCI newly hired health All 72 trained workers in the public and private sectors to contribute to national scale-up of clinical IMCI 14) Number of hospitals 21/50 13 new hospitals Selected 11 Initial evaluations for that received a refresher hospitals targeted for year 3 new hospitals new hospitals training for severe malaria provided for ETAT concluded for 11 of the 13 new hospitals. Two case management training implementation (2) additional hospitals by in Y3 will be assessed in the PISAF next quarter 23) Number of health PY3 Target: 977 health 9 facilitators and Cumulative total year 3: workers trained in case care professionals from 51 nurses and 60 management with 19 HZs (re)trained in midwifes (31 Artemisinin-based case management with female) from combination therapy ACTs using USG funds INMES (ACTs) with USG funds *NB: EUVS data reported in indicators 7 & 8 use data conducted in the Mono/Couffou with a sample of 15 HFs. Data of the EUV/LIAT conducted at the national level with a sample of 190 HFs are included in ARM3 Quarterly Report 6.

Sub-Result 2.3: Integrated Community Case Management (iCCM) Improved This activity was integrated into ARM3 in June 2013, under the Award Modification number 2 to the, Cooperative Agreement AID-680-A-11-00001, by which USAID requests the inclusion of the iCCM activities in to the ARM3’s program description.

Achievements

Preliminary Activities for the Implementation of ICCM The preliminary activities for the implementation of the iCCM component were planned in two phases.

Phase 1 consisted of s a field visit conducted by the Technical Coordinator (TC) of the project, Dr. Moussa Thior and a member of the supply chain department. The purpose of this visit was: i) to review the progress of the implementation of the work plan; ii) to observe any challenges to the implementation of the work plan firsthand; iii) to explore ways to begin activities with the support of for community networks; and iv) to make recommendations to accelerate the implementation of the project.

During his visit the ARM3 TC was able to meet the local stakeholders including HZ directors, CAME officials, leaders of NGOs, community leaders, CHWs and the two departmental health directors

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involved in iCCM implementation. The latter two have reiterated their commitment and full cooperation for the implementation of the ARM3 iCCM activities.

Phase 2 consisted of a second visit to Parakou, to work with the iCCM Coordinator and her team on the operational plan taking into account recommendations made during the first visit. This facilitated the development of a plan for the accelerated implementation of the iCCM program and to increase coordination between operating partners.

Coordination Meeting with Partners Acting in 5 HZs ARM3 organized a workshop with community partners to share information about work plans and coordinate activities within the next 6 months. Participants included Belgium Technical Cooperation (CTB), UNICEF, MCDI/Palu Alafia, and Africare/RCC. Through coordinating work plans, partners determined that2: (i) CTB will train CHWs trainers and (ii) Africare will complete an assessment of active CHW’s as well as group supervisions and data collection.

iCCM NGOs Orientation Workshop A two day orientation Work shop was conducted for 20 directors, program managers, and accountants from the five NGOs supporting the implementation of the iCCM component in Parakou on November 7-8, 2013. The objective of the workshop was to review the scope of work and responsibilities of the NGOs, performance framework, the work plan, budget, and the agreement to be signed with ARM3/Africare. ARM3’s technical coordinator and iCCM coordinator, the MOH directorate of maternal and child health (DSME), representatives from Africare, and the coordination teams from three HZs were present at this orientation session.

Photos 11 & 12: Signature of agreements by ARM3 representatives and local NGOs Directors for the implementation of the iCCM activities iCCM Contracts with Local NGOs The 5 local NGOs selected in iCCM HZs signed their sub agreements with ARM3 for a period of 6 months (November 20, 2013 - May 20, 2014). They received their first disbursement and started their activities. Terms of reference for these activities were approved by ARM3/Africare prior to implementation.

The role of the NGOs is to facilitate community participation at the local level as well as to complement the role of the health facilities by providing a continuum of care to the communities. The NGOs are responsible for: i) supporting the identification and selection of CHWs with the communities; ii) providing training and retraining materials; iii) supporting the implementation of activities in coordination with health facilities; iv) collecting and managing the information collected by

2 UNICEF offered to contribute 20 phones to the ARM3 team for the implementation of the SMS component; however, the phones offered were not fully compatible with ARM3’s SMS/GSM ODK platform

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the CHWs regarding patient case management, referral, stock outs, IPTp, and developing and submitting reports to HZs. Assessment of Active CHWs to Re-initiate iCCM in 5 HZs The ARM3 iCCM Coordinator and iCCM Advisor developed forms, training materials and trained personnel from the 5 NGO staff in data collection in a training held on November 20, 2013 in Parakou From November 27 to December 19, 2013 the 5 NGOs conducted an assessment of the CHWs and CBO’s who have continued iCCM activities in the 5 HZs of Tchaourou, Banikoara, Kandi-Gogounou- Segbana (KGS), Bassila, and Djougou-Ouake-. To achieve this, the NGOs collected CHWs’ and health workers’ information during a supervision organized by PILP/Africare, using tools provided by ARM3. The assessment showed 1,117 CHWs working in areas more than 5km from a health center, a greater number than the previously trained 1,048 CHWs under the former BASICS project. Technical Assistance to the Ministry of Health During the month of October 2013, Dr. Faustin Onikpo, ARM3’s iCCM technical advisor, worked closely with the MOH (DSME DNSP/NMCP) to support: i) the development of new standards and guidelines for iCCM; ii) a review of training materials and CHW tools for the implementation of iCCM; and iii) the development of pre- test tools.

Continuation of SMS/GSM Pilot Study Using the CommCare Application Platform As an extension of the implementation of the iCCM component, ARM3 will continue the pilot data capture initiative in two communities in the north of Benin, Tchaourou and Bassila, that utilizes mobile phones to collect and transmit data. The objective of the updated SMS/GSM pilot study is to improve communication between CHWs and health facilities’ personnel through the routine transmission of electronic community-based records.

In October 2013, MCDI HO explored other options to the MedicMobile parallel SIM card system and ultimately identified a platform called CommCare, which captures data through an Open Data Kit (ODK) operating system and sends data over standard phone networks (GPRS) on the web in real- time. MCDI HO IT personnel successfully programmed the iCCM data forms on CommCare ODK.

The results of the field assessment conducted by the consultant also demonstrated that the CommCare platform is able to work in Benin and costs of operation and maintenance are lower. Due to some difficulties with the installation of the application on Java enabled phones, the consultant further recommended the use of Android phones as they are more suitable than Java phones for the implementation of the CommCare application. The consultant further recommended that the cell phone service provider MTN be used as the GSM service operator due to the strength of the network coverage in the areas where the GSM pilot will be implemented.

