Submitted : April 27, 2020

COAG No. 72068718CA00001

FISCAL YEAR 2020

PROGRAM YEAR 2

(January 1 to March 31, 2020)

Submitted : April 27, 2020

TABLE OF CONTENT

ACRONYMS ...... 3 I- EXECUTIVE SUMMARY ...... 5 II- INTRODUCTION ...... 12 III- MAIN ACHIEVEMENTS DURING QUARTER 2 ...... 12

III.1. IR 1: ENHANCED COORDINATION AMONG THE PUBLIC, NONPROFIT, AND COMMERCIAL SECTORS FOR RELIABLE SUPPLY AND DISTRIBUTION OF QUALITY HEALTH PRODUCTS ...... 12 III.2. IR2: STRENGTHENED CAPACITY OF THE GOM TO SUSTAINABLY PROVIDE QUALITY HEALTH PRODUCTS TO THE MALAGASY PEOPLE 19 III.3. IR 3: EXPANDED ENGAGEMENT OF THE COMMERCIAL HEALTH SECTOR TO SERVE NEW HEALTH PRODUCT MARKETS ACCORDING TO HEALTH NEEDS AND CONSUMER DEMAND ...... 41 III.4. IR 4: IMPROVED SUSTAINABILITY OF SOCIAL MARKETING TO DELIVER AFFORDABLE, ACCESSIBLE HEALTH PRODUCTS TO THE MALAGASY PEOPLE...... 56 III.5. IR5 - INCREASED DEMAND FOR AND USE OF HEALTH PRODUCTS AMONG THE MALAGASY PEOPLE ...... 62 III.6. CROSS-CUTTING ACTIVITIES ...... 69 III.6.1. Monitoring, Evaluation, Research, Learning ...... 69 III.6.2. Gender and Social Inclusion ...... 79 III.7. SUCCESS STORIES ...... 81 III.8. ENVIRONMENTAL MITIGATION AND MONITORING REPORT ...... 81 IV- KEY CHALLENGES AND SOLUTIONS ...... 83 V- MAJOR ACTIVITIES PLANNED FOR NEXT QUARTER (YEAR 2, APRIL – JUNE 2020) ...... 85 VI- FINANCIAL SUMMARY ...... 89 ANNEXES ...... 90

ANNEX A - PERFORMANCE MONITORING PLAN (PMP) ...... 91 ANNEX B – YEAR 1 WORKPLAN UPDATE ...... 99 ANNEX C - ENVIRONMENTAL MITIGATION AND MONITORING REPORT ...... 134 ANNEX D - SUCCESS STORIES ...... 148 ANNEX E – STOCK INVENTORY AS OF MARCH 2020 (USAID AND PMI FUNDED) ...... 158 ANNEX F – STOCK STATUS BY END OF MARCH 2019 ...... 161 ANNEX G - DESCRIPTIONS OF THE SEVEN QUALITY DIMENSIONS FOR THE RDQA ...... 164 ANNEX H – CALL-CENTER FUNCTIONING ...... 166

ACRONYMS A2F Access to Finance LLIN Long Lasting Insecticide-treated ABM AccèsBanque Madagascar Net ADDO Accredited Drug-Dispensing Outlet RLA Regional Logistic Advisor A2F Access to Finance LMIS Logistic Management Information AMM Agence de Médicaments de System Madagascar MEL Monitoring, Evaluation and ARC Artesunate recto-capsules Learning ATR Assistants Techniques Régionaux MCH Maternal and Child Health CACSU Cellule d’appui à la Couverture MNCH Maternal Newborn and Child Santé Universelle Health cCD Community-based Continuous MDA Market Development Authority Distribution MENETP Ministère de l’Education CCDS Comité Communale pour le Nationale et de l’Enseignement Développement Social Technique et Professionnel CCO Centre de Commandement MERL Monitoring Evaluation Research Opérationnel and Learning CGL Comité de Gestion Logistique MOPH Ministry of Public Health CHV Community Health Volunteers MSH Management Sciences for Health CHRD Centre Hospitalier de Référence de MYS Ministry of Youth and Sport District NELM New Essential List of Medicines and CISCO Circonscription Scolaire medical devices CNAPS Caisse Nationale de Prévoyance NGO Non-Governmental Organization Sociale NHMIS National Health Management CNC National Coordination Committee Information System CNFM Conseil National des Femmes de NMCP National Malaria Control Program Madagascar NSP National Supply Plan CRS Catholic Relief Services (CRS) ONP Ordre National des Pharmaciens CSR Corporate Social Responsibility de Madagascar CSB Centre de Santé de Base PA Point d’Approvisionnement CTD Common Technical Document PAIS Plan d’Action d’Intégration des CoGe Comité de Gestion CoAg Cooperative Agreement Intrants de santé COGS Cost of Good Sold PARC Point d’Approvisionnement Relais CPT Certified Peer Trainer Communautaire DAMM Direction de l’Agence de PBO Pyrethroid and Piperonyl Butoxide Médicaments de Madagascar PDPN Plan Directeur Pharmaceutique DCA Development Credit Authority Nationale DEPSI Direction des Etudes de la PMI President’s Malaria Initiative Planification et du Système PMP Performance Monitoring Plan d’Information PPR Performance Plan and Report DGFS Direction Générale de Fourniture PPN Politique Pharmaceutique des Soins Nationale DGMP Direction Générale de la Médecine PSHP Private Sector Humanitarian Préventive Platform

DHIS-2 District Health Information System - IPTp Intermittent Preventive 2 Treatment during pregnancy DPS Direction de la Promotion de la PSI/M Population Services Santé International/Madagascar DLMT Direction de Lutte contre les Pha-G-Dis Pharmacie de Gros de District Maladies Transmissibles Pha-Ge-Com Pharmacie à Gestion DLMNT Direction de Lutte contre les Communautaire Maladies Non Transmissibles RBM Roll Back Malaria DRENETP Direction Régionale de l’Education RH Reproductive Health Nationale et de l’Enseignement RDT Rapid Diagnostic Test Technique et Professionnelle SBCC Social and Behavior Change DPLMT Direction de la Pharmacie, des Communication Laboratoires et de la Médecine SHOPS Plus Sustaining Health Outcomes Traditionnelle in the Private Sector Plus DRSP Direction Régionale de la Santé SILC Savings and Internal Lending Publique Communities DSFa Direction de la Santé Familiale SLRC Service de la Législation, DSS Division Santé Scolaire Réglementation et du Contentieux DSSB Direction des Services de Santé de SMSR Service de Maternité Sans Risques Base SP Sulfadoxine Pyriméthamine EFOI Entreprendre au Féminin Océan SPD Superviseurs de Point de Indien Distribution EMMP Environmental Mitigation STTA Short-term Technical Assistance Monitoring Plan TB Tuberculosis FANOME Financement pour TA Technicien Accompagnateur l’Approvisionnement Non-stop en TCA Total Cost Analysis Médicaments TMA Total Market Approach FP Family Planning TMI Total Market Initiative GAS Gestion des Approvisionnements et ToR Terms of Reference des Stocks ToT Training of Trainers GBV Gender Based Violence TWG Technical Working Group GESI Gender Equality and Social UCP Unité de coordination des Projets Inclusion UHC Universal Health Coverage GFEM Groupement des Femmes UNFPA United Nations Population Fund Entrepreneurs de Madagascar UTGL Unité Technique de Gestion GF Global Fund Logistique GHSC-PSM Global Health Supply Chain – USAID United States Agency for Procurement and Supply International Development Management VSLA Village Savings and Loan GOM Government of Madagascar Association HPN Health Population and Nutrition WHO World Health Organization IMPACT Improving Market Partnerships and ZAP Zone d’Administration Access to Commodities Together Pédagogique IR Intermediate Result IPs Implementing Partners

I- EXECUTIVE SUMMARY

Intermediate Results 1: Enhanced coordination among public, non-profit, and commercial sectors for supply and distribution of health products During Quarter 2, IMPACT continued to achieve progress on the Total Market Initiative (TMI) Technical Working Group (TWG) subcommittee activities within the scope of the operational plan of the TMI roadmap. The three TMI TWG subcommittees held different working sessions to finalize their respective activities which are validated by the TMI TWG larger group and the Ministry of Public Health (MOPH). These activities include updating sections in the Politique Pharmaceutique Nationale (PPN) and the Plan Directeur Pharmaceutique Nationale (PDPN), the review and categorization of the texts regulating the environment of health commodities, and the development of a note to formalize the TMI TWG committee as an official TWG led by the MOPH.

IMPACT held the first Year 2 meeting of the TMI TWG on March 18th under the leadership of the Direction de la Santé Familiale (DSFa) of the MOPH and the Ministry of Economy and Finance, represented by a technical staff from the General Management of Customs, and from the General management of Taxes. The General Secretary of the MOPH, who is fully committed to the TMA implementation process as a TMI Champion, opened the meeting. The meeting was focused on: (i) the introduction of the Family Planning (FP) program and products to the TMA TWG members; (ii) the presentation of the 2020 Finance Law, which favors the tax exemption on FP products; (iii) the quantification process for FP products; and (iv) the sharing of the new law on FP/RH (Family Planning/Reproductive Health). There were 38 participants and 8 of them (including two from the private sector) showed their commitment to the TMA process by signing a letter of participation.

Regarding the malaria market assessment report, IMPACT finalized and submitted a presentation with key results of the studies to USAID for comments. The narrative report with details of the results and recommendations will be disseminated in Quarter 3.

A second group of five TMA Champions were trained in leadership by Corban Consultancy during Quarter 2. Two subcommittee leads, including the Director of Direction de la Promotion de la Santé (DPS) and the Director of the Direction de la Pharmacie, des Laboratoires et de la Médecine Traditionnelle (DPLMT) also participated in the training.

GOM leads TMI stakeholders to coordinate health product quantification and forecasting, procurement, and distribution according to market assessments and segmentation On February 20th, IMPACT supported the DPLMT to organize a one-day meeting to discuss the distribution and ordering systems for malaria commodities through hospitals. Twenty pharmacists working in hospitals and 15 other staff from the MOPH central directions (DPLMT, National Malaria Control Program (NMCP), Direction de Lutte contre les Maladies Non Transmissibles (DLMNT), Direction de Lutte contre les Maladies Transmissibles (DLMT), Direction de l’Agence de Médicaments de Madagascar (DAMM) , IMPACT, technical partners, and SALAMA staff) gathered to identify challenges encountered during the quantification process in 2019 and adopt strategies to prepare for the 2020 quantification exercises.

Intermediate Results 2: Strengthened capacity of the GOM to sustainably provide quality health products to the Malagasy people

During Quarter 2, IMPACT continued to provide technical and financial support to the Gestion des Approvisionnements et des Stocks (GAS) committees at the central and district levels to collect and analyze data on distributed quantities and consumption of malaria, FP/RH, and MNCH commodities to inform the resupply of commodities in all 115 Pha-G-Dis. In Quarter 2, IMPACT mainly focused on the redeployment of supplies between regions and districts and between districts and basic health centers (CSBs). Commodities that were overstocked were redistributed to Pha-G-Dis and CSBs experiencing stock-outs or those who were identified as at risk of stock out. During Pha-G-Dis supervision visits (to all 78 USAID-supported districts) the IMPACT team also assessed the consistency of data at the district level and noted instances that will require further follow-up to improve data accuracy and reliability and the need to provide on-the-job trainings for CHANNEL software. For example: 1) the quantity delivered by SALAMA and reported on the proof of delivery does not correspond to the quantity of ACTs received and reported in the stock cards in Ambatolampy and Antsirabe I; 2) In Vohemar , the quantity of ACTs redeployed was not recorded in the stock cards; 3) The quantity of ACTs delivered to the CSB of Ambodiara-Fenerive-Est was not recorded in the stock cards despite the presence of proof of delivery.

Through the Regional Logistics Advisors (RLA), IMPACT also supported districts with the coordination and implementation of the Last Mile Distribution Strategy. In Quarter 2, 22 Pha-G-dis and 43 CSBs were supported in submitting documents to the Direction Régionale de la Santé Publique (DRSP) and Unité de coordination des Projets (UCP) for reimbursement of the cost of transportation and storage fees.

IMPACT provided technical and financial support for the trainings of Pha-Ge-Com located in Analanjirofo and 117 people (39 CSB Chiefs, 39 Presidents CoGE, and 39 dispensers) were trained in logistics management of health commodities. ACCESS participated in the trainings as facilitators.

IMPACT supported the districts to conduct a physical inventory of cold chain systems in the 78 supported districts. The physical inventory revealed that 41 districts have a well-functioning cold chain system for the storage of oxytocin and other heat-sensitive drugs.

IMPACT implemented the first End User Verification (EUV) survey in 92 randomly selected structures (77 CSBs, 3 Centres Hospitaliers de Réference de District (CHRD), 30 Pha-G-Dis, and the SALAMA central medical store). The EUV report will be shared to USAID in Quarter 3.

Continuous distribution of LLINs in 12 targeted districts During Quarter 2, part of the community-based continuous distribution (cCD) activities were implemented as planned despite challenges from the COVID-19 pandemic:

• Reception of 1,000,000 LLINs to be distributed through the cCD. • Transportation of LLINs from PSI to six PARC and 160 PA for the first group in 6 districts (Toamasina II, Brickaville, Toliary II, Manakara, Vohipeno, and Mananjary).

• Training of actors (CSB Chiefs, Chiefs of Zone d’Administration Pédagogique (ZAP), Chiefs of Fokontany, Community Health Volunteers (CHVs), and teachers) for the first group, except in two communes in Manakara and Vohipeno districts. Training of the second group of six districts has been postponed in May. Despite the COVID-19 pandemic that could further postponed the launch of activity in the second group, it has been decided with the NCMP to accelerate this training and the distribution of LLINs to address the increase of Malaria cases from Quarter 4 2019. • Coordination meetings within the National Coordination Committee (CNC) at the central level on cCD progress, challenges, solutions, and planning for the 2021 LLIN mass distribution campaign. • Set-up with the NMCP and Implementing Partners (IPs) of 6,183 Kom’Lay among 7,927 targeted. • cCD official launch on February 13th in Mahavelona Foulpointe led by the MOPH.

Intermediate Results 3: Expanded engagement of the commercial health sector to serve new health product markets, according to health needs and consumer demand Through the Private Sector Health Humanitarian Platform (PSHP), IMPACT continued to encourage members’ involvement in the TMA TWG. Four new members, NAJMI PHARMA, the Louvre Hotel in Antananarivo, Nutrizaza, and Caisse Nationale de Prévoyance Sociale (CNAPS), have integrated into the PSHP. NAJMI PHARMA, as a pharmaceutical wholesaler, would like to participate in the TWG working on AMM (Autorisation de Mise sur le Marché) process, text regulating the PPN and the PDPN, and Louvre Hotel, Nutrizaza and CNAPS are interested in Corporate Social Responsibility (CSR) activities. Moreover, 8 pharmacies and 25 drug shops located in SAVA region accepted and signed the agreement to share and record LMIS data at their level and will submit it to the national system based at DEPSI (Direction des Etudes de la Planification et Système d’Information).

Increased access to finance for private health commodities supply chain stakeholders • 41 staff at AccèsBanque Madagascar (ABM) and Baobab Banque Madagascar branches in Mahajanga and Toliara were trained on the market opportunities and financing needs of health commodities enterprises during Quarter 2, with the goal of encourage the banks to expand lending to IMPACT client enterprises. The cumulative total number of bank staff trained in Year 2 cumulative total is 90, or 75% of annual target of 120. • ABM launched a new COVID-19 loan product, with preferential conditions, to address potential financing needs of wholesalers and suppliers, pharmacies, and drug shops who may need to increase supplies of protective gear, disinfecting products, or medications to respond to the COVID- 19 pandemic. • Loans totaling $19,728 were disbursed to 2 pharmacies and 6 drug shops by ABM and Baobab. One of these loans was placed under the DCA guarantees.

Strengthened the business management of enterprises in health products supply chain • In February, the team conducted a drug shop training in Mahajanga for the second joint IMPACT/DPLMT mission. 27 drug shops participated in the 1.5-day business training. • Two drug shop owners in the Boeny region were provided one-on-one post-training coaching. • IMPACT initiated reviews of digital inventory management tools from Maisha Meds and PHARMA Plus, to the application(s) to be tested by drug shops in Madagascar

GOM facilitates the work of the commercial sector

In Quarter 2, IMPACT organized a workshop with Parliamentarians from the Health Commission of the National Assembly and presented the project and areas of potential collaboration. As an outcome of the meeting, Parliamentarians expressed their interest and willingness to support IMPACT activities, in particular in the areas of regulatory reform, the Accredited Drug-Dispensing Outlet (ADDO) initiative, and combating illicit markets and counterfeit medicines. Aware of the threats posed to public health by the spread of the illicit market, Parliamentarians are ready to study and implement all the regulatory reforms and other measures necessary to reform the pharmaceutical sector and improve the availability of and equitable access to essential medicines and quality health commodities. To this end, they wish to be integrated into thematic working groups on regulatory texts and the ADDO program.

To enhance the review of the 128 regulatory texts inventoried in 2019, IMPACT organized a dissemination of the review document to the “Regulatory Texts” TMA sub-committee members. The sub-committee members agreed on the classification criteria of existing laws, decrees, and other regulatory texts according to public health priorities, subjects, validity status, and identified gaps in regulations that support implementation of the Health Code promulgated in 2011.

In parallel, IMPACT provided technical assistance to the Direction of “Agence du Medicament de Madagascar” (DAMM) in analyzing results of the self-evaluation using the World Health Organization (WHO) Global Benchmarking tool and defining strategies to improve its key functions such as registration, quality assurance, regulatory reform, and inspection. The results of this self-assessment showed that despite the availability of basic skills and some experience in the registration, pharmacovigilance, and quality control of medicines, the level of maturity of the DAMM is 1 on a scale from 1 to 4 (please see the meaning in section IR3.2.3 ). These results will guide the development of a road map and implementation actions plans, which aim to strengthen the regulatory capacity of the DAMM in order to allow it to improve its level of performance, especially in the areas of registration, quality assurance, and pharmaceutical inspection. IMPACT and other partners (WHO, UCP-Global Fund, etc.) will support the implementation of the developed actions plans. Furthermore, IMPACT supported DAMM to lead the harmonization of quality assurance procedures and coordination between the DAMM, SALAMA (central medical stores), and the MOPH technical and financial partners.

Intermediate Results 4 Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy people In Quarter 2, IMPACT distributed 748,871 cycles of Oral Contraceptives and 567,313 doses of Intra- muscular injectable contraceptives. The Sub-cutaneous Injectable Sayana Press from UNFPA will be available at PSI’s central warehouse from April 2020.

In addition,

• The distribution of Arofoitra in Quarter 1 and Quarter 2 achieved 49% of the annual target (30,378 units). • In Quarter 2, 28,838 ORS were distributed. The total sales in Quarter 1 and Quarter 2 represent 85% of the annual target (58,906 units).

• The total sales of Sur’Eau Pilina in Quarter 1 and Quarter 2 represent 27% of the annual target (3,620,780). • The total sales from Quarter 1 and Quarter 2 of Pneumox account for 30% of the annual target (219,635). IMPACT ran out of stock of Pneumox and the next shipment is expected in April 2020. • Fifteen out of 69 PARC and 244 out of 859 PA received promotional items from IMPACT in appreciation of the high quality of the work they provided during Quarter 1 after a personal performance review. Four PARC and 80 PA were also trained on cCD LLIN distribution management because 989,000 LLINs will be distributed in Year 2, including 104,000 LLINs by PARC and 84,300 by PAs. • For the drone pilot phase, 20 successful flight tests were completed in Quarter 2. Nineteen flight tests were under 25 km as the crow flies (air miles) and 1 flight test was 35 km as the crow flies (75 km land distance from the center of Maroantsetra).

Intermediate Results 5 Increased demand for and use of health products among the Malagasy people March 18th, 2017, the demand creation subcommittee of the TMA TWG led by the Health Promotion Department (Direction de la Promotion de la Santé - DPS) of the MOPH held its third workshop with 25 TMA stakeholders to draft the communication plan on safe behavior for health commodities in order to address self-medication and the lack of awareness about proper use of medicines.

• To promote health products, 5,659 radio spots on CHX were broadcasted from January 1st to February 26th, 2020 in 35 districts of the 10 USAID-supported regions and 2,640 radio spots on Sur’Eau Pilina were aired in 32 districts of the 10 USAID-supported regions from February 27th to March 30th, 2020. • Review the training curriculum in collaboration with the Ministry of Youth and Sport (MYS), which will be used during the Blue Ventures youth members capacity building workshop on leadership, sensitization of good health behaviors, and the use health commodities.

SMS Activity: • During International Women's Day on March 8th, 2020, SMS messages were sent to 1,897,465 subscribers (women and men over 15 years old) through the Telma network in the 10 USAID regions of intervention. The messages focused on women empowerment with regard to the use of modern contraceptive methods and the equal access to health commodities. • For providers, such as PA, PARC, and CHVs, SMS campaigns were also conducted to inform them about stock management and availability of the oral contraceptive ZINNIA. • In agreement with the DPLMT, each month SMS reminders were sent to 78 Pha-G-Dis to remind them to report the monthly physical stock and to sensitize them on stock management.

Cross-Cutting

Monitoring Evaluation, Research and Leaning

Monitoring and Evaluation:

• Distribution of 26 laptops out of the 37 planned. The 11 remaining laptops will be distributed in Quarter 3. • Set up a call center located at PSI office (where unlimited and high-speed Internet connection is available) to remind Pha-G-Dis to submit LMIS data. • Supportive supervision of 33 Pha-G-Dis experiencing LMIS data submission issues, including not having a functional computer, no computer available for LMIS data, CHANNEL issues, electricity issues, organizational problems at Pha-G-Dis (lack of people working on LMIS), etc.

Research:

• Design tools which will be used to collect information for the FP and MNCH market assessments. An open bid process was launched to select external agencies to conduct data collection, data analysis, and reporting related to the different tools (outlet survey, key informant interviews, and FP and MNCH qualitative tools).

Knowledge Management:

• Conduct a field visit in the Vatovavy Fitovinany region to train local staff in documenting their activities, such as writing success stories and lessons learned. The region of Vatovavy Fitovinany was selected because of the malaria peak season combined with an outbreak of malaria that occurred during Quarter 2. Fifteen (15) people (9 from MOPH, 2 from IMPACT, and 4 from other implementing partners) participated and four success stories were collected. Details on success stories are presented in Annex D of this report.

Gender Integration and Social Inclusion (GESI)

During Quarter 2, IMPACT focused on integrating gender equality and social inclusion across several targeted interventions, namely:

• Participated in several International Women’s Day events in Tuléar to highlight IMPACT’s visibility and increased opportunities for partnership and collaboration. • Conducted IMPACT staff training to help improve gender and social inclusion competency and raise the profile of GESI champions across different teams within the IMPACT project. • Integrated gender and social inclusion content into social and behavior change campaigns related to health practices, as well as integrated gender perspectives into training for the banking sector. • Defined strategic entry points for stakeholder partners working on gender equality and social inclusion to play an active role in the TMA.

Graph 1: Summary of the activities achieved vs activities planned for January – March 2020

Sub-Activities to be completed Quarter 2 (+ Remaining activities from Quarter 1) 8 7 7 6 6 5 4 3 3 2 2 1 39% 33% 17% 11% 0 Completed Rescheduled in Q4 Rescheduled in Q3 Postponed in Year 3

Eighteen (18) sub-activities were planned to be completed in Quarter 2, in addition to the remaining Quarter 1 sub-activities. Seven (7) sub-activities (39%) were completely achieved. Nine (9) sub- activities will continue in Quarter 3 and Quarter 4, while two sub-activities are postponed to Year 3. Explanations on sub-activities not completed and postponed in Year 3 are provided in Table 40.

II- INTRODUCTION

Improving Market Partnerships and Access to Commodities Together (IMPACT) is funded by the United States Agency for International Development (USAID) and led by PSI/Madagascar as the prime recipient and its consortium partners for five years from September 4, 2018 until September 3, 2023.

IMPACT supports the Government of Madagascar to improve the capacity of the Malagasy health system to ensure that quality pharmaceuticals and health commodities are available and accessible to all Malagasy people on a sustainable basis. IMPACT’s expected outcome is to increase total market performance for and use of health products and sustained health system performance. IMPACT has five intermediate results such as (i) enhanced coordination among the public, nonprofit, and commercial sectors for reliable supply and distribution of quality health products ; (ii) strengthened capacity of the Government of Madagascar (GOM) to sustainably provide quality health products to the Malagasy people; (iii) expanded engagement of the commercial health sector to serve new health markets according to health needs and consumer demand; (iv) Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy population; (v) Increased demand for and use of health products among the Malagasy people.

This report summarizes the activities carried out during Quarter 2, fiscal year 2020 by the consortium partners. The narrative provides updates on accomplishments, challenges, and solutions for Quarter 2.

III- MAIN ACHIEVEMENTS DURING QUARTER 2

III.1. IR 1: Enhanced coordination among the public, nonprofit, and commercial sectors for reliable supply and distribution of quality health products

Sub-IR 1.1 The total market for health products in Madagascar is understood and documented

IR1.1.1: Support the implementation, monitor and evaluate the overarching TMA roadmap for all health products based on the discussions and decisions taken during the TMA The overarching TMA roadmap aims to solve the main obstacles of the availability and accessibility of health commodities through a joint effort to identify the main blockages and to propose solutions involving all sectors (public, private (for profit and nonprofit), and donors). The overarching TMA roadmap has three initial main areas of focus: (i) the Politique Pharmaceutique Nationale (PPN) and its Plan Directeur Pharmaceutique National (PDPN) documents which regulate all health commodities in Madagascar, (ii) texts and regulations which govern health commodities and health actors, including wholesalers, providers, pharmacies and drug shops, prescribers, and (iii) data quality and availability of health commodities. A TMA TWG subcommittee has been established for each of these areas of the roadmap.

During Quarter 2, these three subcommittees held meetings in order to implement the operational plan of the TMA roadmap.

The table below summarizes participants and meeting details

Table 1: Summary of participant and meeting details Dates Venue Total Female Male Participants organization - 10 from public sector Sakamanga - 4 from private sector January 15 23 12 11 Hotel - 8 from IMPACT Project - 1 from SALAMA - 11 participants from public - 5 participants from private sector February 13 DPLMT office 23 10 13 - 6 from IMPACT Project - 1 from SALAMA - 7 participants from public sector - 4 from private sector March 6 DPLMT office 17 10 7 - 5 from IMPACT Project - 1 from SALAMA

The “PPN PDPN” subcommittee held three working sessions under the leadership of the Direction de la Pharmacie, des Laboratoires et de la Médecine Traditionnelle (DPLMT). During these sessions, each section of the PPN and PDPN documents were reviewed and analyzed to identify missing elements and what needs to be updated following feedback and input, especially from the private sector whose involvement was limited during the initial development of the document. Among the missing elements identified by the subcommittee are the Figure 1: The subcommittee reviewing the structure of the PPN sections on the distribution channel and PDPN documents – January 15, 2010 management in order to facilitate the commodities tracking and improve traceability.

• The subcommittee will propose changes to the decision-makers (high authorities in the MOPH) and will disseminate the updated documents to all relevant stakeholders in Madagascar. This was initially planned in early Quarter 3 but will likely be delayed to Quarter 4 due to the COVID-19 outbreak.

As these documents regulate the entire pharmaceutical sector, the involvement of all stakeholders, especially the private sector, is needed to enhance their adherence to their implementation. Inputs from the working group emphasized joint actions towards fair pricing, streamlining the product registration process, fighting against the illicit sale of drugs, and the need to have sales data from outlets including from the private sector.

Graph 2: Members of the PPN PDPN subcommittee

Members of the PPN PDPN subcommittee

7.69%

34.62% 57.69%

Public sector Private sector Donors

• The “Texts and Regulations” subcommittee held its first working group on February 4th at Motel Anosy with 38 participants (13 male and 25 female) where Marie Paule Fargier, an international expert in pharmaceutical regulation, presented the third book of the Malagasy health code. The session was facilitated by two TMA Champions, the director of the Agence du Médicament de Madagascar (AMM), and the president of the Association of Pharmacists in Madagascar (APM). As part of the implementation of the operational plan of the TMA roadmap, the subcommittee members identified and began the classification process for all texts relating to health commodities according to their sources and areas of intervention. More details on this meeting and examples of texts can be found under IR3.2.2 of this report.

Graph 3: Members of the ‘Texts and Regulations' subcommittee

Members of the 'Texts and Regulations' subcommittee

17.24%

13.79% 51.72%

10.34% 6.90%

Public sector Private sector NGOs Donors Associations

• The “Data” subcommittee led by DEPSI started its working session on February 21st by presenting an official note to institutionalize and formalize the TMI TWG larger group. The restricted section of the committee has shared their feedback on the ministerial note, and it is planned to be presented to the key members of the TMI TWG subcommittee for their inputs and then to the MOPH for validation in Quarter 3.

Table 2: Summary of participant and meeting details Dates Venue Total Female Male Participants organization - 3 from public sector February 21 DPLMT office 9 4 5 - 1 from private sector - 5 from IMPACT Project

IR1.1.2: Support the development and implementation of the malaria TMA roadmap and monitor and evaluate its progress to ensure the availability of quality malaria products at all IMPACT has submitted the preliminary report of the malaria market assessment findings to USAID. Primary takeaways of the report specify that: 1) there is a limited collaboration and involvement between the public and commercial/private sectors; 2) product availability continues to be a challenge with variations between urban and rural areas; 3) Users have a limited understanding and knowledge of many of the malaria products. The final report will be finalized in Quarter 3.

A meeting with the TMA Roll Back Malaria (RBM) group was planned at the end of Quarter 2 to present the main findings of the malaria market assessment. However, due to the COVID-19 pandemic this meeting has been postponed. Once the malaria market assessment findings are shared with the RBM group in Quarter 3, the TMA TWG will work on the development of the malaria TMA roadmap.

IR1.1.3: Collaborate with relevant actors and stakeholders for the evaluation of the 'Roadmap to accelerate the reduction of maternal and neonatal morbidity and mortality 2015-2020' IMPACT provided technical and financial support to the DSFa to organize a TMA TWG meeting on March 18, 2020, with the Ministry of Economy and Finance, and other partners at the Carlton Hotel with 38 participants (21 male and 17 female). This includes 7 participants from the private sector, 4 donor representatives, 7 from NGOs and associations, and 15 from the public sector (cf. Graph 4 below).

This was an opportunity for DSFa and the Ministry of Economy and Finance to introduce the TMA TWG members to FP products by Figure 3: The TMA Champion and Director of DSFa facilitating the TMA TWG on FP products – March 18, 2020 presenting the progress made for FP products. The presentation included the 2020 Finance Law, which favors the tax exemption of FP products, the quantification process for FP products at the national level, and the new law on FP/Reproductive Health (RH).

The new law defines access to FP as a guaranteed right for all individuals, regardless of age. Health care providers are now required to maintain client confidentiality and respect individual choice under the law.

The tax exemption for FP products is a major opportunity for the private sector, especially in the determination of their prices and in the facilitation of their registration and importation process. The private sector’s contribution to the FP market will include providing more products (and more choices)

15 to the clients. The private sector FP products will complement the public sector market by targeting middle and upper-class clients.

Graph 4: TMA TWG on FP products participants

TMA TWG on FP products participants

11%

Public sector 3% NGOs 16% 54% Private sector Associations 16% Donors

In addition, the national quantification of FP products was presented by the Directorate of Family Health (DSFa). The private sector has been invited to participate in the future quantification process to ensure that the need for the FP commodities will be clearly identified and filled and their data will be collected and integrated into the national (logistics?) information system.

This presentation on quantification of FP commodities marked the initiation of the FP TMA subcommittee, led by DSFa, to better understand the FP and MNCH context in Madagascar. Furthermore, FP and MNCH market assessment tools and framework documents have been developed in close collaboration with DSFa and UNFPA and are currently going through the internal validation process prior to USAID validation. Data collection will begin in Quarter 3, presuming it is possible given the COVID-19 pandemic.

IR1.1.4 : With the MOPH , build the capacity of TMA Champions to successfully steward and lead the TMA TWG and subcommittees (including the study tour to a country that has successfully implemented the TMA) All TMA Champions have completed their leadership, time management, teamwork, and public speaking training. During the second training, two directors from the MOPH were trained with the remaining four TMA Champions due to their involvement and contribution in the implementation of the TMA Roadmap. These directors included the Director of the DPS who is the lead of the communication subcommittee and the Director of DPLMT who is the lead of the PPN Figure 4: 2nd batch of the Leadership training with new TMA PDPN subcommittee. After this training, the Champions – January 23, 2020 TMA Champions and subcommittee leads will

16 be better able to steward the TWG members in the implementation of the TMA roadmap and its operational plan.

In addition to the leadership training, IMPACT also planned an advocacy training during Quarter 2 to be led by international experts. However, this training had to be postponed due to the COVID-19 pandemic and will be rescheduled when bans on travel and gatherings are lifted.

A study tour to a country having successfully implemented a TMA was also planned in Quarter 2 but due to the COVID-19 pandemic, and especially considering the extent of the outbreak in the chosen country of Vietnam, the study tour had to be postponed to Year 3 in 2021.

IR1.1.5 : Disseminate the official TMI roadmap documents (overarching, Malaria, FP and MNCH) signed by representatives of the public, private and non-profit sectors The overarching TMA roadmap document was developed at the end of Quarter 1. The document was validated both internally and by USAID. However, due to changes in the staff of the MOPH and shifts in priorities due to the COVID-19 pandemic, the validation of the document by the MOPH is still pending. Once the document is validated by the MOPH, it will be presented officially to all relevant stakeholders.

