StopPalu+ President’s Malaria Initiative (PMI) Program Component Quarterly Report (Quarter 2, FY 2018)

April 30, 2018 This publication was produced for review by the United States Agency for International Development. It was prepared by RTI International.

StopPalu+ President’s Malaria Initiative (PMI) Program Component Quarterly Report

January 1–March 31, 2018 Cooperative Agreement No. 72067518CA000015

Prepared for Dr. Patrick Condo, MD Agreement Officer’s Representative (AOR) USAID/Guinea Telephone: +224.657.10.4124 Email: [email protected]

Submitted by Dr. Aissata Fofana COP StopPalu+ RTI International 3040 East Cornwallis Road Post Office Box 12194 Research Triangle Park, NC 27709-2194

RTI International is one of the world’s leading research institutes, dedicated to improving the human condition by turning knowledge into practice. Our staff of more than 3,700 provides research and technical services to governments and businesses in more than 75 countries in the areas of health and pharmaceuticals, education and training, surveys and statistics, advanced technology, international development, economic and social policy, energy and the environment, and laboratory testing and chemical analysis.

RTI International is a trade name of Research Triangle Institute.

The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. Table of Contents Page

List of Figures ...... iv

List of Tables ...... iv

Abbreviations ...... vi

1 EXECUTIVE SUMMARY ...... 1

2 INTRODUCTION ...... 3 2.1 Background ...... 3 2.1.1 Malaria context in Guinea ...... 3 2.2 Program Description ...... 4 2.2.1 Project goal and objectives ...... 4 2.2.2 Partners...... 4 2.2.3 StopPalu+ results framework ...... 5

3 ACTIVITIES BY RESULT (IR) ...... 6 3.1 IR 1: Increased use of LLINs by the population ...... 6 3.1.1 Sub-IR 1.1: Increased knowledge and skills of health care providers and community leaders on malaria prevention and the effectiveness, correct use, and care of LLINs ...... 6 3.1.2 Sub-IR 1.2: Increased ownership of effective LLINs through continuous and mass distribution ...... 10 3.1.3 Sub-IR 1.3: Increased awareness by family members of need for vulnerable populations to be protected from malaria ...... 13 3.2 IR 2: Increased use of IPTp during antenatal visits ...... 14 3.2.1 Activity 2.1.1: Support provider training on technical and IPC skills .. 14 3.2.2 Activity 2.1.3: Improve supervision of providers and tracking of pregnant women ...... 15 3.3 IR 3: Increased prompt care-seeking and treatment ...... 15 3.3.1 Sub-IR 3.1: Improved technical and interpersonal skills of providers in malaria diagnosis and care ...... 15 3.3.2 Sub-IR 3.2: Increased availability of quality diagnostic tests and treatment at facilities and community level ...... 18 3.4 IR 4: Increased full dose of SMC delivered in a timely manner...... 19 3.4.1 Transversal Sub-IR 1: Increased community involvement in and support for malaria prevention and care ...... 21 3.4.2 Transversal Sub-IR 2: Improved capacity of NMCP (central, regional, district) to manage, implement and monitor prevention, care and treatment activities ...... 22 3.4.3 Activities with insectary and associated laboratory ...... 31

StopPalu+—Quarterly Report—January to March 2018 iii 4 PROJECT MANAGEMENT ...... 32 4.1 Project Deliverables ...... 32 4.1.1 Year 1 Work Plan ...... 32 4.1.2 Monitoring, Evaluation, and Learning (MEL) Plan ...... 33 4.1.3 Life-of-activity exit strategy ...... 33 4.2 Staffing and Human Resources ...... 33 4.2.1 Offices installation ...... 33 4.2.2 Staff recruitment ...... 33 4.2.3 Short-term technical assistance (STTA) ...... 33 4.3 Procurement ...... 34 4.4 Partnership ...... 34 4.4.1 Collaboration with local NGOs ...... 34

5 M&E ...... 34

6 OTHER ACTIVITIES ...... 34

7 MAIN ACTIVITIES FOR THE NEXT QUARTER ...... 36

List of Figures Figure 1: Malaria endemicity in Guinea ...... 3 Figure 2: Results framework ...... 5 Figure 3: Percentage of people sleeping under bednets in Bady ...... 9 Figure 4: Percentage of people sleeping under bednets in Khorira ...... 9

List of Tables Table 1: Results of StopPalu+ home visits ...... 6 Table 2: Results of home visits in eight villages in the Labé Region ...... 7 Table 3: Percentage of people who slept under a bednet in the households visited ...... 8 Table 4: Results of home visits in 10 districts/villages in the Kindia region ...... 9 Table 5: Details of home visits conducted by CHWs during the reporting period (January–March 2018) ...... 12 Table 6: Number of group discussions facilitated by project-trained field agents; number of people reached ...... 13 Table 7: Details of community case management conducted by CHWs during the reporting period (January–March 2018) ...... 18 Table 8: Human bait capture in six villages ...... 26 Table 9: Light trap capture in six villages ...... 27 Table 10: Light trap capture in six villages ...... 28

iv StopPalu+—Quarterly Report—January to March 2018 Table 11: Summary of mosquito collection by light trap and human bait capture methods in three villages (Kaboye Amarayah, Guilere, and Djoumaya) of Boké Prefecture, February 11–27, 2018 ...... 29 Table 12: Summary of mosquito collection by light trap and human bait capture methods in three villages (Balayani, Foulaya, and Tindo) of Faranah Prefecture, February 10–26, 2018 ...... 30 Table 13: Results obtained by generation and by period of breeding of the Kisumu-susceptible strain ...... 31

StopPalu+—Quarterly Report—January to March 2018 v

Abbreviations ACT artemisinin-based combination therapy ALIMA Alliance for International Medical Action ANC antenatal care AOR Agreement Officer’s Representative APIC Association pour la Promotion des Initiatives Communautaires BCC behavior change communication CAM Club des Amis du Monde CDC Centers for Disease Control and Prevention CENAFOD Centre Africain de Formation pour le Développement CHW community health worker CJMAD Comité des Jeunes Mon Avenir D’abord CSH Comité de Santé et d’Hygiène (Health and Hygiene Committee) DPS Direction Préfectorale de la Santé (Prefectural Health Directorate) DQA data quality analysis DRS Direction Régionale de la Santé (Regional Health Directorate) EPI Expanded Program on Immunization FY fiscal year GNF Guinean franc INAASPO Initiatives et Actions pour l’Amélioration de la Santé des Populations IPC interpersonal communication IPTp intermittent preventive treatment of malaria in pregnancy IR intermediate result KAP knowledge, attitudes, and practices LLIN long-lasting insecticide-treated net M&E monitoring and evaluation MCDI Medical Care Development International MEL monitoring, evaluation, and learning MERLA monitoring, evaluation, research, learning, and adaptation MICS Multiple Indicator Cluster Survey MOH Ministry of Health MOP Malaria Operational Plan NGO nongovernmental organization NMCP National Malaria Control Program NMSP National Malaria Strategic Plan PMI President’s Malaria Initiative RDT rapid diagnostic test SBCC social and behavior change communication SGPD Solidarité Guinéenne pour le Développement SMC seasonal malaria chemoprevention SNIS Système National de l’Information de la Santé (National Health Information System) SOP standard operating procedure

vi StopPalu+—Quarterly Report—January to March 2018 SOW statement of work SP sulfadoxine/pyrimethamine SPAQ sulfadoxine/pyrimethamine plus amodiaquine STTA short-term technical assistance TWG technical working group USAID United States Agency for International Development WHO World Health Organization