Graph 5: GSM network coverage in Graph 6: GSM network coverage in the Bassila HZ the Tchaourou HZ

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The MOH forms previously designed by the BASICS project (reference, counter-reference, needs of antimalarial supplies, case management and management of supplies) are being programmed to the CommCare application in addition to two new forms developed by ARM3, one to track pregnancies at the community level and the other to register the administration of LLIN and SP, which will be validated by the MOH. The organization and implementation of the training/retraining of different participants will take place in quarter 2 of Year 3. Meeting of iCCM Implementing Partners Involved at the Community Level in 5 HZs An organizational meeting was held October 22, 2013 in Parakou in order to coordinate the activities of institutions involved in community health activities in the north of Benin. Four (04) institutions (Palu- Alafia, UNICEF, ARM3, Projet D’appui au Renforcement Des Zone Sanitaire) participated in the meeting. PILP/Africare and PLAN Benin did not participate, however they were informed of the agreements determined in the meeting. The agreements are: • Roles, responsibilities and interactions of each partner will be complementary in the action plan • Equipment needs for CHWs will be submitted to UNICEF by the end of November 2013 • Results table will be finalized by the end of the week • Advocate for the Projet D’appui au Renforcement Des Zones (PARZS) to start training in December 2013

At the end of the meeting, the partners made several recommendations: • The review of the work plan should be completed by February 2014 • A consolidation and validation workshop will be organized in the Atacora/Donga and Borgou/Alibori departments

Ensure the Availability of Drugs and Other Supplies for Case Management In an effort to start-up activities, the ARM3 supply chain team took measures to ensure the availability of iCCM drugs. The Technical Coordinator and Supply Chain Coordinator visited two regional CAME depots (Centrale d’Achat des Médicaments Essentiels) (Central Medical Stores or CAME) in Parakou and Natitingou to assess levels of inventory of various iCCM drugs (RDTs, ACT's, Paracetamol, Amoxicillin and diarrhea treatment kits (ORS/ZINC)). ARM3 learned from the visits that both CAME warehouses have sufficient stock availability of the above mentioned supplies and medicines, and that their directors and pharmacists are committed to provide particular support to iCCM implementation. During the visit to the CAME depot in Natitingou the Supply Chain Coordinator (SCC) had the chance to participate in the inspection of an ACT 1x6 stock arrival. In addition ARM3 made the following recommendations and requests: Photo 13: SCC officer and Dr. Djidjoho check ACT stock arrival at a CAME depot • To the Natitingou and Parakou DDSs: i) To ask the in Natitingou Médecin Coordinateur de Zone Sanitaire (HZ Physician Coordinators) to substitute CHW’s Co-trimoxazole with Amoxicillin in compliance with new iCCM guidelines; and ii) to provide an initial package of medicines for new CHWs about to be trained. • To the NMCP Coordinator: A request was sent to make RDT stocks more readily available for CHWs. Based on quantification exercises, table 4 below outlines estimations of medicines and supplies per CHW for a period of three months. Table 5 provides estimates for iCCM-related stock needs for CHWs for a three-month period.

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Table 4: Essential Supplies and Medicines for CHWs for a 3 Month Consumption Period

CHW Operational Needs for 3 Months

According to quantification exercises, for a 3 month period, CHWs will manage: - 30 cases of uncomplicated malaria - 9 cases of pneumonia - 3 case of diarrhea

Table 5: Estimates of Supplies and Medicines per HZ for a 3 Month Consumption Period for CHWs iCCM Implementation

TOTAL TOTAL TOTAL HZS/DEPARTMENTS BASSILA DJOUGOU KANDI TCHAOUROU BANIKOARA BORGOU/ IN 5 DONGA ALIBORI ZONES Number of CHWs 110 444 758 253 204 302 759 1,313 RDT 3,300 13,320 16,620 7,590 6,120 9,060 22,770 39,390 ACT 6 6,600 26,640 33,240 15,180 12,240 18,120 45,540 78,780 Paracetamol 19,800 79,920 99,720 45,540 36,720 54,360 136,620 236,340 500mg cp Amoxicillin 9,900 39,960 49,860 22,770 18,360 27,180 68,310 118,170 500 mg cp ORS/Zinc Kit 330 1,332 1,662 759 612 906 2,277 3,939

Update of the iCCM Database During the former BASICS project, a community database referred to as “iCCM reports" was developed and maintained. Community based data was entered until the end of the project. Since then there has been no follow up to community input of data despite the fact that the data is available, as the PILP/AFRICARE project has continued the collection of the monthly community data registers from April 2012 to December 2013, in the Borgou/Alibori and Donga. Three types of data are available: i) community case management data, including malaria, diarrhea and acute respiratory infection; ii) data of prevention activities conducted at Photo 14: CHWs at iCCM training the community level; and iii) data on the management of drugs and supplies. The update of the iCCM database started with the technical support of iCCM coordinator. The M&E Department revised the data entry forms in order to facilitate the update. The next steps will be the entry of the community forms from the "iCCM reports" and to disseminate this information to the statisticians of the 5 HZs for their validation.

Technical Assistance to the MOH/DNSP on New National Standards and Guidelines for Implementation of iCCM in Benin The DNSP Chief Community Health Service, organized a workshop from December 16 to 20, 2013, with ARM3 support to: i) provide an orientation to the health workers involved in the implementation of

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the iCCM plan; ii) present the upgraded package; iii) present the CHW trainee manual and trainer guideline; iv) validate these training materials (manual and guideline); v) share training techniques and tools; and vi) plan the continuation of the TOT. During this workshop participants were grouped by HZ to review the CHW Trainee’s Manual and Trainer's Guide, and then played roles based on scenarios from the CHW manual as they would in real life; and provided recommendations during plenary sessions. • Two training scenarios were identified for community training sessions: Training of health social workers: 5 days duration per session of 20 participants with 3 trainers • Training of CHWs: 3 trainers for 15 CHWs with the total number of training days depending on the background of the CHW (April-June 2014). Regarding the planning of the trainings of trainers, the iCCM Advisor developed a training program for the 360 CHWs in the two HZs of the Donga. In addition each HZ team planned their respective CHW training schedules. The dates of each HZ’s training will vary, taking into account the availability of materials in the HZ during the training sessions. The representative of CTB committed funds to support the training of 70 CHW trainers before the end of 2013. This training of trainers will take place from December 16 to 20, 2013. This will orient the health workers involved in the implementation of the iCCM plan in the upgraded package. Result 3: The National Health System’s Capacity to Deliver and Manage Quality Malaria Treatment and Control Interventions Strengthened Result 3 consists of three sub-results: Sub-Result 3.1: MOH/NMCP capacity to deliver and manage quality malaria treatment and control interventions improved; Sub-Result 3.2: Capacity to collect, manage and use malaria health information for monitoring and evaluation (M&E) and surveillance improved; and Sub-Result 3.3: Capacity in commodities and supply chain management improved. One of the main implementation platforms for the achievement of this result is the support that ARM3 provides to the various technical working groups that advise the NMCP. Sub-result 3.1: The NMCP’s Technical Capacity to Plan, Design, Manage, and Coordinate a Comprehensive Malaria Control Program Enhanced Through work that is accomplished mainly through the technical working groups discussed below, ARM3 provides critical support to the NMCP in the areas of: improving the quality of the data routinely collected through the RMIS which provides the NMCP with the ability to make management decisions driven by reliable information and data -- this is reflected in the improved quality and timeliness of the data reported by the HZs; ARM3 has closely collaborated with the NMCP and the DSME to improve and/or develop training materials, job aids, and curricula for the in-service training of facility-based personnel in IMCI, iCCM, uncomplicated and severe malaria case management, and IPTp; ARM3 has assisted the NMCP in its efforts to ensure that pre-service training institutions adopt curricula designed to enhance the capacity of graduates to adhere to case management, diagnostic and reporting protocols prescribed by the NMCP. In addition, through its collaboration with ARM3, the NMCP has been able to prioritize interventions at the HZ level through the MOU agreements entered into with the HZs. One of the primary methods includes the support and promotion of NMCP Technical Working Groups (TWGs) (M&E, Supply Chain Management, Communications, and Case Management) to meet regularly and to assist in coordinating with other malaria implementing partners.