Sub-IR 1.2: GOM leads TMI stakeholders to coordinate health product quantification and forecasting, procurement, and distribution according to market assessments and segmentation

IR1.2.1 : Organize meetings to revise and validate the Terms of Reference (ToR) of the UTGL to ensure its updated tasks and responsibilities. IMPACT continued to follow up with DPLMT on the signature of a ministerial decree to appoint new Unité Technique de Gestion Logistique (UTGL) members and to revise and validate their Terms of Reference (ToR). The draft of the decree has been developed and is still pending validation at the Prime Minister’s office. It is expected that the new decree will be signed during Quarter 3.

IR1.2.2 : Organize quarterly meetings (UTGL, CGL, and GAS committee) to analyze routine data on key indicators in public hospitals, such as stock-out, LMIS issues, etc. for learning and adapting the use of DHIS2 in collaboration with the MERL team. On February 20th, IMPACT supported the DPLMT to organize a one-day meeting to discuss the distribution and ordering systems for malaria commodities through hospitals. All 20 pharmacists working in hospitals and 15 staff of SALAMA, DPLMT, NMCP, DLMNT, DLMT, DAMM, IMPACT, and technical partners gathered to identify challenges encountered during the quantification process in 2019 and adopt strategies to prepare for the 2020 quantification exercises. During the meeting, participants identified some issues to be addressed, including: lack of understanding of the distribution process, no clear mechanism on sharing consumption data, and lack of pharmacist involvement in the distribution, data collection, and reporting. The following next steps were agreed to in relation to the quantification exercise of malaria and MNCH commodities:

• DPLMT will send a letter detailing the distribution circuit (the flow of distribution of medicines at different levels) and processes that hospitals must follow to order program commodities for malaria, FP, MNCH, Tuberculosis (TB), HIV/AIDS, etc.

• The vertical programs (ex: malaria, HIV/AIDS, expanded immunization programs) and DSFa must share a template with pharmacists that will be used for data collection at least two weeks prior to quantification. A meeting to analyze and discuss the data collected will be organized. • SALAMA and the hospitals should conduct a joint quantification exercise to avoid duplication of forecasting plans of essential commodities, especially those used in MNCH programs that can lead overstocks in-country. • DEPSI must develop and send a note to all hospitals in order to clarify roles and responsibilities in reporting on services and logistics data. • Pharmacists committed to ensuring a rational use of malaria commodities following the national protocol and to report on consumption and stock status within their hospitals

III.2. IR2: Strengthened capacity of the GOM to sustainably provide quality health products to the Malagasy people

Sub-IR 2.1: Health commodities and pharmaceuticals are continuously accessible and available in the public sector

Emergency distribution of Family Planning products for the public sector In Quarter 2, IMPACT delivered 56,413 vials of Triclofem and 2,445 cycles of Microgynon as part of the FP products dedicated to the public sector emergency plan to 19 Pha-G-Dis in 13 USAID-supported regions. These quantities were delivered following the distribution plan established by DSFa and from the remaining quantity of the Year 1 emergency plan.

Table 3: Distribution during Quarter 1 and Quarter 2 Remaining Qty Qty for FY Qty delivered To be delivered to Qty Provided 20 to Pha-G-Dis in distributed for Products Pha-G-Dis in Achievement by USAID (As of Quarter 2 Year Quarter 3 Year Quarter 1 October 1, 2 2 Year 2 2019) SAYANA PRESS 301,600 (Dose) - - - Depo-Provera

(Dose)/ 950,320 240,289 56,413 93.78% 19,660 316,362 TRICLOFEM Oral

Contraceptive : 537,800 12,000 2,445 45.19% 17,515 31,960 Microgynon

The remaining quantity of the emergency plan will be distributed in Quarter 3.

IR2.1.1: Provide capacity building through trainings and consistent coaching to GOM and partner members of UTGL on forecasting and supply planning, including the use of Quantimed During Quarter 2, IMPACT prepared the quantification exercises to be conducted in the first semester of 2020 (January to June) with DPLMT. The STTA was planned in Quarter 2 to conduct a Training of Trainers (TOT) in order to transfer skills to five Malagasy counterparts who were selected to facilitate future national quantification exercises using the Quantimed and Pipeline software. The TOT was scheduled in March 2020 but did not happen due to COVID-19. The STTA will continue to support the team remotely and the training is rescheduled to later in 2020.

IR2.1.2. Assist the GOM and UTGL members in leading the annual system wide forecasting exercises for the public and private sector for FP/RH, MNCH, and malaria commodities and support UTGL and SALAMA to help mobilize resources to procure commodities in the supply plans IMPACT continued to support finalization of the quantification review exercise that started in December 2019. The review exercise did not consider the needs of the private sector as there is not yet data to make appropriate assumptions. The private sector will be considering the malaria market assessment findings. In addition, the LMIS data (consumption etc.) will be collected for the private sector in collaboration with the TMA TGW LMIS committee to allow the quantification process to be carried out in a good manner. IMPACT used the results of the December 2019 quantification to submit

PPMRm reports for Quarter 1 and Quarter 2 and a supply plan to PSM in March 2020. The results have also been used to evaluate the risk of expiration of over stocked Sulfadoxine-Pyrimethamine (SP). Since January 2020, the Malaria GAS Committee has been using these results to update the national dashboard of malaria commodities before sharing with the RBM committee members. The malaria GAS committee developed three scenarios of assumptions based on services data, logistics data (stocks available, distribution, and consumption), and the national strategic plans. Forecasting and corresponding supply plans were developed and used to advocate to Global Fund for the reallocation process of the NMF2 grant and the procurement process to cover the needs for 2021. The status of ongoing procurements will be described in section IR.2.1.3.

IMPACT started preparations for the 2020 annual quantification exercises by developing forecasting and supply plans to mobilize necessary financial resources. From March 9th to 13th, IMPACT participated in the mid-term review to assess achievements of the Malaria National Strategic Plan 2018-2022 (NSP). Since the NSP was used to develop forecasting and supply plans, forecasting plans were unrealistic because the targets set regarding the anticipated reduction of the number of malaria cases will not be achieved. The mid-term review will continue throughout the year to adjust the NSP. In the interim, IMPACT will support the GAS committee to work with various TWGs to make realistic assumptions based on current trends (services and consumption data), to be used during the quantification exercise planned in Quarter 3.

On March 19th and 20th, IMPACT provided technical and financial support to organize a two-day workshop with the GAS committee and other TWGs (malaria in pregnancy, severe malaria case management, epidemiological surveillance, and Monitoring and Evaluation) to discuss strategies that influence the quantification process.

Participants discussed how to:

• Ensure proper management and use of Arthemeter- Lumefantrine (AL), which has recently been introduced in Madagascar, together with Artesunate-Amodiaquine (AS/AQ) combination therapy. The two combinations are used for uncomplicated malaria cases. • Increase the use of SP for malaria in pregnancy in order to avoid the expiration of approximately 5,000,000 tablets in 2021 since Madagascar is currently in overtstock of SP. SP is not consummed as per the NSP targets (only 55% consummed compared to NSP targets). • Evaluate the introduction phase and plan a second distribution of Artesunate recto-capsules (ARC) for severe malaria at the community level. ARC was introduced in July 2019. • Ensure proper use of Quinine and Artesunate injectable for severe malaria. There is a need to ensure availaibility of Artesunate injectable for both public and private sector hopsitals, clinics, and health centers. Note that Artesunate injectable is used as a first-line treatment and Quinine injectable is used as second-line treatment for severe malaria.

Twenty-six representatives (12 males and 14 females) of DLMT, DPLMT, NMCP, ACCESS, IMPACT, INTER AIDE, MAHEFA MIARAKA, PSI, UNICEF, JHIEPGO, and USAID attended the workshop. The strategies defined to impact the multi-year forecasting and supply plans for 2020, 2021, 2022, and 2023 are:

Table 4: Strategies and timeline defined during the workshop Products Actions to implement Responsible Deadline Arthemeter- • Share with districts an official notification of the co-existence NMCP Completed in Lumefantrine of AL and AS/AQ and highlighting that AL must only be used at March 2020. health centers. All available quantities of AS/AQ will be distributed to CHVs. • A job aid on the standard treatment guidelines for malaria recalling the use of AL will also be shared to districts and to all healthcare providers Sulfadoxine- • Resend the note detailing the use of SP for malaria in Completed in Pyrimethamine (SP): pregnancy. NMCP March 2020 Sulfadoxine- • Continue to work with GHSC-PSM to re-export approximately IMPACT April 2020 Pyrimethamine (SP): 5,000,000 tablets of SP to another country to avoid risk of expiration. Many meetings have been organized with PSM, IMPACT, PMI, PSI, and the Global Fund headquarters to coordinate on this re-exportation. Note that the SP is expiring in August and December 2021. • IMPACT and PSI Madagascar have shared all documentation requested in terms of quality assurance to move forward. Sulfadoxine- • Plan for a push distribution of SP to districts to increase the GAS April 2020. Pyrimethamine (SP): availability at the peripheral level Committee Sulfadoxine- • Monitor the use of SP for malaria in pregnancy and increase NMCP Continuous Pyrimethamine (SP): behavior change communication activities to boost the uptake ACCESS, activity. of SP through ANC services among pregnant women. Mahefa Miaraka, JHIEPGO Quinine/Artesunate • Collaborate with the National Order of Doctors, private NMCP April 2020. injectable wholesalers, and SALAMA to inform the proper use of Quinine and Artesunate injectable to treat severe malaria, especially in hospitals and clinics. Artesunate injectable is the first line of treatment of severe malaria while Quinine is the second line Artesunate • Estimate needs and organize a second distribution to 47 GAS April 2020. Suppositories (ARC) districts that have already received ARC and add new districts Committee to be selected taking into consideration the malaria epidemiological profile (high epidemic districts). • Collaborate closely with the NMCP case management service to plan distribution in districts that are ready to train and supervise health centers and CHVs on the use of ARC for pre- referral treatment of severe malaria cases among children under 5 years. Artesunate • Support the districts in reporting the number of cases treated PNLP Continuous Suppositories (ARC): and the data consumption of ARC. ACCESS, activity. • Strict follow-up on storage conditions of ARC to avoid risk of Mahefa quality deterioration. Miaraka,

Since the decision was made to telework starting March 23rd due to COVID-19, the malaria quantification process will be led by a team of 8 representatives (NMCP (1), Mahefa Miaraka (1), IMPACT and PSI Global Fund principal recipient (5), and PMI (1)) working remotely with support from Andualem Oumer who was scheduled to travel to Madagascar for an STTA. The plans will be used for the gap analysis to secure funding through the Malaria Operational Plan that will be finalized in April. Once the COVID-19 situation improves, the quantification plans for malaria will be presented to UTGL and CGL for validation. IMPACT will also share the results of the Malaria Market Assessment with the

private sector and will organize a quantification workshop including the private sector. IMPACT will involve DAMM and TMA Champions in the process.

IR2.1.3: Coordinate orders, deliveries generation and pipeline monitoring according to agreed- upon supply plan with SALAMA, PSM, GOM institutions and USAID During Quarter 2, IMPACT continued to collaborate with GHSC-PSM to coordinate the procurement process for both 2019 and 2020 procurements.

Table 5, 6, and 7 below shows the status of pending 2019 orders and shipments for PMI (malaria) and USAID (FP/RH) procurements. There is no planned procurement of MNCH commodities for the public sector.

Table 5: Status of pending orders of 2019 FP/RH products to be delivered in 2020 Estimated Quantity Quantity Products Unit Delivery Date Comments Ordered Delivered (EDD) Levonorgestrel/Ethinyl Estradiol 150/30 mcg + Fe 75 Estimated arrival date of April Cycle 1,052,352 24-Mar-20 mg, 28 Tablets/Cycle (SM), 1 - 14, 2020 Cycle [Zinnia-F] Standard Days Method Color-Coded Plastic Beads, 1 Delivered on February 28, 2020; Each 21,000 3-Feb-20 Each [Cycle Technologies] 20,994 6 cycles missing [CycleBeads] Order put on hold by the manufacturer due to COVID-19. Pregnancy Test Kit, hCG, Unit 200,000 1-Apr-20 Waiting updates from PSM on Urine, 50 Each - Agreed Delivery Date with the vendor

Table 6: Status of ongoing orders of FP/RH products for 2020 Quantity Requested Products Unit Comments Ordered Delivery Date Depot (IM) Medroxyprogesterone Acetate Estimated arrival date 150 mg/mL (1 mL) Vial, w/ AD Syringe, 1 UNT 900,000 31-Mar-20 of May 2020 Each [PT Tunggal] [Triclofem] Estimated arrival date Standard Days Method Color-Coded PCS 17,000 29-May-20 Plastic Beads, 1 Each of June 2020

Levonorgestrel/Ethinyl Estradiol 150/30 Shipment planned in cycle 1,400,112 30-Jun-20 mcg + Fe 75 mg, 28 Tablets/Cycle (PS), 1 June 2020 Cycle [Mylan] [Zinnia-F] Shipment planned in Etonogestrel 68 mg/Rod, 1 Rod Implant, 1 UNT 35,064 30-Mar-20 Each [MSD] [Implanon NXT] September 2020

Levonorgestrel/Ethinyl Estradiol 150/30 Shipment planned in cycle 1,800,288 30-Jun-20 mcg + Fe 75 mg, 28 Tablets/Cycle (PS), 1 September 2020 Cycle [Mylan] [Zinnia-F] Estimated arrival date Depot (IM) Medroxyprogesterone Acetate UNT 900,000 31-Mar-20 pending PSM source 150 mg/mL (1 mL) Vial, SR, 1 Vial approval process

Quantity Requested Products Unit Comments Ordered Delivery Date Put on hold, PSM didn’t each 400,000 11-May-20 receive the FY20 TO3 Pregnancy Test Kit, hCG, Urine, 50 Each obligation yet Male Condom (Latex) Lubricated, Put on hold, PSM didn’t Protector Plus v2, 53 mm, 48 CAS 1,158 31-Mar-20 receive the FY20 TO3 Pcs/Dispenser, 90 Disp/Case, 4320 Pieces obligation yet Put on hold, PSM didn’t Depot (IM) Medroxyprogesterone Acetate receive the FY20 TO3 150 mg/mL (1 mL) Vial, SR, 1 Vial UNT 700,000 31-Mar-20 obligation yet

Table 7: Status of PMI malaria procurements to be delivered in 2020 Quantity Requested Products Unit Comments Ordered Delivery Date Artesunate (w/ 1 Amp NaHCO3 5% + 1 Shipment departed, and arrived vial 25,000 22-Apr-20 Amp NaCl 0.9%) 60 mg Vial, 1 Set on April 14th Manufacturing delayed due to Artesunate/Amodiaquine 25/67.5 mg dose 5250 12-May-20 COVID-19; Shipment expected Tablet, 25 x 3 Blister Pack Tablets in Sept 2020 Artesunate/Amodiaquine 25/67.5 mg Shipment departed, expected dose 52,350 20-May-20 Tablet, 25 x 3 Blister Pack Tablets to arrive in May 2020 Manufacturing delayed due to Artesunate/Amodiaquine 50/135 mg dose 386,000 12-May-20 COVID-19; shipment expected Tablet, 25 x 3 Blister Pack Tablets in Sept 2020 Artesunate/Amodiaquine 50/135 mg Shipment departed, expected dose 547,400 9-Dec-19 Tablet, 25 x 3 Blister Pack Tablets to arrive in May 2020 Manufacturing delayed due to Artesunate/Amodiaquine 100/270 mg dose 91,600 12-May-20 COVID-19; shipment expected Tablet, 25 x 3 Blister Pack Tablets in Sept 2020 Artesunate/Amodiaquine 100/270 mg Shipment departed, expected dose 213,725 9-Dec-19 Tablet, 25 x 3 Blister Pack Tablets to arrive in May 2020 Manufacturing delayed due to Artesunate/Amodiaquine 100/270 mg dose 301,625 12-May-20 COVID-19; shipment expected Tablet, 25 x 6 Blister Pack Tablets in Sept 2020 Artesunate/Amodiaquine 100/270 mg Shipment departed, expected dose 186,525 17-Mar-20 Tablet, 25 x 6 Blister Pack Tablets to arrive in May 2020 Manufacturing delayed due to Malaria Rapid Diagnostic Test (RDT) test 1,290,325 12-Dec-19 COVID-19; shipment expected HRP2/pLDH (Pf/PAN) Cassette, 25 Tests in Sept 2020 Goods available, but logistics Malaria Rapid Diagnostic Test (RDT) test 1,000,000 23-Jan-20 delay due to COVID-19. HRP2/pLDH (Pf/PAN) Cassette, 25 Tests Shipment expected in July 2020 Sulfadoxine/Pyrimethamine 500/25 mg On hold pending revised tablet 1,500,000 9-Dec-20 Tablet, 150 Tablets quantification in April 2020

Due to the COVID-19 pandemic, global procurement was impacted, and manufacturers have been delayed or are slowing the process of manufacturing goods to ship to Madagascar and the logistics systems have been impacted by the closure of ports, airports, and lack of reliable transportation during this time. IMPACT continues to monitor the pipeline orders and inform RBM and the national

malaria control program to adjust in-country logistics and ration the distribution of commodities (months of stock to distribute to districts has been reduced to 1.5 months instead of 3 months).

Additional PMI and Global Fund malaria Procurements to be delivered in emergency in 2020

In Quarter 2, IMPACT provided technical assistance to the malaria GAS Committee to analyze the national stock situation of malaria commodities and shared a dashboard with RBM members on a weekly basis. Through these weekly updates, RBM was able to detect that there was insufficient stock of malaria commodities at the central level/SALAMA, which led to the inability to fulfill all requisitions submitted by the districts. The months of stock available at SALAMA for ACTs varies between 4 months (ACT 2-11 months), 3 months (ACT 1-5 years), 6 months (ACT 6-13 years) under the minimum stock level required of 9 months.

To address this critical situation while Madagascar was in the peak malaria season, IMPACT continued to support the malaria GAS Committee to track orders in the pipeline and discuss with the procurement agents of GHSC-PSM (PMI procurement) and PSI (Global Fund procurement) to explore possibilities of advancing the planned shipments. Through the discussions, PMI and Global Fund secured funding in the pipeline to procure an emergency stock of Arthemeter-Lumefantrine (AL) and Artesunate-Amodiaquine (AS/AQ) combination therapy (ACT) that was received in Madagascar in Quarter 2 to address the shortage of malaria commodities.

Table 8: List and quantities of emergency AL procured by PMI and Global Fund in Quarter 2.

Products Quantity/ dose Donor Funding Shipment Status Artemether/Lumefantrine 20/120 mg Received in February 21, 5,010 Global Fund Dispersible Tablet, 30 x 6x1 Blister Pack Tablets 2020 Artemether/Lumefantrine 20/120 mg Received on March 13, 29,280 PMI Dispersible Tablet, 30 x 6x1 Blister Pack Tablets 2020 Artemether/Lumefantrine 20/120 mg Received in February 21, 32,820 Global Fund Dispersible Tablet, 30 x 6x2 Blister Pack Tablets 2020 Artemether/Lumefantrine 20/120 mg Received on March 13, 91,680 PMI Dispersible Tablet, 30 x 6x2 Blister Pack Tablets 2020 Artemether/Lumefantrine 20/120 mg Received in February 21, 34,350 Global Fund Dispersible Tablet, 30 x 6x3 Blister Pack Tablets 2020 Artemether/Lumefantrine 20/120 mg Shipment expected in Dispersible Tablet, 30 x 6x3 Blister Pack Tablets March 2020 but delayed 64,800 PMI due to COVID-19. New schedule is probably May 2020 Artemether/Lumefantrine 20/120 mg Received in February 21, 32,790 Global Fund Dispersible Tablet, 30 x 6x4 Blister Pack Tablets 2020 Artesunate/Amodiaquine 25/67.5 mg Tablet, Shipment planned to arrive 34,350 Global Fund 25 x 3 Blister Pack Tablets in country in May 2020 Artesunate/Amodiaquine 50/135 mg Tablet, 25 Shipment planned in May 75,000 Global Fund x 3 Blister Pack Tablets 2020

IR2.1.4: Provide technical assistance to support the central level GAS Committees to develop quarterly distribution plans for malaria, MNCH, and FP/RH products based on quarterly stock status obtained from district/GAS committees During Quarter 2, IMPACT supported the malaria GAS committee to analyze data reported from Pha- G-Dis through paper-based reporting (Rapport - Bon de commande) and CHANNEL in order to organize the resupply of commodities to all 115 Pha-G-Dis. IMPACT and UCP paid the transportation fees for commodities procured through PMI and Global Fund that were distributed through SALAMA routine and emergency transportation systems. Thirty-nine (39) districts received shipments of emergency commodities via Colis Express, 74 districts were resupplied through routine transportation, and the two hard-to-reach districts of Marolambo and Nosy Varika were resupplied with an airplane.

Below is a table summarizing the malaria commodities shipped to the 115 districts during Quarter 2.

Table 9: Distribution of commodities from SALAMA to 115 Pha-G-Dis, January to March 2020

PMI procured commodities that were distributed in Quarter 2

Artesunat Artemeth Artesuna Artesuna Artesuna Artesuna e (w/ 1 Malaria er/Lumef Sulfadoxin te/Amod te/Amod te/Amod te/Amod Amp Rapid antrine e/Pyrimet iaquine iaquine iaquine iaquine NaHCO3 Distribution Diagnos Quinine 20/120 hamine 25/67.5 50/135 100/270 100/270 5% + 1 mode tic Test tablets mg 500/25 mg mg , 3 mg, 3 mg, 3 mg, 6 Amp NaCl (RDT) / Dispersibl Tablet/ Tablets/ Tablets, Tablets/ Tablets/ 0.9%) 60 Test e Tablet/ Tablet Dose / dose dose dose mg/ dose Vial, Routine/

Cyclic - - - 40,125 66,775 201,275 - 798,600 35,675 distribution Emergency - - distribution - 46,325 91,350 507,825 - 478,200 26,294

- 86,450 158,125 709,100 - 1,276,800 61,969 TOTAL - -

Global Fund commodities that were distributed in Quarter 2

Artesunat Artesuna Artesuna Artesuna Artesuna Artemethe Sulfadoxi e (w/ 1 Malaria te/Amod te/Amod te/Amod te/Amod r/Lumefant ne/Pyrim Amp Rapid iaquine iaquine iaquine iaquine rine ethamin NaHCO3 Distribution Diagnos Quinine 25/67.5 50/135 100/270 100/270 20/120 mg e 500/25 5% + 1 mode tic Test tablets mg, mg, 3 mg , 3 mg, 3 Dispersible mg Amp NaCl (RDT) / 3Tablets Tablets, Tablets/ Tablets/ Tablet/ Tablet/ 0.9%) 60 Test / Dose / dose dose dose dose Tablet mg/ Vial, Routine/

Cyclic 10,575 1,525 - - 288,350 23,400 23,640 - - distribution Emergency distribution 3,200 8,950 - - 91,150 32,600 2,970 - -

13,775 10,475 379,500 56,000 26,610 TOTAL - - - -

Redeployment of stocks between regions and districts and between Pha-G-Dis and CSBs

On January 29th, the GAS committee analyzed stock levels of malaria commodities and produced a dashboard showing an imminent risk of stock out of different formulations of ACT (2-11 months, 1-5 years, and 6-13 years) at the SALAMA level. All RBM stakeholders were alerted and they adopted different strategies to face this situation, including: • Emergency procurement of AL by PMI and AS/AQ by Global Fund that can be rapidly mobilized and shipped in Madagascar in March 2020. Partial shipments have been received at SALAMA (reference Table 8). • Explore possibilities of early shipments of orders in the pipeline from PMI and Global Fund and change the transportation mechanism from sea to air if needed. This change has not been possible due to COVID-19. • Better management of existing stocks of ACTs at SALAMA and identify quantities to distribute to districts. The maximum stock levels were reduced to 2 months instead of 6 months. • Organize redeployment of quantities of malaria commodities from districts and CBS with overstock to districts with understock. The redeployment also constitutes a strategy to avoid expiration in districts with overstock.

In February, the UTGL (Unité Technique de Gestion Logistique) was assigned to lead the redeployment activities in close coordination with regions and districts. IMPACT provided technical and financial support to prepare and conduct supervisions in all the 13 USAID-supported regions during February and March. Supervisions were completed in 56 districts (out of 78 districts) and 92 health centers; 22 districts were inaccessible due to poor road conditions in the rainy season. Fourteen (14) members of UTGL and NMCP staff, 10 staff from Equipes de Management de Région (EMAR), 21 staff from Equipes de Management de District (EMAD), and the IMPACT Regional Logistics Advisors (RLA) were mobilized for this exercise (see Table 10).

On February 20th, a team building session was organized with the UTGL members to strengthen their capacity in analyzing services data (people tested and malaria cases treated) reported through District Health Information Software II (DHIS2) and comparing it with logistics data (consumptions of RDT and ACTs, stocks available) to assess quantities needed in CSBs and Pha-G-Dis and estimate extra quantities available to redeploy to other CSB and Pha-G-Dis. To facilitate the redeployment exercise, the Secretary General of the MOPH signed notes to inform the regions and districts on better management of stocks to face this critical situation of shortage of stocks.

Table 10: Summary of the supervisions visits to organize the redeployment of health commodities by Region Number of facilities Supervisors by affiliation Dates of visit supervised # Region Pha-G-Dis CSB CHRD Central EMAR EMAD IMPACT ATR UCP 1 AMORON I MANIA 4 6 0 1 1 0 0 1 Mar 20 – Apr 6 2 ANALANJIROFO 3 9 2 2 1 3 1 Mar 1 - 15 3 ATSIMO 5 5 0 2 0 2 3 Feb 23 - Mar 7 ANDREFANA 4 ATSINANANA 5 11 3 2 1 5 1 Mar 18 – 3 5 BOENY 3 16 0 0 1 3 1 Mar 10 - 24 6 DIANA 5 0 0 2 0 0 1 Feb 28 - Mar18

Number of facilities Supervisors by affiliation Dates of visit supervised # Region Pha-G-Dis CSB CHRD Central EMAR EMAD IMPACT ATR UCP 7 HAUTE MATSIATRA 4 10 0 0 1 0 1 1 Mar 22 – Apr 2 8 MELAKY 1 1 0 0 0 0 1 Mar 15 - 16 9 MENABE 4 0 0 1 1 0 1 Feb 24 - Mar 8 10 SAVA 4 0 0 1 1 0 1 Mar 1-10 11 SOFIA 6 4 0 1 1 0 1 Mar 5 - 28 13 VAKINANKARATRA 7 22 3 1 1 5 1 1 Feb 25 - Mar 8 12 VATOVAVY 6 8 0 1 1 3 1 1 Mar 1 – 24 FITOVINANY TOTAL 56 92 8 14 10 21 14 4

Table 11: Quantities of malaria commodities redeployed at district and CSB levels

Quantity Quantity Total Total value Products Unit redeployed redeployed quantity Unit price $ $ from Pha-G -Dis from CSB redeployed

Artesunate/Amodiaquine 25/67.5 mg Tablet, 25 x 3 dose 11,806 894 12,700 $ 0.11 $ 1,415.14 Blister Pack Tablets Artesunate/Amodiaquine 50/135 mg Tablet, 25 x 3 dose 6,806 351 7,157 $ 0.20 $ 1,421.18 Blister Pack Tablets Artesunate/Amodiaquine 100/270 mg Tablet, 25 x 3 dose 11,015 431 11,446 $ 0.29 $ 3,319.34 Blister Pack Tablets Artesunate/Amodiaquine 100/270 mg Tablet, 25 x 6 dose 9,274 593 9,867 $ 0.73 $ 7,191.63 Blister Pack Tablets Artesunate (w/ 1 Amp NaHCO3 5% + 1 Amp NaCl vial 1,737 152 1,889 $ 1.74 $ 3,286.86 0.9%) 60 mg Vial, 1 Set Malaria Rapid Diagnostic Test (RDT) HRP2/pLDH (Pf/PAN) test/kit 52,566 3,954 56,520 $ 0.31 $ 17,763.43 Cassette, 25 Tests Sulfadoxine/Pyrimethamine tablet 48,215 14,955 63,170 $ 0.13 $ 8,324.12 500/25 mg Tablet, 150 Tablets Total value $ 42,721.70

This activity was extended to other health commodities. The supervisors assessed stocks of FP commodities by detecting overstocks and redeploying them to other districts in need.

Table 12: Table of quantities of Family Planning commodities redeployed at district level Product Unit Quantity Unit price Total value Depot (IM) Medroxyprogesterone Acetate 150 mg/mL (1 mL)- vial 6,690 $ 0.65 $ 4,348.50 (Depo-Provera, Triclofem) Levonorgestrel/Ethinyl Estradiol 150/30 mcg + Fe 75 mg, 28 cycle 642 $ 0.30 $ 192.60 Tablets/Cycle (PS), Etonogestrel 68 mg/Rod, 1 Rod Implant, 1 Each [MSD] Doses 580 $ 8.50 $ 4,930.00 Male Condom Piece 576 $ 0.04 $ 23.04 Total value $ 9,494.14

The FP commodities were redeployed from 12 overstocked districts to 14 other districts.

Below are the achievements of the supervision/redeployment activity: • Stocks at risk of expiration in districts with overstocks were redeployed to other districts in need. • There is no longer stock out of malaria commodities or overstocks in five districts in Menabe. • Fifteen (15) CSBs are no longer stocked out in Boeny. • The four districts of SAVA have malaria commodities continuously without any district experiencing a stock out during Quarter 2.

However, the following areas of improvement were also identified: • CSB staff need to be trained in stock management. • District managers need to monitor expiration dates and organize redeployment quickly to avoid expiration and destruction of products. • The GAS Committee at the district level needs to be strengthened for better coordination between districts, projects, and donors to avoid duplication which can lead to overstock. • Thirty-eight (38) Pha-G-Dis still need equipment to comply with best storages practices: boxes are placed directly on the ground, lack of refrigerator to store Oxytocin and other thermosensitive products, etc. • Logistics data inconsistencies have been identified in 19 Pha-G-Dis visited and require further investigation. Quantities delivered by SALAMA or districts were not recorded in stock cards or in the CHANNEL software. This is leading inaccuracy of data and inaccurate quantification and causes an issue with traceability.

IMPACT is planning to organize a meeting with all supervisors to share achievements, lessons learned, successes, and challenges observed during the redeployment, and will lead the team to set up recommendations to address these in the upcoming quarters. A report will be developed and shared with RBM stakeholders in May 2020 and based on findings and recommendations, a plan with corrective measures will be developed.

Strengthening distribution process of MNCH commodities

In Quarter 2, IMPACT supported DSFa to create a TWG to improve coordination of stakeholders involved in the MNCH commodities supply chain. IMPACT reinforced the capacity of the Service de Maternité Sans Risques (SMSR) to organize three meetings of the TWG that led to: • Identification of all technical and financial partners involved in the supply chain functions of MNCH commodities. • Development of a dashboard for monitoring stock status of MNCH commodities at the central level in order to detect stocks imbalances and implement corrective measures. • Development and validation of a report format that will be used by districts while reporting on logistics data (consumption, stocks available, days of stock out, expiration dates, etc.) to the central level.

From these meetings, the following activities have been identified: • The TWG should hold periodic coordination meetings on commodity management at the central level (stock management, distribution planning) on the last Thursday of each month.

• The DSFa will send an official note to detail the distribution process of MNCH commodities at different levels, including on use, storage conditions, and reporting by March 2020. • RLA should ensure that management of MNCH commodities is integrated into the activities of the GAS District Committees.

In March, the RLA completed the inventory of the cold chain system in the 13 USAID-supported regions. 41 (out of 78) Pha-G-Dis have a proper functioning cold chain for the storage of oxytocin and other thermosensitive medicines. The other 37 Pha-G-Dis use the district cold chain system available for vaccines. IMPACT shared the Secretary General‘s note on the storage of oxytocin in the EPI cold chain. This integration is still a challenge as vaccines are still a priority and when there is not enough space in the cold chain, Oxytocin and the other thermosensitive medicines are removed from the cold chain and put on the shelf at room temperature. IMPACT will advocate to the DPLMT to mobilize funding to buy refrigerators for the 37 Pha-G-Dis or at least standardize procedures of co-storage in the vaccine fridges to minimize risk to the vaccine cold chain storage.

Implementation of Last Mile Distribution strategy in collaboration with Unité de Coordination des Projets (UCP) - Global Fund

IMPACT continued to support the Service de District de Santé Publique (SDSP) to implement the last mile distribution through an MOU with all 114 SDSP for the storage and transportation of malaria, HIV/AIDS, and Tuberculosis products. The last mile strategy defines the mechanism of reimbursement as the following:

• Pha-G-Dis will be paid 2% of the value of inventory stock at end of the month. • Pha-Ge-Com will be reimbursed transportation fees as per the following:

- Fixed fee of 5,000 Ariary to all CSBs located less than 10km from the Pha-G-Dis. - Fixed fee of 5,000 Ariary and additional amount of 300 Ariary per km calculated to prorated distance (Km) to all CSBs located more than 10 km from the Pha-G-Dis. • Pha-G-Dis and CSBs should submit to the SDSP, a correct and original invoice with supporting documents (a signed copy of an MOU, the stock inventory report with values, a correct purchase order, stock status analysis within Min-Max stock status ) on time (15th day following the end of quarter). • Request of reimbursement is submitted by the SDSP to the DSSB every 30th day following the end of the quarter. • Once verified and approved by the DSSB, the request is sent to DPLMT for a second verification and approval, and then finally submitted to UCP for payment.

IMPACT is finalizing a MOU that will be signed with SDSP in Quarter 3 to pay storage and transportation fees for MNCH and FP commodities. The same reimbursement mechanism described above will apply.