StopPalu+—Quarterly Report—January to March 2018 vii This page intentionally left blank 1 EXECUTIVE SUMMARY The President’s Malaria Initiative (PMI) Program Component (StopPalu+) is a five-year project (December 2017–December 2022) with the goal of assisting the Government of Guinea in reducing malaria-related morbidity and mortality by 75% compared with 2016 levels. This will be achieved through multiple interventions in prevention, diagnosis and treatment, and capacity building of the National Malaria Control Program (NMCP) while increasing community involvement in and support for malaria prevention and care. RTI International is implementing StopPalu+, supported by sub-partners Jhpiego, Centre Africain de Formation pour le Développement (CENAFOD), and Medical Care Development International (MCDI). In the past five years, Guinea has made tremendous progress in malaria control, substantially reducing malaria prevalence in children under 5, annual malaria incidence, and in-patient deaths. Despite this progress, malaria remains the most burdensome communicable disease in Guinea. The entire population of 12.1 million remains at risk, with approximately 1 million cases reported in 2016, accounting for 31% of outpatient visits. The Multiple Indicator Cluster Survey (MICS) showed that malaria prevalence in Guinea is quite heterogeneous, with prevalence ranging from 1.9% in Conakry to 30.2% in N’Zérékoré. The goal of the National Malaria Strategic Plan (NMSP) 2017–2022 is to reduce malaria morbidity and mortality by 75% by 2022. Because of funding delays, the project, in agreement with the United States Agency for International Development (USAID), worked primarily on start-up activities during the period covered by this quarterly report, January 1–March 31, 2018. These activities included development and submission of the deliverables required by USAID: Fiscal Year (FY) 2018 Work Plan and budget (covering the period December 15, 2017, to September 30, 2018); Monitoring, Evaluation and Learning Plan (MEL Plan); and Life of Project Exit Strategy. The project conducted an inclusive three-day workshop to discuss and draft the work plan for FY 2018, with the active participation of key stakeholders such as the NMCP, the USAID/Guinea PMI team, and representatives of the StopPalu+ consortium, as well as representatives from national health programs (e.g., Safe Motherhood and Integrated Management of Newborn and Childhood Illnesses programs), the National Directorate of Community Health, four Regional Health Directorates (Directions Régionales de la Santé, [DRSs]) supported by the project, and the five local nongovernmental organization (NGO) partners. During plenary sessions and working groups, all participants had the opportunity to share their ideas and experiences, propose activities, and contribute to the development of a timeline with respect to the scope of the project activities. In addition, the project hired and oriented some senior staff members, including the Senior Technical Advisor and the Senior Social and Behavior Change Communication (SBCC) Advisor, who started work in January and February, respectively. As a first step in implementing the project’s technical approach, the StopPalu+ developed a statement of work (SOW) for the knowledge, attitudes, and practices (KAP) survey and validated it with the NMCP Behavior Change Communication (BCC) technical working group (TWG). For the revision of the national training manuals on case management for both health providers and community health workers (CHWs) as well as a refresher training manual on malaria diagnosis, the project team worked with the NMCP Diagnosis and Case Management TWG to develop the SOW for national consultants who will revise these documents. The project has revised the training manual on malaria diagnosis and is working on the manual for microscopy maintenance. To improve the quality of services at both health facility and community level, the project team increased supervision activities and conducted on-site training for facilities that were

StopPalu+—Quarterly Report—January to March 2018 1 identified during supervisions as needing additional support. The project also supported monthly monitoring meetings at health centers and Prefectural Health Directorates (Directions Préfectorales de la Santé [DPS]), followed by data quality analysis (DQA) activities in the facilities identified during monthly meetings as having possible data issues. To reinforce the technical capacity of districts in the fight against malaria, the project, in collaboration with World Health Organization (WHO), organized a malariology course for the 19 district malaria focal points, the 4 StopPalu+ regional coordinators, and the project medical advisor for the Kindia Region. The project also supported monthly meetings of the various TWGs as well as the National Coordination Committee overseeing the 2019 long- lasting insecticide-treated net (LLIN) mass distribution campaign. The main results for the project’s first quarter of performance are the following: • Preparation and submission to USAID of the FY 2018 Work Plan, the MEL Plan, and the Life of Project Exit Strategy • Hiring and orientation of several project senior staff members • Development and validation of the SOW for the KAP survey • Distribution of 56,474 LLINs at health facilities • Revision of the refresher training manual on malaria diagnosis • Development and validation of the SOW for the training manual on microscopy maintenance • Development and validation of the SOW for the revision of the training manual on malaria case management for both health providers and CHWs • 27,648 people tested by CHWs • 13,154 people treated by CHWs • 89,119 home visits conducted by CHWs • Support of 465 health centers’ monthly monitoring meetings • Support of 57 DPS monthly monitoring meetings • Participation in the national malariology course by19 district malaria focal points and 4 StopPalu+ regional coordinators

2 StopPalu+—Quarterly Report—January to March 2018 2 INTRODUCTION

2.1 Background

2.1.1 Malaria context in Guinea Guinea has made tremendous progress in malaria control over the past five years, substantially reducing malaria prevalence in children under 5, annual malaria incidence, and in-patient deaths. Despite this progress, malaria remains the most burdensome communicable disease in Guinea. The entire population of 12.1 million remains at risk, with approximately 1 million cases reported in 2016, accounting for 31% of outpatient visits. The Multiple Indicator Cluster Survey (MICS) showed that malaria Figure 1: Malaria endemicity in Guinea prevalence in Guinea is quite heterogeneous, with prevalence ranging from 1.9% in Conakry to 30.2% in N’Zérékoré (Figure 1). The major malaria vectors in the country are members of the Anopheles gambiae complex, including An. gambiae s.s., An. arabienesis, and An. melas (on the coast), as well as members of the An. funestus complex. The goal of the National Malaria Strategic Plan (NMSP) 2018–2022 is to reduce malaria morbidity and mortality by 75%. NMSP implementation has benefited from the Global Fund to Fight AIDS, Tuberculosis and Malaria, which has contributed approximately [Redacted], and the President’s Malaria Initiative (PMI), which provides [Redacted] per year.

StopPalu+—Quarterly Report—January to March 2018 3 2.2 Program Description

2.2.1 Project goal and objectives The goal of the StopPalu+ project is to assist the Government of Guinea in its efforts to reduce malaria-related morbidity and mortality by 75% compared with 2016 levels. The project’s primary results include the following: 1. Increased use of long-lasting insecticidal nets (LLINs) by the population 2. Increased use of intermittent preventive treatment of malaria in pregnancy (IPTp) during antenatal care (ANC) visits 3. Increased prompt care-seeking and treatment 4. Increased full dose of seasonal malaria chemoprevention (SMC) delivered in a timely manner 5. Increased community involvement in and support for malaria prevention and care 6. Improved capacity of the National Malaria Control Program (NMCP) (central, regional, and district levels) to manage, implement, and monitor prevention, care, and treatment activities For each result area, our operational strategy will integrate and link the inputs, processes, and systems required for strong results.

2.2.2 Partners RTI International’s partners for StopPalu+ include the following: • Jhpiego: Jhpiego will work to improve the use of IPTp during ANC visits. • Medical Care Development International (MCDI): MCDI will provide StopPalu+ with evidence-based and context-appropriate approaches to consensus-based diagnostic training and capacity building, monitoring and evaluation (M&E) of laboratory practices and collaborative quality improvement, and country-owned solutions for enhanced performance. • Centre Africain de Formation pour le Développement (CENAFOD): CENAFOD will work to increase community involvement in and support for malaria prevention and care. • Local partners include five Guinean nongovernmental organizations (NGOs) with demonstrated PMI program results in behavior change communication (BCC), social mobilization, and support to community health workers (CHWs):

o Association pour la Promotion des Initiatives Communautaires (APIC) o Club des Amis du Monde (CAM) o Comité des Jeunes Mon Avenir D’abord (CJMAD) o Initiatives et Actions pour l’Amélioration de la Santé des Populations (INAASPO) o Solidarité Guinéenne pour le Développement (SGPD)

4 StopPalu+—Quarterly Report—January to March 2018 2.2.3 StopPalu+ results framework The project’s main objective as well as the four main results (called Intermediate Results [IRs]) and the two Transversal Sub-IRs are shown in Figure 2. The sections that follow describe the activities carried out for each of these results, with a separate section on project management.

Figure 2: Results framework

StopPalu+—Quarterly Report—January to March 2018 5 3 ACTIVITIES BY RESULT (IR)

3.1 IR 1: Increased use of LLINs by the population

3.1.1 Sub-IR 1.1: Increased knowledge and skills of health care providers and community leaders on malaria prevention and the effectiveness, correct use, and care of LLINs Activity 1.1.1: Develop and implement a social and behavior change communication (SBCC) campaign for LLIN uptake, proper use, and care During the reporting quarter, to increase LLIN uptake, proper use, and care, StopPalu+ increased home visits along with practical CHW-led demonstrations on how to hang, care for, and maintain LLINs in villages with high malaria incidences. Based on the December 2017 and January 2018 NMCP monthly bulletins, the health centers of Bintimodia and Koulifanya in the Boké Prefecture and Tanéné in the Boffa Prefecture had a high malaria incidence. In each health center, the project team identified the villages where most cases were coming from. A total of eight villages were identified. The project team worked with the Prefectural Health Directorate (Direction Préfecturale de Santé [DPS]) of Boké to create eight teams of two people each. Over 11 days, these teams conducted home visits to verify the availability and use of LLINs, teach the population about the importance of regular and correct use of LLINs, test all cases of fever, treat all positive cases, and refer severe cases to the nearest health facility. The results of these visits are detailed in Table 1.

Table 1: Results of StopPalu+ home visits Number of households Number of people Village visited reached RDT performed Positive cases Bintimodia Centre 369 2,359 89 25 Colia Sanamato 267 1,944 69 29 Garama 128 982 78 25 Maren 79 562 58 29 Kataco 191 1,871 32 10 Lintang 89 985 26 19 Dari and Sangéya 96 1,795 32 18 TOTAL 1,219 10,498 384 155

The verification team during a daily meeting A team member teaches a grandmother about the regular and correct use of LLINs.