Achievements

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Support Annual PITA Exercise As reported in Q3, ARM3 supported the finalization of the 2014 Integrated Annual Work Plan (PITA). During the reporting period, ARM3 ability to support implementation of PITA activities was constrained by the absence of an approved Year 3 work plan and budget. Neither new nor existing MOUs with HZs were signed. Malaria Case Management TWG The Case Management TWG meeting was held on October 30, 2013. Twenty participants from the NMCP, University Clinic of Gynecology and Obstetrics (CUGO), Directorate Nursing and Midwifery (DSIO), Africare and ARM3 attended. Discussions about the new malaria case management policy initiated during the previous quarter continued.

The agenda included a presentation about the national malaria policy which comprised the following topics: i) purpose and objectives; ii) national priorities; iii) geographical location of interventions; iv) guidelines for the fight against malaria; v) management of malaria interventions and supplies; vi) framework for the implementation of the national policy; and vii) policy updates.

Discussion that followed this presentation addressed the following: i) IPTp with SP should begin in the 16th week of pregnancy and the 2nd dose and subsequent should be administered at each ANC visit until delivery (according with the WHO recommendations on IPTp administration); ii) former policy stating that HIV-infected pregnant women receive a 3rd dose of SP has been amended to state that HIV-infected pregnant women should not receive SP at all; iii) IPTc in children under five years is not included in the national malaria policy; iv) the availability of SP (for IPTp) in public and private health facilities and the community must be guaranteed; and v) similarly RDTs must be available to confirm the diagnosis of malaria prior to treatment when microscopy is not available.

The Case Management (CM) TWG expects the new malaria policy document incorporating selected changes will be available by the end of 2014.

In addition to the above mentioned points, the CM TWG issued two recommendations: • Participants will share contact information/documents and conduct follow-up between TWG meetings in order to ensure action on key issues • Follow-up on BCC activities in order to improve IPTp coverage through Interpersonal Communication (IPC)

As cited above, ARM3 also supported the MOH in the validation and presentation of the new iCCM guidelines.

BCC TWG Following a recommendation made the by the BCC TWG, ARM3 reproduced a music video originally developed by the Association Béninoise de Femmes Chanteuses (ABFC) and approved by the NMCP in audio-visual formats. The content supports malaria prevention by promoting the use of LLINs, ANC visits and the use of intermittent preventive treatment during pregnancy with SP, early care seeking, compliance with malaria treatment, and by discouraging self-medication. These audio-visual materials will be broadcasted by TV and radio stations and distributed to health centers and other community partners. The working group anticipates incorporating findings of the Barrier Study completed in Y2/Q3 for recommendations that will guide the revision of IEC materials focused on IPTp.

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Results

Indicator Baseline LOP Target PY3/Q1 Results Source/Comments Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened Sub-result 3.1: NMCP’s technical capacity to plan, design, manage and coordinate a comprehensive malaria control program enhanced 15) The number of -- The 4 NMCP technical Case ARM3 program meetings held by the working groups Management reports NMCP technical working (monitoring and TWG: 1 groups (monitoring and evaluation, supply TWG Meetings in evaluation, supply chain, chain, PY3/Q1: communications, and case communications, and Case Management: 1 management) case management) are meeting regularly as planned (twice per year)

Sub-Result 3.2: Capacity to Collect, Manage and Use Malaria Health Information for M&E and Surveillance Improved Successful program management requires timely and accurate data to make rational and informed decisions on policy and interventions. ARM3 is evaluating and strengthening each of the major information systems including the HMIS/Routine Malaria Information System (RMIS) (LogiSnigs & LogiHops), Logistical Management Information System (LMIS) (Medistock), Institut Regional de la Santé Publique (IRSP) sentinel surveillance, OTSS, End Use Verification Surveys (EUVS) and other malaria-related systems. The objective is to ensure that each system is providing high quality and timely data for decision-making and to address barriers in information collection, management, and utilization. At the end of Year 2, 81.2% of health facilities and 100% of sentinel sites reported malaria- related information on a regular and timely basis for decision making. As a result of ARM3’s technical assistance provided to Health Facilities, the RMIS completeness increased from an average value of 57% in Year 1 to an average value of 86% in Year 2.

Achievements Health Facility Survey

Preliminary Results of the HFS The HFS was implemented from September 30 to October 30, in 60 Health facilities distributed in the 12 departments of Benin. Data was collected by 3 teams of 5 members under the supervision of a team comprised of ARM3, CDC, USAID, and the NMCP. Data was collected using tablets that had been programmed by the MCDI HO.

Debriefing of Surveyors At the end of the survey (October 31, 2013) the data collectors and supervisors met to share experiences and to make recommendations for the future, with the participation of PNLP, USAID, CDC, ARM3 members and 18 surveyors. The objectives of the debriefing were: i) update the data collected; ii) identify observations and difficulties identified by field investigators; iii) conduct a post- survey assessment of the training of the surveyors and data collection; iv) identify strengths and weaknesses (organization, logistics, implementation, etc.); v) obtain lessons learned and vi) perform administrative duties (e.g., collection of the equipment, materials and payment of surveyors).

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Post Survey Evaluation Feedback Following Training of the Surveyors: • Good organization overall • Supporting documentation easy to understand • Participatory approach was well-suited for the training (some participants thought training could be longer) • Well-functioning tablets • Pre-test was useful to prepare surveyors for field work • Well-chosen case studies • Appropriate site for the training

Post Survey Evaluation Feedback Following Data Collection: • Good coordination • Supervisor was able to motivate teams and provide coaching • Means for transportation were sufficient (though some teams had insufficient access to fuel on days 1 and 2) • A stock of medicines and RDTs was made available • Funds for emergencies and communications were provided

Table 6: Primary Findings of Survey Teams Areas of findings Team North Team Center Team South

Availability of supplies Private sector facilities do Diagnostic results are not Not all required supplies not have access to RDTs available in some health were available in some or ACTs facilities health facilities

National malaria policy National malaria policy In certain facilities, care is Some private sector directives were not provided by unqualified facilities do not apply the systematically respected staff (aides, clerks), who national malaria policy in all facilities. Quinine are often not formally (they feel excluded or are and injectable chloroquine trained in case not associated with the are still used to treat management or malaria in public sector) uncomplicated malaria in pregnancy. Private sector health some facilities. Some health facilities lack facilities treat the largest job aids and guidelines on number of cases. malaria case

management. Even when available, the guidelines were often not fully

followed. Supervision of providers is not regular.