In Quarter 2, the RLAs collaborated with Assistants Techniques Régionaux (ATR) from UCP to collect and validate invoices and supporting documents that were submitted by 22 districts and 43 CSBs. The SDSP then submitted the request for payments to UCP. As of now, the invoices are still being processed and not yet paid. There are multiple interveners to review and validate invoices before payment (districts, regions, DSSB, DPLMT, fiscal agents, UCP). The payment request circuit is as follows (used

29 for GF payment): The SDSPs send the PJs to the regional level. Once they have arrived at the region, the ATR and GCR carry out the verification and validation, and then establish the request for reimbursement. Then, the GRC sends the request directly to the UCP. Once the request of reimbursement reaches at UCP, the copies are sent to DSSB and then to DPLMT for verification, and then after to Agent fiscals and lastly to UCP. Once all entities approve the request, then UCP proceed to transfer the funds to the SDSP account.

In Quarter 3, IMPACT will continue supporting EMAD, EMAR, and ACCESS to inform and guide facilities in the submission of necessary documents to profit from the Last Mile Distribution policy.

IR2.1.5: Conduct TOT and cascade trainings for supply chain management at all levels of the supply chain, in collaboration with the UCP/Global Fund, ACCESS, Mahefa Miaraka and other partners

Coordination forums at region and district levels In Quarter 2, IMPACT continued to advocate for setting up UTGL and GAS committees in regions and districts. At the end of March, 12 out of 13 UTGL were established and the plan is to set up the UTGL in all the 13 regions by end of April. Seventy-five (75) districts (out of 78) have officially set up GAS committees and the 3 remaining GAS committees will be established in Melaky in April 2020. During this quarter, the RLA supported 44 GAS district committees to organize meetings, analyze data on logistics, monitor stocks available at districts, detected stock imbalances, and planned redeployment to correct stock imbalances and reduce stock outs. At the regional level, the UTGL was made up of the EMARs and the technical and financial partners that exist in the region. For example, in the Sofia region, the UTGL was made up of EMAR (DRSP, SMS Manager, GIS Manager, Malaria Manager, FP and MSR Manager, SIGL Manager, TB / HIV Manager) and PTFs (ATR / UCP, CRL IMPACT, Mahefa Miaraka, ACCESS). Similarly, at the district level, the GAS committee was made up of EMADs and the PTFs that exist in the district. For example, in Mandoto district, the GAS committee was made up of EMAD (Médecin Inspecteur, Technical Assistant, Malaria Manager, PF/SR Manager, TB / HIV AIDS Manager) and technical and financial partners (ACCESS).

Following the MOU signed between the three implementing partners (IMPACT, Mahefa Miaraka, and ACCESS) to better coordinate interventions at all levels (central, district, and CSB), RLAs have organized 32 coordination meetings with the three implementing partners to share information on stocks status at the district level, planned joint supervisions at districts and CSB on stock management, preparation for USAID visits, and contribution to COVID-19 prevention and response efforts within their regions. During the coordination meetings, IMPACT presents information on the availability of commodities at the Pha-G-Dis level (stocks, SALAMA delivery, and redeployed quantity), as well as the action plan to address issues encountered. During the coordination meetings the two projects share the progress of activities and ongoing plans. In the event of redeployment of commodities, the two projects communicate and coordinate transportation to CSBs. There is still a need to share information on time especially with the ACCESS teams (AS) supporting the CSB and community levels.

Formative supervision to reinforce capacity of districts on stock management and use of CHANNEL software

In Quarter 2, the RLA conducted formative supervision in 39 Pha-G-Dis, 146 Pha-Ge-Com, and 3 CHRD. During the supervision visits, RLAs provided capacity building on the use of CHANNEL, assisted the

30 stock managers in reconciling the physical inventory vs CHANNEL data, and compared data reported on available stock and consumption at health centers through DHIS2 to detect inconsistency and proceed with corrections. The RLA have checked storage conditions and inventory stock reports to evaluate stock status and ensure that expiration dates were being monitored correctly to avoid expiration and destruction of products. The supervision and EMMP guides are applied to detect weaknesses and develop an action plan with supervisees with corrective measures.

The criteria for prioritizing supervisions include:

• Pha-G-Dis stock level: After the stock status analysis, prioritize the Pha-G-Dis that have overstocks so that IMPACT can redeploy commodities to support districts that are under stocked or stocked out. • Skill level of the service provider: classify the skill level of the Pha-G-Dis in three categories (good, medium, poor). Prioritize the weakest so that their performance will be improved. • Evolution of the LMIS report: prioritize the districts that have a problem with sending logistical reports, then provide capacity building • Human resources: make a human resources inventory, then identify if there are new Pha-G-Dis service providers or a program manager in the districts. Then, prioritize these districts so that IMPACT can carry out on-the-job training

Trainings on stock management

In FY20, a training plan has been developed and finalized to conduct nationwide trainings of stock managers at district and health center levels, as well as CHVs, to cover the 22 regions of Madagascar. The training plan led by UTGL and all partners (UCP Global Fund, ACCESS, IMPACT, Mahefa Miaraka, and UNFPA) will provide technical and financial support and improvement.

From January 26th to 29th IMPACT and ACCESS conducted TOTs in Foulpointe, the region of Atsinanana, where 33 people attended and were enabled to conduct cascade trainings of health workers and CHVs. Five (5) trainers came from IMPACT, DSSB, DPLMT, ACCESS, and Mahefa Miaraka.

Table 13: Participants in the training of trainers on stock management in Foulpointe

Participants Male Female Total EMAR 1 4 5 EMAD 5 7 12 ACCESS 9 5 14 IMPACT 2 0 2 Total 17 16 33

During Quarter 2, IMPACT collaborated with ACCESS to complete trainings of 117 CSB staff from two districts of the region of Analanjirofo (Mananara Nord and Marontsetra). The CSB staff came from 39 out of a total of 51 CSBs, which is 76% of the total CSBs in these two regions. The participants were trained on stock inventory management of essential health commodities to build their capacity to correctly estimate needs, use of stock cards, report movements of stock, timely and correct reporting on consumption and logistics data, and how to monitor expiration dates.

Table 14: Participants to the training of CSB staff on stock management, Analanjirofo region Districts Dates Male Female Total Note 23 CSB Chiefs, Maroantsetra Jan 29-31, 2020 51 18 69 23 Comité de Gestion (CoGe) Presidents, 23 dispensers 16 CSB chiefs, February 5-7, Mananara Nord 30 18 48 16 (CoGe) Presidents, 2020 16 dispensers Total 81 36 117

The cascade trainings of CSBs will be led by ACCESS and UCP-Global Fund in other regions. IMPACT will continue to conduct TOTs and participate in the cascade trainings.

IR2.1.6: Assist the MOPH in creating a five-year LMIS strengthening roadmap and developing and testing a new LMIS software using results from the LMIS in-depth evaluation

In 2019, IMPACT conducted an evaluation of the existing LMIS to collect necessary information that will guide the development of the LMIS roadmap. The LMIS assessment report was finalized during Quarter 2 and is being edited and formatted to be shared with USAID and DPMLT in early April. A workshop to develop the LMIS roadmap was started but has been suspended due to COVID-19.

In the current system, CHANNEL is the only software recognized by the MOPH and used in the public sector. Through supervision visits conducted by the RLA, it is noted that using CHANNEL software as a management tool remains a challenge for most districts (lack of equipment, lack of training on basic computer usage, delay in entering data per each stock movement). The CHANNEL software is used to manage the stock of commodities and report on logistics data (consumption, stock on hand, stock out, wastage) needed for decision-making.

CHANNEL is installed in all the 78 Pha-G-Dis, but the reporting rate is still low with only 34/78 districts having reported timely and complete data for January. Every month, the RLA are reminding Pha-G-Dis to ensure that data should be updated in CHANNEL and submitted to DPLMT on time. IMPACT leveraged resources with UCP-Global Fund and World Bank to equip Pha-G-Dis with laptops. Currently, 26 out of 37 laptops procured by IMPACT have been distributed to 26 Pha-G-Dis. The 11 remaining laptops will be distributed in Quarter 3.

IR2.1.7: Generate evidence through a national supply chain assessment and End User Verification surveys to develop adequate strategies, policies, and SOPs for securing commodities and strengthening the public supply chain

IMPACT plans to conduct two EUV surveys and one National Supply Chain Assessment (NSCA) in FY20 under MOPH leadership.

IMPACT hosted a training of 24 EUV surveyors and 12 supervisors to ensure administration of the EUV questionnaire and data validation. These 36 people were trained in SurveyCTO data collection and the questionnaires were adapted to Madagascar, pre-tested, and revised. In addition, the 12 supervisors were trained in data validation.

From January 13th to 31st, data collection was conducted in 77 CSBs, 3 CHRD, 30 Pha-G-Dis, and the central medical store (SALAMA). The data relates to malaria, FP, and MNCH stock management,

32 storage management, and institutional management. SurveyCTO was used for data collection and analysis, and the database is kept on the IMPACT server. A visualization tool was also developed for all three priority health products and a report on findings, key observations, and recommendations will be disseminated in Quarter 3.

The following key points and recommendations emerged from this assessment:

Key malaria observations:

• 96% (77/80) of SDPs visited have some type of WHO pre-qualified AS-AQ formulation, and 94% have sufficient quantity of RDTs. However, only 64% (51/80) of SDPs had at least one type of ACT formulation to treat children under five years; • 100% of malaria cases were diagnosed and confirmed by using RDTs; • No ACT was administered to children under five years not diagnosed with malaria; • 60% of health facilities have staff trained in malaria case management, but only 46% possess the updated treatment guidelines on malaria case management; and • A majority of the health facilities visited did not systematically update anti-malarial stock cards (AS- AQ: 43%, RDTs: 38%, and SP: 45%).

Key FP/RH observations:

• Only 10-25% of health facilities (CSB and CHRD) stocked commodities according to plan. Also, less than 50% of health facilities regularly updated stock cards. • The low levels of stocking according to plan increases the risk for stock-outs and expiration. • Stock cards were regularly updated in district pharmacies (Pha-G-Dis): 70% of district pharmacies regularly updated stock cards.

Key MNCH observations:

• High stock-out rates observed for commodities, particularly Ampicillin 500mg and Gentamicin 40 mg, are attributable to unavailability at the district and central levels due to limited funding for procurements. There is need to improve quantification and procurement via SALAMA as those commodities are normally sold via the FANOME recovery system. • Temperature monitoring of the cold chain is not regularly conducted. Only 36% (45/125) of storage had a temperature monitoring device, and 24% (11/45) do not use a temperature log. • Inventory management tasks, such updating stock cards, remain a major challenge at the health facilities.

Recommendations:

• Continue periodic supportive formative supervisions by strengthening staff capacities on inventory management and best practices for warehouse and stock management. • Work with all stakeholders to improve the availability of all anti-malarials presentations at all levels (central-SALAMA, districts, and facilities) within the required min-max levels and to ensure order forms are completed with adequate quantities. • Distribute copies of the updated malaria treatment guidelines to all levels. • The central committee for supply chain and stock management will monitor information on stock levels of the district pharmacies and health facilities and organize redeployment as needed.

• IMPACT will work with the MOPH at district levels to provide on-the-job training on temperature monitoring and storage management practices.

The EUV survey is supported by the MOPH through the General Secretary, the DGFS, DPLMT, DSFa, DSSB, DEPSI, and the NMCP.

IMPACT continues to prepare the first NSCA planned in 2020. Meetings were organized with various directions of the MOPH to introduce the NSCA and identify members to form a NSCA technical committee that will lead the assessment. The TOR and assessment protocol for the NSCA have been adapted to the Madagascar context, the tools and materials were translated into French, and technical assistance has been secured from GHSC-PSM.

The table below summarizes the original schedule of activities planned in the NSCA roadmap.

Table 15: The original schedule of activities planned in the NSCA roadmap. STEPS TIMING ACTIONS

1- Conduct a high-level advocacy 2- Organize an advocacy meeting, Introduction of NSCA January-March 2020 mobilization/ownership/engagement of technical and financial partners

1- Organize a review of resource mobilization, engage technical and financial partners and finalize Planning April-May 2020 action plan 2- Set up and orient the members of the NSCA committee

1- Test/validate evaluation tools and plan NSCA implementation Preparations June 2020 2- Adapt training tools and train field workers (tools are already available but need to be adapted to Madagascar context)

Data collection July 2020 1- Collect data within sampled structures

1- Data processing, analysis, development, and Data analysis and report writing August 2020 validation of the report

1- Workshop dissemination of the report based on Dissemination End of September 2020 recommendations received during validation

Due to COVID-19, the NSCA has been postponed to Year 3 and funds have been redirected to the management of Covid-19 in Madagascar.

IR2.1.8: Conduct continuous distribution of LLINs in 12 targeted districts.

Procure 1,000,000 LLINs in coordination with the National Malaria Control Program, PSM, Roll Back Malaria, and PMI and organize the logistics to store 1,000,000 LLINs in PSI's warehouse and transport the LLINs to 12 targeted districts (approximately 500,000 households)

IMPACT received the 1,000,000 LLINs to be distributed through the cCD, which are stored at IMPACT’s central warehouse:

- 924,700 standard LLINs received in December 2019 - 75,300 Pyrethroid-PBO LLINs (new generation) received in January 2020.

According to the supply plan for the 12 targeted districts, the transportation of LLINs to PARC, PA, and Kom’Lay in the 06 districts of Group 1 (see below in table 15) was completed in Quarter 2.

Table 16: Number of LLINs transported from PARC and PAs to Kom’Lay Households level (% achievement PARC level PA level Kom’Lay level compared to # of ITN received at PARC level) Targeted Targeted Targeted LLINs to LLINs LLINs LLINs LLINs to LLINs Number LLINs to be be received distributed Group 1 transported % be received % % % of PARC transported received by to to PARC received by PA to PARC by Kom’Lay households by PA Kom’Lay Toamasina II 01 13 900 13 900 100% 13 900 11 900 86% 11 900 8 455 71% 7 148 51% Brickaville 01 12 200 12 200 100% 12 200 6 100 50% 6 100 5 520 90% 1 961 16% Toliara II 01 19 800 19 800 100% 19 800 19 600 99% 19 600 19 200 98% 12 088 61% Manakara 01 26 900 26 900 100% 26 900 26 900 100% 26 900 5 405 20% 611 2% Vohipeno 01 8 700 8 700 100% 8 700 8 700 100% 8 700 2 325 27% 935 11% Mananjary 01 22 500 22 500 100% 22 500 13 100 58% 13 100 10 650 81% 5 864 26% TOTAL 06 104 000 104 000 100% 104 000 86 300 86 300 51 555 60% 28 607 28 %

Among the 104,000 LLINs delivered to PARCs in January 2020, 86,300 LLINs were received by PAs (83%). The 86,300 LLINs represent the need for one month for the communes belonging in the 6 districts. The remaining quantity will serve as buffer stocks for PAs and Kom’Lay in the event of an increase of LLIN needs at the community level or to deal with the risk of stock out.

To address the malaria outbreak, the extension of the cCD activities in the districts of Port Bergé, Antanambao Manampotsy, Mahanoro, Farafangana, Vangaindrano and Bekily will be planned during Quarter 3. The action plan is as follows: • Organizing TOT within each district in May 2020; • Transportation of LLINs from central level to PARCs of the 06 districts scheduled in May 2020; • Recovery of LLINs from PARC level by PAs: late in May and early June 2020; • Distribution of LLINs to the community by Kom’Lay: June 2020; • Social mobilization and broadcasting of spots: June 2020.

Develop training materials and organize cascade trainings of key actors involved in the continuous distribution of LLINs, including PAs, CHVs, teachers, school directors, etc.

The training curriculum was reviewed and validated and the TOT at the central level for Group 1 was finalized. IMPACT conducted cascade trainings of CSB Chiefs (from MoH), ZAP Chiefs, educational support areas (from MENETP), Technical Assistants (TA from IMPACT), and Kom’Lay members (community actors: Fokontany Chiefs, CHV mobilizers, CHV distributors, school directors, and teachers).

Table 17: Cascade training achievements in Quarter 2 NUMBER OF TRAINED ACTORS LEVEL TRAINERS PARTICIPANTS TOAMASINA II BRICKAVILLE MANANJARY MANAKARA VOHIPENO TOLIARA II TOTAL Targeted % DLMT-NMCP- EMAR-EMAD- CENTRAL DGS-IMPACT DRENETP-CISCO- 10 8 8 10 8 10 54 54 100% Trainers SRD-SUP TA EMAR-EMAD- Chief of CSB DRENETP- DISTRICT Chief of ZAP 55 51 66 41 18 67 298 300 99% CISCO-SRD- TA SUP TA Chief of CSB Kom’Lay members: COMMUNE Chief of ZAP chief of fokontany, 997 1019 1331 591 572 1673 6183 7927 78% TA CHVs and teachers

The training of Kom’Lay members in 28 communes of Manakara and 06 communes of Vohipeno have been postponed due to the COVID-19 pandemic.

Train and supervise new PARCs and PAs for Continuous LLIN Distribution.

In February 2020, 4 PARC and 80 PA in Antanambao Manampotsy, Mahanoro, Farafangana, and Vangaindrano districts received training on the LLIN cCD in addition to those trained in Quarter 1. The attendance rate was 100% with 53 men and 31 women. The two-day training took place in the district where the PARC are located and focused on the following themes:

• Malaria disease and prevention • Distribution of LLINs through continuous distribution • Management tools and the transportation and storage payment system

A follow-up session/on-job training will be scheduled by SPDs for the trained PA and PARC during the monthly supervision visits.

Coordination of continuous distribution of LLINs in 12 targeted districts IMPACT continues to support the monthly CNC coordination meetings (including the MENETP team) to monitor field activities and address challenges encountered during the LLINs distribution. Due to COVID-19, these meetings are conducted through conference calls.

The cCD operational team at the district level (TA Supervisor and TA) participate in regular coordination meetings with EMAD and the USAID implementing partners ACCESS and TIPTOP.

In Quarter 2, IMPACT recorded that 6,183 Kom’Lay among 7,927 were functional (78% are trained). These Kom’Lay have received approval from mayors and CSB chiefs.

In January 2020, organic cultivation cooperatives in the district of Brickaville (Atsinanana region) expressed their concern to the SDSP and local authorities for the safety of their production of cloves

36 and saffron and their opposition to the distribution of LLINs. To address this, a delegation composed of the DLMT, NMCP, EMAR of Atsinanana region, and IMPACT went to Brickaville and Anivorano to meet and discuss the LLIN distribution with the cooperatives.

The resolutions taken after this meeting are the following:

• Exclude Razanaka and Anivorano communes from the cCD intervention. • Since the population refuses to use LLINs, then the NMCP will collaborate with SYMABIO (organic cultivation syndicate) through social mobilization to strengthen other malaria preventive methods such as removing bushes, water stagnation, etc. Communication tools will be developed and distributed. Additionally, NMCP and SDSP will work together to sensitize the local population to seek early treatment after the onset of malaria symptoms (mainly fever). SDSP will conduct follow- up actions to ensure that the treatment is fully completed and surveillance systems will be set up. Preventive measures will be provided to households receiving LLINs during LLIN mass distribution campaigns to prevent contamination of insecticides from ITN for organic products such as cloves.

Official launch of the cCD activities

On February 13th, 2020, an official launch of the LLINs cCD activities was organized in the commune of Mahavelona, district of Tamatave II, Atsinanana region.

This event was attended by the Minister of Public Health, the Minister of Education, Minister of Population, the Director of USAID, representatives from implementing partners, and local authorities (regional, district, and commune).

Further details on the event launch of the LLINs cCD activities are reported in the IR5 section.

Set up an M&E system to collect, analyze, and disseminate accurate and timely data on LLIN distributed through continuous distribution in approximately 3,095 Kom'Lay. Following the validation of the cCD strategies, management and reporting tools were reviewed in Quarter 2 and transported to the Kom’Lay with the LLINs.

The M&E team participated by:

• Training 74 Kom'Lay (35 men and 39 women), 13 Chief Fokontany, 41 CHVs, 11 school directors, and 9 teachers from 14 Fokontany in the rural commune of Mahavelona. The purpose of the training focused on the use of management tools and waste management. • Developing cCD data collection tools to be used and completed by TA and TA supervisors who will submit the data to the central team. The data will help the monitoring of the progress of the cCD activities by the central team (CNC) based in Antananarivo.

The reporting scheme for cCD activities follows the provisional reporting circuit as described in the table 18.

Table 18: Provisional reporting scheme for cCD activities Level Deadline for submission of the report Kom’Lay prepare the monthly report and submit it Report for the previous month is Fokontany to CSB submitted by 07th of the following month Report for the previous month is TA collect the monthly reports from CSBs and submit Commune submitted by 15th of the following month them to TA Supervisor (Sub-District) TA Supervisor compile all the reports received from Report for the previous month is District TA and submit them to the IMPACT Monitoring and submitted by 20th of the following month Evaluation central team IMPACT Monitoring and Evaluation central team, Report for the previous month is compiles monthly reports received from TA submitted by 30th of the following month Supervisor and submit to IMPACT cCD project Central manager Final verification and validation of the report by the Two days after reception of the report IMPACT cCD project manager from the monitoring and evaluation team

The final and approved cCD reporting schemes agreed with the committee (CNC) is described in the graphic below. CNC developed this scheme in Quarter 2 and the implementation is scheduled in Quarter 3.

Final cCD reporting scheme:

• At the community level, the Kom'Lay fill out a paper template called the “Kom'Lay report” each month using information collected from the management tools at their disposal (voucher, LLIN request register, awareness and distribution register, stock sheet, etc.). Then, the Kom’Lay send the completed report to the CSBs. • At the commune level, the TAs (Techniciens Accompagnateurs) compile the reports from Kom’Lay to get them approved by the ZAP Chiefs and the CSB Chiefs. Then, they send the physical reports to the district level. • At the district level, the reports are compiled by TA Supervisors and entered digitally into DHIS2. After the MOPH’s district (SDSP) team’s approval, they are sent to DRSP.

• At the regional level, the reports approved by the DRSP are sent to the central level to DEPSI. • At the central level, the consolidated reports approved by DEPSI and the NMCP and will be shared with MENETP, IMPACT, and the other partners.

IMPACT is working with Measure Evaluation and DEPSI to discuss on how the cCD monthly report will be integrated into the National DHIS2 system.

Develop and disseminate Behavior Change Communication through mass media campaigns, household visits, radio spots, posters, etc. to mobilize households and school children in the 12 targeted districts to correctly use and maintain LLINs Job aids, posters, and key messages related to malaria were developed, produced, and disseminated. (In Quarter 2, IMPACT continued broadcasting cCD spots and messages

IR2.1.9: Provide technical and financial support to the NMCP to develop and implement activities for the preparation of 2021 LLIN campaign including the procurement of LLIN As planned in the NSP 2018 - 2022, NMCP intended to organize a mass LLIN distribution campaign in the control districts in order to achieve the set objective to "Protect at least 90% of the population in the targeted areas by LLINs distribution including key populations, by the end of 2022" and achieve the LLINs universal coverage target.

In Quarter 2, preparatory activities started for the mass LLIN distribution campaign planned for June 2021, including LLIN procurement processes, mass campaign preparation meetings, and microplanning meetings.

Procurement of LLINs

• The technical specifications of standard and new generation LLINs were validated by the NMCP during the RBM meeting on March 20th, 2020. • The remaining orders of LLINs will be submitted to GHSC PSM in April 2020 after confirming the number of districts to be covered by new generation LLINs by NMCP. • The desired reception date of all LLINs will be February 2021.

Mass Campaign Preparation meetings During the annual AMP partners meeting in Geneva in January 2020, NMCP and the IMPACT team had discussions with AMP experts on the recommendations for the success of the 2021 LLIN mass campaign. The following outcomes were agreed:

• The planning of activities was developed and then validated within the CNC. • The budget process for the 2021 LLIN mass campaign activities was established. • The CNC will share the budget with all RBM partners for resource mobilization.

LLINs micro planning meeting: To carry out this activity, NMCP and IMPACT need capacity building in terms of microplanning for an LLIN mass distribution campaign (lessons learned from the 2018 campaign). Also, the AMP expert suggested an exchange visit in Togo to participate in its microplanning scheduled in May 2020. However, face to COVID-19, Togo postponed the trip at a later date.

Sub-IR 2.2: The public-sector supply chain achieves financial sustainability

IR2.2.1: Conduct a total cost analysis of the public supply chain and propose an alternative and more efficient supply chain model by establishing at least two scenarios with the MOPH to improve SALAMA's financial sustainability During Quarter 2, IMPACT prepared a Total Cost Analysis (TCA) of the supply chain as part of activities to develop the new PAIS. The STTA and local consultant advocated to set up a TCA committee composed of staff from various directions and the General Secretary office of the MOPH. The steering committee is made up of 17 representatives from the DGFS, DGR, DPLMT, DSSB, UNICEF and IMPACT.

From February 24th to 25th, IMPACT organized a two-day workshop with the TCA committee members to orient them on the study objectives, the TCA framework, the sampling method, the implementation process, the study sites, and the data collection tools.

IMPACT then organized a training of surveyors from February 27th to 28th. 24 surveyors were trained and were given a series of assessments to ensure competencies and necessary skills. The data collection forms for pharmacies, districts, and basic health centers were pre-tested on March 2nd in four facilities: the Pha-Ge-Com of Ampasanimalo and Ambohijanaka; the Pha-G-Dis in central Isotry; and the pharmacy of Joseph Ravoahangy Befelatanana University Hospital. The data collection forms were subsequently updated on March 3rd and validated by the steering committee. The questionnaires are currently being designed in an online software that can be uploaded on smartphones and used to facilitate data collection.

Due to the COVID-19 situation, data collection has been postponed to a later date once the situation improves. It is anticipated that data analysis will be completed by the end of September 2020.

IR2.2.2: Strengthen management of FANOME at Pha-G-Dis and PhaGeCom levels to increase transparency and good governance.

This activity is awaiting the findings of the TCA to target interventions to improve the FANOME system.

III.3. IR 3: Expanded engagement of the commercial health sector to serve new health product markets according to health needs and consumer demand

Sub-IR 3.1: Commercial actors are incentivized to expand into new health product markets

IR3.1.1: Create partnerships with PSHP and non-PSHP members to collaborate in generating innovative solutions on transportation, data collection, and health-focused CSR and CSV. In Quarter 2, new members, such as NAJMI Pharma, Nutrizaza, the Louvre hotel, and Caisse Nationale de Prévoyance Sociale joined the PSHP in March 2020. NAJMI PHARMA, a pharmaceutical wholesaler, has a specific interest by participating in the regulatory text review and PPN, PDPN TMI TWG while Louvre Hotel, Nutrizaza and CNAPS are interested in setting-up Corporate Social Responsibility (CSR).

A virtual meeting with these new members is planned in Quarter 3 to share the health commission action plan and identify on how they can be involved. IMPACT is continuing to assist members of the health commission to define their contributions to UHC activities linked to IMPACT activities (availability and transport of commodities, etc.).

Private Sector Partnership Implementation Concerning the Corporate Social Responsibility (CSR) activity, Société Générale Bank and Telma are still collaborating with IMPACT to broadcast 10 TV spots, including five on malaria campaigns, three on FP, and two on MNCH. This is to support IR5. The contract between SOMAPHAR and IMPACT to transport health products is finalized and the aim is to provide a better solution for transporting quality health products from national to regional and district levels. IMPACT plans to extend this experience to the public sector. In addition, IMPACT is exploring a partnership with Energie De Madagascar (EDM), an electricity provider and member of the AXIAN Group located in 1,300 communes of Madagascar, to transport public commodities. IMPACT is finalizing the action plan with this company and an MOU will be signed in Quarter 3. IMPACT and EDM are discussing how to define the detail of the partnership by identifying regions, frequency of transport, and volume of commodities that it can support. As this is for transport of public sector commodities, IMPACT will shift the coordination with SALAMA to ensure sustainability.

IR3.1.2: Organize quarterly meetings to monitor and assess the progress of health commission action plan. The quarterly meeting to assess the progress of the health commission action plan was held on January 30th with 9 members in attendance. This quarterly meeting aimed to monitor achieved activities versus the action plan.

During the session, the president of the health commission presented the progress of the project and highlighted private sector’s contribution to IMPACT in Quarter 1:

Table 19: Activities planned, achievements and perspectives during the meeting Activity Planned Achievements Perspectives Mobilize members in - Two meetings have been held: - Develop simplified UHC document for the UHC - Monthly meeting of health commission private sector. where UHC was presented and - Organize meeting with the Director of CACSU to understood by the participants of the validate the document. health commission. - Present the document to PSHP active members. - Meeting with the Director of CACSU - Define contribution of members for UHC. (Cellule d’Appui à la Couverture Santé Universelle) in February 2020. Create new - New companies recruited. - Formalize recruitment by signing PSHP partnerships with membership form. private sector - Invite members to participate in IMPACT activities (TMA TWG, finding innovative solutions on transportation and LMIS data collection). Transport solutions - Meeting with SOMAPHAR to formalize an - Discussing modality and details process on agreement through a MOU on transportation with SOMAPHAR commodities transportation - Explore transportation partnership with Energie De Madagascar. Support IMPACT in - Outlet identification completed in - Identify outlets in SAVA. collecting LMIS data Atsinanana, Boeny, and Diana. - Train drug shops in Boeny, Menabe, and Diana and capacity building - Training completed in Atsinanana, (to coordinate with MOPH). of drug shop Analanjirofo and Boeny. Private sector participated on defining the agenda and shared best practices on financial and stock management

COVID-19: Activities showing that private sector collaborates with MOPH and all stakeholder to deal with Covid19. • PSHP and the health commission initiated a meeting with WHO on March 18th before any cases of COVID-19 had been confirmed in Madagascar. Over 50 companies participated in learning about the context, receiving guidance, exchanging knowledge, and asking questions about COVID-19. • The health commission is now providing communications support (flyers) to PSHP members on awareness of COVID-19 and is supporting the government and MOPH in sensitizing Malagasy population through SMS broadcasts. • The PSHP also coordinates support from the private sector, including from the AXIAN Group (a diversified entity operating in five key sectors: real estate, energy, telecoms, financial services, and innovation) who has offered financial support to Operational Commandment Centre and communities. • On March 22nd, the PSHP joined an emergency conference call with World Food Program, Bureau National de Gestion des Risques et des Catastrophes (BNGRC), major telecommunications operators, and companies from other sectors to discuss and evaluate the capacity of the telecommunications operators in supporting response efforts. During the meeting, the national CCO national has requested to the mobile companies to provide high quality Internet connection and phone calls to enable teleworking in Antananarivo.

IR3.1.3: Conduct mapping exercise to present IMPACT and LMIS data submission among representative sample of pharmacies and drug shops The process to identify pharmacies and drugs shops to collaborate with IMPACT was completed in the SAVA region. The objective of this exercise is to have a representative sample of pharmacies and drug shops for LMIS data reporting. The commercial sector (pharmacies and drug shops) will integrate the LMIS national system within DEPSI as planned in the TMA LMIS roadmap. In Quarter 2, IMPACT visited some the selected pharmacies (09) and drug shops in SAVA (25) to explain the purpose of the LMIS data collection.

As a result, an agreement letter was signed by 33 private actors (8 pharmacies and 25 drugs shops) to confirm their commitment, particularly in submitting their LMIS data to the national database. Below is the summary of the exercise:

Table 20: Findings during the mapping exercise in SAVA Drug Shops Pharmacies

Sex disaggregation of drug shop owners Sex disaggregation of pharmacy owners

72% of interviewed are Men and 28% Women 55% of pharmacy owner are women and 45% are men

Education level of drug shop owners Education level of pharmacy owners

40% of owners have University degrees 100% of owners have University degrees

Drugs shops affiliated with financial institutions

68% of drug shop are affiliated with financial Pharmacies affiliated with banks institution and 80% with OTIV compared to 100% of pharmacies are affiliated with bank. 20% with bank The repartition is showed above

While waiting for the LMIS assessment findings dissemination workshop, IMPACT proceed to analyze the results of the surveys related to the identification of outlet willingness to share their LMIS data in four regions (Atsinanana, DIANA, BOENY, SAVA). IMPACT found that Pharma Plus is the software used by many pharmacies for stock management. IMPACT then conducted phone interviews to ask Pharma Plus users about their satisfaction while using Pharma Plus and additional needs. The pharmacies expect to use software in order to help them to ensure efficiently their supply chain and stocks management and provide a clear and comprehensive financial situation.

In addition, IMPACT conducted a test using Maisha Meds software and a virtual meeting with the Maisha Meds team was held in Quarter 2. Maisha Meds is the stock and financial management tool used in Tanzania and Kenya under the ADDO program. During the virtual meeting, the adaptation of Maisha Meds as a tool to be adopted and used by drug shops in Madagascar was discussed. The selection of the final tools, such as stock, financial, and LMIS management for pharmacies and drug shops would be determined with the TMA TWG LMIS sub-committee in Quarter 3 after receiving the LMIS assessment report.

IR3.1.4: Ensure that the Health Commission members of the PSHP participate in the TWG and follow up on the roadmap as a way to engage the commercial sector to identify barriers in the health sector and provide solutions During Quarter 2, members of health commission continued to participate in the TWG.

Table 21: Participation TWG committee meetings Dates TWG / subcommittee Number of participants (/6 members) 15 January 2020 PPN PDPN 03 04 February 2020 Text and regulations 02 13 February 2020 PPN PDNP 03 06 March 2020 PPN PDPN 03 17 March 2020 Demand Creation Subcommittee 02 18 March 2020 TMA TWG 07* 19 March 2020 Text and regulations 00 *One private sector non PSHP member attended this TWG

The active participation of the health commission members in the TMA TWG workshops shows their willingness and interest to be involved on the improvement of the health market environment in Madagascar.

Main results from the TWG committee meetings:

• The private sector proposed an amendment to reduce AMM procedures which are perceived to be too long by the private sector and the need to clarify/document the private sector supply system per outlet type. • The private sector participated in the TWG during the presentation of the FP tax exemption. • The private sector wants to be integrated into the national quantification of FP products (GAS committee). The private sector will be trained and will participate to the FP quantification exercise using evidences such as use, need, etc. based on survey and routine data.