6 StopPalu+—Quarterly Report—January to March 2018 At the end of these visits, the project team organized community dialogues with the local authorities and community members to share data on the high malaria incidence and the importance of regular and correct use of nets as the best way to prevent malaria. During these dialogues, community members explained that two of their heads of health post are often absent because one is sick and the other lives outside the village. They advocated to have at least one CHW per village who will be able to conduct home visits and treat all malaria cases. They confirmed that the existing CHWs are performing well, but they live so far away that they do not come often. The project asked the president of the district to work with the head of the health center to identify one person in each village who meets national CHW criteria to be trained in May 2018. The president of the district also committed to find housing for the head of the health post who lives outside the village. In the region of Labé, the project team also organized home visits and community outreach activities in eight villages in the districts of Dinguiraye, Lélouma, and Tougué to increase the use of LLINs. According to a London School of Hygiene and Tropical Medicine evaluation of the 2017 SMC campaign, these villages had a low rate of LLIN use. During these activities, 82 households were visited and 339 people reached. The results of the home visits are summarized in Table 2. Table 2: Results of home visits in eight villages in the Labé Region Number of Number of Number of Number of Number of Health households people sleeping LLINS LLINs in good District center Village visited reached spaces hung condition Lafou Yalaya 10 37 20 19 18 Lélouma Sagalé Thiakoura 12 73 39 18 23 Subtotal 22 110 59 37 41 Konah Bourouwal 10 22 22 12 14 Tougué Kounsin 10 23 18 11 11 CSU Djoloki 10 34 37 27 27 Subtotal 30 79 77 50 52 CSU Souloukoufalan 10 53 34 26 26 Dinguiraye Sélouma Sélouma centre 10 55 25 20 20 Diatiféré Bandiaya 10 42 29 18 18 Subtotal 30 150 88 64 64 Total 82 339 224 151 157

StopPalu+—Quarterly Report—January to March 2018 7 During the home visits, the project team asked about the number of people who slept under a bednet during the previous night. The results are listed in Table 3.

Table 3: Percentage of people who slept under a bednet in the households visited Percentage of Percentage of people children under 5 who over age 5 who slept Health slept under a bednet under a bednet the District centers Villages the previous night previous night Lafou Yalaya 100% 100% Lélouma Sagalé Thiakoura 62% 60% Konah Bourouwal 70% 42% Tougué Kounsin 100% 92% CSU Djoloki 85% 67% CSU Souloukoufalan 64% 61% Dinguiraye Sélouma Sélouma centre 53% 89% Diatiféré Bandiaya 90% 63%

At the end of the visits, the project team organized community dialogues to share the results of the visits and to learn the reasons why some people are not regularly using bednets. The reasons vary from one village to another. Among the reasons given, the following were the most relevant: • In Souloukoufalan, during the dry season, parents who are fishers take the LLINs with them to the riverbank to sleep, leaving the children without LLINs. • In Sélouma, two households said they do not sleep under an LLIN during this period because of the heat. • In Thiakoura, one household does not use an LLIN because of its rectangular shape. • In Bourouwal, which is in the health district of Konah, two households said they sent their LLINs to Conakry for their children residing there, claiming that there are no mosquitoes in their locality. During these dialogues, the communities of Bourouwal and Yalaya advocated to have a CHW in their village because those currently covering their areas are limited in their ability to visit often (the CHWs live 10 and 15 kilometers from the villages). The project team asked the authorities of theses villages and the heads of the health centers to identify village residents who meet the national criteria, so they can be included in the training of new CHWs planned by the project in late May 2018. The project team also explained the importance of regular and correct use of LLINs as the best way to prevent malaria. They told community members that malaria is present in Guinea year-round, and pregnant women and children are the most vulnerable. The CHWs demonstrated how to transform a rectangular net into a circular net and explained that both forms can protect against mosquito bites. In the region of Kindia, the health centers of Bady and Khorira were among the health centers with the highest malaria incidence, according to the January NMCP bulletin. The project used health center data to identify the 10 villages where most of the cases occurred. In these villages, the project team organized home visits to assess the availability and use of LLINs, and to promote the regular and correct use of LLINs. The results of these home visits are summarized in the tables and figures below.

8 StopPalu+—Quarterly Report—January to March 2018 Table 4: Results of home visits in 10 districts/villages in the Kindia region Number of Number of Number of Number of Number of people sleeping LLINs LLINs hung District / village in households sleeping in spaces in available in in N° Bady or Khorira visited households households households households 1 Melita 10 72 32 38 18 2 Garankela 10 44 26 62 19 3 Boussoura 10 54 39 59 32 4 Bady centre 1 10 80 32 64 23 5 Bady centre 2 Yenyah 10 96 36 45 29 TOTAL Bady 50 346 165 268 121 1 Kangoleah Dembayah 10 106 50 43 34 2 Tabounsou 10 52 23 56 19 3 Khorira centre 1 10 68 38 42 20 4 Khorira centre 2 10 69 32 30 29 5 Gbantama 10 67 35 14 4 TOTAL Khorira 50 362 178 185 106

Figure 3: Percentage of people sleeping under bednets in Bady

Percentage of people who slept under a bednet the previous night in Bady

83% 90% 79% 80% 70% 70% 58% 60% 50% 40% 30% 20% 10% 0% MELITA GARANKELA BOUSSOURA BADY CENTRE 2 Yenyah

Figure 4: Percentage of people sleeping under bednets in Khorira

Percentage of people who slept under a bednet the previous night in Khorira 120%

97% 100% 100% 92%

80% 75%

60%

40%

20% 12%

0% Kangoleah Tabounsou Khorira centre 1 Khorira centre 2 Gbantama Dembayah

StopPalu+—Quarterly Report—January to March 2018 9 At the end of these home visits, the project organized community dialogues to share these results with the local authorities and community leaders, and to propose concrete actions on how to increase regular and correct use of bednets. The presidents of all the districts committed to use traditional communicators and religious leaders to increase the education of communities on bednet use. The project team asked the heads of health centers and the presidents of districts to identify new CHWs to increase coverage and ensure that all the hard-to-reach villages have a CHW. Activity 1.1.2: Update communication materials for all aspects of LLIN use, care, and maintenance During the reporting period, the project produced and distributed 2,500 2018 calendars with key messages on LLIN use, care, and maintenance and the importance of regular and correct use. These calendars were distributed in all health facilities, DPSs, and Regional Health Directorates (Directions Régionales de Santé [DRSs]), and each CHW in project- supported areas received one. The project also supported a group of well-known Guinean comedians (Kabakoudou and Grand Devise) in the production of a video on the importance of regular and correct use of LLINs. This video has been distributed to health facilities with televisions, so they can broadcast it during consultation hours to educate patients. The project teams also use this video during social mobilization events to provide the community with concrete examples of proper LLIN use. The video has been uploaded to YouTube, and to date, 64,781 people have viewed it. Activity 1.1.4: Enhance provider training and supervision During the reporting period, the project team supervised health providers and CHWs to assess how they deliver key malaria control messages during consultations, the tools they use, and how they interact with patients. Supervisors noticed that health providers often do not provide enough interpersonal communication (IPC), especially on the topic of prevention; they focus more on diagnosis and treatment. This is also the case for CHWs, who often feel that providing treatment is more valuable than giving information on health behaviors. During supervision sessions, the project team also found that IPC data collection tools are not updated and maintained in the health facilities. To solve these problems before the formal training on IPC, supervisors encouraged the health providers and CHWs to pay more attention to their roles as counselors and to use the IPC materials they have, such as the storyboards that contain all the key messages on malaria prevention and treatment.

3.1.2 Sub-IR 1.2: Increased ownership of effective LLINs through continuous and mass distribution Activity 1.2.1: Support routine LLIN distribution at health facilities During the reporting quarter, StopPalu+ supported routine LLIN distribution in health facilities that already implement this activity. The project worked with the NMCP, the Central Pharmacy of Guinea (Pharmacie Centrale de Guinée [PCG]), private carriers, and the DPSs to deliver 14,200 LLINs to health facilities in the Conakry Region and 47,900 LLINs to health facilities in the districts of Coyah, Dinguiraye, Dubréka, Forécariah, and Labé. The project also distributed LLIN distribution vouchers in public health facilities. The project supported supervision of routine LLIN distribution, which is integrated into the national supervision guide. Under the previous project, StopPalu, availability of LLINs at health posts increased visits by pregnant women (to access ANC services) and parents/families (for children’s immunization). To continue this trend and support routine distribution in the health posts covered by StopPalu+, the project regional team in Kindia assessed the health post of Kassoyah to see if it meets the following selection criteria for integrating routine LLIN distribution: provides ANC services, has more than one provider, has space to store LLINs, follows malaria case management protocols, and has well-maintained data collection tools.

10 StopPalu+—Quarterly Report—January to March 2018 The results of the evaluation showed that the health post provides ANC and Expanded Program on Immunization (EPI) services and has eight staff members, three of whom who are permanent. The malaria case management protocols are mostly adhered to. During the months of January and February 2018, 94% of fever cases were tested, and 100% of positive cases were treated according to national guidelines. The monthly malaria reports are available and well maintained. The case management data in the January and February 2018 report are consistent with those in the primary tools. However, there were discrepancies between the ANC data reported and the data in the ANC registers for the period of January and February 2018. At the end of the visits, the team determined that the health post of Kassoyah meets the criteria to integrate routine LLIN distribution, but the ANC staff needs training on IPTp uptake and routine data registration and collection.