Source: HFS preliminary report

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Reading of HFS Slides The surveyor teams collected 280 slides during the HFS to assess the quality of malaria diagnostics performed by health facility staff. Malaria microscopy is used as a ‘gold standard’ which complements the diagnosis conducted through RDTs. These slides were stored after completing the implementation of the HFS. The ARM3 malaria diagnostics team, working jointly with the Centre National Hospitalize et Universites de Cotonou (CNHU) and the CDC, developed a protocol for reading and analysis of the slides. ARM3 issued a service contract to CNHU. The results of these readings are expected for the second week of January 2014.

Photo 15: HFS Surveyors travelling to a HF to collect data Tabulation of Data and Development of the Database The data collected on tablets was transmitted to the MCDI HO via Internet on a routine basis. The IT team, in collaboration with ARM3 local staff, reviewed the data for quality and completeness. A preliminary database was made available for the descriptive analysis. The CDC and MCDI reviewed the data analysis plan and jointly developed table shells to be used in the descriptive analysis. Tables will be finalized upon receipt of the data from the slide readings, followed by the descriptive analysis and development of the final report.

Support for RMIS Validation During the reporting period, ARM3 provided technical support to the NMCP in the analysis of data from LogiSnigs software in preparation for the RMIS validation workshop of data collected from July- December 2013. Data presented in this quarterly report has not been validated yet, as the 3 validation meetings with the HZs planned for this quarter were not conducted (due to delays in the work plan approval due Partial Termination). As a result of work between the NMCP and ARM3, 52 new health facilities were added into the RMIS in Year 3 (6 from the public sector and 46 from the private sector).

Graph 7 (below) presents a slight reduction in the RMIS completeness from quarter 7 to quarter 83 from 84.8 % to 83.2%. This means that despite the increase in the number of HFs a high number of reports have been submitted.

3 The graphics presented below are part of the set of information developed by the ARM3 team to be presented in the RMIS validation meetings and has not been validated yet.

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Graph 7: RMIS Completeness by Quarter

Graph 8 illustrates that the private sector facilities have slightly progressed in their RMIS completeness, with an increase from 62.4% to 68.6%.

Graph 8: RMIS Completeness by Type of Health Facilities (Public vs. Private)

This situation is also due to the fact the validation workshop was not held. The ARM3 M&E team noticed that in some cases, the HZ statisticians received reports from HFs but did not enter it in the database before attending the workshop, where they have been advised to avoid these practices.

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Provided Technical Assistance for the Implementation of the Tracking of LLINs Distributed Through the Private Sector During the reporting period, the ARM3’s M&E Manager and the Statistician provided technical assistance for the implementation of the protocol for the tracking and monitoring of the LLINs distributed through the private sector in Phase 1. Technical assistance consisted of training and supervision of surveyors, data entry and analysis. (This activity complements the tracking and monitoring of LLINs distributed in Phase 1, under sub result 1. 2, Supply and Use of LLINs Increased).

Update NMCP Central Data Platform ARM3 continued to provide technical support for the updating of the NMCP databases: RMIS, MEDISTOCK, LMIS, HMIS, the Palu-Alafia GFATM database and the EUV survey database. Data from different regions of the country were merged and analyzed to detect outliers and errors within databases. Results

Indicator Baseline LOP Target PY3/Q1 Results Source/Comments

Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened Sub-result 3.2: MOH capacity to collect, manage and use malaria health information for monitoring, evaluation and surveillance improved 16) Percent of targeted 37.8% ≥ 95% of targeted 74.6% RMIS results are facilities reporting through facilities reporting PY2/Q4 from PY2/Q4 RMIS and sentinel Source through the RMIS RMIS: (Jul-Sep 2013) surveillance sites are RMIS and sentinel (829 HFs reported providing complete (PY1/Q4) surveillance sites out of 1,110 information on a regular and are providing facilities) timely basis for decision complete making information on a IRSP Sentinel no regular and timely data received basis for decision making Sub-Result 3.3: Capacity in Commodities and Supply Chain Management Improved In order to reduce malaria related morbidity and mortality in Benin, consistent availability of high quality malaria commodities is crucial. The main objective of ARM3’s malaria commodities supply chain management (SCM) component is to strengthen Benin’s SCM activities, including building the capacity of and improving the performance of Benin’s CAME. ARM3 is working with CAME to improve governance practices, drug warehouses, and financial information systems.

ARM3 is supporting the NMCP and CAME in planning and implementing a well-designed Malaria Logistics Management Information System (LMIS) in order to reduce stock-outs and overstocking.

ARM3 has continued to work with CAME to improve governance practices, a process which started in 2010, when ARM3 first began working with CAME on warehousing and financial information systems in order to improve its performance. The LMIS end goal is to track malaria commodities in the national supply chain system and to make sure that the right products are available in the right quantity, condition, time, place and cost. Consumption data is used to forecast malaria commodities.

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Achievements Supported NMCP Drafting of Malaria Commodities Management Directives During the reporting period, ARM3 supported the NMCP in drafting the national malaria commodities management directives. The role and importance of malaria commodities LMIS, the Logistic Management Unit (LMU) and waste management were validated and detailed in the draft document. This document promotes best practices in malaria commodities management from the field to NMCP partners.

Malaria Commodities LMIS Reporting Tool Reprinted and Distributed ARM3 reprinted 1,000 copies of the malaria commodities LMIS monthly reporting tool for HFs and 34 copies of malaria commodities quarterly reporting tools for DRZs. Additionally, 600 of the 1,000 copies of the reporting tool for HFs and all 34 of the malaria commodities reporting tools for DRZs have been distributed. HFs’ malaria commodity needs are reported to DRZ managers that in turn order the quantities required to distribute to the health facilities in their HZs.

Prepared Implementation of MEDISTOCK V4+ at CAME’s Warehouses with CAME and the NMCP CAME, the point of entry for malaria commodities in Benin, plays a key role in the management of malaria commodities LMIS. CAME’s information’s system does not currently have access to Depot Repartitions de zone (Health Zone Depots) (DRZ) stock status in order to be able to alert key stakeholders and the NMCP on stock statuses in its warehouses.

ARM3 supported the value of having MEDISTOCK V4+, a commodities management program, in CAME’s warehouses. With MEDISTOCK V4+, CAME will have a more comprehensive view of stock statuses in all DRZs and will be able to use malaria commodities LMIS to avoid stock outs and/or over stocks. The pilot installation of MEDISTOCK V4+ in the CAME warehouses is being supported by a project team composed of staff from CAME, the NMCP and ARM3. This pilot project is scheduled to be implemented for 6 months starting with the training of the field team in the 2nd quarter of Year 3 and will continue with the implementation of MEDISTOCK V4+ at DRZs.