IR3.1.5a : Revitalize regional drug shop associations in preparation of the ADDO pilot phase to be conducted in Year 3 The Malagasy delegation’s trip to Tanzania on the Accredited Medicines Depot Initiative (ADDO) organized three advocacy meetings to introduce the ADDO concept to pharmacists in Antananarivo and the regions on January 17, January 22, and February 22. On February 22, approximately 300 pharmacists participated and were interested with the ADDO Tanzanian model. At the end of the meeting, pharmacists expressed their willingness to adapt this model to the Malagasy context in order to supervise depots and ensure that they are complying with best pharmacy practices. A steering committee for the ADDO program will be established in Quarter 3 with the DPLMT and in consultation with the National Order of Pharmacists.

Part of the ADDO process is to regroup regional drug shops into regional associations. From February 28th to 29th, IMPACT and DPLMT organized sensitization meetings coupled with training activities for regional drug outlets in the six districts of Boeny (Mahajanga I, Mahajanga II, Mitsinjo, Soalala, Marovoay, Ambato-Boeny). Forty-four (44) drug outlet representatives were oriented on existing regulations governing the opening and operation of drug outlets/depots (i.e. setting a minimum distance between pharmacies and depots, operating conditions, the list of drugs authorized for sale) and the financial management of depots. Participants also learned from IMPACT about the benefits of forming regional associations. Banyan Global led a session on financial management in collaboration with a partner bank and IMPACT will continue to support the creation of this regional association in Boeny.

IR3.1.5b : Develop curriculum for training of peer trainers with simplified materials and tools, to be used in piloting a sustainable mechanism for business strengthening program of drug shops IMPACT has begun to identify potential candidates to serve as Certified Peer Trainers (CPT) for drug shops, with a goal of establishing an affordable and sustainable drug shop training program throughout the country. As described under IR3.1.7, IMPACT is conducting its own business and financial management training for drug shops in five regions in Year 2. During these trainings, IMPACT selects trainees as potential CPT candidates to receive the TOT later. In subsequent years, the CPT certification process would be developed and tested along with the low-cost, sustainable peer training program. The sustainability concept to be tested is whether it is viable to use regional peer trainers with simple materials to conduct trainings at drug shops in the field, rather than using external

45 consultants with more expensive daily rates, travel costs, and infrastructure needs (e.g. renting hotel conference rooms).

The identification of CPT candidates began in Quarter 1 and continued during the business and financial management training in the Boeny region in February 2020, where six potential CPTs were identified. These trainings are conducted in conjunction with DPLMT’s regional awareness workshops, and DPLMT representatives observe and offer support during the business training. At the end of Quarter 2, a total of 11 potential CPT candidates had been identified, exceeding the Year 2 target of 10. With the goal of finding potential CPTs for all regions, additional candidates may be identified in other trainings this year. However, it is anticipated that some of the candidates may drop out before the Training of Trainers. Only drug shop owners operating in compliance with MOPH regulations are considered as potential CPT candidates. Since we are still at designing and learning phase, regional MOPH nor DPLMT were not yet involved in the process.

Identification criteria for these candidates were based on their participation, dynamism, and level of understanding during the training, as well as on the geographic distribution of drug shops in the region. The IMPACT team also evaluated criteria used by Catholic Relief Services in the selection of their Private Sector Provider peer leaders for their Savings and Internal Lending Communities (SILCs) in Madagascar and other countries. In addition, during Quarters 1 and 2 the project generated estimated cost and revenue projections, to explore the financial viability of the CPT model. After analyzing those projections, it appears that due to the limited number of drug shops in many districts and the large distances between drug shops, it might not be financially viable for CPTs to deliver trainings independently. This discovery is an example of the team’s commitment to “failing fast,” part of an adaptive management approach to exploring this innovative model, enabling the team to revise key assumptions and make necessary adjustments early, before investing substantial time and resources in an approach that will not work. The team is currently considering other approaches, for example having the CPTs be part of the regional drug shop association rather than trying to function as independent operators.

Due to the COVID-19 pandemic, the last three regional business and financial management trainings for drug shops, planned in Quarters 2 and 3, will be postponed until later in Year 2. These training delays will also delay the on-going adaptations of the simplified training curriculum. The development of the TOT curriculum, which was scheduled to begin in Quarter 3 will be rescheduled for Year 3 Quarter 1. The TOT for CPT candidates would then be expected to happen in Year 3 Quarter 2.

Increase access to finance for private health commodities supply chain stakeholders

Smaller urban and peri-urban pharmacies have limited financing options because wholesalers and financial institutions view them as being riskier. In addition, drug shops and rural pharmacies have minimal access to finance and are generally forced to pay cash when purchasing health commodities from both wholesalers and pharmacies. This lack of financing impacts the ability of these commercial businesses to expand and to maintain adequate levels of essential commodities stocks, resulting in stock-outs. In Quarter 2, IMPACT continued to provide technical assistance to the partner banks in developing tailored financial services or products for health commodity supply chain stakeholders,

46 identifying the financial needs of health commodities enterprises, presenting those needs to bank teams, and then working with them to conceptualize new financial products.

IR3.1.6: Strengthening partner banks and other financial institutions' capacity to better serve private health commodities supply chain. In Quarter 2, IMPACT’s support to partner banks focused on bank staff training and on finalizing the development of financial products for PAs, drug shops and small pharmacies, and a COVID-19 loan product. Revise capacity building plans and training curricula for DCA partner banks to incorporate GESI issues and as needed, to consider newly identified needs.

The team took advantage of the visit of an international GESI expert in March 2020 for the IMPACT GESI workshop to discuss how to integrate GESI issues into the training provided to DCA partner banks. In Q3, the team will incorporate GESI issues into the existing presentation made to bank staff at regional branches about the IMPACT project and business opportunities in the health commodities sector. A meeting with the partner banks management will be planned for a later date to increase their awareness of GESI issues and to determine if there is interest in helping the banks’ training departments to establish a more in-depth training on GESI issues within the health sector.

Train and support DCA partner banks in credit analysis and loan structuring for health commodities businesses

In Quarter 2, IMPACT provided training to 41 staff (16 women, 25 men) at AccèsBanque Madagascar (ABM) and Baobab Banque branches in Mahajanga (February 26) and Toliara (March 2). This brings the total of bank staff trained in Year 2 to 90 (41 women, 49 men), representing 75 percent of the annual target of 120.

These training sessions focus on the business opportunities for the banks in terms of the financing needs of health commodities enterprises and the appropriate financial products that the banks offer. In Mahajanga, the bank staff training was followed by drug shop business training on February 27 and 28.

The bank staff training in Toliara was an exception, as IMPACT A2F was invited by the Ministry of Population Figure 5: IMPACT A2F Team with Baobab’s Bank’s branch staff in Mahajanga to attend the week of celebration events for International Women’s Day and to help lead Day 3, “Levons-nous pour le droit à l’autonomisation économique des femmes.” The bank staff training was conducted the day before, and the IMPACT trained and prepared bank staff to present their financial offerings to representatives of women’s associations in Toliara. Day 3 included three topical presentations, and the two banks intervened between the sessions and had booths outside. The celebration was attended by more than 150 women, as well as a number of men. One attendee expressed appreciation for the banks’ participation, saying, “It’s rare to have banks during an event like this and see that there are interested in us, members of women’s associations.”

To ensure the sustainability of the banks’ efforts to facilitate access to finance for private health sector, IMPACT is collaborating with SHOPS Plus to identify “health champions” at each bank. These

47 champions will serve as information resources on the private health sector for their colleagues, and as such, will provide support to IMPACT’s work with health commodities enterprises. In Quarter 2, five health champions were identified, with three in Mahajanga and two in Toliara, making a total of 11 to date for the two banks. The champions will receive on-going training from both projects on appropriate financial products, on how to better serve the health private sector in general, and on providing information on health sector to their colleagues.

The training campaigns for partner banks will resume once the COVID-19 travels ban are lifted and the regional business trainings for drug shops resume.

Develop and adapt loan products and financial tools for small and micro health enterprises in health commodities sector (e.g., scoring, nano loans, pharma loans, motorbike loans).

Since the beginning of Year 2, four new financial products have been developed with the two partner banks:

• COVID-19 Loan: To help mitigate against the pandemic risks of COVID-19, IMPACT has assisted ABM in designing a special financial product for health commodity supply chain stakeholders to facilitate the purchase of supplies such as facial masks, disinfectant gel, and respiratory assistance devices. IMPACT organized a group meeting between ABM and some wholesale suppliers to present the conditions of the new financial product: loan terms of 3-16 months for supplies and 3-24 months for respiratory equipment; 3- 6 months’ grace period for repayment; reduced interest rate; and credit decision and loan disbursement within 72 hours. However, no loans have been disbursed so far. The commercial entities stated that before they begin importing these supplies and equipment, they need to know what the government’s policies will be for the procurement and pricing of this type of inventory. If the government decides to distribute these items for free or to set price caps, the private suppliers could lose money on their purchases.

• Pharmaloan: This loan product was designed by the IMPACT A2F in partnership with ABM’s health focal point team. These loans would facilitate access to credit for pharmacies and drug shops for the purchase of health commodities from wholesalers willing to partner with the bank. Only pharmacies or drug shops recommended by a partner wholesaler would be eligible for a Pharmaloan, and the bank will determine the credit ceiling for eligible pharmacies and drug shops. With a proforma invoice, the bank would disburse the loan amount directly to the wholesaler’s account. The pharmacy or drug shop would benefit from the wholesaler’s cash discount for the purchase and would have three to six months to repay the bank. The interest paid to the bank should be less than the cash discount, resulting in net savings to the pharmacy or drug shop. SOPHARMAD is the first wholesaler to express interest in this type of loan and has already provided the contacts of three pharmacies and one drug shop to the bank for a pilot test.

• Automated withdrawal: This financial service was proposed to Baobab Banque to encourage wholesalers to grant payment terms to drug shops which agree to allow automatic payment to be made from their Baobab account to the wholesaler. The development of this product was delayed due to the change in Baobab Banque’s strategy, as the bank has been focusing more on improving the quality of its existing loan portfolio rather than on new products. IMPACT’s contact point at the bank expects that Baobab may develop this new product, based on existing ones that could be adapted to health sector clients.

• PA Motorbike Loan: a loan product designed to allow PAs to purchase motorbikes, which could be used for the transportation of social marketing commodities from PARCs. With support from the IMPACT distribution team and COP, the project decided with ABM to conduct a pilot with PAs located less than 75 kilometers from ABM branches in the 13 regions covered by IMPACT. The bank is partnering with several motorbike distributors for this offer. At the end of March, a total of 381 PAs had indicated that they are interested in a motorbike loan. The bank will screen these interested PAs, and for those who pass the bank screening, site visits will be done in partnership with PSI’s regional SPDs. The first loan disbursements are expected in Quarter 3.

Design and develop new financial mechanism (e.g. risk sharing facility), following principles of USAID's Blended Finance Roadmap for Global Health, possibly including additional financial institution partners, to facilitate A2F within the pharmaceutical supply chains and other stakeholders.

The first step of this sub-activity had three objectives: (i) define the characteristics of target sectors; (ii) identify the financing available vs. what is needed, and (iii) analyze the challenges associated with securing financing. A preliminary evaluation of donor and other non-financial institution instruments such as guarantees and grant funds that might be leveraged, was also conducted. The report about the initial findings from the visit was submitted to the COP of IMPACT for validation and is now being submitted to USAID Madagascar for its comments and guidance.

During a presentation made by the IMPACT team at the PTF meeting in February 2020, Dr. Saina from the World Health Organization (WHO) expressed interest in developing a health fund or financial mechanism and wanted to know more about this IMPACT initiative. The A2F team was going to meet with Dr. Saina in March, but the meeting was delayed due to COVID-19 pandemic. The IMPACT team will follow up with him.

In addition, IMPACT has been approached by KRED, the microfinance department of BNI. KRED is interested in financing drug shops in IMPACT priority regions. In general, it seems worthwhile to promote competition in the financial sector, and so with USAID’s authorization, the IMPACT A2F team could develop an MOU to collaborate with KRED.

Results IR3.1.6: In Quarter 2, ABM and Baobab1 disbursed eight loans totaling $19,728 to pharmacies and drug shops, of which one was put under the DCA guarantee. This DCA loan was made to a pharmacy in Manakara, Vatovavy Fitovinany region. Most of the loans were used for inventory purchases and working capital.

Table 22: Loans Disbursed to Health Commodity Enterprises in Year 2, Quarter 2 Year 2 Quarter 2 Year 2 Cumulative to Date Target Non Non Achievement DCA- DCA- Proposed DCA- TOTAL DCA- TOTAL Initial in % (based backed backed Revised backed LOANS backed LOANS Targets on Initial loans loans Targets loans loans Targets) Number of loans disbursed 1 7 8 4 18 22 10 50 220% Volume of loans $3,340 $16,388 $19,728 $25,286 $51,723 $77,009 $15,000 $90,000 513%

1 Baobab’s March loan data is not yet available, so reporting for Baobab loans is only for two months (Jan-Feb 2020).

Strengthen the business management of enterprises in health products supply chain In Year 2, IMPACT is focusing on drug shops, to strengthen their capacity in business and finance management and their knowledge of the legal and regulatory framework. Five priority regions were jointly selected with MoPH for the implementation of the awareness and training campaign in Year 2. The Atsinanana training was completed in Quarter 1, and the Boeny training was completed in February. The Diana training was planned for Quarter 2 but was postponed due to COVID-19 and is now expected to be conducted in Quarter 3 or 4, along with trainings in Menabe and Melaky.

IR3.1.7: Provide business strengthening capacity building to enterprises in health commodities supply chain and develop partnership with private companies to sustain the training. In Quarter 2, to strengthen the business capacity of health commodities enterprises, IMPACT continued to work on the following five sub-activities, three of which began in Quarter 1.

Develop and adapt business-strengthening training curricula for drug shops A simplified curriculum was developed in Quarter 1 for the drug shop business and financial management training. The curriculum includes four modules: (i) Business financial and operational diagnostic, (ii) Regulatory and pharmaceutical compliance, (iii) Inventory management, and (iv) Financial book-keeping.

Key Findings: • The training curriculum is a living document, adapted based on feedback and findings of each training session. For example, remarks and comments on the Regulatory module from the DPLMT team after the training in Quarter 1 were incorporated into the curriculum. In addition, all the documents (slides, exercises, participants book) have now been translated into Malagasy. This adaptation saves time in delivering the training, allowing discussions with the trainees on the need for them to create a regional drug shop association.

• This simplified curriculum remains the foundation of the CPT training approach. As mentioned above, the project believes that CPTs as independent micro-social enterprises may not be financially viable. However, the project continues to believe that a simplified curriculum—one that can be delivered in a variety of settings and requires minimal equipment or preparation—is necessary for the long-term sustainability of the training program. The project has developed materials that achieve the required learning objectives using only about 20 slides, which could in the future be produced as portable, reusable laminated cards that do not require a computer or projector. As a possible pivot away from the model of independent CPTs, the project is considering an external collaboration with a local entity, potentially the regional drug shop associations, to house a version of the proposed CPT program. The project plans to co-create the structure of the CPT program with the identified partner(s), to ensure that the program addresses the partner’s interests, thus increasing the likelihood of long-term sustainability.

Provide initial business-strengthening training to drug shops On February 27-28, 2020, the second joint IMPACT/DPLMT mission was held in Mahajanga. The DPLMT team led a half-day information session on the legal and regulatory framework. This session was also a way to identify formal, active drug shops in the region. The session was followed by 1.5- day business training conducted by IMPACT for selected drug shops.

The training was voluntary, and drug shops were required to cover their own transportation and lodging costs for the training. All six districts in Boeny were represented.

The cost of the training was shared with SOMAPHAR. This cost-share arrangement increases the engagement of private sector stakeholders within the pharmaceutical supply chain distribution. SOMAPHAR has expressed interest in continuing this type of partnership with IMPACT.

Key Findings: • Drug shop owners in the Boeny region have a higher level of education than drug shop owners trained in other regions, which facilitated the training. Fifty-six percent (14/27) of participants have high school diplomas and 26% (7/27) had attended university. • Attendance of the DPLMT team in the training adds value, and their knowledge and experience- sharing are appreciated by the trainees. • Trainings should not be scheduled during the rainy session because it makes travel more difficult and costly for participants. Some trainees had to travel by boat, and others by foot for two days to get to Mahajanga. • While DPLMT only allowed the licensed owners (and not managers) of drug shops to attend the information session, IMPACT recommends that for the three remaining regions in Year 2, regulatory awareness sessions should be organized for drug shop managers who are already in activity and willing to comply with the law. Having a more open attendance policy will allow DPLMT and IMPACT to determine how many drug shops are operating in a region, how many are formal, and how many are operating illegally. These information sessions will also help illegal drug shops learn what steps are needed to comply with regulations.

Table 23: Number of Drug Shops Attending Awareness Sessions and Business Training Year 2 Proposed Achievement Year 2 Initial Cumulative to Revised in % (based on Quarter 2 Target Date target Initial Target) Number of drug shops attending 42 85 NA NA NA awareness session lead by DPLMT 27 54 Number of drug shops attending (16 men, 11 (31 men, 23 75 80 72% IMPACT business training session women) women)

Provide one-to-one coaching on business strengthening to enterprises/individuals identified as potential peer trainers in health commodities supply chain Two post-training coaching were provided, both in Amboromalandy. Both the coached drug shops were already using sales record and prescription registry books. The owners also stated that they are willing to use the new management tools from the training session, not only for their drug shops, but also for their other businesses.

Table 24: Number of Drug Shops Receiving One-on-One Coaching Year 2 Cumulative to Initial Achievement Year 2 Quarter 2 Date Target in % Number of drug shops 2 5 10 50% receiving coaching (1 man, 1 woman) (2 men, 3 women)

IMPACT continues to follow up on the adoption by drug shops of new tools introduced during the training sessions: stock cards, daily cash registry, profitability analysis.

Regional drug shops have complained about miscommunication on the transport of medicines and other supplies during the COVID-19 pandemic. Although the government announced that the transportation of medicines and supplies is allowed, some regional roads have been blocked, and drug delivery trucks have been forced to return to Antananarivo. Therefore, IMPACT team has started conducting a mini survey to understand issues related to drug supply in regions during the pandemic. This information, including any urgent issues arising such as blocked supply shipments, is being transmitted to the authorities to help coordinate the appropriate response.

Identify potential partnerships with private training companies to expand and sustain options for business training to enterprises in the health commodities supply chain In order to set up a sustainable training mechanism for pharmacies, IMPACT initiated the identification of training institutions that would be able to take over the project after its end in delivering such training modules. FORMASANTE, a private training firm which already offers technical and management training modules to pharmacies, has been identified. The firm is also interested in developing customized modules for drug shops with IMPACT. The elaboration of a partnership agreement, rescheduled for Quarter 4 due to COVID-19, would be the next step of this sub-activity.

Explore digital inventory management applications for use by private health commodities enterprises and which would be incorporated into future business training IMPACT consortium partners have conducted an analysis of existing LMIS tools used by pharmacies and drug shops (“Résultats du rapport de l’enquête SIGL”), showing that pharmacies use various software in parallel with physical tools to manage their inventory. The most commonly used is PHARMA Plus (50% of a sample of pharmacies surveyed in Atsinanana, Boeny and Diana in Quarter 1), a software developed locally. For drug shops, the majority do not have inventory management tools, and very few use Microsoft Word or Excel.

As stated in IR3.1.3, IMPACT is testing two software applications: PHARMA Plus and Maisha Meds, to be used by drug shops as digital inventory, financial and LMIS management tools. Selection of the tool will be conducted with the team and with the TMA TWG LMIS sub-committee in Quarter 3.

Sub-IR 3.2: GOM facilitates the work of the commercial sector

IR3.2.1 : Facilitate high-level advocacy meetings involving the MOPH, Ministry of Commerce, customs services, Ministry of Economy and Finance, the National Board of Physicians and the National Board of Pharmacists to develop policies and regulations that will favor importation and commercialization of a packet of vital Essential medicines, including contraceptives, anti-malarial, and key MNCH products. On March 16th, IMPACT organized a workshop with Parliamentarians from the Health Commission of the National Assembly to present the objectives and main activities of IMPACT, with the aim of soliciting their support and collaboration to achieve these objectives to the interest of the Malagasy population and public health. The parliamentarians expressed interest and willingness to support the IMPACT project, particularly in the areas of regulatory reform, the ADDO initiative, and combating counterfeit markets. As a next step, a meeting is planned in Q3 with Parliamentarians, DPLMT, DAMM,

National orders of Pharmacists and medical doctors, Association of depots and IMPACT to 1) develop the implementation plan of the ADDO 2) revitalizing of the Interministerial committee in charge of fighting the Illicit market and counterfeit medicines.

Following the signature of the New Essential List of Medicines and medical devices (NELM) in November 2019, IMPACT supported DAMM and DPLMT during this quarter to meet with the Ministry of Economy and Finance, and tax and customs experts, to share the NELM and engage in an open- dialogue to advocate for tax exemption for essential drugs and health commodities to increase access to health programs.

IR3.2.2 : Support DAMM and MOPH to put in place strong regulatory processes related to the registration, importation, and distribution of medicines based on reviews of the Common Technical Document, New Law on Regulatory Body in Africa, and experience from other countries through study tours. Regulatory reform, capacity building in terms of registration, inspection, and quality assurance of medicines, and sanitation of the pharmaceutical sector are key activities carried out by IMPACT in close collaboration with the DAMM (National Drug Regulatory Authority), the DPLMT (Directorate in charge of the management of health products and drug stores) and professionals in the pharmaceutical sector (pharmacists and drug vendors).

During Year 1, IMPACT completed a literature review of 128 legal and regulatory documents in the form of laws, ministerial decrees, guidelines, and instructions related to pharmaceutical management.

To enhance the document review of the 128 regulatory texts inventoried in 2019, a TWG/TMI “Regulatory Texts” sub-committee workshop was organized on February 4, 2020 with the participation of an international expert in pharmaceutical regulation, Marie Paule Fargier. During this workshop, participants agreed on classification criteria according to : 1) Utility (regulatory functions, pharmaceutical profession, professional orders, type of health products, policies, missing texts ) 2) current status (valid and applicable or not) compared to the new Health Code from 2011, and 3) public health priorities (quality assurance, inspection, availability and accessibility of drugs, sanitation of the pharmaceutical sector). Gaps and/or need for updates were identified by the consultant, particularly in the following areas: registration procedures, illicit markets and counterfeit medicines, medical devices, pharmaceutical inspection, the distribution circuit, and the absence or insufficiency of manuals for technical and financial procedures and of directives relating to standards of good practice (distribution practices, dispensing practices, storage practices, pharmacy practices, laboratory practices, clinical practices). The international expert will suggest recommendations to consider while updating the regulations in Quarter 3.

IR3.2.3: Support DAMM in streamlining the registration and importation procedures for medicines based on the latest WHO recommendations. From January 27th to February 7th, the international expert Dr. Marie Paule Fargier, provided technical assistance to the DAMM using the results of the self-assessment that DAMM completed using the World Health Organization (WHO) Global Bench marking tool (GBT). The results of this self- assessment showed that despite the availability of basic skills and some experience in the registration, pharmacovigilance, and quality control of medicines, the level of maturity of the DAMM is 1 on a scale of 1 to 4. These results will guide the development of an action plan, which aims to strengthen the

53 regulatory capacity of the DAMM in order to allow it to improve its level of performance, especially in the areas of registration, quality assurance, and pharmaceutical inspection.

Below are the definitions to evaluate the maturity level: • Scale 1: There is no formal approach, but some elements of the regulatory system exist. • Scale 2: There is a reactive approach - the system performs part of the essential regulatory functions. • Scale 3: There is a formal and stable systems approach - the regulatory system is stable, functional, and integrated. • Scale 4: The regulatory system operates at an advanced level of performance and the focus is on continuous improvement.

The GBT tool is developed to assess the functioning of the regulatory authority in registration and quality assurance, regulatory reform, and inspection. The expert assisted in defining short-term and long-term strategies to improve the functioning of the DAMM. IMPACT facilitated a meeting between DAMM and UCP-Global Fund to explore opportunities for raising funds to support the WHO prequalification process of the DAMM laboratory quality control. IMPACT will continue to support mobilization activities to engage multiple partners to support the new strategies developed for DAMM. Also, IMPACT facilitated a working session to familiarize DAMM, DPLMT, and SALAMA staff on the WHO CTD format (Common Technical Document) for the registration of medicines, and to identify the needs for adapting national regulations to the African Union Model Law on Medicines. To continue the process of harmonization of quality assurance procedures and coordination between the DAMM, the SALAMA central medical stores, technical and financial partners, and MOPH, two drafts of the MOU have been developed 1) MOU between the MOPH and its technical and financial partners, and 2) MOU between DAMM and SALAMA. The draft MOUs were discussed with both parties and should be finalized in Quarter 3.

IR3.2.4: Support the MOPH and the professional associations to revitalize the inter-ministerial committee to fight counterfeit and illegal medicines. A strategy will be defined through a mid-term evaluation of the Stratégie de Lutte Contre le Marché Illicite and the Contrefaçon des Medicaments et Intrants de Santé and an action plan will be developed. During Quarter 2, IMPACT continued discussions with the Executive Secretary of the Interministerial committee in charge of fighting illicit markets and counterfeit medicines. A meeting was organized to review the status of the implementation of strategies developed in 2015. While waiting to secure a meeting with the Prime Minister on the restructuring of the committee, the following activities were identified to be implemented with DAMM and DPLMT:

• Dissemination of existing laws, ministerial decrees, and notes governing the pharmaceutical sector which can contribute to combatting illicit markets. This will be done through the TMA “Texts and Regulations” subcommittee TWG in Quarter 3. The targets of the dissemination are professionals from the pharmaceutical sector (pharmacists, drug sellers [dépositaires]), health professionals (medical doctors, paramedics), administrative officials and health authorities, police administration, and authorities of the Ministry of Justice at the central and regional levels.

• Provide technical and financial support to DPLMT and the manager of stock management of commodities at the regional level to monitor the destruction of all expired medicines to combat illicit market. This is a continuous activity.

III.4. IR 4: Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy people

Sub-IR 4.1.1: Socially marketed products are continuously available at convenient and accessible locations

IR4.1.1: Distribution of socially marketed products across 10 regions for MNCH and FP/RH products and distribution of only FP/RH products in three PARN Regions through PARCs and PAs. In Quarter 2, IMPACT continued to distribute a range of socially marketed FP/RH and MNCH products to support the national program. Table 25 and 26 show the distribution of FP/RH and MNCH health products through Quarter 2 against annual targets.

Table 25: Distribution of FP/RH commodities in Quarter 2 YEAR 2 Quarter 1 Quarter 2 % of Year 2 FP PRODUCT Year 2 Target Achievement Achievement Target Achieved OC (Community Channel) 1,724,880 484,152 748,871 71.48% Injectable (Depo- Provera/TRICLOFEM) (Community 1,473,355 513,453 567,313 73.35% Channel) FP condom Protector Plus (Community and Commercial 1,633,794 557,904 445,488 61.41% Channels) FP Youth Condom Yes 671,689 N/A N/A N/A (Commercial Channel) Sayana Press (Community 474,355 6,601 N/A N/A Channel) Pregnancy Test (Community 100,000 4,245 20 604 24.85% Channel)

• Oral Contraceptive (Microgynon and Combination 3): Oral contraceptives had an increased distribution rate and reached 71.48% of the annual target. This is due to the increase of regular users from 175,648 in Quarter 1 to 231,088 in Quarter 2 (source: Mahefa Miaraka and CSBs for ACCESS zones). • Intra-muscular Injectable Contraceptive (Depo-Provera/Triclofem): The cumulative quantity distributed achieved 73.35% of the annual target. There is a slight increase of regular users of Injectable contraceptives with 401,447 in Quarter 1 versus 471,978 in Quarter 2, which is a result of Sayana Press stock out. While waiting for the delivery of the 390,200 Sayana Press doses from UNFPA, expected in mid-April, Sayana Press users continue to use Triclofem. • Sub-cutaneous Injectable Contraceptive (Sayana Press): In Quarter 2, Sayana Press experienced stock-out (11% at PA level) while waiting for the availability of 390,200 units to arrive from UNFPA. o As agreed with UNFPA, the MOU will be signed between IMPACT and UNFPA at the time of reception of the product expected in mid-April. • Yes With You Male Condom: The portfolio analysis results recommend maintaining Yes condoms with the new flavors (banana or vanilla) depending on the consumer panel choice. The consumer panel is a group of condom users who will be asked to respond to specific questions based on their Yes condom test experiences. The procurement of this product is not yet initiated pending the

validation by USAID of the products portfolio analysis. However, the AMM process has already been initiated. • Protector Plus Male Condom: IMPACT has distributed 445,488 units of Protector Plus male condoms through the community and commercial channels during Quarter 2 in the 13 USAID- supported regions. The cumulative quantity distributed represents 61.41% of the annual target, mostly from the commercial channel. • Pregnancy Test Kit: IMPACT has allocated 12,330 pregnancy test kits to Mahefa Miaraka for the scale-up in Menabe (10 kits per CHV) and 1,251 kits to use for the ToT of CSBs and tests for CHVs during the training (1 kit per CHV). Pregnancy tests are also distributed to PA. At the end of March, there were 21,758 remaining kits at PSI warehouses, which will be sufficient stock for almost 9 months. The scale up scheduled in SAVA region will wait for the new procurement of pregnancy tests which are already packed in containers and are waiting for the clearance to shit to Madagascar by sea following COVID-19 restrictions.

Table 26: Distribution of MNCH Commodities in Quarter 2 YEAR 2 Quarter 1 Quarter 2 % of Y2 Target MNCH PRODUCTS Target Achievement Achievement Achieved ORS/Zinc DTK (Community) 58,906 21,008 28,838 84.62% Sur Eau 150 ml (Commercial) 904,910 N/A N/A N/A Sur Eau Pilina (67mg Tablet) 3,620,780 703,300 289,200 27.41% (Community) Arofoitra (CHX 7,1%) (Community) 30,378 12,946 1,871 48.78% Pneumox (amoxicilline) 219,635 48,182 18,352 30.29% (Community)

• ORS/Zinc: The high achievement in Quarter 2 is due to the rainy season which causes a higher prevalence of diarrhea. • Sûr’Eau 150 ml (commercial): The procurement of this product is in progress and the results of the tender will be known in April. • Sûr’Eau Pilina (community): The achievement is low in Quarter 2. Though Sûr’Eau Pilina is available at the PA level with a zero stock out rate during Quarter 2, this product was in stock out in several of PSI’s warehouses. The remaining stock of Sûr’Eau Pilina at end of March 2020 corresponds to 0.43 months of stock (approximately 15 days). The water treatment project in Analanjirofo and the pumps providing clean drinking water by Japanese Cooperation in Menabe partially explained the low consumption of Sur’Eau Pilina. Additionally, the CHVs prefer to stock other health products such as Pneumox and FP products instead. When the product arrives, IMPACT will reinforce its promotion to raise people's awareness on its importance in order to increase demand creation. • Arofoitra (Chlorhexidine 7.1%): The distribution of Arofoitra achieved 48.34% of the annual target. The distribution resumed with a slow rotation in Quarter 2 despite PARCs and PAs being restocked and with no stock out due to low usage by health facilities. Posters of Arofoitra were placed at each PARC and PA for product visibility and trainings for CHVs are scheduled by Mahefa Miaraka and ACCESS to increase the use of Arofoitra in health facilities, which is only 11%, and which does not correspond to the number of births.

• Pneumox: In Quarter 2, Pneumox is in stock out so only achieved 30.29% of the annual target. The product will arrive in Tamatave in mid-April 2020 and will arrive at PSI’s central warehouse in early May.

The MNCH product procurement for 2020 was launched as stated below:

Table 27: MNCH Procurement ETA Products Quantity Status (Estimated Time of Arrival) Pneumox 23,700 Boxes of 10 Certificate of analysis approved. Shipping April 2020 at SALAMA blisters of 10 tablets authorized with estimated time of arrival at the and early May at PSI end April 2020. central warehouse. ORS 152,000 sachets Request of quotation sent to SALAMA but was June 2020 unsuccessful because of the absence of valid Market Authorization. AMM file is under review for filling on behalf of PSI for DTK, not only ORS. Zinc 18,400 boxes of 10 Approval of the waiver request will be obtained in June 2020 sulfate 20 blisters of 10 tablets early April 2020. mg Sur’Eau 5,786,800 tablets Purchase Order sent to MedTech. Finalization of June 2020 Pilina the approval of the different artworks has been completed.

All requests for quotations were launched in September 2019. IMPACT has finalized the procurement process of the MNCH products after USAID approval on November 4, 2019.

Field visits with USAID: In Quarter 2, IMPACT’s social marketing distribution team, with Mahefa Miaraka and ACCESS, accompanied USAID during field visits in Analanjirofo from February 10th to 12th. In addition to the visits of the CSB II, Pha-Ge-Com, and Pha- G-Dis, the PARC and PAs in Fénerive Est, in Fénerive Est, Ampasina Maningory and Mahambo were also visited by USAID.

Figure 6: Dr. Joss from USAID visiting PA (left) and PARC (right)

during field visits Training and refresher training of the distribution staff: At the end of January 2020, a workshop including 6 SRD and 6 central team members was held in Antananarivo to monitor the development of an action plan at the beginning of Year 2. Main topics discussed during this workshop were: • Assess progress, lessons learned, challenges encountered, and identification of solutions.