The project team reviews the health post’s monthly The project team shares the results of the data. assessment with the health post team.

Activity 1.2.2: Support continuous LLIN distribution In February 2018, a CHW at the Bintimodia health center informed the project that the district of Maren had become home to a population of farmers with many women and children. These people will stay there for five months and will leave before the rainy season, the CHW reported. They sleep outside, using palm leaves to build temporary houses. They live with their animals in spaces where there are many places that are favorable to the development of mosquitoes. For all these reasons and to avoid another increase of malaria incidence in the Bintimodia health center, the project team, in collaboration with the health center team and the members of the Health and Hygiene Committee (Comité de Santé et d’Hygiène [CSH]), decided to visit the site to get a better idea about the number of people living there, their knowledge about malaria and related services available, their behaviors, and their needs with regard to preventing malaria.

Temporary houses of farmers in the district of Maren

StopPalu+—Quarterly Report—January to March 2018 11 On February 26, 2018, a team composed of project staff, six field facilitators, the district malaria focal point, the CHWs, and a member of the CSH visited the site. During the visit, the team conducted the following activities: • Counted the number of households and assessed the availability, use, and need for LLINs; • Provided the community with general information about malaria (causes, symptoms, and consequences); • Informed the community about the availability of free malaria prevention and treatment services; • Tested all cases of fever, then treated all positive simple cases and referred severe cases; • Assessed the use of ANC services by pregnant women and their IPTp uptake; and • Distributed LLINs to cover all the sleeping spaces. In total, 58 households were identified with 167 people, including 65 women. Each household received a distribution voucher, with the number of LLINs they could receive, based on the sleeping spaces. The team distributed 62 LLINs and explained how to use the nets (ventilate for 48 hours in shade and hang; wash it using no bleach, soap, etc.). The team also explained how to transform rectangular nets into a circular form.

The community receiving nets The team showing community members how to use the nets

Activity 1.2.3: Conduct community outreach activities to promote and monitor correct LLIN use and care During the reporting quarter, StopPalu+, through its NGO partners, supported CHWs in conducting door-to-door visits to monitor the regular and correct use of LLINs, and, if needed, hang LLINs and disseminate key messages on IPTp and malaria case management. The project-supported CHWs conducted 89,119 home visits and reached 445,816 people, including 258,515 women. The details of these activities are presented in Table 5.

Table 5: Details of home visits conducted by CHWs during the reporting period (January–March 2018) Number of home Number of people reached Prefecture visits conducted Men Women Total Boffa 5,664 12,554 16,784 29,338 Boké 7,776 23,329 30,822 54,151 Coyah 3,636 8,326 10,788 19,114 Conakry 1,248 2,990 3,623 6,613 Dinguiraye 5,656 10,847 15,227 26,074

12 StopPalu+—Quarterly Report—January to March 2018 Number of home Number of people reached Prefecture visits conducted Men Women Total Dubréka 6,466 12,594 17,077 29,671 Forécariah 6,648 13,168 17,389 30,557 Fria 3,768 11,657 15,011 26,668 Gaoual 4,896 12,039 16,011 28,050 Koubia 4,826 10,969 13,325 24,294 Koundara 3,936 6,797 9,666 16,463 Labé 12,243 21,516 32,059 53,575 Lélouma 7,020 11,642 18,701 30,343 Mali 8,520 16,582 23,401 39,983 Tougué 6,816 12,291 18,631 30,922 Total 89,119 187,301 258,515 445,816

Discussion groups facilitated by the project’s NGO partners To increase knowledge about malaria and promote the practice of healthy behaviors related to malaria prevention and treatment, the project’s 75 field agents conducted 929 group discussions and reached 17,029 people, including 10,185 women, in the 14 prefectures and 5 communes covered by the project (see Table 6 for details of the discussions in prefectures). These discussions took place in health centers and public places such as soccer fields, marketplaces, hair salons, and sewing salons. During the past quarter, the messages focused on promoting regular and correct use of LLINs and early care-seeking, especially for pregnant women and children under 5.

Table 6: Number of group discussions facilitated by project-trained field agents; number of people reached Number of group Number of people reached Prefectures discussions Men Women Total Boffa 100 630 848 1,478 Boké 126 1,395 2,098 3,493 Conakry 77 256 815 1,071 Coyah 49 245 508 753 Dinguiraye 63 674 909 1,583 Dubréka 65 350 564 914 Forécariah 62 523 719 1,242 Fria 25 140 252 392 Gaoual 99 596 845 1,441 Koundara 49 776 778 1,554 Koubia 13 94 113 207 Labé 65 323 473 796 Lélouma 38 210 358 568 Mali 63 434 632 1,066 Tougué 35 198 273 471 Total 929 6,844 10,185 17,029

Activity 1.2.5: Conduct LLIN durability monitoring This activity will be conducted during the next quarter as per World Health Organization (WHO) standards.

3.1.3 Sub-IR 1.3: Increased awareness by family members of need for vulnerable populations to be protected from malaria No specific activity has been carried out for this result during the reporting period. Challenges and Specific Measures Used/Planned to Overcome Them The correct and regular use of LLINs is a challenge for several reasons. First, populations tend to trivialize malaria as something normal and habitual. Second, although malaria exits

StopPalu+—Quarterly Report—January to March 2018 13 year-round, some communities rarely use LLINs in the dry season. And third, people who move a lot or sleep outdoors have difficulty using LLINs. To increase the effective use of LLINs by the population, the project plans to increase the number of home visits to verify the actual use of LLINs and to promote their regular use. Activities Planned for Next Quarter • Integrate routine LLIN distribution in more health posts. • Revise training manuals and BCC materials based on the results of the knowledge, attitudes, and practices (KAP) survey. • Continue to support routine LLIN distribution.

3.2 IR 2: Increased use of IPTp during antenatal visits

3.2.1 Activity 2.1.1: Support provider training on technical and IPC skills For the past quarter, the project team organized on-the-job training in the health facilities of Maciré in Conakry and Maferinyah in Forécariah. The topics included IPTp uptake, with the focus on adherence to recommendations from direct supervisions; effective counseling to encourage pregnant women to come to follow-up visits; and the correct and regular use of bednets. A total of 66 health providers, including 44 women, were trained and coached at the health centers.

On-the-job training in the health centers of Maciré (left) and Maferinyah (right)

14 StopPalu+—Quarterly Report—January to March 2018 3.2.2 Activity 2.1.3: Improve supervision of providers and tracking of pregnant women During the reporting period, the project team organized several supervision activities that targeted all malaria control activities, including IPTp. Please see Activity 3.1.7 for details.

3.3 IR 3: Increased prompt care-seeking and treatment

3.3.1 Sub-IR 3.1: Improved technical and interpersonal skills of providers in malaria diagnosis and treatment Activity 3.1.1: Strengthen malaria diagnostics for case management During the reporting period, the project recruited an international consultant to develop a refresher training manual for malaria diagnosis (microscopy and rapid diagnostic test [RDT]). The document was reviewed and validated by the NMCP Diagnosis and Case Management TWG. In preparation for the refresher training of trainers planned for the end of April 2018, the project recruited an international consultant to facilitate this training. The project has also made copies of standard operating procedures (SOPs), job aids, and training manuals. Activity 3.1.3: On-site training for providers in technical and IPC skills During the reporting period, the project conducted on-site training for providers at the health centers of Maciré in Conakry and Maferinyah in Forécariah. These facilities were identified during supervision as having some capacity reinforcement needs. The training topics included adherence to protocols, data recording, internal supervision, and IPC methods for discussing early care-seeking with clients. These on-site training sessions offered project staff the opportunity to share basic malaria control information with the health facility staff, especially new staff members and interns who are performing tasks with no training on national guidelines and protocols. A total of 66 health providers, including 44 women, benefited these trainings. Activity 3.1.6: Training for microscope maintenance Assessment of microscope conditions in the PMI-supported zone During the past quarter, from February 27 to March 2, 2018, the project assessed the state of microscopes available in health facilities in the PMI-supported area to better define training needs on microscope maintenance. To carry out this activity, the project developed a checklist for data collection, visited laboratories in districts where the project has an office, and contacted the laboratories in other districts by telephone to fill in the checklist and analyze the data. Results of the evaluation • Total number of microscopes: 153 • Total number of microscopes in good condition: 82 (54%) • Total number of microscopes in poor condition: 71 (46%) • Types of microscopes encountered in Guinea: binocular microscopes • Brands of microscopes encountered in Guinea: Zeiss Primo Star, Olympus of all kinds, COIC, Lasec, Model max, Micromaster, Motic, Zazi, STUDARlab, Sunny, Cyanstar, Spenter, and HumaSens. The predominant brand is Olympus, followed by Zeiss Primo Star and CETI • The identified faults included problems with lenses, eyepieces, valet, platinum, bulbs, power cables, lighting, micro and micrometer screws, trolley, mirror, and fuses. • Parts to be replaced: bulbs, eyepieces, power cables, fuses, and lenses