Supported CAME Warehouse Design Due to anticipated shortages in CAME’s storage space, ARM3 supported the design of new CAME warehouses and provided technical guidance to maximize storage space in all CAME’s warehouses. Additional technical support will be provided based on funding availability and coordination between CAME and ARM3.

Coached Malaria Commodities DRZ Managers to Collect Consumption Data at HF Level In early 2013, ARM3 began supporting the NMCP’s efforts to implement an LMIS to provide information on malaria commodities issued from DRZs to health facilities and to ensure that monthly malaria commodities consumption reports are submitted by health facilities to DRZs. The malaria commodities LMIS reporting rate has increased from 47% in the first quarter of implementation to 85% in the second quarter of implementation. In addition to obtaining information on malaria commodity quantities issued from DRZs to health facilities, the NMCP must confirm that reports from the health facilities contain consumption data.

During the reporting period, ARM3 has implemented “coaching” visits to 34 DRZs and pharmacy managers to reinforce the habit of reporting consumption data. This strategy has helped ARM3 to collect and confirm the quality of data reported by DRZ managers.

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One of the main purposes of these coaching visits was to promote DRZ managers supervision visits to health facilities and encourage HF staff to report quality consumption data on monthly basis. The results of these visits will be present in the next quarterly report.

Conducted EUV Survey in the Mono/Couffo Department4 ARM3 jointly conducted a EUVS in November, 2013 in the Mono/Couffo department with the NMCP and HZ training teams5. The EUVS methodology was developed by PMI to assess the availability and proper use of malaria commodities and to provide quarterly information that can be used for programmatic purposes. Prior to the start of the EUVS, 12 surveyors were trained and organized into 4 teams of 2 collectors and 1 HZ manager. The survey was conducted from November 18 – 22, 2013. The EUVS teams visited a sample of twenty health structures in 4 HZs. Key observations and recommendations are:

• 59% of case management staff and 32% of ANC staff have not been trained on the NMCP’s Case Management Guideline. • Health facilities are experiencing difficulties getting reimbursed for the treatment of pregnant women and children under five (which is offered to patients for free). It is likely that quinine is prescribed in lieu of free treatment. This could explain the large quantities of quinine in health facilities that are being used to treat simple cases. ARM3 will provide support to the NMCP to train and coach Mono/Couffo health care providers on the case management guideline. We recommend that the NMCP and DDS Mono/Couffo investigate the use of quinine and solve the issue of reimbursement of “free treatment”. • This EUV found that 88% of government health facilities had ACTs available for treatment of uncomplicated malaria. • Only 10% of facilities have all four treatments of Artemether + Lumefantrin (AL). This may be a result of national decision to use AL 4x6 and AL 3x6 before expiration to compose the other treatments or to over-stock of these treatments. These changes are not documented at the facility-level. ARM3 will support the NMCP in updating the national quantification and supply plan and recommends that the NMCP ensure the availability of malaria commodities according the forecasting and supply plan. Graph 9 below shows the index of availability of AL.

Graph 9: Index of Availability of Artemether + Lumefantrin (AL)

• 50% of the facilities visited were out of SP stock the day of the visit. The situation is due to a stock-out of SP at the national level. The NMCP has procured a quantity of SP which is available

4 EUVS data reported in results tables/ indicators 7, 8 and 18 use data conducted in the Mono/Couffou with a sample of 15 HFs. Data of the EUV/LIAT conducted at the national level with a sample of 190 HFs are included in ARM3 Quarterly Report 6.

5 ARM3 changed the location of the EUV conducted during the reporting period from the Borgou/ to the Mono/Couffo department due to conflicting agendas with the DDS Borgou/Alibori

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at the central level since November 11, 2013; however, it had not yet been distributed to HZ depots by the start of the survey. ARM3 recommends: i) the NMCP coordinate with the Mono/Couffo DDS to make sure that SP and RDT’s are regularly available at health facilities for use; and ii) the NMCP make sure that the Mono/Couffo health department monitors and coaches health staff on a rational use of commodities. • The malaria commodities LMIS reporting rate for the Mono/Couffo is only 75%, the lowest rate in Benin, and needs to increase in order to improve the availability of commodities. During the last malaria commodities LMIS supervision feedback, the department’s Director of Health emphasized the importance of increasing reporting rates to his medical coordinators at HZs. • The study found overstocks of RDTs and LLINs in the zonal hospitals, which have low consumption rates of both of these commodities. We recommend that the NMCP transfer RDT’s and LLIN’s from the zonal hospitals to health facilities where they are needed.

The Procurement Planning and Monitoring Report for Malaria (PPMRm) Report Submitted ARM3 supported the NMCP in the preparation of the October – December, 2013 PPMRm report, this report provides data on central-level stock availability for critical malaria drugs and commodities.

Results

Indicator Baseline LOP Target PY3/Q1 Source/Comments Results Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened Sub-result 3.3: MoH capacity in commodities and supply chain management improved 17) Number of quarterly and -- The national malaria Quarterly Available LMIS annual reports generated by commodity supply reports from: reports: the LMIS per year chain is functioning All 34 DRZ have with an LMIS that Annual reported but not all regularly provides reports: 34 DRZ reports cover all quarterly and annual of the health facilities reports (4 quarterly under their and 1 annual supervision. reports) 18) Percent of government 80.3% ≥85% of government 87.6% EUVS* Nov, 2013 health facilities with ACTs health facilities have available for treatment of Source ACTs available for Sample size is uncomplicated malaria RMIS treatment of limited to scope of (PY1/Q4) uncomplicated EUVS malaria for patients of any age at any point in time covered by project-supported EUV surveys 18.a) Percent of health 77.3% ≥85% of health 52.7% RMIS results are facilities reporting no stock- Source facilities report no from PY2/Q4 outs of ACTs RMIS stock-outs of ACTs (Jul-Sep 2013) (PY1/Q4) 19) Percent of facilities in 0% Complete (100%) 100% 3 CAME warehouses compliance with CAME implementation of in compliance with reforms reforms initiated in CAME reforms. CAME so as to Source: improved ARM3 program governance and reports transparency of its NB: Indicator operations reformulated to

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Indicator Baseline LOP Target PY3/Q1 Source/Comments Results reflect reforms implemented within CAME in lieu of CAME reforms implemented by other facilities. 20) Percent of facilities that Results Results from the 100% All HFs in submit an action plan in pending EUVS EUVS are analyzed Ouémé/Plateau response to the End-Use report and used to identify where EUV was Verification Survey management and conducted in June operational issues in 2013 have submitted the commodity an action plan. supply chain system This indicator will be updated based on the level of completion of the action plans per HZ as a response to the future EUVS. *NB: EUVS data reported in indicator 18 use data conducted in the Mono/Couffou with a sample of 15 HFs. Data of the EUV/LIAT conducted at the national level with a sample of 190 HFs are included in ARM3 Quarterly Report 6. Result 4: Cross Sectional Activities Achievements Community BCC Mass Media During the reporting period, ARM3 BCC initiatives continued to support the dissemination of information on: i) proper use of LLINs; ii) IPTp utilization; iii) seeking prompt care; and iv) adherence to treatment protocols. Key messages were disseminated regarding the use of LLINs, the importance of confirming diagnosis before treatment with ACTs, the importance of women attending antenatal care visits and the benefit of IPTp. ARM3 relied on several channels to reach and mobilize its target audience, in order to increase knowledge, change attitudes and stimulate behavioral change. Television ARM3 aired a TV spot on malaria prevention and the consistent use of LLINs. It was broadcasted 30 times between November and December, 2013 on ORTB TV channel.