• Exchange ideas within the IMPACT consortium partners and other departments. • Capacity building through training on project management according to standard ISO 21500 was provided by SMS Consulting for this management team (SRD, Distribution Coordinator, Community and Commercial Supervisor, and Distribution Director). The capacity of each regional team was strengthened in order to add value to the Year 2 IMPACT action plan. • Guest intervention: Tantely RAJAOBELINA, USAID Supply Chain Systems Specialist, reminded the group about: - Rational management of commodities - The fight against products leakages - The importance of the quality of field team supervision - Close collaboration and coordination with ACCESS and Mahefa Miaraka

IR4.1.2: Establish a motivation system for PAs and PARCs and follow up on their quarterly performance to address supply chain inefficiencies in social marketing in order to prevent stockout. In Quarter 2, IMPACT evaluated PARC and PA on the quality of their work during Quarter 1. The number of PARC and PA has increased from 925 to 954 at the end of this second term due to the PAs activation in some Mahefa Miaraka and ACCESS areas. The evaluation was based on the following criteria: (i) availability of products, (ii) respect of storage conditions, (iii) quality on the filling of all management tools, and (iv) pointed GPS of PA and PARC locations to confirm that they are evaluated by the SPD. 15 PARC and 244 PA met all of the criteria and they have all received IMPACT promotional items, including two pens and a calendar for each of them. PAs and PARCs should be assessed at the end of each quarter.

IR4.1.3: Expand last-mile distribution and emergency distribution through a pilot to deliver health products using drones. As planned, the two districts of Mandritsara and Befandriana are included in the drone pilot project with Maroantsetra and will be reached from Maroantsetra. Thus, one SPD was recruited mid-January 2020 in Antsohihy (SOFIA region) to collect GPS data of PA and dropdown points areas, report flight deliveries, as well as ensure the community mobilization and sensitization of authorities related to the pilot project. These activities were conducted prior to the flight distribution tests conducted by drone from the Maroantsetra base.

To properly follow the drone activities, an application was installed on the tablets of the SPDs in charge of drones. This application is used for: • Analyzing stock data and risk of stock-outs at the PA level • Scheduling deliveries by drone • Recording all flight operations and delivery data • Recording incident data (if there is any) • Making dashboards of the drone project.

The application and dashboard are constantly updated to adjust as best as possible the drone-use pilot expectation and will be ready by early Quarter 3. IMPACT staff (Coordinator and all SPDs) and Aerial Metric staff were trained by the M&E Supervisor and database manager on how to use the drone application.

Courtesy visits from MOPH staff (Health Regional Director, Medical Inspector, CSB Chief), the mayor, and the Fokontany Chief continued in Sambava, Antalaha, and Andapa for SAVA, Antsohihy, Mandritsara, Befandriana Avaratra for SOFIA, and Maroantsetra as well sensitization of the population by the Supply Point Supervisor. These districts are part of the pilot intervention areas.

Figure 7: Sensitization of population by the SPD in Tsarahonenana - Befandriana Nord

A video report on the use of drone for distribution was produced in Maroantsetra and has been shared with USAID and the MOPH.

Flight tests continued in Quarter 2 and 20 successful flight tests were completed (19 flights under 25 km and 1 flight test at 35 km). 2.5 liters were transported per each flight. The commodity deliveries served 11 selected PA in Maroantsetra located at between 18 km to 85 km from the take-off point of the drone. Products delivered were Sayana Press, Protector Plus, Oral Contraceptives, Triclofem and syringes, ORS, Pneumox, and Arofoitra. Below is the list of test flights in Quarter 2.

Table 28: List of test flights in Quarter 2 Number of Number of Date PA Distance successful flights incidents Andranofotsy, Ankofa, Voloina, Antsirabe-sahatany, Mariarano, January 2020 19 1 PA<25 km Ambinanitelo, Anjahana, to March 2020 Mahalevona, Manambolo,

Ambodimanga Rantabe 1 1 25km

IR4.1.4: Transition the community distribution model from select PAs and PARCs to the Pha-Ge-Com and Pha-G-Dis in coordination with DDS/DPLMT/DSFa/ACCESS/Mahefa Miaraka. The performance of Pha-G-Dis and Pha-Ge-Com needs to be improved progressively prior to ensuring the transfer of the PAs and PARCs. The transfer process will be postponed to Year 3.

IR4.1.5: Select and introduce socially marketed products across 10 IMPACT regions and 3 PARN regions through the private sector (pharmaceutical and commercial channels) pending the results of the COGS analysis.

The COGS analysis was submitted within the products portfolio analysis for USAID approval. At least two products (DMPA-SC self-injection and Yes condom) have been identified and recommended to be introduced into the private sector.

IR4.1.6: Define the needs for a product monitoring system and conduct a study of a product tracking system. Find technological solutions which allow IMPACT to earn and grow brand loyalty while protecting the brand from supply chain fraud, including counterfeiting and theft. IMPACT explored technological solutions such as barcodes to mitigate the leakage of FP products. Up to now, the number of batches, which is the same for the numerous products sent to different areas of Madagascar, could not help IMPACT to properly track the leakage of products. In addition, the MOPH integrated the fight against health products leakage in the PDPN with the possibility of using barcodes.

Technical specifications for the use of a tracking technology have been identified and these specifications will prevent FP products from leakage. The main objective is to find and set up a system to trace each stage of the distribution. Thus, during control visits, it will be easy to read the tracking code and check the stock status of the product stored in warehouses by using laser readers/scanners or to identify the origin of the product by using a cellphone.

In Quarter 2, national and international suppliers were prospected in order to have proposals and quotes to study the feasibility of setting up the system. Sub-IR 4.2: Socially marketed products achieve cost recovery at an affordable price for consumers

IR4.2.1 : Leverage TMA findings from IR1 to analyze COGS and continue to propose options for the optimization of financial sustainability for the current socially marketed products portfolio and explore brand extension of Yes With You condoms and introduce a new brand of pharmaceutical products depending the results of the COGS analysis. Cost of Goods Sold (COGS) were analyzed and finalized and new FP products were proposed and integrated in the product portfolio analysis and the document was submitted to USAID for review. Meanwhile, samples of Yes With You Banana and Vanilla were requested from suppliers to anticipate the validation panel to determine the scent that will be adopted.

After visiting retailers, a gap of condoms was noticed in the commercial channel despite the existence of a few brands which do not cover the market. Yes With You was identified to be maintained, but also the scent should be diversified. Quantification of Yes needs was conducted, and a procurement plan was developed and finalized. Official process for getting AMM is initiated and the approval request for the procurement of Yes With You will be submitted to USAID when the product portfolio analysis is finalized and validated. Through the re-introduction and exploration of the extension of Yes With You condoms and with Protector Plus serving the commercial market, and other brands of condoms in pharmacies, all segments of the condom market will be served.

III.5. IR5 - Increased demand for and use of health products among the Malagasy people

IR5.1.1 : In collaboration with the demand creation subcommittee of the TMA TWG, develop and implement activities to increase demand and use of health products During Quarter 2, the demand creation subcommittee of the TMA TWG held its third workshop on March 17th, 2020 at the DPLMT meeting room and was led by the Health Promotion Department (DPS) of the MOPH. Twenty-five (25) participants were present including 14 from the MOPH (DPS), Agence Malgache du Médicaments (AMM), and DPLMT, 3 pharmaceutical wholesalers from the private sector, and 8 participants from NGOs. This workshop focused on the main barrier identified during the first workshop which is the self- medication and lack of awareness about proper use of medicines. A draft communication plan on the safe use of health commodities and self-medication was developed with a focus on two goals: - Purchase health products from licensed establishments (pharmacies, hospitals, drug shops, and health centers) - Encourage proper use of health products, according to the prescription obtained at health centers/hospitals

For each objective, messages and communication support (media, materials, etc.) were tailored by each target group, including the final users, pharmacists, community leaders, etc. The next step will be to finalize the communication plan with the timeline and budget, by a small group including DPS, DAMM, DPLMT and IMPACT. It should be completed and finalized by the end of Quarter 3.

Furthermore, the DPS of the MOPH provided training on the development Figure 11 : Overview of the participants of the third workshop of of a communication plan and on the the demand creation subcommittee of the TMA TWG basic principles of health communication. Different steps to build a communication plan were detailed including key activities to consider (advocacy, proximity or mass communication, events, etc.). Finally, participants were trained on photography basics, such as what is a good photo, different types of photography angles (overview, close-up, etc.), and the rules for taking pictures (foreground, background, high and low shooting positions, etc.). For the next meeting, committee members are invited to take pictures and present them for feedback so that they can learn how to improve their work. This was one of the capacity building needs that the members of the demand creation subcommittee requested.

In addition, DPLMT received funding from the Unité de Coordination des Projets (UCP) to produce a video on the fight against illicit drug market that will be broadcasted on TV and on social media such as Facebook. The demand creation subcommittee of the TMA TWG participated in the development of the creative brief for this video that was submitted to the communication agency for production. The next phase will include the finalization of the script before the shooting of the video by the

62 communication agency. The demand creation subcommittee will be present at all stages of the video's development. This video is expected to be finalized by the end of Quarter 3 and to begin the broadcast in Quarter 4. The video will be broadcasted on TV and on social media such as Facebook.

IR5.1.2 : Provide technical and financial support to contribute to the activities of the MOPH During Quarter 2, IMPACT organized the official launch of the LLINs cCD on February 13th in Mahavelona Foulpointe Commune (sub-district) in the Atsinanana region. The ceremony was led by the MOPH and attended by the Minister of National Education and Technical and Vocational Education (Ministre De l’Education Nationale et de l'Enseignement Technique et Professionnel), the Minister of Population, Social Protection, and Women, the USAID Mission Director, high local authorities, and representatives from various NGOs. The local community performed a skit Figure 12: High delegates who attended the official ceremony demonstrating the cCD principles (encouraging LLIN use and purpose of the cCD) and a nationally renowned artist, Kapepeky, and a humorist, Honorat, produced an animation to raise awareness of the prevention value of malaria and the use of LLINs.

The mid-term review of the National Malaria Control Program was organized on March 9-13, 2020 at the NMCP office in Androhibe with the Figure 13: Staging of students from grade four participation of different MOPH departments at central and regional levels, financial and technical partners, and NGOs. IMPACT was represented for the review of communication activities related to the national strategic policy.

COVID-19 Due to the COVID-19 pandemic and the declaration of a health emergency for Madagascar, IMPACT provided technical assistance to COVID-19 response led by the DPS of the MOPH, with the participation of WHO, UNICEF, ACCESS, and Mahefa Miaraka by soliciting the creation of messaging and sharing publications related to COVID-19 prevention on PSI’s Facebook page. Given the confinement restriction, the members of the communication commission (including MOPH and the technical and financial partners) used WhatsApp and e-mail to exchange news and information.

IR5.1.3 : Conduct communication campaigns for promoting health products of the three prioritized health Broadcast Radio and TV spots IMPACT has broadcasted 5,659 radio spots from January 1st to February 26th, 2020 in 35 districts of the 10 USAID-supported regions to sustain CHX demand.

To increase the knowledge of Sur’Eau Pilina, and to promote the use of this product by ensuring water safe for drinking during the rainy season, 2,640 radio spots were broadcasted in 32 districts of the 10 USAID-supported regions from February 27th to March 30th, 2020.

For LLINs cCD, 2,640 radio spots were broadcasted through 11 radio stations in the 6 districts as part of the cCD Group1 including Toamasina II, Brickaville, Toliara II, Manakara, Vohipeno, and Mananjary. Radio spots announced the cCD, the home visits by the CHVs, and the distribution of coupons for receiving LLINs in the community.

Table 29 : Summary of the Radio Spots Aired Communic Period Region Number of Number of Spots Comments ation Districts Aired Campaign Broadcastin January 1st to Sofia 2 346 th g of CHX February 26 Diana 5 692 Radio Spots 2020 Boeny 3 519 2 stations in Majunga Melaky 1 173 V7V 3 519 Menabe 2 346 Sava 4 865 2 stations in Sambava Atsinanana 8 1211 Analanjirofo 3 469 Atsimo 4 519 Andrefana Total 35 5,659 Broadcastin February 27th Sofia 2 176 th g of to March 30 Diana 5 352

Sur’Eau 2020 Boeny 3 176 Pilina Radio Spots V7V 2 176 Menabe 1 88 88 spots aired per district Sava 4 352 except: Atsinanana 8 528 Diego: 2 stations Analanjirofo 3 440 Tamatave: 2 stations Tuléar: 2 stations Atsimo 4 352 Majunga: 2 stations Andrefana Total 32 2,640 Broadcastin February 6th to V7V 3 1200 240 spots aired per g of LLIN March 29th Atsinanana 3 960 district except: cCD 2020 Atsimo Mananjary: 3 stations 2 480 Andrefana Tamatave: 3 stations Total 8 2,640

Promote health products in the field with communication teams using mobile sound systems Social mobilization at the community level was designed and conducted in Quarter 2 to increase the awareness of FP and MNCH health products. Six communications teams composed of an animator and a driver used mobile sound systems to promote CHX, Sur’Eau Pilina, and Protector Plus condoms in order to support the broadcasted radio spots. Promotions led by the communication teams helped

the CHVs to sell their products and contributed to increasing the sales report, as shown in Table 29 below.

Table 30 : Percentage of sales from Communication Teams and CHVs January February March Sales of Sur'Eau Pilina 80,000 124,000 85,200 Sales made during sensitization by Communication Teams with CHVs 170 1,998 % of sales from Communications Teams and CHVs 0.1% 2.3% Sales of CHX 600 440 831 Sales made during sensitization by Communication Teams with CHVs 17 81 % of sales from Communications Teams and CHVs 3.9% 9.7% Sales of Protector Plus (rural) 28,176 40,512 44,160 Sales made during sensitization by Communication Teams with CHVs 192 4,034 % of sales from Communications Teams and CHVs 0.5% 9.1%

Communication teams also sensitized the community on malaria by providing messages on prevention of malaria, the use of LLINs, and encouraging pregnant women to attend ANC during pregnancy in order to receive doses of SP. In Quarter 2, 59 sensitization activities on malaria were conducted and 5,503 people received the messages.

IR5.1.4 : Provide technical and financial support to the Ministry of Youth and Sport (MYS) to develop and implement Youth activities in collaboration with Telma Foundation based on the Human Centered Design (HCD) study and support training for youth on health, leadership, communication, etc.

• A MOU was established between IMPACT and the Ministry of Youth and Sport (MYS) to define collaboration agreements. The main goal of the MOU is to (i) raise youth awareness on health, (ii) access to health products, and (iii) encourage youth to practice healthy behaviors, such as using FP products to avoid early pregnancy. The MOU should have been signed during Quarter 2, but due to the COVID-19 pandemic, the ceremony of signature has been postponed. Currently, the MOU is with the Minister of Sport and Youth for signature. • A MOU was signed with Blue Ventures, an international NGO whose objective is to improve the access to health services and commodities for people who are living on the coast and protect the local ecosystems. Through the MOU, Blue Ventures youth members will receive capacity building on leadership, sensitization to healthy behaviors, and education on the use of health commodities. • PSI’s HIV team has expertise in the peer education strategy. During Quarter 2 the training curriculum was revised with support from PSI’s HIV team and in cooperation with the MYS, Blues Ventures, and IMPACT. Messages on GESI targeting youths were also integrated, such as “For the youths, let’s go to the doctor to choose the family planning method which suits you. Confidentiality is respected.” The training session for youth members of Blue Ventures is scheduled in Quarter 3.

IR5.1.5 : Leverage new technology to drive demand for malaria, FP/RH and MNCH health commodities.

Support the 910-call center in partnership with ACCESS

The transfer of the “910” call center to ACCESS is ongoing. IMPACT continues to pay the salary of the hotliners until the end of June 2020. During January, the “910” call center was not operational from the 1st to 30th while the transfer to ACCESS to support the communication cost is ongoing and will be completed by the end of June. On February 25th, IMPACT and the DPS of the MOPH, have handed over to ACCESS the call center 910 equipment.

The number of calls received in Quarter 2 decreased for the three priority health areas (MNCH, malaria, and FP) compared to the increase of calls related to COVID-19, as demonstrated in the Table 30 below.

Table 31: Summary of the number of hotline calls received during Quarter 2 vs Quarter 1

Quarter 1 Year 2 (October - Quarter 2 Year 2 (January- December 2019) March 2020)

Number % Number % Hotline calls received on Malaria (% of total) 27,810 24% 17,642 14% Hotline calls received on Family Planning (% 9,928 9% 843 1% of total) Hotline calls received on Maternal, Child, 14,820 13% 9,238 8% Health (% of total)

Hotline calls received on other (% of total)* 64,126 55% 95,331 77%

Total hotline calls received 116,684 100% 123,054 100% * calls for diseases: measles, COVID-19, plague, etc.

Graph 5 : Calls on COVID-19 before and after GOM Declaration Calls received 4 days before and 4 days after the Calls received on COVID-19 in March declaration of confinement.

The data reported in the table above reflects the calls received by the 18 hotliners supported by IMPACT. The Government of Madagascar also increased the number of “910” hotliners through the collaboration with other private call centers.

On March 22nd, the President of Madagascar encouraged people to call the “910” hotline for free if they need information on COVID-19. Afterwards, the number of calls drastically increased as shown in the graphs 5 above.

Send SMS broadcast to target population On March 8th, 2020 during the celebration of International Women's Day, SMS messages were sent to 1,897,465 people (women and men over 15 years old) who are subscribed to the Telma network in the 13 USAID-supported regions. The SMS were sent in collaboration with the MOPH and the Ministry of Population, Social Protection, and Women (MPSPW). The content of the message was focused on the empowerment of women with regard to the use of modern methods of contraception and health commodities. • For PA and PARC, SMS were sent to inform them about stock management and availability of the oral contraceptive ZINNIA. • CHVs in Mahefa-Miaraka intervention areas were reminded to encourage pregnant women to attend antenatal consultations at the CSB to benefit from the use of SP during pregnancy. The details are summarized in the table below. CHV telephone numbers belonging to the ACCESS zones will also be obtained and the same SMS will be sent on ANC reminder. • In agreement with the DPLMT, each month a reminder SMS is sent to the 76 Pha-G-Dis to report the monthly physical stock at the end of the inventory to DRSP, SDSP, ATR, and RLA .

The Pha-G-Dis were also sensitized on stock management.

Table 32 : Summary of SMS Sent during Quarter 2 Health English Translation Target Network Number of People Period Area group Reached

Remind CHVs to take ZINNIA the new PA Telma - 477 March 2020 family planning pills distributed by USAID Orange - IMPACT (which have the same effects as Airtel Microgynon). Request Zinnia the new family planning CHV Telma - 3,307 March 2020 pills distributed by USAID IMPACT at your Orange - usual PA Airtel

USAID IMPACT thanks you for your PARC Telma - 60 March 2020

collaboration to improve the health of your Orange -

community. Airtel

USAID IMPACT thanks you for your PA Telma - 455 March 2020 collaboration to improve the health of your Orange - FP community. Airtel USAID IMPACT thanks you for your CHV Telma - 3,240 March 2020 collaboration to improve the health of your Orange - community. Airtel Malaria Hi, encourage pregnant women to do their CHV Telma - 3,066 March 2020 Antenatal consultation at the CSB so that Orange - they can get the SP to protect them and Airtel their babies from malaria.

Health English Translation Target Network Number of People Period Area group Reached

Hi, keep medicines in a cool and dry place, CHV Telma - 3,259 March 2020 moisture and poor ventilation during its Orange - transport and storage because it can Airtel damage them Thank you. Hi, keep medicines in a cool and dry place, PA Telma - 454 March 2020 moisture and poor ventilation during its Orange - transport and storage because it can Airtel damage them Thank you. Hi, keep medicines in a cool and dry place, PARC Telma - 61 March 2020 EMMP moisture and poor ventilation during its Orange - transport and storage because it can Airtel damage them Thank you. Hi, keep medicines in a cool and dry place, Pha-G-Dis Telma - 76 March 2020 moisture and ventilation during its Orange - transport and storage because it can Airtel damage them Thank you. Monthly Hi, as soon as you fill in the monthly Pha-G-Dis Telma - 76 March 2020 Reminder inventories on CHANNEL send the stock Orange - situation for malaria, FP, and MNCH to Airtel DRSP, SDSP, RLA IMPACT, ATR. Thank you! World 8 March 2020: Encourages women to take Women and men Telma 1,897,465 March 2020 Women's responsibility for their own health and to above 15 years Day act for equal access to medicines for all. old in the 10 USAID

III.6. Cross-Cutting Activities Cross-cutting activities focus on five aspects: Monitoring, Evaluation, Research, Learning, and Gender/Social Inclusion.

III.6.1. Monitoring, Evaluation, Research, Learning

6.1.1. Monitoring and Evaluation CC2.1: Strengthen LMIS/HMIS (all sectors: public, private, non-profit, and commercial) including formative supervision, capacity building of data senders, and supporting implementation of the LMIS roadmap with consideration of DHIS2 as the main LMIS electronic tool.

In Quarter 2, to strengthen the current public LMIS system, the committee (DEPSI, DSFa, EMAR, EMAD, IMPACT) led by DPLMT continued the use of a call center to collect information on barriers to LMIS data submission and to remind providers to submit LMIS data.

IMPACT financially and technically supported the DPLMT and the LMIS committee composed of DPLMT, DEPSI, DSFa, and Measure Evaluation for the continued implementation of the provisional roadmap developed in Quarter 1 based on the quick situational analysis. As a reminder, the following aspects were identified as barriers to LMIS: no computer, lack of internet connection, training on CHANNEL (linked to the organizational problems within Pha-G-Dis), electrical/power cuts, etc.

The implementation of the roadmap was conducted mainly by EMAR, EMAD, RLA, and the central team composed of DPLMT, IMPACT, DEPSI, and DSFa.

Graph 6 provides progress on the implementation of the provisional roadmap.

Graph 6: Progress on the implementation of the provisional roadmap

100% 97% 96% 80% 94% 95% 60% 76% 73% 40% 47% 44% 20% 0% Availability of a Internet access Electrical issues/ Training in computer for power cut CHANNEL Channel Quarter 1 Quarter 2

• Proportion of Pha-G-Dis having a computer increased from 47% in Quarter 1 to 76% in Quarter 2. Twenty six out of the 37 laptops purchased by IMPACT were distributed to the Pha-G-Dis in Quarter 2. Three new laptops were damaged (Ikalamavony, Manakara, Nosy Varika) and were sent back to Antananarivo for repair prior to resending to the Pha-G-Dis planned in Quarter 3. The remaining of 11 laptops will be distributed to the Pha-G-Dis in Quarter 3. • In Quarter 2, 97% did not have Internet connection issues. The Pha-G-Dis providers and the RLA negotiated with ACCESS and Mahefa Miaraka, who have an active Internet connection, for the

submission of LMIS data. This collaboration is part of the MOU signed between the three USAID- funded projects. Cybercafés are also an alternative for some Pha-G-Dis when the Internet connection credit is not enough. • Regarding the unlimited Internet connection endowment to the SDSP and DRSP project, the MOPH continued to collect the mobile companies’ financial proposals (Airtel, Orange, and Telma). The concept note is finalized and sent to the MOPH for signature. For the 13 USAID-supported regions, it is agreed with the financial and technical partners that:

- IMPACT will pay for 3 DRSP (Boeny, Atsimo Andrefana, and Melaky) within 20 SDSP, - ACCESS is supporting 4 DRSP (Vatovavy Fitovinany, Atsinanana, Analanjirofo, and Sava) including 27 SDSP, - Mahefa-Miaraka is supporting 13 SDSP throughout 2 DRSP (Menabe and Sofia) - Diana with 6 SDSP regions are supported by Global Fund Malaria under the New Financial Mechanism phase 2 through PSI/M. - The 3 PARN regions (Vakinankaratra, Amoron’I Mania, and Haute Matsiatra) also under the IMPACT mandate will be supported by the World Bank.

The distribution of DRSP and SDSP per financial and technical partners will be discussed 3 months before the end of the contract with the Internet provider companies to prevent the funding gap after the end of some projects.

IMPACT will proceed with the final selection of the mobile companies based on the information obtained by the MOPH and will collect additional information as needed as per its procurement procedures.

• In Quarter 2, 95% of Pha-G-Dis had people trained on CHANNEL. CHANNEL training issues are more frequent as there were often new people assigned to send LMIS data that were not trained on CHANNEL. The RLA recommended the Pha-G-Dis provider to always ensure skill transfer on CHANNEL to the new staff to be assigned to use CHANNEL. • Use of a call center (see Annex H for call center functioning) to remind the Pha-G-Dis providers to submit LMIS data: The call center reminds Pha-G-Dis providers if LMIS data is missing from October 2019 to January 2020. 234 reminders were sent, 154 providers submitted LMIS data after receiving the reminder, and 80 Pha-G-Dis providers did not respond to the reminder. Table 33 provides results per month. The list of those who did not respond after reminder was sent to RLA and DPLMT for close follow-up during supervision.

Table 33: Summary of reminders done by call center Pha-G-Dis submitted data Pha-G-Dis did not send data Month Reminder to Pha-G-Dis after reminder after reminder October 2019 33 16 17 November 2019 59 43 16 December 2019 70 51 19 January 2020 72 44 28 Total 234 154 80

• The reasons why Pha-G-Dis did not submit data even after reminders are: (i) not having a functional computer, (ii) no computer available for LMIS data, (iii) CHANNEL was having issues, (iv) electricity issues, (v) lack of enough people to work on LMIS. These issues were communicated to DPLMT and RLA who organized formative supervision visits as described in Table 34 below. • Thirty-three Pha-G-Dis were visited by EMAR/EMAD, RLA, and the central team (DPLMT, IMPACT, DEPSI, and DSFa) from January to March 2020. The purpose of the visits was to provide solutions to the LMIS issues already identified by the call center prior to the visit. • Table 34 provides a summary of the formative supervision visits conducted in Quarter 2.

Table 34: LMIS submission issues and solutions reported by the call center. Districts Supervised (33) Explanations Solutions Awaiting computer (to be Ambatofinandrahana Computer not functional offered by UCP) Pha-G-Dis closed (MOPH Being addressed by SDSP, DRSP, LMIS reports missed Mahanoro decision for finance and DPLMT Pha-G-Dis) management issues) Awaiting computer (to be Sambava Computer not functional offered by IMPACT) - Reminders sent by call center - Workload/not enough time - Formative supervision to (Pha-G-Dis providers only work remind staff that only Pha-G-Dis 4 half days a week) Ambositra, Manandriana, providers should work on LMIS - LMIS report is not a priority Beroroha, and CHANNEL (to be used as - Only one computer is used at Toamasina I, Vatomandry, management tool but not a the Pha-G-Dis for several staff Vohibato, Antalaha, Vohemar, reporting tool). Reporting - Three different manager of Bealanana, Befandriana North, timeline is also followed up with each health area (malaria, Mampikony, Antsirabe I, a reminder MNCH, FP/RH) prepares the Antsirabe II, Faratsiho, - Follow up of the laptop to be report independently which Mananjary, Ikongo, Nosy Varika supplied by IMPACT complicates the compilation - To be addressed during the by the people responsible of LMIS workshop using results of LMIS data submission the LMIS assessment Irregular/incomplete . New assigned people haven’t - Formative supervision to train submission of LMIS Maroantsetra, Mahajanga I benefited proper training on the new Pha-G-Dis responsible reports CHANNEL for CHANNEL (30 Pha-G-Dis) Antsiranana I, Morondava, IMPACT offered laptops that

Mandoto, Ambohimahasoa, were delivered in Quarter 2 No computer available Fianarantsoa I, Antsohihy,

Betioky Sud Ankazoabo, Ambatolampy Regional TICs will be sent to sort Computer not functional out IT issues The RLA installed the new Miandrivazo CHANNEL software issues version of CHANNEL Awaiting JIRAMA organization to fix the electricity or using Cybercafés in the nearest district Frequent and long-term Betafo (Antsirabe I). This will be electricity issues discussed during the LMIS workshop after the LMIS assessment

As a result of the LMIS provisional roadmap, including the contribution of the call center, IMPACT has noted an improvement in the reporting rates in Quarter 1 (79%) compared to average reporting rate in Year 1 (70%). Graph 7 shows the LMIS reporting rates from October 2019 to February 2020. Some Pha-G-Dis did not respect the submission deadline (27th of each month for the month-1 LMIS report) and data was received slowly in the CHANNEL central system which explained the low reporting rate for the recent months.

Reporting rates from DHIS2 is stable around 90% as the data entries are ensured by the Commodity Health Manager based at SDSP who is fully dedicated to DHIS2.

For Pha-G-Dis, the LMIS reports come progressively. Now the system still receives reports from previous months, even three or four months before, which is the result of non-respect of the deadline submission. So, these reasons explain higher reporting rate for the previous months compared to the more recent period.

Graph 7: Overall progress on reporting rates in Quarter 1 Year 2

100% 90% 93% 92% 91% 90% 86% 80% 79% 82% 76% 70% 71% 64% 60% 50% 40% 30% 20% 10% Oct. 19 Nov.19 Dec.19 Janu.20 Feb.20

Channel DHIS2

CC2.2: Support technically and financially the DPLMT to conduct Routine Data Quality Assessment (RDQA) at all levels and sectors.

The objective of the RDQA was to check the performance system through the seven quality dimensions: availability, completeness, timeliness, integrity, confidentiality, precision, and accuracy (See Annex H for a detailed description of the 7 quality dimensions). The tool used for the RDQA exercise was adapted from the Measure Evaluation RDQA tool to fit the LMIS context in Madagascar.

Two main activities were conducted on the RDQA:

A. Monitoring of the recommendations provided during the previous RDQA conducted in Quarter 1. The LMIS committee led by DPLMT set up an action plan based on the previous RDQA recommendations. A small questionnaire was used to check whether the recommendations were applied or not. The RLA with EMAR ensured the follow-up of the recommendations using the short questionnaire during supervision visits. 51 Pha-G-Dis and 133 Pha-Ge-Com were supervised. The Pha-

G-Dis and Pha-Ge-Com supervised by RLA in Quarter 2 included people who were not visited for the RDQA conducted in Year 1 and Quarter 1.

Table 35: Follow up of the RDQA recommendations at Pha-G-Dis level Quarter 1 Total Pha-G-Dis visited Pha-G-Dis evaluated in Quarter 2 for RDQA in Quarter 1 Questionnaire (n= 51) and visited in Quarter 2 for follow up (n =21) Use of stock cards per product at Pha-G-Dis 51 21 Insertion of inventory line in the stock card at the end of each 49 21 month Set-up logistic monthly report per program at Pha-G-Dis level 49 20 Access to the computer using password 30 11 CHANNEL password needs to be different per user 10 01 A copy of the CHANNEL database needs to be stored in another 29 12 backup system such as an external hard drive Training of new Pha-G-Dis providers and Pha-Ge-Com dispensers 43 18 on LMIS and GIS by EMAR and EMAD Pha-G-Dis has a manual on GIS management. 46 20

The findings of the visits showed that many CHANNEL responsible have no individual password. Twenty-two (22) out of 51 Pha-G-Dis do not store the CHANNEL database in a secure place. For the Pha-G-Dis providers who did not follow the recommendations, the RLA explained the proper protocols and underlined the importance of following the instructions.

Table 36: Results of RDQA recommendations at Pha-Ge-Com level in Year 1 and Q1 FY2 Total Pha-Ge-Com visited Pha-Ge-Com evaluated for RDQA in Quarter Questionnaire in Quarter 2 1 and visited in Quarter 2 for follow up (n= 133) (n =10) Commodity management tools is only at 94 8 Pha-Ge-Com level Use of stock cards per product at Pha-Ge- 105 8 Com levels Insertion of inventory line in the stock 98 9 card at the end of each month Training of new Pha-Ge-Com dispensers 98 4 on GIS by EMAR and EMAD Pha-Ge-Com has a manual on GIS 89 4 management.

For the Pha-Ge-Com that did not follow the recommendations, the RLA explained the proper protocols and underlined the importance of following the instructions. The need for a manual on GIS management was communicated to DPLMT. On-the-job training was provided for those who reported not having been trained on GIS management. The other aspects (insertion of inventory line in the stock card at the end of each month and use of stock cards) of the recommendations were reexplained to the Pha-Ge-Com dispensers.

B. Conducting RDQA in Quarter 2

RDQA activities were conducted in Quarter 2 with participation of DPLMT, DSFa, and EMAD in 4 regions (Sofia, Menabe, Amoron’i Mania and Vatovavy Fitovinany) for 6 Pha-G-Dis, 12 Pha-Ge-Com, 5 PARCs, and 7 PAs. RDQA activities for two Pha-G-Dis in Vohipeno and Bealanana were cancelled due to COVID-19 restrictions and accessibility issues during the rainy season. As a result, RDQAs for four Pha-Ge-Com belonging to those two districts were not completed.

For Pha-G-Dis, the overall data quality score was 88% (calculation method shown in the footnote of tables 37 and 38 below) with higher scores seen in Menabe and Sofia (92%). At Pha-Ge-Com level the overall data quality score is estimated at 83%, with a higher score of 90% in Amoron’i Mania and Sofia.

The challenges among Pha-G-Dis included:

• 75% average score for Confidentiality: one computer has been used by several SDSP program managers which increases the risk of modification or false manipulation. • 71% average score for Accuracy: data from stock monitoring sheets, data from activity monthly report do not match with data in the CHANNEL system. It is noted that the lack of monthly reporting by EMAD makes it difficult to triangulate or compare data during RDQA exercise. The Pha-G-Dis in Vatovavy Fitovinany have lower overall data verification scores (74%) for the following reasons: absence of supporting documentation such as a manual available (50%), completeness issues (50%) explained by missing stock cards for some health areas and data are not up to date, precision issues (50%) because there are no tools to record information on disaggregation (e.g.: stock cards missing for ACT by age group), and accuracy (70%) which means that CHANNEL data does not match with the information recorded in the paper tools.

Vatovavy Fitovinany also had data quality issues with Pha-Ge-Com with an overall data quality score at 52%, explained as follows:

• 69% overall data verification score: No confidentiality (50%) which means that anyone can access to the management tools, no precision (50%) means that no tools are available to record information on disaggregation (e.g.: stock cards missing for ACT by age group), absence of supporting documentation available (50%), and completeness issues (50%) explained by missing stock cards for some health areas and data are not up to date. • 35% average score for System Assessment: due to a lack of training or lack of attention by the manager, who did not apply also the guidelines on commodity management, including the use of management tools, calculation of indicators, and use of data.