StopPalu+—Quarterly Report—January to March 2018 15 • Parts to be repaired: jacks, turntables, micro and macro-metric screws • Of the 71 microscopes in poor condition, 55% have defective lenses; 25% have issues concerning light bulbs; 17% illumination; 14% ocular; 8.5% carriage; 6% brightness, fuse, and capacitor; 4% plates, power cable, or mirror; and 3% valet. • Of the faults identified, 55% require spare parts (lenses, bulbs, eyepieces, power cables, mirrors, fuses), and 36% are in need of simple repair such as unlocking the condenser or fixing the turntable, jack, revolver, micro and micrometer aims, trolley, or lights. Conclusion: The results of this evaluation show that microscope preventive and curative maintenance is a real problem in Guinea. This is due to the lack of procedure manuals, maintenance plans for microscopes, and qualified staff. Recommendations: the findings of this assessment will be included in the microscopy maintenance manual that the project is planning to help the NCMP develop in April 2018. This training manual will be used to train lab technicians. Development and validation of the SOW for the recruitment of a national consultant to develop the microscope maintenance manual During the reporting quarter, the project team worked with the NMCP Diagnosis and Case Management TWG to develop and validate the SOW to recruit a national consultant to develop a training manual on microscope maintenance. The team determined that the consultant must carry out the following activities: • Revise the report on the assessment of microscope conditions in the PMI area and collect additional information if necessary • Review the 2016 WHO SOPs for the Use, Care, and Maintenance of Microscopes (MM-SOP-12) • Complete the “Procedures” sections of the draft training manual for basic preventive maintenance and microscope repair in accordance with the above documents, including: − Transport, displacement, and placement of the microscope − Correct configuration and use of microscopes − Proper storage of the microscope in hot and humid climates to prevent the growth of fungi − Daily maintenance (check for damage or malfunctions and record damage, clean the lenses, cover the equipment with dust cover, cut off the power supply, protect the lens ports) − Cleaning and replacement of bulbs, fuses, and other external parts according to the manufacturer’s instructions (Olympus, Zeiss Primo Star, and/or CETI) − Replacement of external parts such as bulbs, fuses, and micro and macro screws (among others), taking care not to use the wrong parts − Recording all repairs on a maintenance sheet • Add to procedures if necessary, based on the findings of the PMI microscope condition assessment report • Complete other sections of the draft training manual so that they are adapted to the Guinean context to the greatest extent possible • Insert the illustrated guide for the microscope maintenance practical training at the end of the training manual

16 StopPalu+—Quarterly Report—January to March 2018 • Participate in a validation session of the microscope maintenance training manual with the project team and NMCP Based on the SOW, the project recruited a national consultant who will begin the work in April. After the development and validation of the manual, the project will train lab technicians in the PMI zone on malaria diagnosis (microscopy and RDT), including microscope maintenance. Activity 3.1.7: Improve supportive supervision for case management During the reporting period, the project staff conducted several supervision activities to improve the quality of malaria prevention, case management, and data quality. In the Conakry Region, staff conducted 105 supervision visits in 22 public health centers and 11 private facilities. These supervision visits reached 545 people, including 300 women. In all public structures visited, IPTp is well-administered to eligible women; LLINs are distributed to target populations; and the care protocols are adhered to—all fever cases are tested, and all positive cases are treated. The two major problems are stock management and discrepancies between reported data and those in primary tools. To address these problems, StopPalu+ has collaborated with the district malaria focal points and field agents since February 2018 to organize monthly data quality analysis (DQA) activities in 50% of all Conakry public health centers. This has significantly improved the quality of the data. Some health centers now have 100% consistent data. However, in private health facilities, the prevention and case management protocols are not adhered to. They are still not testing all fever cases, and they treat many cases without testing. They are not properly using primary data collection tools, and the data quality is poor. The NMCP should meet with these facilities to enforce compliance with their signed agreement. It is also important to conduct a formal assessment of all the integrated private facilities to clearly identify their weaknesses and propose concrete solutions on how to improve the quality of their services. In the region of Boké, 42 health centers and 40 health posts were supervised, reaching 182 health providers. In all the health facilities, IPTp is provided to all eligible pregnant women, LLINs are distributed to eligible clients, and most of the fever cases are tested. However, many fever cases noted as “severe” have no overt signs of severity. Data quality is also an issue, with some discrepancies between data reported and the ones in the primary tools. Stock management is the biggest problem. The stock management tools are not updated or well-maintained, and the stock reported is different from the physical stock. In a few health posts, the team also found some forms of artemisinin-based combination therapy (ACT) that are not provided by the NMCP. To address these problems, the project team is collaborating with the district malaria focal points and field agents to conduct a monthly DQA that includes commodities data in selected centers. This has helped improved the quality and consistency of data as well as stock management. In the region of Kindia, the team supervised 15 health centers and 7 health posts during the reporting quarter, reaching 128 health providers. The supervisors noticed a high improvement in case management of both simple and severe cases of malaria in the health centers and health posts. Data quality has also improved, and there are only minor discrepancies between the reported data and the data noted in the primary tools. The prevention and case management protocols and posters to inform clients about the free commodities are available in all the visited facilities. There are problems with the use of the new National Health Information System (Système National de l’Information de la Santé [SNIS]) report forms, stock management in the hospitals, and the new health facilities’ staff members appointed by the Ministry of Health (MOH) who have not been trained on the national malaria prevention and treatment protocols. At the end of each supervision visit, the project team shared the findings with the staff, emphasized the facility’s weaknesses, and taught staff best practices through some practical exercises. The team also conducted an

StopPalu+—Quarterly Report—January to March 2018 17 on-site training for the Maferinyah health center staff and health workers from the Alliance for International Medical Action (ALIMA) NGO. In the region of Labé, the team made supervision visits to 23 health centers and 51 health posts, reaching 196 health providers. The supervisors noticed a high improvement in case management; among the 23 health centers visited, 18 had tested 100% of the fever cases and all treated 100% of positive cases with the appropriate antimalaria drug. In all the visited facilities, eligible beneficiaries receive LLINs at no cost, and pregnant women also receive sulfadoxine/pyrimethamine (SP) in accordance with the national protocol. Stock management requires the most improvement. Most of the stock management tools (forms) are not updated, and there are discrepancies between the number of cases treated and the amount of malaria commodities used.

Supervision activities in the Dionfo health center Supervision activities in the health center of Bady

3.3.2 Sub-IR 3.2: Increased availability of quality diagnostic tests and treatment at facilities and community level Activity 3.2.1: Ensure availability of diagnostic supplies and antimalarial treatment During the reporting quarter, the project teams worked with the DPSs and the heads of health centers to ensure that the CHWs have necessary commodities such as RDTs, antimalarial drugs, and ancillary supplies for case management of uncomplicated malaria and pre-referral treatment for severe malaria. In the 19 prefectures/communes supported by the project, the CHWs tested 27,705 people—among whom 13,142 were positive—and treated 13,142 people with ACT (Table 7).

Table 7: Details of community case management conducted by CHWs during the reporting period (January–March 2018) RDTs Number of Number of Number of people Prefecture performed positive RDTs negative RDTs treated with ACT Boffa 2,803 1,489 1,314 1,489 Boké 4,207 2,565 1,642 2,565 Coyah 1,160 712 448 712 Conakry 150 62 88 62 Dinguiraye 1,395 680 715 680 Dubréka 2,511 1,548 963 1,548 Forécariah 2,728 1,480 1,248 1,480 Fria 2,571 1,365 1,206 1,365 Gaoual 1,547 711 836 711

18 StopPalu+—Quarterly Report—January to March 2018 RDTs Number of Number of Number of people Prefecture performed positive RDTs negative RDTs treated with ACT Koundara 1,053 463 590 463 Koubia 475 145 330 145 Labé 2,151 627 1,524 627 Lélouma 1,000 300 700 300 Mali 3,028 756 2,272 756 Tougué 926 239 687 239 Total 27,705 13,142 14,563 13,142

Challenges and Specific Measures Used/Planned to Overcome Them The main challenges in case management are adherence to national guidelines and protocols, especially in the private health facilities and health posts, and stock management. To overcome these challenges, the project team will train the new providers who have been recruited by the MOH and also increase supervision visits. It is important to mention that the MOH has launched the new community health strategy. This strategy proposes to pay CHWs 450,000 GNF per month. The current StopPalu+ budget cannot afford this cost—the 1,400 CHWs supported by the project to date will cost US$849,000 per year. This does not include other costs related to community case management: supervision, data collection tools, and other equipment. This approach will be implemented in 40 communes to start, with the goal of integrating 100 communes by the end of the year. An approach that only pays some of the CHWs may have a negative impact on project activities—the remaining CHWs who are volunteers working in the same districts but not receiving these payments may stop activities or provide low-quality services. This will reduce the population’s access to care and reverse many of the efforts that have been supported by USAID for several years. Activities Planned for Next Quarter • Revise the training manual in case management for both health providers and CHWs. • Train the national malaria diagnosis trainers and lab technicians. • Train national trainers, new health providers, and new CHWs on malaria case management. • Support the national supervisory system.