Radio Programs Representatives from ten radio stations partnering with ARM3 participated in a two day workshop (19- 20 November 2013) to discuss the implementations achievements and challenges in allowing people to have access to malaria information. Participants made the following recommendations:

1. Media is an effective approach in transmitting malaria information due to the interactive and specific nature of Q&A radio shows and TV spots; ARM3 should continue to collaborate with radio stations and ORTB TV 2. Each station should adapt its broadcast time to the audience’s preference time 3. Use songs in a more systematic manner, since many used in BCC activities have shown positive results in promoting key malaria prevention behavioral changes 4. In order to strengthen communication, ARM3 needs to involve the HZ by appointing one person to serve as a link and to participate in radio programs 5. Continue to support a resource person from the HZ to participate in radio shows

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During the workshop, participants received a booklet titled “La Radio Realité ou Radio Jeu Public au Bénin”. It is a guide created by ARM3 for radio managers describing the features, the targets and six steps to implement the radio reality program. BCC Materials ARM3 offices in Cotonou, Abomey and Parakou continued to distribute printed materials to health centers, communities, and partners. Over 58,000 flyers were distributed during the reporting period, including 24,520 in Parakou, 15,000 in Cotonou, and 18,850 in Abomey. Community Events

“Let’s Make the Mosquito’s Life Impossible” Campaign Under the campaign “let’s make the mosquito’s life impossible”, ARM3 partnered with a local theater group from Cotonou called “Embuscade de la Scene” to promote malaria prevention messages including use of LLINs and IPTp. A community fair was held in Cotonou where ARM3 projected on screen a mosquito and malaria prevention TV spot, distributed flyers and disseminated IEC/BCC materials. More than 250 people attended this event.

Support to Bembereke-Sinende HZ During the reporting period, the RMIS reported a high under-five mortality due to malaria in the Bembereke-Sinede HZ. In response, ARM3 collaborated with local administrative and health authorities, the Bembereke public schools committee, and the FM Nonsina Radio to disseminate malaria prevention messages and conduct community activities. The following activities were carried out: 1. ARM3 produced four radio spots and supported their broadcast in three local languages: Peuhl, Bariba and Boo. A magazine from Wari city was also provided with information about malaria prevention and the issue was released the following week 2. ARM3 collaborated with Bembereke public schools to integrate BCC messages during the school’s centennial celebration event held in November 2 3. A radio show was produced in Wari (in the Sinende district) called “Emission Grand Public” transmited by the FM Nosina Radio. The facilitator asked men and women questions about their perception of malaria and how they can protect themselves and their families from malaria. This program was supported by the HZ’s medical doctor who considers it important to educate the people of Wari about malaria prevention because the local health facility does not yet provide SP or LLINs for pregnant women 4. A skit by the group Bio Guerra supplemented the radio program, emphasizing the prompt care of febrile children. Almost 500 people attended and heard the message from the skit

During the presentation primary school student Nanga Karami Eva presented the following message:

“Dear Parents, do not let our young children die from malaria. As soon as you find that he or she has fever, take him or her to the health center immediately for proper case management. It is not good to sleep without an LLIN. If your net has holes, students can help because we have learned to sew at school and we have a kit for that. Doing so will commit all of us to fight malaria”.

Other testimonials from the participants include the following:

Zato Barikissou, 32, mother of three children: “I have recently heard messages on FM Nonsina Radio about malaria prevention in pregnancy, LLIN use to prevent malaria and the importance of seeking for diagnostic and early treatment at the health centers in case of disease. ”

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Photo 16: A young girl Eva Nanga Karami invites the public to adopt key life- saving practices against malaria during the Bembereke event

Amadou Dado, milk seller and mother of 4 children: “I heard messages in the Peulh language on the FM Nonsina radio. The message was about the net use and going to a health center for any febrile child case. I will pass similar messages to my peers who did not have a chance to attend the event. I will recommend to the organizers to continue to perform the sketches in the Peulh language as many people of our ethnic group do not understand well the Bariba language.”

Garba Mahazath, 22, student: “I remember listening to educational messages during the sensitization yesterday at the Nonsina Radio. Sketches conveyed messages on SP and ACT. I know now that a test has to be done before confirming malaria cases. Before I did not know that the fetus can be exposed to malaria. At home, I will pass messages to my neighbors encouraging them to go to health centers, avoid self-medication, keep a clean and water-free yard, and protect children by using LLINs”.

Assisting Local NGOs in Implementing Community Engagement Activities

Conducted Final Evaluation of the 18 NGOs Under Contract in Year 2 The 18 NGOs under contract with ARM3/Africare closed out their activities on September 30, 2013. A final supervision was conducted on December 9, 2013 for a final assessment that addressed completion of scope of work, successes, data archiving, and financial & material management. The assessment showed that approximately 95% of planned activities were completed and 96% of funds were spent. The remaining funds were returned by the NGOs to ARM3. Also, the assessment showed that 99% of materials provided by the project were still available and being used. Achievements from the 18 NGOs for period January to September 2013 are presented in the following graphs:

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Graph 10: Number of Pregnant Women Referred to Health Facilities for IPTp

Overall 2482

Q3T3 1270

Q2T2 927

Q1T1 285

0 500 1000 1500 2000 2500 3000

Graph 11: IPTp Uptake in Littoral Graph 12: IPTp Uptake in Ouémé/ Departments

41% 40%

29% 25% 32% 21%

15% 20% 5%

Q1 Q2 Q3

PERCENTAGE OF PREGNANT UNDER TPIIPTp 1 1

July August September PERCENTAGE OF PREGNANT UNDER TPIIPTp 2 2

The graphs show an increase of the IPTp uptake through implementation period in Littoral as well as Ouémé/Plateau departments.

Graph 13: LLINs Use in Households

83% 80% 77% 72%

Q1 Q2 Q3 T1 T2 T3 Overall

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The initiation of the Community BCC program was followed by an increase of LLIN use in households from January to September.

Graph 14: Number of People Educated through Home Visits and Groups Sessions

Q3T3 136901

Q2T2 59784

Q1T1 13333

0 20000 40000 60000 80000 100000 120000 140000 160000

Over 136,000 persons were reached and educated through home visits and grouped sessions from January to September in the 18 HZs. Quality Assurance/Quality Improvement The ARM3 team drafted a paper on quality control/assurance as a reference for both the project staff and those involved in implementing the Memorandums of Understanding (MOUs). The draft has been reviewed internally by ARM3 technical staff under the leadership of the Technical Coordinator.