Recommendations were provided to Pha-G-Dis in Vatovavy Fitovinany and the two Pha-Ge-Com with data quality problems. They will be monitored again in Quarter 3. The RDQA issues reported by IMPACT among Pha-Ge-Com are regularly communicated to ACCESS for further action.

For PARC and PA, the overall data quality score was 95% which means that data submitted are in good quality.

Table 37: Summary of the RDQA findings for the public sector STORAGE LEVEL Pha-G-Dis (n=6) Pha-Ge-Com (n= 12) Average Average AMORON' I VATOVAVY AMORON' VATOVAVY MENABE SOFIA Score MENABE SOFIA Score REGION MANIA FITOVINANY I MANIA FITOVINANY (n=2) (n=1) (n=4) (n=2) Pha-Ge- (n=2) (n=1) Pha-G- (n=4) (n=2) Dis Com Data Quality Parameter Availability 100% 50% 100% 78% 88% 100% 50% 88% 81% 84% Completeness 100% 50% 100% 78% 88% 100% 50% 72% 81% 79% Timeliness 67% 100% 100% 100% 89% 100% 100% 100% 100% 100% Integrity 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Confidentiality 50% 100% 75% 100% 75% 88% 50% 100% 100% 88% Precision 100% 50% 100% 100% 92% 100% 50% 88% 92% 86% Accuracy 74% 70% 74% 58% 71% 90% 83% 80% 71% 82% Summary Overall Data 84% 74% 93% 88% 86% 97% 69% 90% 89% 88% Verification Score1 System 83% 91% 91% 97% 89% 86% 35% 88% 90% 78% Assessment Score2 Overall Data 84% 82% 92% 92% 88% 90% 52% 89% 90% 83% Quality Score3

Table 38: Summary of the RDQA findings for social marketing PARC and PA STORAGE LEVEL PARC (n=5) PA= 7 AMORON' I VATOVAVY Average AMORON' I VATOVAVY MENABE MENABE SOFIA Average REGION MANIA FITOVINANY Score MANIA FITOVINANY (n=2) (n=2) (n=1) Score PA (n=2) (n=1) PARC (n=3) (n=1) Data Quality Parameter Availability 100% 100% 100% 100% 100% 100% 100% 89% 98% Completeness 100% 100% 100% 100% 100% 100% 100% 89% 98% Timeliness 100% 100% 100% 100% 100% 100% 100% 100% 100% Integrity 100% 100% 75% 92% 100% 100% 100% 100% 100% Confidentiality 100% 100% 75% 92% 100% 100% 100% 100% 100% Precision 100% 100% 100% 100% 100% 100% 100% 100% 100% Accuracy 91% 100% 94% 95% 91% 100% 96% 76% 92% Summary Overall Data 99% 100% 92% 96% 99% 100% 99% 93% 98% Verification Score1 System Assessment 94% 92% 96% 94% 86% 96% 96% 96% 92% Score2 Overall Data Quality 96% 96% 95% 95% 92% 98% 97% 95% 95% Score3

- 1: Average score on the seven quality dimensions (availability, completeness, timeliness, integrity, confidentiality, precision, accuracy) - 2: Qualitative assessment of the strengths and weaknesses of the functional areas of the data management and reporting system. A series of questions are used to calculate the average score based on the responses - 3: Average score on “Overall Data Verification Score” and “System Assessment Score”

Legend Score 90% and above 80% - 89% Below 80%

CC2.3: Implementing monitoring and evaluation system ITN community continuous distribution, including creating M&E tools, training, data collection and supervision, RDQA (budget included in the continuous distribution activities) The Monitoring and evaluation team is coordinating the collect of the monthly cCD activities reports from the TA Supervisors (see details of the achievements in cCD section).

6.1.2. Research CC2.5 Conduct market assessment studies for FP and MNCH, including key informant interviews, outlet surveys, and routine data in collaboration with IR1.

Market assessment on FP and MNCH: Different data collection tools will be used to collect information to feed the market assessment design:

• Outlet survey on MNCH and FP have been combined. The outlet survey is designed to measure the availability of MNCH and FP tracer products and to estimate the volume and value among all potential outlets categorized as public sector, private for-profit sector, and private for nonprofit sector. The tool was shared with PSI’s Regional Researcher for feedback. The data collection is scheduled in June within 45 communes in the 13 USAID-supported regions for FP and 10 USAID-supported regions for MNCH. • Key informant interviews to identify key players in FP and MNCH programs and to collect the views of key stakeholders, such as government officials, donors, implementing partners, the private sector, and supply chain players to understand the in-country FP and MNCH landscape with an emphasis on the priority or tracer products. For FP, 41 people will be interviewed in 5 regions namely in Analamanga (Antananarivo central offices), Haute Matsiatra, Menabe, Atsimo Andrefana, and Diana. For MNCH, 52 people will be interviewed in Analamanga (Antananarivo central offices), Boeny, Analanjirofo, Atsimo Andrefana, and Sava. Data collection is scheduled in June (which is delayed because of COVID-19). • The collection of routine data will be completed along with the outlet survey. This survey is used to collect exhaustive data among this public sector (hospitals, Pha-G-Dis, Pha-Ge-Com), private for profit (pharmaceutical wholesalers, pharmacies, and drug shops), and private for non-profit (social marketing, NGOs, confessional outlets). The information to be collected will focus on market volume, market value, market share, and analysis on forecasts versus procurement. The routine data collection will be limited to the 13 USAID-supported regions and to the 2019 data. • FP qualitative survey among the primary target audience (women of reproductive age 15-49 years old) is to understand their willingness to pay for FP tracer products and the potential barriers and motivation on access and use of FP products. 36 women will be interviewed among women of reproductive age living in urban and rural areas. Data collection is planned in June. • MNCH qualitative surveys among health care providers: the primary target groups do not know the products such as Magnesium Sulftate, Oxytocin, Gentamicine, etc. used at health centers/clinics. As a result, the primary target groups ability to pay will be collected via interviews with the providers. This tool will also be used to collect information on views and perceptions (barriers and motivation on access and use of clinical products) of health providers related to provision of MNCH care. Thirty-six (36) providers (including CHVs) selected among the public and private sectors will be interviewed. Data collection will be carried out from June to July.

IMPACT will hire external agencies to implement data collection, data analysis, and reporting. An open tender will be launched to select one agency for the key informant interviews, one agency for the outlet survey including routine data collection, and one agency to ensure implementation of the two last qualitative surveys cited above.

Since IMPACT will disseminate two separate reports for the FP and MNCH market assessment designs the following timeline will be followed:

• For better coordination, IMPACT will collect data for all the five tools listed above for both FP and MNCH at the same time by mid-July. • Data analysis for FP will be prioritized and dashboards from the outlet survey, routine data collection, and qualitative reports will be expected by the end of August. • Dashboards from the outlet survey, routine data collection, and qualitative reports for MNCH will be finalized after FP and will be expected by the end of October. • Elaboration of the market assessment designs for FP and MNCH will follow the above timeline. The FP market assessment report will be drafted and finalized first and the MNCH one will be completed after.

CC2.6 Implement additional studies, including: archetype study/segmentation, journey mapping, assessment of pharmacies and drug shops on products supply, KAP study on IPTp use, and an evaluation on the introduction of the last mile distribution strategy (drones) at the community level.

CC2.6.1 Elaborate study design of the archetypes/Segmentation study, recruit agency to implement the study from creation/finalization of the survey tools to the dissemination of the results

• The research brief for the archetype/segmentation and journey mapping studies was received from the program team. The archetype/segmentation and journey mapping are complementary studies which mean that the archetype/segmentation need to be done first and then the results will be used for the journey mapping. The journey mapping is a qualitative approach used to evaluate client’s journey in order to better understand the opportunities or challenges they face in seeking healthcare/use of health products. A literature review and key informant interview will be conducted in order to identify different categories of segments of youth that will be the main audiences for the journey mapping. • Depending on the COVID-19 restrictions, the journey mapping may be pushed back to Quarter 1 of Year 3.

CC2.6.4 Formulate research needs and share with USAID that will recruit an external agency to evaluate the pilot phase of the introduction of drone as last mile distribution

• The study protocol was sent to USAID. Since the pilot activity is conducted in Maroantsetra district then the evaluation will be completed in the same district. Approximately 22 people will be interviewed including the local authorities (Chief of Fokontany, Medical Inspector, Chief of Commune), the aviation authority ACM (Aviation Civile de Madagascar), the IMPACT staff involved in the drone project, and the people living in the commune served by the drone. USAID will coordinate the evaluation.

CC2.6.5 Elaborate study design of the qualitative study to understand knowledge, attitude and practice on IPTp use. Recruit the agency that will implement the study from creation/finalization of the survey tools to the dissemination of the results.

• The study to understand the barriers and motivations on IPT uptake is a mix of qualitative and quantitative methods. The qualitative methods will provide barriers and motivations on IPT uptake and the quantitative method will be used to identify factors associated with the use of IPT during pregnancy. The qualitative component will be conducted among 36 women delivering in the last 12 months and the quantitative component will be a representative sample of 504 women in the 10 USAID-supported regions having given birth in the last 12 months. This research activity will be completed internally by the IMPACT research team.

Data collection is scheduled in June, the data analysis will be completed in July, and the final report and dissemination will be completed in August.

6.1.3. Knowledge Management CC2.7: Knowledge Management: Support partners in developing and collecting success stories and documenting IMPACT's innovations in the field.

CC2.7.1 : Organize field visits to collect success stories and project's innovations (Ex: last mile distribution using drones , achievements of the TWG, youth program, ect.) every quarter

IMPACT organized field visits in Vatovavy Fitovinany region to collect success stories and to train IMPACT regional staff in documenting success stories and lessons learned through discussions with target audiences on their views and perceptions of IMPACT’s activities. The region of Vatovavy Fitovinany was selected because of its malaria peak season during Quarter 2 combined with an outbreak of malaria. Four success stories were collected during the field visit and are presented in Annex D.

CC2.7.2: Post success stories through the project’s online platforms (Website and Social media), to USAID Madagascar and to Consortium partners platform

During Quarter 2, IMPACT worked with USAID Madagascar to disseminate success stories through USAID platforms, such as websites and Facebook pages. For International Women’s Day on March 8th, the story of a woman working in the public supply chain was submitted to USAID which was published on USAID Madagascar’s website and Facebook page. The success story illustrates how new IT skills help to improve supplies of health commodities.

For internal communication, IMPACT continues to use Intranet to enhance learning and share important information and files to IMPACT staff, such as the latest news about the project activities, achievements, a dashboard tracking the evolution of project key indicators and key documents (national laws and politics, researches findings, project templates, PMP updates, stock out status, sales reports, etc.). Through SharePoint, IMPACT electronically archives final documents.

The table below provides the total number of visits on the Intranet site and most visited pages

Table 39: Total number of visits on Intranet site and most visited pages Number of staff having access to Intranet 123 staff Number of visits during Quarter 2 2,955 visits Most visited pages - IMPACT Annual Workplan (Year 2) - About the project - IMPACT Dashboard - IMPACT Key Indicators - News and Success Stories

CC2.7.3: Identify with the consortium partners the appropriate tools to disseminate IMPACT results (market assessment and studies, TMA Roadmap, LMIS Assessment and roadmap, supply chain assessment, End User Verification).

Dissemination of the malaria market assessment design, LMIS assessment, and End User Verification are scheduled in Quarter 3 due to COVID-19 pandemic restrictions.

III.6.2. Gender and Social Inclusion

This quarter, the GESI team focused on strengthening partnerships with key stakeholders, collaborating across teams to ensure gender and social inclusion was holistically integrated into interventions, and raising visibility of key issues impacting women, girls, and other marginalized groups with respect to access to family planning and MCH resources.

Celebrating International Women’s Day to Strengthen Visibility and Partnership

This year marks the 25th anniversary of the adoption of the Beijing Declaration and Platform for Action (1995), commemorating the global commitment to women’s rights and gender equality. In Madagascar, many events were organized in line with this year’s UN Women theme, placing a greater emphasis on engaging with youth on issues related to gender equality. IMPACT staff participated in International Women’s Day (IWD) celebrations in Toliara during the first week of March. IMPACT led several events related to promoting access to finance and to health promotion and awareness raising on the importance of integrating gender equality and social inclusion in improving access to health services and commodities for the Malagasy population, highlighting strategies such as the use of drones to distribute essential health commodities to remote communities. IMPACT collaborated with the Ministry of Population by providing 300 MILDS to be distributed to six selected health centers and 100 mosquito nets to vulnerable households. The IMPACT program strengthened its visibility, partnership and commitment to the promotion of gender equality and social inclusion through this IWD celebration.

Figure 15: Visit from Ministry of Population at IMPACT Figure 16: USAID Madagascar HPN and GESI Focal stand Point’s speech on IWD

IMPACT Staff Training

In line with proposed interventions embedded within the work plan, IMPACT held its first staff training on GESI during the first quarter to identify opportunities for advancing gender equality in upcoming activities. During this quarter, Malanto Rabary, GESI Local Advisor, and Maimouna Toliver, GESI International Expert, co- facilitated the GESI staff training in Antananarivo on March 11-12, 2020. The training workshop engaged several stakeholders, including representatives from the Ministry of Population, CNFM, USAID, and IMPACT staff

A total of 53 participants, including 32 women and 21 men, attended the workshop. Several members of the team expressed the importance of identifying ways to reach traditionally marginalized groups and the utility of holding another workshop before work planning for Year 3 begins.

Figure 17: Exercise on Identifying Opportunities and Figure 18: Group work GESI training March 11th Constraints related to GESI

Building Relationships with Partners Working in Gender Equality and Social Inclusion to Advance TMA IMPACT continues to forge strategic partnerships with women’s rights organizations and associations, to ensure balanced gender representation among the TMI TWG. This quarter, IMPACT reached out to Entreprendre au Féminin Océan Indien (EFOI) to join the Conseil National des Femmes de Madagascar (CNFM). Representatives from CNFM and EFOI met in Toliara to discuss partnership details and the opportunities to serve together as GSESI champions and engaging the Gender Working Group.

Follow-up meetings are planned in Quarter 3 to elevate gender expertise into the stakeholder group working on the TMA. Both GESI partners will participate in the development of a malaria road map within the TWG and will liaise with banking partners to facilitate access to finance.

III.7. Success Stories • Vohipeno district: Coaching Pha-G-Dis service providers increases health facilities data reporting rate • Sakoana: a model health facility that has never experienced stock-out of antimalarials due to careful adherence to guidance of stock management • Mananjary: IMPACT and ACCESS join efforts to improve the availability of malaria products in remote rural to help save lives • Maroantsetra: Devotion of Point d’Approvisionnement Relais Communautaire (PARC) manager and support from IMPACT helps prevent stockouts of family planning and maternal and child health supplies • Joffre Ville: Collaboration among IMPACT Point d’Approvisionnement (PA), Mahefa Miaraka, and health facilities help satisfy family planning needs • Applying the Training: Lessons Learned from Financial and Operational Management Training • Tapping into innovation for family planning: applying drone technology to bring contraceptives to remote Communities in Madagascar

III.8. Environmental Mitigation and Monitoring Report

Public Sector: General findings:

• 66 CSB providers (22 Male, 44 Female) in 40 Districts were trained on proper storage, use, and disposal of commodities. • 95% (38/40) of Pha-G-Dis and only 32% (41/130) of Pha-Ge-Com visited were trained on management of expired, obsolete, and surplus commodities. • 80% of Pha-G-Dis (32/40) and 48% (63/130) Pha-Ge-Com providers participated in the workshop to enhance coordination and distribution of quality health products.

Challenges identified included:

• 49% of CSB providers are not trained in good practices for handling and disposing of health care waste. • 31% of PhaGeCom do not comply with proper disposal of commodities. This is due to poor infrastructure of CSBs. • Lack of guidelines and job aids on good storage practices in Pha-G-Dis and PhaGeCom. • Pha-G-Dis and PhaGeCom are not controlling the temperature for their warehouses/storage spaces, which can lead to deterioration of quality of sensitive medicines. • Low level of coordination and distribution of health commodities at the peripheral level.

Recommendations:

• Support DPLMT and DSSB in resource mobilization to construct or renovate storage spaces (explore opportunities to engage the private sector on social corporate responsibilities). • Collaborate with ACCESS, districts, and other stakeholders to follow-up with CSBs and ensure that medical equipment is purchased and/or donated. • In December 2019, the training curriculum on stock management (including management of expired medicines) was validated. Trainings will be rolled out in 2020 by ACCESS and in collaboration with other stakeholders. The RLA will contribute to the training sessions as facilitators and provide on-the-job training during supervisions. • IMPACT will print and disseminate the guidelines to Pha-G-Dis and PhaGeCom in Quarter 3 or Quarter 4 depending on Covid-19 restrictions. • Purchase thermometers to control temperature of storage rooms at Pha-G-Dis level.

Social Marketing:

General findings:

• All PAs, PARCs, and employees at PSI’s central warehouse that were visited were trained on management of expired, obsolete, or surplus commodities. • Visited warehouses were equipped with guidelines and communication tools. • 88% (59/67) of PARC and 93% (820/887) of PA visited had guidelines and communication tools in their storage rooms. • LLIN Distribution: - Storage of LLINs: The first group of 6 districts (PARC) for the cCD met the criteria (LLINs in wooden pallets, dry, ventilated, and in secured areas to prevent theft or unauthorized access). - Warehouses at central and PARC are secure. - The communications tools and key messages on malaria prevention and the use of LLINs were revised, produced, and distributed at all levels (district, CSB, and Kom’Lay).

Challenges identified included:

• Expired 850 blisters of Pilplan® without packaging and 24,994 blisters of Combination 3 were identified at PSI’s central warehouse and one regional warehouse in January 2020. • Surplus of products were found at PA and PARC that were supervised. The surplus products (namely: Combination 3/Microgynon, Depo-Provera/ Triclofem, ORS – Zinc, Arofoitra, Pneumox, Protector Plus, Sayana Press, SE Pilina, Rojo) is used to prevents stock out during the rainy season for PA and PARC located in remote areas. • 12% (8) of PARC and 7% (67) of PA do not have guidelines and communication tools. • PA do not have communication tools or guidelines for transportation requirements.

Recommendations:

• On-the-job training to reinforce the training done during the SPD supervision visits. • For the expired products, IMPACT will contract with ADONIS company which will ensure the incineration procedures are completed. • IMPACT will set up an alert system to rectify the coordination between the Central Warehouse Manager, Regional Assistant, and Regional Warehouse Assistant to improve the inventory management of the products in order to avoid expired products. Markings will be used to monitor products with expiration dates of less than 12 months and for the items that have not moved in the past three months. • Management of surplus products at PARC and PA is now included in the scope of the SPD during the supervision visits to avoid waste. • IMPACT will print updated tools that will highlight instructions and guidelines on storage conditions. This updated version will be available for SPD for distribution during monthly supervisions for PARC and PA. • Communication tools and guidelines on commodities transportation requirements will be provided to non- compliant PAs. Follow-up will be completed at each supervision visit.

V- KEY CHALLENGES AND SOLUTIONS Table 40 : Key challenges and solutions (Quarter 2) Key Challenges Solutions Challenges related to COVID-19 Availability of decision-makers, especially from the MOPH • IMPACT asked the MOPH to appoint someone within Pending validation of documents by MOPH their department to continue implementing activities in partnership with IMPACT. • IMPACT continues to exchange emails with the MOPH for the validation of documents Restrictions in meetings, workshops, and in-country travel • Meetings rescheduled to Quarter 3. due to the COVID-19 outbreak, including trainings in the • IMPACT continues to organize the monthly CNC regions for cCD coordination meetings (including MENETP team) for monitoring field activities and resolving implementation challenges. Due to COVID-19 these meetings are conducted through conference calls. • The cCD operational team at the district level (TA Supervisor and TA) participate in coordination meetings with EMAD and the USAID implementing partners ACCESS and TIPTOP. International travel ban caused by COVID-19. • STTA will continue to support the team remotely and the training is rescheduled to later in 2020. • Study tour had to be postponed to Year 3 in 2021. Delay of arrival of products because of COVID-19 • IMPACT has to wait because products have to be put in quarantine at arrival in Toamasina and cargo was confined at departure and has to wait for authorization. Due to the COVID-19 pandemic, global procurement was • IMPACT continues to monitor the pipeline orders and impacted, and manufacturers have been delayed or are inform RBM and the national malaria program to adjust slowing the process of manufacturing goods to ship to in-country logistics and rationing distribution of Madagascar and the logistics systems have been impacted commodities (months of stock to distribute to district by the closure of ports, airports, and lack of reliable has been reduced to 1.5 months instead of 3 months). transportations during this time. Delay in data collection for evaluations and research • Data collection has been postponed to a later date once (NSCA) the situation evolves Other Challenges Insufficient stock of malaria commodities to supply • New emergency procurement of Arthemeter districts Lumefantrine by PMI was partially shipped in March 2020. • Supervision in 59 districts to evaluate available stock and organize redeployment. Low uptake of SP that can lead to expiration of • Coordination meetings with GHSC-PSM, PMI approximately 5 million tablets (Washington and Madagascar), Global Fund (in-country PR/PSI, CCM, and portfolio team in Geneva) to explore the possibility of exporting the SP to another country. • Prepared all documentation necessary for exportation to another country in Quarter 3. • Delivered a stock of 6 months to districts to increase availability and use of SP. Identify the best business model to set up a sustainable • Explore all potential implementing partners from both training mechanism for drug shops in Madagascar the public sector and the private sector to seek a sustainable solution which will be affordable for beneficiaries. Continue identifying and preparing to train CPT candidates. Sensitize all types of drug shops about regulatory • Continue to support the awareness campaign with compliance, including already formalized and informal DPLMT, but also collaborating with other partners ones inside IMPACT (MSH) to launch a media communication campaign and specific approach to informal operators who are willing to formalize.

Key Challenges Solutions Set up quickly an operational financial product that may • Work closely with partner banks to develop products help financing COVID-19 response commodities based on existing ones that meet wholesalers, pharmacies and drug shops needs in response to the pandemic. Drone test flights between 25km and 50km are difficult • Inventory of pylons. Letter was sent to Telma, Orange, because of existing pylons from Mobile Operators which Airtel, and ARTEC asking for locations of their existing may cause interference to drones. The flight itineraries pylons in Maroantsetra. Telma has already provided must be modified to avoid interference with the pylons. the requested information. Recognized need to increase gender and social inclusion • Plan and budget more frequent GESI pause and reflect competency amongst stakeholder partners, along with sessions amongst IMPACT staff, particularly to IMPACT staff. Staff need training in identify opportunities strengthen GESI dimensions within targeted and entry points to holistically integrate gender and social interventions. inclusion considerations into interventions to maximize • Coordinate closely with the GESI Technical Working reach and equity. Group • Ensure adequate planning and time for stand-alone gender and social inclusion sessions in conjunction with upcoming staff retreat/work planning sessions.

VI- MAJOR ACTIVITIES PLANNED FOR NEXT Quarter (YEAR 2, APRIL – JUNE 2020)

IR 1: Enhanced coordination among the public, nonprofit, and commercial sectors for reliable supply and distribution of quality health products

IR 1.1. The total market for health products in Madagascar is understood and documented

• Continue to support the implementation and monitor and evaluate the overarching TMA roadmap for all health products; • Disseminate the findings of the malaria market assessment, and support the development and implementation of the malaria TMA roadmap based on these findings; • Continue to implement the FP and MNCH market analysis; • Conduct a refresher training for TMI Champions in leadership; • Disseminate the official TMI roadmap document.

IR 1.2 . GOM leads TMI stakeholders to coordinate health product quantification and forecasting, procurement, and distribution according to market assessments and segmentation

• Orient new UTGL members on their roles and responsibilities once Ministerial appointment letter is signed.

IR 2: Strengthened capacity of the GOM to sustainably provide quality health products to the Malagasy people

• Hold annual quantification exercises for malaria, FP, and MNCH products. • Contribute to the gap analysis with Malaria Operational tables to secure funding for commodities as part of the development process of the MOP 2021 in April. • Hold periodic meetings with the GAS malaria committee and TWG for MNCH. • Ensure distribution plans for malaria, FP, and MNCH commodities to resupply the 78 districts. • Implement the Last Mile Distribution strategy in 114 districts. • Orientation of GAS Committee district members on key supply chains functions. • Conduct the data collection for the TCA. • Organize a dissemination workshop of the LMIS evaluation results and develop the road map to strengthen the LMIS. • Implement EUV plan and recommendations. • Distribution of LLIN in the 12 targeted districts • Continue implementing cCD cascade training

IR 3: Expanded engagement of the commercial health sector to serve new health product markets according to health needs and consumer demand

IR 3.1 Commercial actors are incentivized to expand into new health product markets

• Develop partnership with EDM to transport public health commodities. IMPACT and EDM will work to define regions, frequency, and volume of transport. • Define the data collection tools for drug shops and pharmacies. • Ensure that the health commission continues to participate in the TWG.

Strengthening partner banks and other financial institutions' capacity to better serve private health commodities supply chain:

• Revise capacity building plans and training curricula for DCA partner banks to incorporate GESI issues and, as needed, to consider newly identified needs. • Train and support DCA partner banks in credit analysis and loan structuring for health commodities businesses (continuous activity – Training planning to be revised depending on availability of DPLMT team and on COVID-19 travel restrictions). • Develop and adapt loan products and financial tools for small and micro health enterprises in health commodities sector (e.g., pharma loans, motorbike loans, COVID-19 response product). • Design and develop new financial mechanism (e.g. risk sharing facility), following principles of USAID's Blended Finance Roadmap for Global Health, possibly including additional financial institution partners, to facilitate A2F within the pharmaceutical supply chains and other stakeholders.( This activity is developed with international staff and meetings with stakeholders so it will probably be postponed to Year 3).

Provide business strengthening capacity building to enterprises in health commodities supply chain and develop partnership with private companies to sustain the training:

• Provide initial business-strengthening training to drug shops (continuous activity – Training planning to be revised depending on availability of DPLMT team and COVID-19 travel restrictions). • Seek potential solutions (implementing partners) to sustain training, including with CPTs. • Provide one-to-one coaching on business strengthening to enterprises/individuals identified as potential peer trainers in health commodities supply chain (depend on training schedule). • Explore digital inventory management applications for use by private health commodities enterprises and which would be incorporated into future business training (in collaboration with other IMPACT partners).

IR 3.2 GOM facilitates the work of the commercial sector

• Sensitization of regional depot/drug outlet owners on regrouping regional associations. • Set up the committee to develop an implementation of the ADDO model. • Continue advocacy meetings with the Ministry of Budget and tax experts on the exemption of essential medicines and medical devices. • Assess the needs for a software for registration of medicines and key functions of the DAMM. • Draft guidelines for registration of medicines to guide the process at DAMM. • Continue resource mobilization to support the WHO prequalification process of the Quality control Laboratory. • Finalize and sign the two MOUs on harmonization of quality assurance. • Disseminate existing laws and ministerial decrees in relation to pharmacy practices.

IR4: Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy people

• Continue the distribution of social marketing products to the 10 regions of IMPACT and 3 regions of PARN. • Continue the process initiated for the tracking system and finalization of the technical specifications for the tracking system to find an agency to study the feasibility and implementation. • Approval of the portfolio analysis and the COGS analysis by USAID • Procurement of Yes With You male condoms.

• Exploration of the extension of Yes With You by introducing new scent validated by a consumer panel in the commercial market. • Extension of the distance for flight tests (> 25 km) for drones. • Training of the last group of PA and PARC on LLIN cCD.

IR5: Increased demand for and use of health products among the Malagasy people

• By the end of Quarter 3, the demand creation subcommittee of the TMA TWG will finalize the communication plan on safe behavior of health commodities. • Continue to send SMS broadcasts to the providers: PA, PARC, CHVs, Pha-G-Dis, and Pha-Ge-Com. For example, PAs, PARCs, and CHVs will be alerted by SMS when a shipment of products arrives. Pha-G-Dis will continue to receive reminders to send data each month. • SMS will also be sent to the general population. For example, during World Malaria Day on how to prevent malaria. • Blue Venture’s youth members will receive capacity building on leadership, sensitization on how to have good health behaviors, and the use of health commodities. It will be conducted by the Ministry of Youth and Sport and the PSI HIV team. • IMPACT will continue to support the MOPH on the fight against COVID-19, particularly through the “910” call center.

Cross-cutting

Monitoring and Evaluation

• Support LMIS committee led by DPLMT on the development of a document on LMIS data validation in order to have clean data for data analysis and data to be disseminated to the UTGL. • Continue implementation of the provisional roadmap using the call center and ongoing formative supervision. • Organize RDQA among a sample of sites visited during the previous RDQA exercises in order to check whether the Pha-G-Dis, Pha-Ge-Com, PARC, and PA are following the recommendations. • Finalize contracts with the selected mobile companies for Internet connection at RDSP and SDSP.

Research Market assessment on FP and MNCH: • Finalize all tools related to the data collection: outlet survey including routine data collection, key informant interviews, and FP and MNCH qualitative surveys based on comments and feedback on the market assessment framework from the IMPACT HQ team (Regional Researcher, marketing team, consortium partners) and USAID. • Finalize recruitment of the agencies for the assessments. • Supervise field work conducted by the selected agencies.

Other research activities:

• Finalize study protocol on barriers and motivation of IPT uptake, submit the study protocol to the Research Ethics Board and start data collection. • Work with USAID on the evaluation of the drone pilot activity in Maroantsetra. • Finalize recruitment of the consultant who will coordinate with the agency to complete the literature review and segmentation analysis used for the journey mapping. • Organize an open bid to recruit a research agency to implement the segmentation and journey mapping.

Knowledge Management

• Support IMPACT staff in collecting project success stories. The regions will be identified with partners and regional staff depending on progress of indicators. • Provide content to be posted on PSI and USAID Madagascar Facebook pages for the upcoming world events, including World Community Health Volunteers Week, World Health Day, World Malaria Day (April), Small Business Day (June), and COVID-19 activities in line with USAID guidance. • Support the dissemination of IMPACT results (malaria market assessment study, LMIS assessment, and End User Verification) to partners and all stakeholders involved (MOPH, private sector, technical and financial partners).

Gender and Social Inclusion

Considering the ongoing challenges posed by COVID-19, the GESI team will continue to move forward on specific interventions that can help advance the integration of GESI considerations into future programming, including

• Finalize the GESI and Access to Finance Training curriculum (3.1.6.1). • Inform the design, implementation, and monitoring of GESI-informed communications campaigns on FP in April 2020 and for MNCH in June 2020, incorporating gender/social inclusion best practices in SBCC GESI campaign (CC.1.5). • Strengthen strategic partnership with CNFM and EFOI to ensure balanced gender representation among the TMI TWG (CC.1.1). This activity will continue in Quarter 4 given the challenge of getting partner’s meetings with the current COVID-19.

VII- FINANCIAL SUMMARY

Table 41: Financial summary Estimated Estimated remaining Actual Expenditures Description Obligated Amount Expenditures Funds as of as of Dec 2019 Jan-Mar 2020 Mar 2020 Malaria 4 134 500 2 326 643 674 805 1 133 052 MCH 3 492 100 2 464 082 507 091 520 927 FP/RH 3 698 825 2 416 144 503 698 778 983 TOTAL $11 325 425 $ 7 206 869 $ 1 685 595 $ 2 432 961

ANNEXES

ANNEX A - Performance Monitoring Plan (PMP)

Note: - The indicators calculated using data from public sector (Pha-G-Dis and Pha-Ge-Com) for the Quarter 1 report were updated after receiving some late LMIS data. - PMI Quarterly report is attached in an Excel File sent with this Annual Performance Report. - HPN Quarterly report is available on DHIS2 website https://data.mis-psimada.org/

USAID IRs Y2 Reporting Measure and Sub- Indicator Achievement Achievement Comments to of Unit Target IRs Quarter1 Quarter2 Intermediate Outcomes/Outputs Short-term Outcomes SO2 PPR Couple Year Protection (CYP) in USG

(IR 2.9) USAID supported programs - This is the number of FP product distributed to public sector (part of the Year 1 emergency distribution). Public sector 60 872 14 266 109 697 - The target in Year 2 is the remaining products not Number distributed in Year 1 but is distributed as per the distribution plan in Year 2. Private for nonprofit sector 163 430 195 465 679 148 52% Data collection among pharmaceutical wholesalers Commercial sector N/A N/A 67 915 are expected to start from Quarter 4. IMPACT can request data from the previous Quarter.

IR1: Enhanced coordination among public, non-profit, and commercial sectors for supply and distribution of health products

IR1.1. The total market for health products in Madagascar is understood and documented GOM-led TMI TWG (Technical Working Group) meets at least four times a year as a PMP A meeting of the TMI TWG was held on March 18, IR1.1.9 forum for consultations and roundtables Number 0 1 4 IMPACT 2020 which counted 38 participants. between public, non-profit, and commercial stakeholders IR2: Strengthened capacity of the GOM to sustainably provide quality health products to the Malagasy people IR2.1. Health commodities and pharmaceuticals are continuously accessible and available in the public sector IR2.1.1 Average stockout rate at service delivery PMP (IR2.4.1 points (SDP) of tracer essential drugs (MCH, USAID IR3.1.3) malaria) In Quarter 2, there is slight increase of stock out of Pha- Public sector Malaria ACT New born Percent 19 15 10 ACTs which can be explained as follow: G-Dis - Due to malaria outbreak and malaria peak season

(during rainy season), where there was increase of ACT Infant 9 16 10 consumption of ACT within CSB in December and during Quarter 2. - Shipment from central level to district was delayed due to insufficient stock at central level in ACT Adolescents 11 15 10 Q2 to fulfill all requests from districts. The central team led by DPLMT conducted an assessment of the number of months covered with the quantity of product available at district level and organized redeployment of the products within Pha-G-Dis and Pha-Ge-Com. The assessment helped reducing ACT Adult 12 16 10 stock out at national level. PMI procured in emergency 185,760 treatments of Arthemeter Lumefantrine to respond to this situation. Partial shipment was received and distributed to districts in Q3 Rapid Diagnostic Test 7 8 10 (RDT) SDSP with RLA conducted redeployment of SP to other Pha-G-Dis experiencing stock out. The central GAS Committee conducted a push Sulfadoxine- 11 6 10 distribution to districts in Q2 of a 6-months stock pyrimethamine (SP) (based on demographic data). The RLA will continue to monitor the use of SP to avoid an expiration. Injectable Artesunate 11 10 10 Oxytocin (10 IU Injection) 20 16 21.2 Magnesium Sulfate - Stock out is calculated based on the tracer 64 75 45 (500mg Inj) products for program, although districts have the same products under FANOME system. Gentamicin (20mg inj) 70 85 45 - Pha-G-Dis do not send procurement orders to MCH SALAMA and DSFa for resupply. Due to availability of the products through FANOME and Vertical programs, there is still confusion at district level on Gentamicin (80mg inj) 68 82 39.6 the distribution circuit. Instructions on the use of FANOME and free-of-charge products are being drafted and will be disseminated in the next

quarter to inform clearly on the management of both types of products.