3.4 IR 4: Increased full dose of SMC delivered in a timely manner Activity 4.3.1: Revise SMC planning, management, and monitoring tools From January 28 to 31, 2018, to address the various observations and weaknesses identified during the 2017 SMC campaign, the NMCP and its partners organized the revision of SMC training manuals, data collection tools, and communication materials to improve the quality of both communication and effective drug administration activities. General Objective Improve the quality of communication and data collection tools for the 2018 SMC campaign. Specific Objectives • Review all the tools for the SMC campaign, taking into account lessons learned and weaknesses noted from the previous campaigns. • Validate SMC harmonized tools. • Quantify the validated tools according to the SMC target populations, the number of teams, the number of supervisors, and the number of communication actors.

StopPalu+—Quarterly Report—January to March 2018 19 The workshop brought together 26 participants, composed of the DPS directors or their representatives from the districts of Labé, Lélouma, Mali, Koubia, Tougué, Dinguiraye and Gaoual in the PMI-supported zone and those of Siguiri and Mandiana in Global Fund- supported areas; a representative of one health center (the head of center Thianguel Bori in Labé) as well as representatives of the DRS Labé; and the representative of the National Directorate of Community Health. The participants were divided into four working groups to revise the following: • Communication tools • Training manuals • Drugs distribution and management tools • Supervision and M&E tools Results At the end of the four days of work, the following tools were revised. Communication tools: • SMC promotion poster • The storyboard • Job aid for health workers • Poster on treatment preparation • Poster on correct dose administration • SMC messages for radio programs • The monitoring forms for radio programs • Town crier/social mobilizer awareness message sheet • Communication activities data collection form • Messages for the banners Training tools: • Pre- and post-test checklist • Trainer’s guide • Participant guide Drug distribution and management tools: • Score card • Distribution card • SMC register • Drug management summary sheet • Adverse reaction management sheet • Side effects notification form Supervision tools: • CHW/community volunteers competency checklist • Daily summary form • Reference form

20 StopPalu+—Quarterly Report—January to March 2018 • Supervision grid by level: central/regional, district, and health center • Health center summary cycle report sheet After the validation of these tools, the participants estimated the quantities for each of these tools and manuals per districts. The last day of the workshop, the NMCP shared the main weaknesses of the 2017 SMC campaign and asked the participants to make some recommendations on how to reduce these problems in 2018 The main recommendations were as follows: • Organize harmonization meetings with all partners. • Conduct trainings and refresher trainings of agents on time. • Increase the number of prefectural supervisors. • Reduce the daily target for distribution teams, especially in rural areas. • Increase and improve communication and advocacy activities before and during the campaign. • Increase the number of social mobilization and town criers from 3 to 10 per health center. • Apply the fluctuation rate in mining areas. • Finance the campaign launch activities in the prefectures and sub-prefectures. • Make all the resources (drugs and funds) available on time. • Develop district micro-plans before the macro-plans. • Plan to provide rain protection equipment (raincoats, boots, flashlights, etc.) for community agents. • Involve the DPS in the training of data managers. Challenges and Specific Measures Used/Planned to Overcome Them Delay in obtaining the funds is the main challenge in implementing the SMC campaign. To overcome this challenge, RTI will continue to work with the Agreement Officer’s Representative (AOR) to ensure that the funds are available by the end of April. Activities Planned for Next Quarter • Develop the micro-plans for the SMC campaign. • Produce communication materials and tools for the SMC campaign. • Hold advocacy meetings at the district level. • Train SMC trainers at the different levels.

3.4.1 Transversal Sub-IR 1: Increased community involvement in and support for malaria prevention and care Under this result, StopPalu+ planned to collaborate with the NMCP to develop detailed community mobilization, SBCC, and capacity strengthening plans to increase community involvement and support for malaria prevention and care. Because the results of the KAP survey will be fundamental for this, we have not developed these plans yet. We expect to implement this activity next quarter.

StopPalu+—Quarterly Report—January to March 2018 21 3.4.2 Transversal Sub-IR 2: Improved capacity of NMCP (central, regional, district) to manage, implement and monitor prevention, care and treatment activities Activity T2.1: Support NMCP coordination capacity Support and facilitate TWGs’ monthly meetings During the reporting quarter, the project supported and facilitated the NMCP BCC, Vector Control, and Diagnosis and Case Management TWGs’ monthly meetings. The project team also participated in the meetings of other TWGs, such as the Supply Chain Management and the M&E TWGs. During these meetings, members reviewed the implementation of their action plans and made recommendations. These meetings were also good opportunities to review the SOW for many planned activities, such as the KAP survey, the revision of training manuals on case management for health workers and CHWs, and the microscope maintenance manual. However, participants noted that most of the planned activities have not been implemented during the quarter because of a delay in funding. Conduct malariology course To strengthen the skills of the districts and the project team on implementation of malaria control activities, StopPalu+ collaborated with the NMCP and WHO to organize a malariology course for the 19 malaria focal points from PMI-supported districts, the four project regional coordinators, the project medical advisor in Kindia, and the doctor in charge of training in the district of Dinguiraye. The course, held February 12–23, 2018, was facilitated by three WHO regional trainers supported by national malaria trainers. The course covered the 10 following topics:

• Module 1: Generality • Module 6: Diagnosis and treatment of malaria • Module 2: Epidemiology • Module 7: Management and supplies • Module 3: Planning • Module 8: Vector control and malaria prevention • Module 4: M&E • Module 9: Communication and social mobilization • Module 5: Operational research • Module 10: Partnerships and resource mobilization

Group work, practical exercises, and field visits, including mosquito capture activities, allowed the participants to gain a better understanding of all malaria control aspects. At the end of the training, each participant developed a topic for a research protocol on a particular theme related to malaria issues in their area of intervention.

Participants practicing microscope use Participants collecting mosquitoes

22 StopPalu+—Quarterly Report—January to March 2018 Activity T2.2: Support M&E surveillance and research Conduct a KAP survey in the project’s districts During the reporting quarter, the project team worked with the NMCP BCC TWG to develop and validate a SOW for the recruitment of a survey agency to conduct the KAP. During the PMI visit for the Malaria Operational Plan (MOP) 2020, there were several meetings to discuss the issue of conducting both a KAP and the Malaria Behavior Survey that Breakthrough Action was planning to do. The final decision was to allow StopPalu+ to conduct the KAP survey because of the time constraint and because StopPalu+ needed the information per district. However, StopPalu+ will share the questionnaire with the PMI/Washington team so they can provide any necessary comments. A request for applications was sent out in April, and the survey is expected to start in mid-May 2018. Improve M&E DQA and use at the national level and among statistical analysts at the regional and district levels During the reporting period, the project supported monthly monitoring meetings at health center and district levels to review, compile, and analyze monthly malaria data before transmission to the upper level. The project supported 465 health center meetings: 66 in Conakry, 126 in Boké, 75 in Kindia, and 198 in Labé. The main points were the absence of severe signs in most of the reported “severe” cases; the unavailability of some heads of health centers, especially in urban areas; registration of the same patients several times, which can lead to double counting; and stock management (discrepancies between the malaria cases treated and the commodities used). We also noticed that some facilities in the commune of Matoto and the region of Labé have a large stock of commodities, while some health facilities from other communes were out of stock. The team took immediate actions to solve some of these problems, such as highlighting all the patients who were double counted in the registers and informing the district pharmacist about the centers that had a large stock of commodities and suggesting they give some to other facilities. To address stock management, the team recommended collaborating with Chemonics to conduct training for the facilities’ stock managers. During March 2018, the health facilities received the SNIS report forms, and the project team helped them understand how to use these new tools. Each facility was supposed to receive six copies, but in reality, the number varied from one to six throughout the prefectures/communes. It is also important to note that in all the regions, there are young doctors who have been appointed as heads of health centers. Most of them are very motivated but have not been trained on the national protocols and guidelines. The older heads of health centers are frustrated because they feel that they are being pushed out, so they are not teaching the national protocols and guidelines to the new providers. At the district levels, the project supported 57 meetings: 15 in Boké, 15 in Conakry, 9 in Kindia, and 18 in Labé. During these meeting, the main points discussed were problems related to stock management in the health facilities (discrepancies between malaria cases treated and commodities used, stock management tools not being updated, high consumption of artesunate injectable by the hospitals, etc.), the low implementation of recommendations from previous supervision visits, data quality, and the new SNIS report forms. The team also discussed the non-participation of many heads of health centers in the monthly meetings in the commune of Matoto and the increasing occurrence of private facilities attending the meetings but sending interns who have no information on the reporting requirements. Most of these new private facilities are not recognized by the health districts. To address that problem, the Communal Health Directorate (Direction Communale de la Santé [DCS]) proposed a meeting with the NMCP to define the criteria to integrate private facilities into the health system.