Testimonials from Mothers in Benin:

“When my first son was born I bought a mosquito net but it tore and I stopped using it. My child and I frequently fell ill. Thanks to Mrs. Nicole (CHW), during my second pregnancy I respected my ANC appointment where I was given an LLIN. I used it consistently and delivered my baby safely. My baby and I are doing very well. I am grateful to ARM3 project and its managers.” -Anicette from commune in Ouémé department

Photo 17: CHW Nicole Chokki (on left) with Anicette Adanvoessi and her baby (on right)

“When my wife was six-months pregnant we received a visit from Mr. Barnabé (CHW). He advised us to go to health facility for an ANC and gave us a referral voucher but we did not use it due to a lack of money. With the CHW insistence and support, my wife finally went to the health facility where she has been registered as impoverished and the appointment was free of charge. She delivered safely and she and the baby are doing very well. Thanks to Barnabé and ARM3 project that save women and children lives.” - Honoré Adjahoun from commune in

“On September 2014, my daughter Honorine, 4 years old, suffered from a severe case of malaria. I kept using traditional medication based on leaves. Three days later we received a visit from CHW Bertin who convinced us to take the child to health facility and gave us a referral voucher. At the health facility, the first visit was free of charge and afterward our child felt better. This encouraged my husband and I to pursue the treatment. A few days later my child was totally recovered. I would like to thank Bertin who encouraged us to take action at the health facility and thank also the ARM3 project and its entire staff for the wonderful work they do to improve our community welfare.” - Hervine Anagogni from in Zou department

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Program Management Field Office ARM3 Y3 Work Plan and Budget ARM3 field staff worked on and submitted an initial Year 3 work plan in October. In early November, ARM3 received comments to the work plan from PMI/CDC and USAID. ARM3’s field office staff held a two-day retreat to rework the plan and to reply to all comments. MCDI HO reviewed the revised work plan for resubmission to USAID in early December. However, the work plan was not submitted due to information received from USAID that ARM3 would be requested to engage in a “de-scoping”/partial termination process. This was confirmed through an official letter received by MCDI on December 24, 2013 from the Regional Agreements Officer; this Partial Termination request suggested actions that would result in a $10 million reduction in ARM3’s TEA. As a result ARM3 did not have an approved work plan or budget during the first quarter of Year 3. In the absence of an approved work plan and budget, ARM3 was constrained in its ability to implement activities proposed in its initial work plan and was thus unable to provide the anticipated level of support to the NMCP.

LLIN Phase 2 Distribution As described under Sub-result 1.2, “Supply and use of LLINs increased”, ARM3 team launched the Phase 2 Distribution of LLINs to private sector employees in December 2013. iCCM Startup The iCCM technical team reviewed the iCCM implementation plan, initiated coordination with partners and completed assessment of CHWs participating in the iCCM activities.

Technical Support for the Implementation of iCCM Dr. Faustin Onikpo, ARM3’s iCCM technical advisor, worked closely with the MOH (DSME DNSP/NMCP) to support the development of new standards and guidelines for iCCM and review training materials and CHW tools for the implementation of iCCM.

Health Facility Survey (HFS) ARM3 FO continued supporting the implementation of the HFS until its finalization in October 31, 2013.

Recruitment of ARM3 Staff In addition to the 2 accountants for Cotonou and Bohicon and 8 community assistants (already mentioned in the 8th Quarterly Report), Africare hired an accountant for the Parakou field office responsible for supporting the local NGOs in finance management for community-based activities. He took up his duties on October 7, 2013 in Africare’s Parakou office.

Home Office Backstopping and Reporting MCDI Home Office: Technical/Financial Support and Coordination ARM3 Y3 Work Plan MCDI HO staff worked extensively with ARM3 field staff on the preparation and submission of the Year 3 work plan in October. USAID/PMI replied to the work plan with comments from the MOP team. While responding to the MOP’s comments, MCDI HO received USAID’s Partial Termination letter. HO continued to work with ARM3 partners and the FO to prepare a response to the “de-scoping”/Partial Termination letter. The suggestions included a request for revised project activities and a budget compliant with the new USAID programmatic and budgetary guidelines.

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LLIN Phase 2 Distribution and tracking of LLINs distributed in Phase 1 MCDI HO provided TA in the planning for the implementation of the Phase 2 distribution and by doing the final review of the protocol for the tracking and monitoring of LLINs distributed in Phase 1.

SMS/GSM Pilot Study MCDI HO worked with field staff in the testing of mobile phones using the CommCare-ODK GRPS data application designed to complement data collection activities in two iCCM target HZs.

Health Facility Survey (HFS) HO reviewed data collected on tablets from the HFS for data quality and completeness and the forwarded the database to the CDC technical team for validation. Dr. Luis Benavente, Pablo Aguilar, and Matt Worges provided technical support in the planning and implementation of HFS.

Assessment of LDP/Collaborative Improvement (CI) Approaches MCDI HO reviewed and provided comments to MSH on Dr. Mahamane Karki’s mission report on ARM3’s LDP and Collaborative Improvement (CI) approaches in the Atlantique/Littoral and Ouémé/Plateau departments.

Africare Home Office Africare HO contributed to the finalization of a set of documents (including ARM3’s Year 2 annual report, Africare revised Year 3 work plan and budget) and submitted them to MCDI.

JHU-CCP Home Office JHU-CCP HO contributed to the finalization of a set of documents (including ARM3’s Year 2 annual report, JHU-CCP’s revised Year 3 work plan and budget) and submitted them to MCDI. JHU-CCP also submitted their review of the ‘Barriers to the LLIN and IPTp use in Benin’ literature review and adjusted the new version with comments suggested by MCDI.

MSH Home Office MSH HO contributed to the finalization of a set of documents (including ARM3’s Year 2 annual report, MSH’s revised Year 3 work plan and budget) and submitted them to MCDI.

Home Office Backstopping and Reporting Dr. Luis Benavente, MCDI’s Senior Health Program Officer, provided STTA to ARM3 field staff in from November 24 to 27, 2013. The technical support was provided in the following areas: • Strengthening malaria diagnostics in support of the Year 3 Work Plan • Train the field team in WHO’s methodology for assessing holes using a predetermined chart

Major Challenges (per ARM3 Sub-result): Cross Sectional Activities (Behavior Change Communication) • Delay in ARM3 Year 3 work plan and budget approval by USAID: mainly iCCM activities, approved through an agreement amendment with MCDI on September 2013, were implemented in this quarter • NMCP is understaffed in supply chain • Coordination of NMCP stakeholders • NMCP and Partners quantification and supply planning skills • Quality of consumption data reported by health facilities • SP registration in Benin • Waste management and reverse supply chain

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Major Activities Planned for Next Quarter (Year 3, Jan-Mar): RESULT 1: Implementation of Malaria Preventions in Support of the National Malaria Strategy Improved • Conduct the training of health workers on IPTp and IPC • Air TV spot on malaria prevention among pregnant women • Publication of the results of the tracking of LLINs • Incineration of 100,000 LLINs bags • Report on results of the two LLINs distribution campaigns