ACT New born 24 31 10 ACT Infant 14 27 10 Consumption of ACT at CSB increased due to ACT Adolescents 14 23 10 malaria outbreak and malaria peak season. Pha-G- ACT Adult 14 22 10 Dis had not enough stock to respond to CSB needs. Malaria Rapid Diagnostic Test In February and march 2020, UTGL members, 8 16 10 (RDT) EMAR and RLA have supported SDSP to redeploy Sulfadoxine- ACT between CSBs to correct this situation. Pha- 28 28 10 Ge- pyrimethamine (SP) Com Injectable Artesunate N/A N/A 10

Oxytocin (10 IU Injection) 30 24 26.05 Magnesium Sulfate - Stock out is calculated based on tracer products 43 44 33.3 (500mg Inj) for program which were not available at some Pha- MCH Gentamincin (20mg inj) 50 63 38.8 Ge-Com. - The CSB have FANOME products which is the Gentamicin (80mg inj) 57 69 40.5 reason why they do not systematically submit procurement request to Pha-G-Dis ORS/Zinc DTK 22 0 5 (Community) Sur Eau Pilina (67mg 0 0 5 tablet) (Community) Arofoitra (CHX 7,1%) 1 0 5 PARC MCH (Community) Pneumox (amoxycilline) Pneumox is out of stock at PSI central warehouse, 0 10 5 Private for nonprofit (Community) with new arrival expected in May Percent sector Pregnancy Test 0 0 5 (Community) ORS/Zinc DTK 21 0 5 (Community)

Sur Eau Pilina (67mg PA MCH 0 0 5 tablet) (Community) Arofoitra (CHX 7,1%) 0,3 0 5 (Community)

Pneumox (amoxycilline) 0 2 5 (Community) Pregnancy Test 0 0 5 (Community) Average stockout rate of contraceptive IR2.1.2 PPR commodities at Service Delivery Points by (HL7.1.3) USAID family planning methods Implantable Hormonal 26 33 10.5 Contraceptives Injectable Hormonal Contraceptives (Depo 16 23 36.0 provera) Injectable Hormonal Explanation of stock out at Pha-G-Dis: Pha-G- Contraceptives (Sayana 27 27 32.3 - Arrival of the products in the country was Dis Press) delayed. Intrauterine Devices 31 34 28.5 - The cyclic shipment from SALAMA should be Oral Hormonal enough for 6 months. However, the DSFa reduced Contraceptive. 11 20 14.3 it into 4 months due to the insufficient product at Microgynon central level which is not enough. Consumption at Oral Hormonal CSB has increased. 21 30 28.5 Contraceptive. Microlut Public sector Percent Implantable Hormonal 8 7 21.8 Contraceptives Injectable Hormonal Contraceptives (Depo 9 8 11.3 provera) Injectable Hormonal Pha-Ge- Contraceptives (Sayana N/A N/A 37.5 Com Press) Intrauterine Devices 3 3 39.0 Oral Hormonal Contraceptive. 11 9 13.5 Microgynon Oral Hormonal 6 5 24.8 Contraceptive. Microlut Oral Contraceptive 0 0 5 Private for nonprofit sector PARC (Community) Percent Injectable (Community) 0 0 5

FP Condom Protector 0 1 5 Plus (Community) Product is out of stock at PSI warehouses, with Sayana Press 3 22 5 arrival expected in mid-April Oral Contraceptive 0 0 5 (Community) Injectable (Community) 0 0 5 PA FP Condom Protector 0 0 5 Plus (Community) Product is out of stock at PSI warehouses, with Sayana Press 1 11 5 arrival expected in mid-April Number/Percentage of required supply PMP IR2.1.16 plans submitted to GHSC-PSM during the 2 1 12 IMPACT quarter. Number Supply plan for malaria commodities has submitted Malaria 1 1 4 according to plan FP/RH 1 N/A 4 USAID do not procure PF commodities MCH 0 N/A 4 USAID do not procure MCH commodities IR2.2. The public-sector supply chain achieves financial sustainability PMP Percent of product that is unusable due to IR2.2.1 IMPACT expiry or damage Expiry SALAMA Percent 0 0 1 Damaged Expiry Pha-G-Dis Percent 0,01 0,6 5 Damaged Expiry Pha-Ge-Com Percent 8 6,1 5 Damaged

IR3: Expanded engagement of the commercial health sector to serve new health product markets, according to health needs and consumer demand

IR3.1. Commercial actors are incentivized to expand into new health product markets PMP Number of loans (in general) disbursed to Quarter 2 : 1 DCA and 7 non-DCA loans; 6 men and IR3.1.2 Number 14 8 50 IMPACT businesses (excluding service providers) 2 women PMP Value of loans (in general) disbursed to Quarter 2 : $3,340 DCA and $16,388 non-DCA; IR3.1.3 USD 57 281 19 728 90 000 IMPACT businesses (excluding service providers) $10,226 men and $9,502 women

PMP Number of people trained in business and IR3.1.4 Number 27 27 80 Quarter 2 : 16 men and 11 women IMPACT financial management

IR4: Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy people

IR4.1. Socially marketed products are continuously available at convenient and accessible locations PMP Number of socially marketed products IR4.1.2 IMPACT distributed 71%: Higher achievement due to increase of the number of regular users. - HOW? The number of OC Community 484 152 748 871 1 724 880 regular users is updated every quarter as well as in Mahefa-Miaraka and ACESS intervention areas 73%: Higher achievement due to increase of the Injectable (Depo- number of regular users. Additionally, Sayana Press 513 453 567 313 1 473 355 Provera/TRICLOFEM) Community is not available on stock then Depo- FP Provera/Triclofem is the alternative solution

FP Condom Protector Plus 61%: Achievement mainly from the commercial 557 904 445 488 1 633 794 (Community) channel

FP Youth Condom Yes (Commercial) N/A N/A Product not yet available 671 689 1%: Product is out of stock at PSI warehouses, with Sayana Press 6 601 0 474 355 arrival expected in mid-April 85%: Good performance during rainy season where ORS/Zinc DTK (Community) 21 008 28 838 58 906 diarrhea prevalence is higher

Product not yet available. Tender process for Sur Eau 150 ml Commercial N/A N/A 90 491 procurement is ongoing

27%: Lower performance in Quarter 2. Not only is MCH this product out of stock at PSI warehouses but also other water treatment methods are available Sur Eau Pilina (67mg tablet) Number 703 300 289 200 3 620 780 (offered by certain NGOs in some regions). When (Community) Sur'Eau Pilina is available, IMPACT will reinforce its promotion to raise people's awareness on its importance in order to increase demand creation

Arofoitra (CHX 7,1%) (Community) 12 946 1 871 30 378 49%

30%: Lower performance in Quarter 2 explained by Pneumox (amoxycilline) stock out at PSI Warehouses. Reception of the 48 182 18 352 219 635 (Community) product in country is pushed back in April 2020 because of Covid-19 25%: Mostly distribution in Sofia region, plus Starter Kits and a quantity provided for ToT training Pregnancy Test (Community) 4 325 20 604 100 000 organized by Mahefa-Miaraka in Menabe. It is noted that the target defined in Year 2 includes some quantity for scale up in other regions

IR5: Increased demand for and use of health products among the Malagasy people/Output/Activity PMP IR.5.4 Number of mass media spots aired IMPACT 26% of achievement. Radio spot to support cCD MALARIA 0 2 640 10 000 were broadcasted in 6 districts part of the first group of the cCD program Number Production of a TV spot on FP is ongoing with FP 0 0 10 000 Health area broadcast scheduled in Quarter 3 67% of achievement. In Quarter 2, 5,659 radio spots on CHX and 2,640 radio spots on Sur'Eau MCH 1 700 8 299 15 000 Pilina were broadcasted to increase demand creation.

ANNEX B – Year 1 Workplan Update

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

Intermediate Result 1 Enhanced coordination among public, non-profit, and commercial sectors for supply and distribution of health products

1.1 The total market for health products in Madagascar is understood and documented

Support the implementation, monitor and evaluate the 70% completed, overarching TMA roadmap All operational plans completed, for all health products IR1.1.1 X X X X X X X X X X X X Ongoing Next step :Approval of the based on the discussions overarching TMA roadmap and decisions taken during by SG et DGMP the TMA Technical Working Group (TWG) meetings in Year 1

Support the development 70% completed and implementation of the malaria TMA roadmap and Assuming Malaria market monitor and evaluate its assessment findings and IR1.1.2 X X X X X X X X X X X X Ongoing progress to ensure the report will be presented availability of quality and validated in Q3, this malaria products at all activity will take place in levels Q4

100

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

Support the development and the implementation of the FP and MNCH TMA Given the COVID-19, roadmap to ensure the Postponed research activities will be IR1.1.3 X X X X X X X X X X X X availability of quality FP in Year 3 delayed (data collection and MNCH products at all mainly). levels and monitor and evaluate its execution

With the MOPH , build the capacity of TMA Traveling outside the Champions to successfully country is currently steward and lead the TMA Partially forbidden. Traveling to IR1.1.4 TWG and subcommittees X X X X X Postponed Asia will be for sure (including the study tour to in Year 3/ limited within the next a country that has semester. successfully implemented the TMA)

Through the IMPACT Knowledge Management Malaria market platform and assessment to be IR1.1.5 dissemination meetings, X X X X Ongoing presented and ensure that TMA results disseminated by end of Q3 from roadmap analyses, studies and market

101

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

assessments are known to all key stakeholders

1.2 GOM leads TMI stakeholders to coordinate health product quantification and forecasting, procurement, and distribution according to market assessments and segmentation

Organize meetings to 50%. Awaiting for new revise and validate the members to be officially Terms of Reference (ToR) appointed by the SG. After, of the UTGL to ensure its IMPACT will support the IR1.2.1 X X X X Ongoing updated tasks and UTGL to orient new responsibilities. members on their Terms of reference and assist in developing work plan.

Organize quarterly 25% . IMPACT supported meetings (UTGL, CGL, and DPLMT to organize a half- GAS committee) to analyze day meeting with routine data on key Continuous pharmacists of hospitals IR1.2.2 X X X X indicators in public activity (CHRR and CHU) on 20th hospitals, such as stock- February to discuss on how out, LMIS issues, etc. for to collect data within their learning and adapting the settings for the next use of DHIS2 in quantification exercises of

102

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

collaboration with the malaria and MNCH MERL team. commodities. The distribution circuit and requisition procedure will be clarified to hospitals.

IR 2.1 Health commodities and pharmaceuticals are continuously accessible and available in the public sector

Provide capacity building The training has been through trainings and completed, but coaching is consistent coaching to a continuous activity GOM and partner members of UTGL on IR2.1.1 X X X X X X X Completed forecasting and supply planning, including the use of Quantimed and Pipeline (NMCP, DSFa, DPLMT, SALAMA)

103

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

Assist the GOM and UTGL 75% : Continued to work members in leading the on quantification of annual system wide malaria commodities for forecasting exercises for 2021- 2023. Data the public and private collection started to sector for FP/RH, MNCH, complete data on logistics and malaria commodities (Consumption, stock and support UTGL and available, #days of stock SALAMA to help mobilize out, expiry date, wastes, resources to procure etc.) and services data ( # commodities in the supply of tests performed, #of IR2.1.2 plans X X X X X X Ongoing treatments of ACT dispensed, # of pregnant women that received SP doses, etc.). This week, data will be analyzed and discussed in a short committee (DPAL, IMPACT, PMI, PNLP) to make assumptions and adjustments necessary for forecasting and supply planning.

104

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

Coordinate orders , deliveries generation and pipeline monitoring Continuous IR2.1.3 according to agreed upon X X X X X X X X X X X X 100% of malaria and FP/RH activity supply plan with SALAMA, commodities forecasted in PSM, GOM institutions and 2020 are already ordered USAID to GHSC-PSM.

Provide technical 55%- Distribution plans of assistance to support the malaria commodities for central level GAS Q1 (Oct- Dec 2019) and Q2 Committees to develop (Jan- March 2020) have quarterly distribution plans been completed for all the for malaria, MNCH, and 114 districts. IMPACT FP/RH products based on supported the GAS Continuous IR2.1.4 quarterly stock status X X X X X X X X X X X X committee, EMAR and activity obtained from district/GAS EMAD to conduct committees supervisions visits and redeployments in the regions of Amoron’i Mania and Haute Matsiatra to complete the all 13 supported zones.

105

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

Conduct TOT and cascade 25% - From January 27 to trainings for supply chain February 7, IMPACT management at all levels of conducted training on the supply chain, in stock management of collaboration with the commodities for CSB in UCP/Global Fund, ACCESS, Maroantsetra and Mahefa Miaraka and other Mananara. 117 partners participants have been trained (Head of CSB, PCOGE, Dispensers) on the Continuous IR2.1.5 X X X X X X X new training curriculum activity developed in collaboration with ACCESS, Mahefa Miaraka and various Ministry of Health directions. Also, the CRL conducted on-the-job supervisions of 68 Pha-G- Dis in Quarter 1. Supervisions visits are planned every quarter.

Assist the MOPH in The LMIS report is available creating a five-year LMIS Continuous and can be disseminated. IR2.1.6 strengthening roadmap X X X X X X X X X X X X activity But the workshop to and developing and testing develop a road map is a new LMIS software using rescheduled in Q4. The

106

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

results from the LMIS in- activity of developing and depth evaluation testing a new LMIS software is postponed to Year 3 as based on consensus and selection of the software as an outcome of the workshop

Generate evidence through * The second EUV data a national supply chain collection is scheduled in assessment and End User Q4 and could be Verification surveys to postponed in Year 3 due to develop adequate COVID Situation (minimize strategies, policies, and travel and movements SOPs for securing throughout the country) commodities and * The NSCA will be strengthening the public IR2.1.7 X X X X X X X X X Ongoing postponed in Year 3: There supply chain are a lot of in-country advocacy meetings to organize with in country stakeholders and the Ministry of Health to get buy-in, mobilize STTA from PSM (as Travels are suspended) that are

postponed in Q4. Data

107

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

collection will likely happen earlier Year 3

Conduct continuous The distribution activity distribution of LLINs in 12 may be extended till IR2.1.8 X X X X X X X X X X X X Ongoing targeted districts. March 2021

Provide technical and No authorized meeting financial support to the because of COVID-19, the NMCP to develop and prioritization of activities implement activities for after the COVID-19 will IR2.1.9 X X X X X X X X X Ongoing the preparation of 2021 make this one postponed. LLIN campaign including Budget from other donors the procurement of LLIN available for the meeting with the NMCP

IR 2.2 The public-sector supply chain achieves financial sustainability

Conduct a total cost Rescheduled in Q4: analysis of the public All preparatory work has supply chain and propose been completed an alternative and more (assessment protocol, IR2.2.1 efficient supply chain X X X X X X Ongoing questionnaires finalized, model by establishing at samples defined, least two scenarios with introduction letter signed the MOPH to improve by SG allowing data collection, software to

108

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

SALAMA's financial collect data, set up of a TCA sustainability committee, orientation of the both TCA committee and 24 data collectors). Once the situation evolves, data collection will be completed and then after analysis. The TCA report with scenarios might be delayed depending on data collection and analysis

Strengthen management of FANOME at Pha-G-Dis The activity is depending Postponed IR2.2.2 and Pha-Ge-Com levels to X X X X X X on completion of Total to Year 3 increase transparency and Cost Analysis

good governance.

Intermediate Result 3 Expanded engagement of the commercial health sector to serve new health product markets, according to health needs and consumer demand

IR 3.1 Commercial actors are incentivized to expand into new health product markets

Review the scope of the private sector humanitarian platform to engage businesses in health product markets

109

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

Create partnerships with PSHP and non-PSHP 35% members to collaborate in generating innovative Continuous New members: Nutri'zaza, IR3.1.1 X X X X X X X X X X X solutions on activity CNAPS, and Hotel Louvre. transportation, data

collection, and health- focused CSR and CSV.

Organize quarterly meetings to monitor and Action plan validated and IR3.1.2 assess the progress of X X X Ongoing implementation ongoing health commission action plan.

Conduct mapping exercise to present IMPACT and 80%- Mission in SAVA: 12 LMIS data submission Continuous IR3.1.3 X X X X X X X X X X X to 19 February 2020 done among representative activity sample of pharmacies and 8/9 pharmacies, 25 dépôts drug shops signed

Ensure that the Health Health Commission Commission members of members of the PSHP Continuous IR3.1.4 the PSHP participate in the X X X X X X X X X X X actively participated in all activity TWG and follow up on the meetings organized by the roadmap as a way to TMA TWG engage the commercial

110

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

sector to identify barriers in the health sector and provide solutions

Revitalize regional drug Rescheduled in Q4: shop associations in This activity is in preparation of the ADDO coordination with the IR3.1.5 pilot phase to be X X X X Ongoing training of depots a conducted in Year 3 managers. The pilot phase of ADDO is postponed to Year 3

Develop curriculum for Due to COVID-19 , drug training of peer trainers shop trainings, where with simplified materials potential peer trainers are IR3.1.5 and tools, to be used in Postponed identified, will not be X X X b piloting a sustainable in Year 3 completed until end of Y2, mechanism for business so ToT will be delayed to strengthening program of Y3. drug shops

Increase access to finance for private health

commodities supply chain stakeholders

111

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

Strengthening partner banks and other financial IR3.1.6 institutions' capacity to X X X X X X X X X X X X Ongoing better serve private health commodities supply chain.

Revise capacity building Ongoing 40% plans and training curricula - Incorporating GESI issues for DCA partner banks to into training curriculum in incorporate GESI issues progress. Meeting with and, as needed, to take banks depends on the IR3.1.6 IR3.1.6.1 into account newly x evolution of the COVID-19 identified needs. situation. Discussion continuing with Banyan Global HQ. Delayed to Quarter 4.

IR3.1.6 IR3.1.6.2 Train and support DCA Ongoing - 57% Year target, 50% Q2 partner banks in credit target. DIANA session in analysis and loan March re-planned to next structuring for health Quarter. commodities businesses. X X X X X X X X X X X X - 68 staff from the two partner banks trained from Atsinanana and Mahajanga (February 2020) branches.

112

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

- List of drug shops trained shared with partner banks for prospection. Target number might not be reached due to travel ban in regions

Develop and adapt loan Ongoing 70% Year and Q2 target, products and financial - One loan product tools for small and micro “Pharmaloan” to finance health enterprises in health commodities health commodities sector purchase developed with (e.g., scoring, nano loans, ABM before presenting it pharma loans, motorbike to wholesalers. Mini- loans). survey launched with ABM IR3.1.6 IR3.1.6.3 X X X X X X X X X X X X to get more details about drug shops habits. Pilot launched with 4 clients of SOPHARMAD - One loan product “PA/PARC- Motorbike Loan” in discussion with ABM following survey undertaken to PA/PARC. List of interested PAs

113

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

transmitted to ABM for screening. '- COVID-19 special product: presented to wholesalers to facilitate supply of health commodities to face COVID-19. Individual approach - Automatic withdrawal: design to be developed with Baobab.

Design and develop new Ongoing financial mechanism (e.g. 15% Year target, 100% Q2 risk sharing facility), target following principles of Initiated during Ignacio's USAID's Blended Finance visit in September 2019. Roadmap for Global Presentation to USAID IR3.1.6 IR3.1.6.4 Health, possibly including X X X X X X X X X X X X done on 19 December. additional financial Report sent to COP for institution partners, to comments. facilitate A2F within the This activity will need more pharmaceutical supply time to explore the chains and other different options, and the stakeholders. current travel ban will

114

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

create delays.

Strengthen the business management of

enterprises in health products supply chain

Provide business strengthening capacity building to enterprises in health commodities supply IR3.1.7 X X X X X X X Ongoing chain and develop partnership with private companies to sustain the training.

Develop and adapt 100% Year Target business-strengthening Training material and training curricula for drug curriculum used during the shops. training session in IR3.1.7 IR3.1.7.1 X Completed Toamasina on 13-14 November. A living documents to be adapted to the drug shops level of education. Training

115

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

materials translated in Malagasy used for the session in Mahajanga on 27-28 Feb. 2020

IR3.1.7 IR3.1.7.2 Provide initial business- - 72% Year target in strengthening training to number and 40% in nb of drug shops. region. 50% Q2 target due to the cancellation of the DIANA session planned for March - 54 drug shops owners and dispensers from the region of Atsinanana and Boeny (27 on Feb. 2020) trained. X X X X X Ongoing Training combined with a half day sensitization session conducted by DPLMT. Target number might not be reached, depending on the lift of travel ban in region

-Meeting with DPLMT on Feb. 20 hold to discuss the

116

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

planning of next sensitization and training sessions. Due to the travel ban in region target number might not be reached Last 5th session may be postponed in Year 3

Provide one-to-one 50% year and Q2 target coaching on business due to the cancellation of strengthening to the training in DIANA for enterprises/individuals March. identified as potential peer 5 DM coached: 3 in trainers in health Atsinanana and 2 in Boeny. IR3.1.7 IR3.1.7.3 commodities supply chain. X X X X X Ongoing Some of them are identified as potential peer trainers. Target number might not be reached, depending on the lift of travel ban in region

117

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

Identify potential 50% of year target; partnerships with private training companies to 100% Q2 target; expand and sustain options FORMASANTE identified as IR3.1.7 IR3.1.7.4 for business training to X X X Ongoing potential partner. enterprises in the health The formalization of the commodities supply chain. partnership may be rescheduled on Q4 because of the COVID-19

Explore digital inventory 10% Year target; management applications 80% Q2 target for use by private health Depending on the SIGL commodities enterprises evaluation activity and which would be Draft SIGL evaluation incorporated into future analysis in progress with business training. MERL and TELMA Foundation in order to IR3.1.7 IR3.1.7.5 X X X X Ongoing identify the different alternative tools to be adopted. Call with Maisha Meds held on March 18, Mada team testing the tool and will give feedback. Maisha Meds has sent cost break-down. Another candidate, a local

118

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

developer, also approached (Pharma Plus).

IR 3.2 GOM facilitates the work of the commercial sector

Facilitate high-level advocacy meetings involving the MOPH, Ministry of Commerce, customs services, Ministry of Economy and Finance, Rescheduled in Q4: the National Board of There is still advocacy Physicians and the National meetings to organize with Board of Pharmacists to Continuous IR3.2.1 X X X X X X X X X X X X the Ministry of Health and develop policies and activity Ministry of Budget on tax regulations that will favor exemption on medical importation and devices as part of Essential commercialization of a medicines. packet of vital Essential medicines, including contraceptives, anti- malarial, and key MNCH products.

119

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

Support DAMM and MOPH 80%- STTA has come in to put in place strong Madagascar from Jan 26- regulatory processes February 7 to support related to the registration, DAMM on Common importation, and Technical Document in distribution of medicines relation of Registration, based on reviews of the and on the domestication Common Technical of African Union Law on Document, New Law on Medicines. The Literature Regulatory Body in Africa, review on pharmaceutical and experience from other regulations has been countries through study validated during a Continuous IR3.2.2 tours. X X X X X X X X X X X X workshop held with the activity Comité AMT/legal texts. Next step is to assist DAMM to implement the recommendations according to the report which will be delivered by the STTA.

The process is ongoing to review the registration process but might not be completed by end of Year 2; Continuous activity

120

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

throughout the life of the project

Support DAMM in 50%- the STTA has streamlining the facilitated working registration and meeting between DAMM importation procedures for and SALAMA technicians to medicines based on the discuss and to find how to Continuous IR3.2.3 latest WHO X X X X X X X X X X X X harmonize SALAMA activity recommendations. prequalification with DAMM registration requirements in order to facilitate the market authorization procedure.

Support the MOPH and the professional associations to revitalize the inter- Not yet Meetings may be delayed IR3.2.4 X X X X X X ministerial committee to started due to COVID-19 fight counterfeit and illegal medicines. A strategy will be defined through a mid-

121

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

term evaluation of the Stratégie de Lutte Contre le Marché Illicite and the Contrefaçon des Medicaments et Intrants de Santé and an action plan will be developed.

Intermediate Result 4 Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy people

IR 4.1 Socially marketed products are continuously available at convenient and accessible locations

Distribution of socially marketed products across 10 regions for MNCH and FP/RH products and Continuous IR4.1.1 X X X X X X X X X X X X Continuous activity distribution of only FP/RH activity products in three PARN Regions through PARCs and PAs.

Establish a motivation system for PAs and PARCs Continuous IR4.1.2 and follow up on their X X X X X X X X X X X X Continuous activity quarterly performance to activity address supply chain inefficiencies in social

122

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

marketing in order to prevent stockout.

Expand last-mile distribution and emergency distribution IR4.1.3 X X X X X X X X X X X X Ongoing To be completed by end of through a pilot to deliver Year 2 health products using drones. Pilot < 50 km

Transition the community Prior the transfer of PA to distribution model from Pha-Ge-Com and PARC to select PAs and PARCs to Pha-G-Dis, the Pha-G-Dis the Pha-Ge-Com and Pha- and Pha-Ge-Com G-Dis in coordination with performance needs to be Postponed IR4.1.4 DDS/DPLMT/DSFa/ACCESS X X X X X X improved, which is an in Year 3 /Mahefa Miaraka. activity rescheduled in

Quarter 4. Thus, the PA and PARC transfer to Pha-Ge- Com and Pha-G-Dis will be postponed to Year 3.

123

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

Select and introduce socially marketed products across 10 IMPACT regions and 3 PARN regions IR4.1.5 through the private sector X X X X X X X X X (pharmaceutical and commercial channels) pending the results of the COGS analysis. Ongoing

Define the needs for a product monitoring system and conduct a study of a product tracking system. Find technological solutions which allow Continuous IR4.1.6 X X X X X X X X X X X Continuous activity IMPACT to earn and grow activity brand loyalty while protecting the brand from supply chain fraud, including counterfeiting and theft.

IR 4.2 Socially marketed products achieve cost recovery at an affordable price for consumers

124

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

Leverage TMA findings from IR1 to analyze COGS and continue to propose options for the optimization of financial sustainability for the current socially marketed Continuous IR4.2.1 X X X X X X X X X X X X Continuous activity products portfolio and activity explore brand extension of Yes With You condoms and introduce a new brand of pharmaceutical products depending the results of the COGS analysis.

Continue to explore 65% completed optimization of financial Yes Positioning known sustainability for the current socially marketed Continuous AMM ongoing in IR4.2.1 IR4.2.1.1 X X X X X X X X X X X X products portfolio and activity collaboration with PSM et explore brand extension of the provider Yes With You condoms Next step: Choice of Yes to be adopted

Explore introduction of Continuous IR4.2.1 IR4.2.1.2 X X X X X X X X X Continuous activity new brand of activity Pharmaceutical

125

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

products pending the results of the COGS analysis

Intermediate Result 5 Increased demand for and use of health products among the Malagasy people/Output/Activity

In collaboration with the demand creation subcommittee of the TMA Continuous IR5.1.1 TWG, develop and X X X X X X X X X X X Continuous activity activity implement activities to increase demand and use of health products

Provide technical and Continuous activity financial support to Continuous IR5.1.2 X X X X X X X X X X X X contribute to the activities activity of the MOPH

Conduct communication campaigns for promoting health products of the three prioritized health Continuous IR5.1.3 X X X X X X X X X X X X Continuous activity areas (Malaria, FP and activity MNCH) through radio, TV spots, job aids, and digital communication incorporating gender

126

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

messaging to promote and use health commodities for population and providers

Provide technical and * This activity depends on financial support to the the signature of MOU with Ministry of Youth and Sport the MJS which has been (MYS) to develop and delayed due to COVID-19. implement Youth activities * Training of young leaders in collaboration with Telma Continuous with Blue Venture is IR5.1.4 Foundation based on the X X X X X X X X X X X X activity scheduled in Q3 but Human Centered Design depends on evolution of (HCD) study and support the current situation. training for youth on However, training curricula health, leadership, has been developed and communication, etc. training tools are ongoing

Leverage new technology to drive demand for Continuous IR5.1.5 X X X X X X X X X X X X Continuous activity malaria, FP/RH and MNCH activity health commodities.

Develop a strategy for Development of the youth on the use of strategy will be completed IR5.1.6 vouchers for youth health X X X X X X in Q3 and adjusted with the coverage and findings of segmentation and journey mapping Ongoing researches.

127

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

implementation of a Implementation highly voucher pilot. depends on evolution o

Cross Cutting Gender

Target women and human Rescheduled in Q4: rights associations to serve During the IWD in Tulear, as strategic partners of IMPACT met with the EFOI IMPACT and to play an president and the CNFM active role in the Total newly elected president. A Market Approach. CC1.1 X Ongoing meeting to discuss about effective partnership in terms of GESI and A2F will be planned in Q3 integrating head of bank partners

Ensure the participation of Rescheduled in Q4: key GESI partners in TMI During the Women's day TWG. celebration in Tulear, CC1.2 X Ongoing meetings with Presidents of CNFM and EFOI have been effective. Partnership will be discussed in depth to involve them more on

128

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

IMPACT project mainly GESI and A2F

Produce and distribute This quarter, IMPACT SBCC tools on GESI for participated in the Ministry different target groups. of Population's national celebration of International Women's day in Tulear from March 2 to CC1.3 X Ongoing 8. IMPACT supported the Access to Finance and Health components, as well as serve as an exhibitor to raise awareness about USAID’s IMPACT program.

Integrate GESI-informed During the GESI training messaging into family workshop March 2020, planning & MNCH sessions on message CC1.4 communication X Ongoing conception on FP, Malaria campaigns. and MNCH were conducted with all IMPACT staff.

129

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

Raise awareness of IMPACT Rescheduled in Q4: stakeholders on GESI IMPACT shared 150 integration into a TMA CC1.5 X Ongoing brochures on GESI during through meetings and an the conference and the annual workshop. journalist training.

Build the capacity of The second training session IMPACT staff to serve as on GESI was held 11th and GESI champions. *** 12th March 2020 . Banyan Global International GESI CC1.6 X X Ongoing expert, MinPop Key GESI focal points, USAID focal Point, HP+ , CRS GESI focal points, CNFM were involved in the training

Cross Cutting MERL

Strengthen LMIS/HMIS ( all Partially completed in Year sectors: public, private, 2 and postponed in Year 3 non-profit, and The workshop to develop a commercial) including: Continuous road map is rescheduled in CC2.1 formative supervision, X X X X X X X X X X activity Q4. The activity of capacity building of data developing and testing a senders, and supporting new LMIS software is implementation of the postponed to Year 3 as LMIS roadmap with based on consensus and

130

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

consideration of DHIS2 as selection of the software as the main LMIS electronic an outcome of the tool. workshop

Support the mapping exercise to identify and CC2.2 X X X X X Completed train pharmacies and drug shops for LMIS data.

Support technically and financially the DPLMT to 3 RDQA will be completed conduct Routine Data Continuous in Year 2. However, the CC2.3 X X X X X X X X Quality Assessment activity RDQA session in Q3 may be (RDQA) at all levels and cancelled due to sectors. uncertainty of COVID-19

Implementing monitoring and evaluation system on continuous distribution, including: creating M&E CC2.4 tools, training, data X X X X X X X X X X Ongoing collection and supervision, RDQA (budget included in the continuous distribution activities)

131

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

Conduct market assessment studies for FP and MNCH, including key Fieldwork rescheduled in CC2.5 informant interviews, X X X X Ongoing Q3 and Q4 outlet surveys, and routine data in collaboration with IR1.

Implement additional Partially completed in Year studies, including: 2 and postponed in Year 3: archetype Assessment of pharmacies study/segmentation, and drug shop products journey mapping, supply study, the journey assessment of pharmacies mapping study postponed and drug shops on in Year 3 CC2.6 products supply, KAP study X X X X X X X X Ongoing on IPTp use, and an KAP study on IPTp use : Due evaluation on the to COVID-19, fieldwork is introduction of the last postponed in Q4. All the mile distribution strategy procurement process is (drones) at the community suspended. level.

Knowledge Management:

Support partners in Continuous CC2.7 X X X X X X X X X X X developing and collecting activity Continuous activity success stories and

132

Timeline YEAR 2

Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4

Description of the Activity

Oct Nov Dec Feb Mar May Aug Sep activityCode - Jan 20 Apr 20 Jun 20 Jul 20

Activity Code Activity 19 19 19 20 20 20 20 20 Sub

documenting IMPACT's innovations in the field.