StopPalu+—Quarterly Report—January to March 2018 23

Monthly meeting at the health center of Sikhourou Monthly meeting at the prefecture of Forécariah

Conduct DQAs To improve the quality of data collected at the health facility level, the project organizes monthly DQAs in 50% of the project-supported facilities. Conducting DQAs has helped identify and explain the causes of data discrepancies and enables staff to take appropriate action. It has helped improved data quality. In all the regions covered by the project, there are health centers with 100% consistency between the reported data and those in the primary tools in January and February. The results of the DQAs are presented during each DPS meeting, and the facilities with discrepancies are asked to explain the reasons. The heads of health facilities do not want to be cited, so they are now more involved in the data collection process.

Stock management verification in the health center of DQA in the health center of Bowloko Kouriah

Conduct periodic health facility and community supervision visits (Please see Activity 1.1.1 for details.)

24 StopPalu+—Quarterly Report—January to March 2018 Strengthen the NMCP’s vector control capacity Surveillance activities Carry out entomological surveillance activities, such as monitoring mosquitoes, seasonality, behavior, and infectivity of malaria vectors at the sentinel sites of Boké, Dabola, Faranah, Kissidougou, Kankan, and Labé In February 2018, the project collaborated with the NMCP to conduct a visit to the Boké and Faranah sites. The objective was to gather information on the seasonality of the vectors. During these site visits, three sampling methods (human bait capture, light trap capture, and pyrethrum capture) were used to obtain information on species’ composition, mapping, physiological status, and hours of aggression. The results of these visits are presented in the tables below.

StopPalu+—Quarterly Report—January to March 2018 25 Table 8: Human bait capture in six villages

Human bait capture in six villages An. gambiae An. funestus An. nili Culex Aedes/others Site ViIlage Int. Ext. Int. Ext. Int. Ext. Int. Ext. Int. Ext. Kaboye 0 0 0 0 0 0 0 1 0 0

Guillèrè 1 0 0 0 0 0 25 18 0 0 Boké Dioumaya 0 0 0 0 0 0 0 30 0 0 TOTAL 1 0 0 0 0 0 25 49 0 0 Balayani 52 110 0 0 5 12 0 0 0 2

Foulaya 46 86 0 0 6 37 0 0 0 0 Faranah Tindo 57 77 0 0 22 19 0 0 0 0 TOTAL 155 273 0 0 33 68 0 0 0 2 Total species (interior/exterior) 156 273 0 0 33 68 25 49 0 2 Overall species totals 429 0 101 74 2

PERCENTAGE OF SPECIES 36% 64% 0% 0% 33% 67% 34% 66% 0% 100%

Total Anopheles 530 Percentage of Anopheles 81% 0% 19% Total mosquitoes 606

Using the human bait capture method, the team collected 606 mosquitoes in the six villages, including 530 female An. s.l. (87%). Among these Anopheles, 429 were An. gambiae s.l. (81%) and 101 were An. nili (19%). The team observed the vectors’ level of aggression from 8 p.m. to 7 a.m. The peak of aggression was observed between 2 a.m. and 3 a.m., and the vectors were much more exophilic (64%) than endophilic (36%).

26 StopPalu+—Quarterly Report—January to March 2018 Table 9: Pyrethrum capture in six villages Pyrethrum capture An. gambiae An. nili Culex Additional information Number of Semi- Semi- Semi- Sleeping people who Site Village Fasting Gorged gravid Gravid Fasting Gorged gravid Gravid Fasting Gorged gravid Gravid spaces LLINs used LLINs Boké Kaboye 0 0 0 0 0 0 0 0 0 0 0 0 11 5 28 Guillèrè 0 0 0 0 0 0 0 0 0 1 0 0 14 26 26 Dioumaya 0 0 0 0 0 0 0 0 0 1 0 0 11 5 19 TOTAL 0 0 0 0 0 0 0 0 0 2 0 0 36 36 73 Faranah Balayani 7 13 0 0 0 0 0 0 0 7 0 0 11 9 26 Foulaya 5 17 0 0 0 1 0 0 7 14 0 0 14 12 23 Tindo 0 5 0 0 0 0 0 0 2 0 0 0 10 5 26 TOTAL 12 35 0 0 0 1 0 0 9 21 0 0 35 26 75 Total Species 47 1 30 71 62 148 Percentage of 26% 74% 0% 0% 0% 100% 0% 0% 30% 70% 0% 0% species Total Anopheles 48 Percentage of 94% 6% Anopheles Total mosquitoes 78

Using this method of collecting pyrethrum residual fauna in the households of the six villages, we obtained 78 mosquitoes, including 48 Anopheles (62%). Of those, there were 12 An. gambiae in a fasting state, 35 An. gambiae gorged, and one An. nili gorged.

StopPalu+—Quarterly Report—January to March 2018 27 Table 10: Light trap capture in six villages Light trap capture in six villages An. gambiae An. funestus An. nili Culex Aedes/others Site Village Int. Ext. Int. Ext. Int.r Ext. Int. Ext. Int. Ext. Boké Kaboye 0 0 0 0 0 0 1 1 0 0 Guillèrè 0 0 0 0 0 0 7 4 0 0 Dioumaya 0 0 0 0 0 0 6 2 0 0 TOTAL 0 0 0 0 0 0 14 7 0 0 Faranah Balayani 2 4 0 0 4 0 0 3 0 0 Foulaya 13 7 0 0 2 2 2 11 0 3 Tindo 0 0 0 0 0 0 0 4 0 0 TOTAL 15 11 0 0 6 2 2 18 0 3 Total species 15 11 0 0 6 2 16 25 0 3 (interior/exterior) Total species 26 0 8 41 3

Percentage of species 58% 42% 0% 0% 75% 25% 39% 61% 0% 100%

Total Anopheles 34 Percentage of Anopheles 76% 0% 24% Total mosquitoes 78

Using the Centers for Disease Control and Prevention (CDC) light trap method during two nights in the six locations, the team collected 26 An. gambiae s.l., 8 An. nili, 41 Culex, and 3 Aedes/others. The largest number of Anopheles was caught indoors: 21 of 34 (62%). To have an idea of the number of species collected per location, per day, and per position and to be able to compare two of the three capture methods, we used a comparative table of the numbers collected by human bait and by traps in the two prefectures.

28 StopPalu+—Quarterly Report—January to March 2018 Table 11: Summary of mosquito collection by light trap and human bait capture methods in three villages (Kaboye Amarayah, Guilere, and Djoumaya) of Boké Prefecture, February 11–27, 2018 Capture on human bait Capture on light traps

An. An. Aedes/ An. An. Aedes/ DAYS Villages Position gambiae funestus Total An. Culex others gambiae funestus Total An. Culex others

Interior 0 0 0 0 0 0 0 0 0 0 D1 Exterior 0 0 0 1 0 0 0 0 1 0 Interior 0 0 0 0 0 0 1 0 Kaboye Kaboye 0 0 Amarayah D2 Exterior 0 0 0 0 0 0 0 0 0 0

Interior 1 0 1 0 0 0 0 0 6 0 D1 Exterior 0 0 0 10 0 0 0 0 2 0

Guilere Interior 0 0 0 25 0 0 0 0 1 0 D2 Exterior 0 0 0 8 0 0 0 0 2 0

Interior 0 0 0 0 0 0 0 0 2 0 D1 Exterior 0 0 0 24 0 0 0 0 1 0 Interior 0 0 0 0 0 0 0 0 4 0 D2 Djoumayah Exterior 0 0 0 6 0 0 0 0 1 0 Subtotal 1 0 1 74 0 0 0 0 21 0 Total Anopheles 1 0 Total overall Anopheles 1

StopPalu+—Quarterly Report—January to March 2018 29 Table 12: Summary of mosquito collection by light trap and human bait capture methods in three villages (Balayani, Foulaya, and Tindo) of Faranah Prefecture, February 10–26, 2018 Capture on human bait Capture on light trap

An. An. Aedes/ An. Aedes/ Days Villages Position gambiae nili Total An. Culex others gambiae An. nili Total An. Culex others Interior 36 0 36 0 2 0 0 0 0 0

D1 Exterior 61 2 63 0 0 0 0 0 0 0 Interior 16 5 21 0 0 2 4 6 0 0

D2 Balayani Exterior 49 10 59 0 0 4 0 4 3 0

Interior 24 4 28 0 0 11 0 11 1 0 D1 Exterior 39 16 55 0 0 1 1 2 9 3 Interior 22 2 24 0 0 2 2 4 1 0 Foulaya D2 Exterior 47 21 68 0 0 6 1 7 2 0 Interior 38 11 49 0 0 0 0 0 0 0

D1 Exterior 44 10 54 0 0 0 0 0 0 0 Interior 18 11 29 0 0 0 0 0 0 0

D2 Tindo Exterior 34 9 43 0 0 0 0 0 4 0 Subtotal 428 101 529 0 2 26 8 34 20 3 Total Anopheles 529 34 Total overall Anopheles 563

30 StopPalu+—Quarterly Report—January to March 2018 By comparing the two methods in these two sites, we found that the capture on human bait produced the greatest number of Anopheles (530)—529 in Faranah and 1 in Boké. Comparatively, light traps captured 34 Anopheles in Faranah and only 1 Anopheles in Boké.