RESULT 2: Malaria Diagnosis and Treatment Activities in Support of the National Malaria Strategy Improved • Print and distribute training manuals for the malaria case management, IPTp, and MIP in all HZs • Organize a workshop for the elaboration of integrated registers of ANC/IPTp, Expanded Program on Immunization (EPI) and PTME • Disseminate 200 manual of SOP for malaria diagnostic • Carry out OTSS supervision in all 118 sites • Deliver emergency equipment to the 12 hospitals trained in ETAT • Conduct monthly validation of indicators in 12 hospitals involved in ETAT • Organize the second learning session of the 12 hospitals involved in ETAT • Assess hospitals for enrollment in the next phase of ETAT (human, material and technical) • Conduct orientation workshop for officials and their staff on ETAT for newly identified hospitals • Train new hospital providers on ETAT • Conduct an assessment of the implementation of activities under the MOUs in place in all departments • Organize the signing of MOU amendments with the 25 existing HZ and 4 existing DDS • Organize the signing of new MOU with the 9 new HZ and 2 new DDS of Atacora/Donga and Mono/Couffo • Support the organization of learning sessions (for 20 health facilities in the ) for collaborative approach • Organize a workshop to review the MOUs in 3 HS (Tchaourou, KGS, Banikoara) integrating activities in the iCCM Borgou/Alibori • Conduct needs assessment for the development implementation activities iCCM in HZ ex BASICS • Select 220 new CHW to replace resigning in HZ iCCM • Organize the training of 70 trainers in the Donga (Djougou and Bassila) in collaboration with PARZS / CTB and PILP/Africare (RDT complete package and SMS/GSM) • Briefing master trainers in Borgou/Alibori (KGS, BN, TCH) • Organize the training of 145 trainers in BA (KGS, BN, TCH) in collaboration with PILP • Continue to work with 468 CHW in the Donga (Djougou and Bassila) on the use of RDT and the complete package • Continue to work with 595 CHW Borgou/ Alibori on the use of RDT and the complete package • Train new 220 CHW at 5 HZ iCCM on the use of RDT and the complete package • Order and deliver CHW kit at 5 HZ iCCM • Training/retraining of 7 Donga NGO staff on the use of RDT and the complete package • Training/retraining staff of 10 NGOs Borgou/Alibori on the use of RDT and the complete package • Conduct post- training follow-up (on-site supervision) of the 1063 CHW • Contract with radios to broadcast messages iCCM at 5 HZ • Organize TOT in Bassila and Tchaourou on the use of the CommCare application on android phones

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• Supervision of training of community HZ CHWs in Bassila and Tchaourou on the use of the application on android phone CommCare • Update the database community liaisons for the implementation of IMCI in areas such basics • Support community input data at 5 HZ • Ensure the availability of drugs and inputs for the implementation of iCCM • Conduct selected NGOs training/refresher training on completed package and RDT use • Provide local NGO materials (computer and accessories, registers) • Supervise iCCM activities • Collect iCCM related data • Publication of 2,500 copies of text on requirements for private practice registration • Support the organization of one session of the Commission on Accreditation of private health facilities • Training of 30 health workers in the private sector

RESULT 3: The National Health System’s Capacity to Deliver and Manage Quality Malaria Treatment and Control • Organize a workshop to finalize the malaria commodities directives • Organize a training session on qualification • Organize a workshop to carry out a quantification exercise for malaria commodities for 2014 and 2015 • Organize EUV in Borgou/Alibori • Organize a malaria commodities LMIS supervision • Control and validate malaria commodities quarterly reports of DRZ and monthly reports of health centers • Support NMCP to prepare January 2014 forecasting exercise by collecting data needed • Coaching visits to DRZ and health facilities managers • Implement a pilot phase of MEDISTOCK V4+ in CAME’s offices in Cotonou, Parakou and Natitingou • Assist NMCP in the organization of the PITA • Quarterly supervision HMIS • Quarterly data validation of HMIS data • Drug efficacy testing • Quarterly bulletin HMIS (Palu-Info)

RESULT 4: Cross Sectional - BCC • Participate in the development of ARM3 transitional work plan and budget for Year 3 • Support radios and local theater groups to reach more people • Continue to distribute flyers, banners and posters • Attend PITA meeting and include times for meetings to complete the development of BCC strategy • Visits to new departments and make contacts with local authorities in the Mono/Couffo, Atacora/Donga and Alibori departments

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Annex 3: Summary of the Partial Termination Letter

RESULT 1: Implementation of malaria prevention programs

Suggested changes to this Result:

• ARM3 should phase out its operationalization of community BCC activities. After October 1, 2013, no new sub-grants should be awarded. Any sub-grants made before that date should be terminated by June 30, 2014. Any future community BCC activities will be managed through the Community PIHI Grants with local NGOs.

• ARM3 should continue to provide technical assistance in the formulation of a malaria behavior change communications (BCC) plan. ARM3 should contribute to national malaria communication campaigns including Africa Malaria Day and should conduct formative research as determined in the annual Malaria Operational Plan.

RESULT 2: Malaria diagnosis and treatment activities

Suggested changes to this Result:

• ARM3 should transfer the authorization and responsibility for approving funding of activities, supervision, and trainings at the HZ level, as well as approving agreements between HZs and hospitals, to NMCP by July 1, 2014.

• ARM3 should discontinue community level BCC and iCCM activities (added in June 2013 modification for one year bridge funding) as of October 1, 2013. ARM3 should continue to play a leadership role in the national BCC strategy for malaria, coordination of national BCC strategic communication efforts as stipulated in the MOP.

• Effective October 1, 2013, the Consortium (under the leadership of the Clinical Management Manager) should have a greatly reduced role in modifying the existing malaria related curriculum used in universities and technical schools. The NMCP should adopt this responsibility. Particularly important issues are: malaria diagnostic procedures (use of microscopy and RDTs), malaria treatment (including case management of severe malaria and IMCI), and integrated supervision (using the NMCP guidelines and the OTSS procedures). After the NMCO and MOH approve the revised curricula for official use, the Consortium should provide specific technical and financial assistants (e.g. small grants) to the training institutions to implement the revised program.

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

Suggested changes to this Result:

• Effective October 1, 2013, ARM3 should limit support to “technical assistance only” to the NMCP’s existing working groups on leadership/policy and reform, human resources, and technical groups in the areas of supply chain management, monitoring and evaluation, communications, and diagnostic/case management. Technical advisors from the consortium team will work with the appropriate working groups to provide technical assistance.

• Effective July 1, 2014, all ARM3 activities related to the Routine Malaria Information System including data collection, validation, and production of the quarterly surveillance bulletin should be discontinued and managed directly by the NMCP under a government-to-government agreement.

• Effective July 1, 2014, ARM3 should discontinue sub-result routine supervision under 3.3.2 Strengthening of HZ’s malaria supply chain management as this will be directly funded in the NMCP government- to-government mechanism to build capacity and improve sustainability.

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