3.4.3 Activities with insectary and associated laboratory

Table 13: Results obtained by generation and by period of breeding of the Kisumu-susceptible strain Month Generation Number of mosquitoes January 2018 1st 107 February 2018 2nd 205 February 2018 3rd 276 March 2018 4th 702 Total 1,290

The team raised 1,290 mosquitoes from first to fourth generation (F1 to F4) and identified various characteristics for 1,222 of these. They identified 632 females and determined their physiological state: 451 fasted and 181 gorged. The team conditioned the female mosquitoes with Silicagel and then coded, labeled, and chilled them for analysis. Challenges and Specific Measures Used/Planned to Overcome Them The first challenge we face with the NMCP is the failure to replace the Deputy Coordinator after he was appointed National Director of Epidemiology and Disease Control. He coordinated the technical aspects of the program. Delay in replacement may have negative impacts on program activities. The second challenge is the delay in obtaining funds, which prevents the implementation of major activities as planned. To overcome these challenges, we will continue to advocate for the rapid replacement of the former Deputy Coordinator and maintain regular contact with the project AOR for the availability of the funds. Activities Planned for Next Quarter • Conduct KAP survey in the 19 districts supported by the project. • Conduct the health facility survey. • Support vector control activities. • Support the TWG meetings.

StopPalu+—Quarterly Report—January to March 2018 31 4 PROJECT MANAGEMENT During this reporting period, project management activities focused on the project’s start-up. These activities are briefly described below. (Note: activity numbering refers to the Work Plan list of activities.)

4.1 Project Deliverables

4.1.1 Year 1 Work Plan On January 24–26, 2018, the project held a workshop to develop the Year 1 Work Plan (December 15, 2017–September 30, 2018) through a participatory approach. Attendees included key stakeholders such as the NMCP, USAID/Guinea PMI team, representatives of the StopPalu+ consortium, representatives of national health programs (e.g., Safe Motherhood and Integrated Management of Newborn and Childhood Illnesses programs), National Directorate of Community Health, representatives of four DRSs supported by the project, and representatives of the five local NGO partners. Participants identified the main activities and sub-activities of each IR, period of implementation, responsible actors, and estimated budget. The general objective of the workshop was to bring the various project partners together to gain a common understanding of the project and develop a coherent work plan. In addition, workshop activities aimed to develop regional work plans based on the national work plan. The specific objectives of the workshop were the following: • Allow a better understanding of the project partners and their different roles. • Develop a work plan based on the project’s four main results and two intermediate results over the period December 15, 2017–September 2018 (Year 1 of the project). • Develop the four regional work plans. • Present key project indicators with their definition and proposed annual targets. The proceedings of the workshop were held in plenary sessions, and the participants took part in six working groups: (1) prevention (LLIN and IPTp); (2) diagnosis and treatment, including SMC; (3) M&E; (4) communication and community involvement; (5) vector control; and (6) NMCP capacity building. During the plenary sessions, participants shared the outline of the project (objectives, expected results, operational strategies, etc.), pooling the results of group work. In the working group sessions, participants discussed and clarified the different activities of each project result, clearly identifying the required actors, timelines, and resources. At the end of the four-day workshop, participants developed a first draft of the Year 1 Work Plan and the four regional work plans. The workshop also helped familiarize members of the project team with their colleagues and their different roles, as well as build team spirit. The work plan was developed in a highly participatory manner, which gave the stakeholders a strong sense of ownership of the plan. The Year 1 Work Plan was submitted to USAID on February 13, 2018.

32 StopPalu+—Quarterly Report—January to March 2018

The officials during the opening ceremony of the Participants in working groups workshop for project planning

4.1.2 Monitoring, Evaluation, and Learning (MEL) Plan During the annual planning workshop, the M&E team, in collaboration with the RTI home office and NMCP team, proposed a MEL Plan. This plan defines performance indicators for measuring activity results (i.e., outcomes and outputs) and how the data will be used to generate learning for StopPalu+ and to adapt activity implementation. For each indicator, the MEL Plan defines the source of data, method, frequency and schedule of data collection, person(s) responsible for data collection, target, and target rationale. A complete MEL Plan document was submitted to USAID on February 13, 2018.

4.1.3 Life-of-activity exit strategy The project team developed a life-of-activity exit strategy that documents the steps RTI will take to strengthen in-country capacity to sustain and potentially expand the interventions and results of StopPalu+. This document was submitted to USAID on February 13, 2018.

4.2 Staffing and Human Resources

4.2.1 Offices installation The project has renewed the leasing and insurance for the national and the three regional offices. RTI also used a competitive process to recruit a security company to provide security services to the regional offices.

4.2.2 Staff recruitment During this reporting period, RTI signed all employee agreements for continuation to StopPalu+. The project recruited and oriented the Senior Technical Advisor and the SBCC Advisor. Staff orientation focused on explaining staff members’ roles and responsibilities, the project’s harmonized approach for successful implementation, and a gender training on how to integrate gender in all project activities. Staff were also oriented on the submitted work plan and other deliverables submitted to the Mission.

4.2.3 Short-term technical assistance (STTA) During the reporting quarter, the project had some STTA from RTI home office staff members who supported the team in developing deliverables such as the Year 1 Work Plan

StopPalu+—Quarterly Report—January to March 2018 33 and budget, the MEL Plan, and the project learning agenda. STTA also provided support for project start-up activities and some project management issues. It also reinforced the project teams’ and partners’ capacity, especially on StopPalu+’s Monitoring, Evaluation, Research, Learning and Adaptation (MERLA) approach, which uses M&E data as more than a reporting requirement; instead, this approach leverages programmatic data and adds Operational Research findings to drive planning, decision making, and implementation. The MERLA approach also incorporates the principles of USAID’s Collaborating, Learning, and Adapting approach to ensure that progress toward StopPalu+’s objectives is anchored in continuous learning and adaptation.

4.3 Procurement The project has procured a few computers and some needed additional office furniture for newly recruited staff. However, because of the delay in obtaining funding, the project could not begin the process of procuring vehicles, motorbikes, office furniture, and information technology equipment to enable the project staff as well as NGO partners’ field agents and the offices to be fully operational. This step is very important to implement our planned activities, especially to execute the SMC campaign planned for July 2018.

4.4 Partnership

4.4.1 Collaboration with local NGOs National NGOs will be key implementation partners in the StopPalu+ project. During this quarter, RTI sent out a competitive bid to select local NGO partners. The project expects to finalize this process by the end of the next quarter.

5 M&E The StopPalu+ project submitted the MEL Plan to USAID on February 13, 2018, and we received comments on March 20. We are finalizing the plan to include USAID comments. We plan to resubmit the revised version in April. Pending the response to this resubmission, there are no agreed-upon indicators to be reported during this quarter.

6 OTHER ACTIVITIES Participation in the workshop presentation of the PMI/Guinea MOP 2019 As part of the development of the 2019 MOP, the project supported the NMCP in a workshop presentation of the 2019 MOP. The objective of the workshop, held March 9, 2018, was to present the following: • The major results of FY 2018 • Planned activities for FY 2019 The conseiller of the Minister of Health and the Director of USAID/Guinea chaired the workshop. Attendees included the team of PMI/Washington and CDC Atlanta, USAID/Guinea, and representatives of national and international NGOs involved in malaria control activities, as well as the staff of the NMCP, the PCG, the Ministry of Defense, the malaria research committee, and the media.

34 StopPalu+—Quarterly Report—January to March 2018 It was noted in the workshop that the main activities identified for FY 2019 are as follows: Prevention • Procure 233,326 doses of sulfadoxine/pyrimethamine plus amodiaquine (SPAQ) for the SMC campaign. • Support distribution costs of the LLIN mass campaign in 19 districts. • Conduct entomological capacity building though CDC technical assistance. • Support the costs of the SMC campaign. Diagnosis and treatment Diagnosis: • Procure 2,599,875 RDTs for malaria diagnosis by health workers and community workers. • Procure lab consumables for laboratories. • Assist in improving the quality of diagnosis and quality assurance at both health facility and community levels. Treatment: • Procure 1,098,000 tablets of Quinine for simple malaria case management in pregnant women before the 13th week. • Procure 7,751 treatments of artesunate suppository. • Procure 153,500 treatments of intravenous artesunate for the treatment of severe malaria. • Procure 2,599,875 treatments of ACT for use in health facilities and at the community level. • Support community case management. Strengthening the health system/NMCP • Strengthen the capacity of the NMCP in M&E, management, leadership, teamwork, and strategic communication. • Coordination of district malaria focal points. • Support the prefectural and regional coordination.

StopPalu+—Quarterly Report—January to March 2018 35

Officials during the MOP 2019 presentation

7 MAIN ACTIVITIES FOR THE NEXT QUARTER • Submit, review, and validate project deliverables according to comments from USAID (Year 1 Work Plan, MEL Plan, Exit Strategy). • Conduct the KAP survey. • Revise malaria prevention and case management training manuals based on KAP results. • Train new health providers and new CHWs on malaria case management. • Develop the micro-plans for the SMC campaign. • Produce communication materials and tools for the SMC campaign. • Select local NGO partners and sign the grants.

36 StopPalu+—Quarterly Report—January to March 2018