133

ANNEX C - Environmental Mitigation and Monitoring Report

134

Summary number of the outlets visited

Number of Field Number Type of Outlet Total Outlets Team Visited Supervisors Public Sector SALAMA/Central Warehousing 0 6 Pha-G-Dis 40 78 13 RLA CSB/Pha-Ge-Com 130 1,734 Nonprofit Sector (Social Marketing) Warehouse 1 14 PARC 67 67 27 SPD Supply Point 887 887

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OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION 1. Capacity building through technical workshops and training to enhance coordination and distribution of quality health products. 1. Technical assistance, 1.1.1. Training of CSB (Centre de Number of CSB providers trained: Outstanding Issues: trainings, workshops, and tools Santé de Base) providers on proper Infrastructure remains an issue in the developed must include storage, use and disposal of Male Female Total public sector. appropriate management commodities. Training support may 22 44 66 practices for facilities of health include communication materials Recommendations: commodities and integrate and packaging (Job Aids) The criteria of proper storage and disposal of commodities: • Share issues with poor storage sound procedures to manage ⮚ Proper Storage: infrastructure found in CSBs that and properly dispose of health - stored on pallets or shelves doesn’t allow for proper disposal care waste (including expired - stored at least 30 cm away from walls and other piles of commodities. health products). - stored in a functional refrigerator • Support DPLMT and DSSB in - protected from direct sunlight resource mobilization to - storage rooms dry and adequately ventilated construct or renovate storage spaces (explore opportunities to ⮚ Proper Disposal of Commodities: engage the private sector for - expired or damaged stored in a separate location social corporate responsibilities).

Number of CSB not respecting proper storage: Proper Storage 116 Medium 13 Improper Storage 1

Issues: 49% of CSB providers are not trained in good practices for handling and disposing of health care waste.

Resolution: In collaboration with ACCESS and Mahefa Miaraka, UCP and DPLMT, there is a plan to conduct cascade training on stock inventory management throughout the year. Furthermore, IMPACT will continue to provide on-the-job training on stock management during supervisions visits.

Number of CSB not respecting proper disposal of commodities:

Proper Disposal of 90 Commodities Medium 0

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OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION Improper Disposal of 40 Commodities

Issues: 31% of PhaGeCom do not comply with proper disposal of commodities. This is due to poor infrastructure of CSBs.

Resolution: Continue to advocate to DPLMT and DSSB to mobilize resources to renovate/improve infrastructure. 1.1.2. Provide supervision of CSB Infrastructure and non-medical equipment for infection Outstanding Issues: providers by using a Rapid prevention: Absence of non-medical devices and Monitoring Tool to assess - handwashing device with a bucket to catch water equipment can be due to the lack of infrastructure and equipment for - soap for washing hands financial resources, limited water handwashing, infection prevention - tissues for cleaning access, or organizational issues. (decontamination and containers - chlorinated water for infectious waste), waste cans, Recommendations: safety boxes, etc. Issues: 16% (21/130) of CSBs visited in Quarter 2 are without IMPACT will collaborate with ACCESS non-medical equipment to prevent infection and and local community leaders, CSB contamination. chiefs, and other stakeholders to support CSBs in installing Resolution: Discuss with districts, CSB, DPLMT, DSSB, and handwashing devices and procuring partners to mobilize resources to procure the appropriate equipment and consumables. equipment for handwashing and infection control. Explore the possibility of local installations. 1.1.3. Provide CSB providers with: Medical equipment for infection prevention: Outstanding Issues: garbage cans & gloves for ordinary - Safety box The CSB does not always give proper waste; sharps containers and - Sharps containers attention to the purchase of medical gloves; handwashing device with a - Gloves equipment for infection prevention. bucket to catch handwashing water - Garbage disposal

Issues: 7 CSB are not equipped with medical equipment for Recommendations: infection prevention. Collaborate with ACCESS, districts, and other stakeholders to follow-up Resolution: Sensitize the CSB to purchase this medical with the CSB and ensure the medical equipment within their own budget. equipment are purchased and/or donated. 2. Social Marketing, Education, & Social Behavior Change Communication (SBCC).

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OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION 2. “Programs involving 2.1.1 Include messages on proper SMS were sent to PA, PARC, CHVs, and Pha-G-Dis to sensitize Outstanding Issues: nutrition, health care, or storage, use and disposal of on stock management specifically on proper storage, use, and Proper disposal during storage and population and family planning commodities in the communication disposal of commodities. The messages were as follows: “keep transportation are still challenges. services” campaigns using various channels medicines in a cool and dry place, avoid moisture and poor These activities promote the such as mass-media. Messages will ventilation during transportation and storage that can damage Recommendations: use of commodities such as be tested with a diverse audience commodities.” IMPACT continues working with HPD condoms, drugs, and (differences in sex, age, literacy to produce various promotional insecticide-treated nets. level, and socio-economic status). Job aids on stock management were designed for Pha-G-Dis, materials (job aids, posters, etc.) to Improper disposal of these PA, and PARC, and are waiting for validation by the HPD of the sensitize on proper disposal during items by end-users (the targets Details of the activities will be MOPH before printing. storage and transportation. of the marketing messages) included in the communication IMPACT does not have a waste plan. management process cycle available yet. IMPACT will ensure to make it available in Quarter 4. 3. Storage, management, distribution, transportation & disposal of public health commodities & equipment. 3. Storage, Management, 3.1.1. Include in training curriculum Nonprofit sector Distribution & Disposal of how to properly manage expired Number of PSI central warehouses, PARC, and PA trained on Outstanding Issues: Public Health Commodities & (properly logged), obsolete or expired, obsolete, and surplus commodities: None Equipment surplus commodities for PSI central warehouse, PARC, PA and public Type Male Female Total Recommendations: sector (SALAMA/central Warehouse 1 0 1 On job training is always provided to warehousing, Pha-G-Dis, Pha-Ge- PA 402 500 902 reinforce the classroom training Com and CSB). A disposal plan will PARC 21 53 74 during the SPD supervision visits. be created and will be available for Some of PARC and PA had more than two people trained the trainees following the national guidelines. Curriculum will be- - All employees at PSI central warehouse, PARC, and PA visited adapted to different literacy or were trained on management of expired, obsolete, or surplus education levels to ensure effective commodities except for two PA. understanding - Issues: Two PA did not received training (formal training session) on management of expired, obsolete, or surplus commodities.

Resolution: The two PA received on-the-job training during the monthly supervision by the SPD. Public sector Number of public sector people trained: Outstanding Issues:

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OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION Lack of proper training for Pha-Ge- Type Male Female Total Com providers. SALAMA 0 0 0 Pha-G-Dis 13 25 38 Recommendations: CSB/Pha- 10 31 41 In December 2019, the training Ge-Com curriculum on stock management - (including management of expired - - 95% (38/40) of Pha-G-Dis and only 32% (41/130) of Pha-Ge- medicines) has been validated. Com visited were trained on management of expired, obsolete, Trainings will be rolled out in 2020 by and surplus commodities. ACCESS and in collaboration with - other stakeholders. RLA will Issues: PhaGeCom are not yet trained on management of contribute to the training sessions as expired commodities as part of the stock management training facilitators and will provide on-the- curriculum. job training during supervisions.

Resolution: The training curriculum has been updated, pre tested, and is being rolled out at the CSB level since January 2020 by ACCESS and other stakeholders supporting CSB. 3.1.2. Regularly check expiry date of Nonprofit sector commodities during monthly visit of Number of expired, obsolete, and surplus products at PSI’s Outstanding Issues: PSI central warehouse, PARC, PA central warehouse, PARC, and supply point: Expired products are placed in and public sector (SALAMA/central quarantine until destruction process warehousing, Pha-G-Dis , Pha-Ge- Product Expired Surplus Obsolete can be completed. Com and CSB). Warehouse 25,844 0 0 Recommendations: “If there are expired products in the PA 0 4,545 0 - For the expired products, IMPACT warehouse, the supervisor will take PARC 0 104 0 will contract with ADONIS company to appropriate action to rectify the ensure the incineration process is practice" Issues: completed. - Expired 850 blisters of Pilplan® without packaging and 24,994 - IMPACT will set up an alert system to blisters of Combination 3 were identified at PSI’s central rectify the coordination between the warehouse and one regional warehouse in January 2020. Central Warehouse Manager, - Surplus of products were found at PA and PARC supervised. Regional Assistant, and Regional The surplus products are used to prevents stock out during the Warehouse Assistant to improve the rainy season for PA and PARC located in remote areas. inventory management of the products in order to avoid expired Resolution: products. Markings will be used to

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OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION - Expired products are placed in quarantine while waiting for monitor products with an expiration the destruction process date of less than 12 months and for - The surplus products were redeployed to other PARC and PA the items that have not moved in the to avoid waste. past three months. - Management of surplus products at PARC and PA is now included in the scope of the SPD during the supervision visits to avoid waste.

Public sector Number of expired, obsolete, and surplus products at the Outstanding Issues: public sector: In Quarter 1 and Quarter 2, some ACTs 2-11 months and 1-5 years have Product Expired Surplus Obsolete expired due to lack of close monitoring of expiration dates and SALAMA 0 0 0 not planning to redeploy the Pha-G-Dis 2,022 0 0 quantities at risk. Pha-Ge-Com 2,307 24 25 Recommendations: - Expired, obsolete, and surplus commodities were detected • Each Pha-G-Dis and PhaGeCom at Pha-G-Dis and PhaGeCom visited. conducts a monthly physical inventory and evaluates usable Issues: Expired medicines constitute waste that must be stock to detect quantities of managed separately from the usable stock and be destroyed. products at risk of expiration. Then after, a redeployment is Resolution: The expiration date is being systematically organized to avoid waste. monitored by RLA and Pha-G-Dis at the end of each month to • If the product expired at the detect the risk of expiration and organize redeployment on PhaGeCom level, this should be time to avoid waste. transferred to Pha-G-Dis for incineration to avoid keeping the expired product on shelves. • Incineration must follow standards to avoid impact on climate and environment.

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OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION 3.1.3. Provide guidelines and Nonprofit Sector appropriate communication tools Number of PSI central warehouse, PARC, PA that have Outstanding Issues: on storage conditions for each guidelines and communication tools: None product by following standard guidelines for Proper Storage and Warehouse 1 Recommendations: distribution of Health Commodities PARC 59 IMPACT will print updated tools that for PSI central warehouse, PARC, PA PA 820 will highlight instructions and and public sector (SALAMA/central guidelines on storage conditions

warehousing, Pha-G-Dis , Pha-Ge- including messages to address - Visited warehouse was equipped with guidelines and Com and CSB) potential environmental risks. This communication tools. updated version will be available for - 88% (59/67) of PARC and 93% (820/887) of PA visited had SPD for distribution during monthly guidelines and communication tools in their storage rooms. supervision visits for PARC and PA.

The SPD will ensure that the tools are Issues: 12% (8) of PARC and 7% (67) of PA did not have displayed on a visible area before guidelines and communication tools. leaving the PARC and PA.

Resolution: Guidelines on storage were sent to the field and distributed to the 8 PARC and 67 PA that didn’t haves the tools. Public Sector Number of public sector that have guidelines and Outstanding Issues: communication tools: Copies of Good storage practices are not available to serve as a reference SALAMA 0 document. Pha-G-Dis 23 CSB/Pha-Ge-Com 26 Recommendations: - - 23 out of 40 Pha-G-Dis (58%) and only 26 out of 130 Pha-Ge- IMPACT will print and disseminate the Com (20%) had guidelines and appropriate communication guidelines to Pha-G-Dis and tools on storage condition. PhaGeCom in Quarter 3 or Quarter 4 depending on Covid-19 restrictions. Issues: Lack of guidelines and job aids on good storage practices in Pha-G-Dis and PhaGeCom .

Resolution: Print and disseminate laminated copies of good storage practices for all the 78 and 1764 PhaGeCom. 4. Storage and distribution of LLIN

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OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION 4.1. Insecticide quality and 4.1.1.1. Use pre-approved WHOPES Pre-campaign of the 2021 LLIN mass campaign Outstanding Issues: resistance brands of LLINs to ensure the None quality and efficacy of the LLINs Issues: NMCP sensitivity data demonstrated existence of purchased, that they contain resistance to pyrethroid in certain districts. Recommendations: effective pyrethroid levels. None Resolution: Establish a note signed by NMCP on the technical specifications of LLINs for the 2021 campaign on the basis of the rotation of insecticides provided for in the National Resistance Management Plan and list of LLIN brands prequalified by WHO. Introduce PBOs LLINs in the districts identified with pyrethroid resistance: Port Bergé and Tamatave II. 4.2. Storage of LLIN 4.2.1.1. Store LLINs in wooden Number of PSI warehouses that meet storage quality: Outstanding Issues: pallets, dry, ventilated, and secure None areas to prevent theft or Level number unauthorized access. Central warehouse 2 Recommendations: PARC 6 IMPACT will conduct control of the remaining 6 districts selected for the

cCD. The first group of 6 districts (PARC) for the cCD met the criteria (LLINs in wooden pallets, dry, ventilated, and in secured areas to prevent theft or unauthorized access).

Issues: None

Resolution: None 4.2.1.2 Post guard or use barred Number of PSI warehouses and field storage areas with post Outstanding Issues: windows as needed guard or barred windows: None

Level Number Recommendations: Central Warehouse 2 None PARC 6

Warehouses at central and PARC are secured

Issues: None

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OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION Resolution: None

4.2.1.3. Post visible warning signs on Number of PSI warehouses and field storage areas equipped Outstanding Issues: doors and windows in local with warning signs: Warning signs for additional cCD language to alert people that districts. pesticide products are stored inside Level Having warning signs Central warehouse 2 Recommendations: PARC 0 Preparing/printing warning signs for PARC in the 6 additional cCD districts.

Issues: Six PARC do not have warning signs.

Resolution: Warning signs are being printed for PARC. 4.2.2.1. Ensure provision of gloves Pre-campaign Outstanding Issues: and instruction on their use No specific recommendation on the purchase of gloves for the None LLINs distribution. Recommendations: Issues: None None Resolution: None 4.2.2.2. Provide worker training on Pre-campaign Outstanding Issues: the proper handling and display of For cCD, the communications tools and key messages on None LLINs. The training materials will malaria prevention and the use of LLINs were revised, include messages related to malaria produced, and distributed at all levels (district, CSB, and Recommendations: prevention and proper use of LLINs Kom’Lay). None using mass-media and interpersonal communication (by Mahefa- Quantity Items Users Miaraka and ACCESS) produced Community poster 12,000 For CHV Job aids 8,500 Mobilization activities Schools poster 6,000 For school Multi pocket school tool 3,000 activities Sticker board 3,000 Sticker 770,000 Bracelet 90,000

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OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION Key messages on malaria prevention and the use of LLINs were included in the topics covered during the cascade training: - Central level: 54 trained actors; - District level: 298 trained; - Community level: 6,183 Kom’Lay members trained

Issues: None

Resolution: None 4.4. Packaging 4.4.1.1. Ensure that SBCC messages For cCD activities, the LLINs are packaged in bulk so there are Outstanding Issues: inform campaign distributors and no key messages on the packaging. None local communities about the potential harm to human health and Issues: None Recommendations: the environment if bags and baling None materials are reused and are in line Resolution: None with the malaria national communication plan (2018-2022) 4.4.1.2. Support the NMCP in the The 2018 - 2022 communication plan on malaria is already Outstanding Issues: development of the national available and shared. None malaria communication plan 2018- 2022) which will provides guidance, Issues: None Recommendations: best practices for handling and None disposing of bags and baling Resolution: None materials. Messages need to be adapted for literacy or education levels. 4.4.1.3. Encourage the MOH and the A meeting with the RBM committee took place on March 20th Outstanding Issues: RBM (Roll Back Malaria) committee 2020 during which IMPACT presented for validation the None to procure LLINs with bulk technical specifications of LLINs whose bulk packaging has packaging. The project will already been taken into account. Recommendations: coordinate with NMCP to create a None waste management plan. Issues: None

Resolution: None 5. Climate Risk Management

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OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION 5.1. Proper storage and 5.1.1.1. The storage and The storage and transportation meet the following criteria: transportation of commodities transportation of the commodities and LLIN and LLIN should be: ⮚ Standard Storage: - away from humidity, - SS1: Dry and ventilated - protected from high - SS2: High temperature/heat - SS3: Robust - in a high area to avoid damaged - SS4: Temperature controlled or deterioration by flood, - SS5: Away from moisture - stored in a robust building - SS6: Heat (made with burnt brick, cement - SS7: Direct sunlight or modern materials) to avoid deterioration of the warehouse ⮚ Standard transportation conditions: by cyclone and landslide, - ST5: Away from moisture in area with temperature - ST6: Heat controlled, including transportation - ST7: Direct sunlight from central warehouse to the Pha- G-Dis , Pha-Ge-Com, and to the LLIN distribution sites Nonprofit sector Number of warehouses meeting the criteria of storage and Outstanding Issues: transportation of products: There are a significant number of PA and PARC that do not meet Storage standard transportation of Warehouse PARC PA commodities requirements ST6 SS1 1 NA NA and ST7: 23 PARC and 271 PA.

SS2 1 NA NA Recommendations: SS3 1 NA NA Communication tools and SS4 1 NA NA guidelines on commodities SS5 1 NA NA transportation requirements will SS6 1 NA NA be provided to non-compliant PA SS7 1 NA NA and will be displayed at PARC and PA. Follow-up will be done at each Transportation supervision. IMPACT will collect ST5 1 67 859 best practices from compliant PA ST6 1 44 616 on commodities transportation ST7 1 44 618 requirement, that will be shared during classroom or on the job

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OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION Issues: PA do not have communications and guidelines for training of PA. Additionally, the transportation requirements. communication tools and guidelines on commodities Resolution: SPD verbally reminded (and written in the PA book) transportation will be displayed the PA about the standard conditions for transportation during for use as job aid at post.

monthly supervision. Public sector Number of public sector meeting the criteria of storage and Outstanding Issues: transportation of products: Temperature control is still an issue to Storage improving the storage conditions. SALAMA Pha-G- Pha-Ge- Dis Com/CSB Recommendations: • Purchase thermometers to SS1 0 37 124 control temperature. SS2 0 37 122 • Keep sensitizing Pha-G-Dis and SS3 0 39 125 PhaGeCom to meet standards. SS4 0 7 12 SS5 0 39 122 SS6 0 36 115 SS7 0 38 123 Transportation ST5 0 39 122 ST6 0 36 115 ST7 0 38 123

Issues: Pha-G-Dis and PhaGeCom are not controlling temperatures for their warehouses/storage spaces which can lead to deterioration of quality of sensitive medicines.

Resolution: IMPACT is planning to purchase thermometers for Pha-G-Dis and will discuss with ACCESS and other stakeholders to purchase thermometers for Pha-Ge-Com. 5.1.1.2. Organizing capacity building Nonprofit through technical workshops and Number persons from PSI central warehouse, PARC, PA: Outstanding Issues: training to enhance coordination None

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OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION and distribution of quality health Type Male Female Total products: among PSI central Warehouse 1 0 1 Recommendations: warehouse, PARC, PA and public PA 402 500 902 SPD will continuously build the sector (SALAMA/central PARC 21 53 74 capacity of PAs in terms of distribution warehousing, Pha-G-Dis , Pha-Ge- Some of PARC and PA had more than two people trained. of quality health products and Com and CSB), and those coordination during each monthly responsible for sending - All employees at PSI central warehouse, PARC, and PA visited supervision by SPD. commodities and LLINs. were trained on coordination and distribution of quality health products except for two PA.

Issues: Two PA did not receive training on coordination and distribution of quality health products.

Resolution: SPD provided on-the-job training during monthly supervision. Public Sector Number people from public sector trained: Outstanding Issues: Coordination is key to solving Type Male Female Total problems around ordering and SALAMA 0 0 0 distribution of health commodities. Pha-G-Dis 10 22 32 CSB/Pha-Ge-Com 17 45 62 Recommendations: - • The GAS committees’ members - - 80% of Pha-G-Dis and 48 % Pha-Ge-Com providers will be trained in Quarter 3 to participated in a workshop to enhance coordination and enhance their capacity in stock distribution of quality health products. management. - • The GAS committee will improve Issues: Low level of coordination and distribution of health coordination of all interveners commodities at the peripheral level. involved in the supply chain to analyze issues together that can Resolution: 76 (out of 78) districts have created a GAS (Gestion be addressed quickly to improve des Approvisionnements et des stocks) committee for better the supply chain at the peripheral coordination of ordering and distribution systems. level. The GAS committee members are meeting on quarterly basis.

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ANNEX D - SUCCESS STORIES

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Vohipeno district : Coaching Pha-G-Dis service providers increases data reporting rate from health facilities

Twenty-seven-year-old Sandra Raharimalala works as a service provider at the District Pharmacy (Pha-G-Dis) of Vohipeno. During the annual malaria peak season from October to January, the Pha-G-Dis play an important role in supplying health facilities and community health volunteers (CHVs) with health commodities to treat malaria .

Sandra received training and continuous coaching from the IMPACT project on commodity and inventory management. During these trainings, Sandra learned that obtaining accurate, complete, and timely logistics data from the health facilities is Figure 1 : RAHARIMALALA Sandra, service very important for her to be able to supply them correctly. provider, District Pharmacy (Pha-G-Dis) of Consequently, Sandra has taken the initiative to call health Vohipeno. Photo : PSI/IMPACT facilities herself every month so that they submit their reports. "Without health facilities consumption and order reports, I cannot calculate the correct and sufficient quantity of health supplies we need, which is the reason why I am trying to remind them on a specific date so that it becomes a habit for them," says Sandra. Her perseverance and devotion to her work paid off. In March 2019, only 17% of health facilities sent complete and on-time reports, but by January 2020 this rate increased to 96% (RMA Report, Vohipeno) which enabled her to have the right information to order health supplies at the central level. Thanks to her efforts and advices from IMPACT, the Pha-G-Dis was able to maintain enough stock (three to six months stock) of antimalarials, including Rapid Diagnosis Tests (RDTs), Artemisinin Combination Therapy (ACT), and Injectable Artesunate during the period of high malaria transmission. “Having enough stock enabled us to face the outbreak. When products are available, patients can get the right treatments,” she Figure 2: Malaria commodities at the Pha-G-Dis in said. Vohipeno Photo : PSI/IMPACT IMPACT provides continuous support to the Vohipeno MOPH team to ensure that health supplies are available at all levels of the supply chain.

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Sakoana: a model health facility that has never experienced stock-out of antimalarials due to careful adherence to guidance of stock management

Sakoana is a rural commune located ten kilometers from Manakara. In this municipality, malaria remains a public health issue and still claims many lives every year, especially during the malaria peak period. From November 2019 to February 2020, the local health facility received an average of 195 weekly consultations, 63% of which were confirmed malaria cases according to the Rapid Diagnostic Tests (RDTs) administered.

Randriamamonjy Fidèle is the head of the health facility (CSB) of Sakoana. Known for his devotion and passion for his work, Fidèle is committed to serving his community.

Despite the increased of the number of malaria cases during the period of high malaria transmission, the health facility Figure 3 : Randriamamonjy Fidèle, Head of Sakoana has never experienced stock-out and has even been able to CSB, Manakara health district treat cases from other health facilities that were Photo : PSI/IMPACT experiencing stock-out. "We are trying to carefully follow the guidelines by correctly calculating our needs, sending our reports on time, managing medicines well at the community pharmacy level (PhaGeCom), and following good storage practices. Except in the case of shortage or insufficient of products from the central level, the CSB of Sakoana has never experienced stock shortages in RDTs and anti-malarial, ” explains Fidèle.

Thanks to the leadership and dedication of Fidèle, 100% of patients that tested positive for malaria were properly cared from November 2019 to February 2020.

The IMPACT project supports health facilities like Sakoana in the improving the availability of health commodities through periodic supportive supervision Figure 4: Randriamahazomanana Serge, Regional visits and supporting commodity transportation in case Logistic Advisor, Vatovavy Fitovinany region during supportive supervision in Sakoana Photo : of emergency. PSI/IMPACT

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Mananjary: IMPACT and ACCESS join efforts to improve the availability of malaria products in remote rural to help save lives

Eight-year-old Sergio lives in the rural village of Ambohimiarina in the southeastern district of Mananjary with his family.

One day very early in the morning he went with his father to the Community Health Volunteer (CHV) of the village for a medical consultation as he felt his symptoms worsening.

As a CHV, Randrianasolo is a trusted member of the community. Sergio had a high temperature and was tested with Rapid Diagnostic Test (RDT), which came back positive for malaria. Figure 5 : Randrianasolo and Sergio using RDT Photo: PSI/IMPACT Sergio was very lucky as he could be tested and treated with Artemisinin Combination Therapy (ACT) rapidly without having to reach the health facility, which is a five kilometer walk away. “We are delighted to have malaria products available so that we can test people on the spot and treat them rapidly,” said Randrianasolo. In remote villages like Ambohimiarina, the distance of health facilities encourages people to go to traditional healers, which may lead to death due to delay in getting the right treatment.”

In order to address such challenges, the USAID-funded projects IMPACT and ACCESS have set up a collaboration agreement to support the Ministry of Public Health in improving the availability of medicines and health products up to the last mile, including in very rural villages. While the IMPACT project ensures the availability of products at the district level and provides coaching to regional and district MOPH staff, ACCESS follows up on IMPACT’s recommendations at health facilities and works with the CHVs who are present at the community level. “IMPACT and ACCESS interventions are very complementary. Before, the needs of the CHVs were not considered in orders sent to districts. After the implementation of this collaboration, they are gathered with those of the health facilities and the latter are supplied correctly,” says Freddy Alphonse, Community Health Assistant of ACCESS project, based in Mananjary.

Freddy works in 5 out of the 31 communes of Mananjary, 90% of which are in remote areas. As a result of the IMPACT and ACCESS collaboration, the 78 CHVs within the five communes are correctly supplied with antimalarials and other essential products for family planning and maternal, newborn, and child health.

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Maroantsetra: Devotion of Point d’Approvisionnement Relais Communautaire (PARC) manager and support from IMPACT helps prevent stockouts of family planning and maternal and child health supplies

The district of Maroantsetra is only accessible during three months of the year, making transportation of health products to this district very difficult.

Rasoanilova Juliette owns a clothing shop in Maroantsetra. Since June 2019, Juliette has been volunteering in holding the Point d’Approvisionnement Relais Communautaire (PARC) in Maroantsetra district. The PARC supplies 20 community-based Point d’Approvisionnement (PAs) with health products for family planning and maternal, newborn and child health.

Even though Juliette is a volunteer, her commitment to serve her community is very remarkable. Juliette takes the initiative to pick up the products at the port of Figure 6 : Rasoanilova Juliette, Community Relay Maroantsetra so that essential health products are Supply Point (PARC) in Maroantsetra district Photo: PSI/IMPACT available in her community. PSI does not have an office or staff in Maroantsetra, so Juliette is the one who takes care of the reception of the products at the port and the transport to her home, which serves as a warehouse. Juliette is very involved and serious in carrying out her work as a PARC despite her other occupations.

Juliette’s capacity has been enhanced by technical training and advice from the IMPACT team during supervision visits. Thanks to the quality of her work and the IMPACT supervision, there was no product stock- out and products are always available to meet the needs of the district, except Sayanna Press, which is also in shortage at the national level. "Thanks to IMPACT, I can help my community. I was able to acquire knowledge, particularly in the management of stocks, and I can apply it in my own business as well," she said.

IMPACT supports the availability of essential commodities and health products in the Maroantsetra region by training on stock management and capacity building of the PARC during each supervision.

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Joffre Ville: Collaboration among IMPACT Point d’Approvisionnement (PA), Mahefa Miaraka, and health facilities to help satisfy family planning needs

Thirty-year-old Angelette Herimalala, mother of four, lives in the commune of Joffre Ville in the district of Antsiranana II, Diana region. Together with her husband, they earn their livelihood from farming. In addition, she is also the manager of the community-based Point d’Approvisionnement (PA) in the commune.

As a volunteer, she has stood out among the other PA managers in the region through the quality of her work, including storage standards, proper use of management tools, reporting, availability of products, and her relationship with other stakeholders in her Figure 7 : HERIMALALA Angelette and her community. family Photo: PSI/IMPACT Since 2018, Angelette has ensured the availability of health products in her community. Six Community Health Volunteers (CHVs) from three villages (Fokontany) in the commune regularly come to buy products from her supply point. Monthly, she participates in the meeting of CHVs at the health facility (CSB) in the Joffre Ville commune to share information with the CHVs, the CSB head, and the USAID-funded Mahefa Miaraka team.

“The collaboration between CHVs, the CSB head, and the PAs of the Joffre Ville commune is very good. There has never been shortages of products and the CHVs are satisfied in the purchase of the products and collaboration with PAs because their orders are honored especially for family planning products. Every month, Angelette participates in the meeting of the CHVs and CSB and during this meeting she shares the situation of available products and collects the orders of the CHVs,” said Ginet SOLOZANDRY, District Coordinator of Mahefa Miaraka. Figure 8 : HERIMALALA Angelette, PA of Joffre Clementine, a CHV in the village of Morafeno, also Ville Photo: PSI/IMPACT confirms Angelette’s devotion to her work. “Since Angelette is responsible for PAs our orders are always satisfied and in line with the number of regular users for family planning, as well as for maternal and child health products. She is always available when we go to her place to buy the products. My customers are also satisfied because I have always enough stock,” she said.

While population supply needs vary according to the season, all health products are still available at the supply point level. As a result, orders from CHVs are always satisfied, whether for family planning products or supplies for child health (treatments for diarrhea, pneumonia, etc.). The head of the CSB, Razanamalala Volatiana, appreciates IMPACT’s support in supplying the commune with low cost products. “With IMPACT’s support, the 681 children under five in the commune are protected and correctly treated for diseases and women are protected from unintended pregnancies,” she said.

According to Angelette, the IMPACT project helps her solve her financial problems but also her integration into the community. The capacity building that she receives has enabled her to acquire new knowledge that she can apply in her daily life, such as financial management.

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Applying the Training: Lessons Learned from Financial and Operational Management Training

The USAID-funded IMPACT Program partnered with the Government of Madagascar’s Ministry of Public Health (MoPH) to engage the private sector in order to strengthen the health supply chain system and serve new health markets. Drug Shops, especially those in remote areas, are a crucial link in the health supply chain in Madagascar, albeit a somewhat forgotten and unregulated one. Officially, the number of drug shops in Madagascar is 1,600, but the national president of the Association of Drug Depots of Madagascar (ADDM) claims that there are more than 3,000 drug shops in operation. These illicit drug shops can pose a threat to the health of the Malagasy population for several reasons: 1) Illicit drug shops may not report the data of their stock and sales to national systems like DHIS2. The low rate of reporting makes it difficult to quantify the essential medicine that a territory or region may need. 2) Illicit drug shops may not always be compliant with authorized practices or sale activities. 3) Illicit drug shops may not be connected with official drug wholesalers and therefore may purchase products from unlicensed drug dispatchers. 4) Illicit drug shops may not store medicine correctly as they have not taken the internship required for licensed drug shops. Overall, drug shops which are not operating with the proper MoPH license have more difficulties in selling health commodities in a safe and professional manner, leading to inefficiencies in ensuring the supply of quality medications for the population.

To remedy this, the IMPACT Access to Finance (A2F) team has worked with the MoPH to provide half-day information sessions for drug shop owners on the laws and regulations governing drug shop licensure. These sessions are followed by optional training to strengthen capacity in financial and operational management of one’s shop. Trainings in the Atsinanana and the Boeny regions have already been carried out in November 2019 and February 2020 respectively. Following the training, the IMPACT A2F team provides coaching for owners wishing to benefit from a Figure 1: The IMPACT A2F Team facilitates a financial and deeper understanding and more tailored operational management training for drug shops in Mahajanga. approach for the management of their shop. So far, the A2F team has coached five drug shop owners, teaching them the management method and tools that should be used by the all drug shops and how to adapt and integrate these methods and tools to their shops. Mr. Jeremy Patrick, an owner of a drug shop in Toamasina (Atsinanana region), talked about his experience after using the tools for a month and a half following his training/coaching: "Before, I only used a registry where everything was intertwined and not systematic. After the training I wanted to apply the tools, and they have allowed me to understand the financial situation of my shop.” Thanks to the training, Mr. Patrick told the IMPACT Team that he was seeing:

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1. A significant reduction in debtors: By keeping a debtor book, he has recorded and been able to follow up with people when repayment is due. 2. Improved inventory management: Each product is inventoried appropriately and considers the standard requirements for storage, inventory, sale, and purchase. 3. Better records and clearer understanding of his shop’s profitability using a daily Figure 2: Mr. Jeremy Patrick in his drug shop in operations journal. Antsampanana / Brickaville - Atsinanana Region.

Now that Mr. Patrick is convinced of the importance and relevance of management tools, he is starting to realize that running a drug shop is not a one-man job. For a drug shop to be most successful, there should be one person who provides financial and administrative management and another person whose focus is on dispensing medicine and building customer relations. Unfortunately, because he could not both manage finances and customers, Mr. Patrick was forced to return his main focus to the sale and dispensation of drugs for the foreseeable future.

Even though Mr. Patrick has not succeeded in maintaining everything he learned in training, he has provided some crucial lessons that can be adapted for future implementation by IMPACT. One lesson learned from recent participants is that it may not be feasible for a single person to run both the financial and dispensary portions of their drug shop business. However, due to the Ministerial Decree N° 11092/2016, it may not be possible for drug shops to obtain that needed support. The decree stipulates: "The owner is obliged to manage the drug shop for which he/she received authorization under the penalty of permanent closure and the repeal authorizing the drug shop.”2 This decree means that for drug shops to truly improve their management and in that way improve the pharmaceutical supply chain in their area, it may be required for IMPACT and the Government of Madagascar to collaborate on how to revise this portion of the decree. Overall, the lessons drawn from Mr. Patrick’s experience are:

- (i) With support from IMPACT, the government of Madagascar should find a way to implement a program similar to that of the Accredited Drug Dispensing Outlets (ADDOs) Program in Tanzania, which recommends that a drug shop should be managed by two people: the manager (often the owner) and the provider. Also, each staff of the drug shop should participate in a training linked to his/her role within the drug shop - (ii) The IMPACT Program should create computer/tablet tool for drug shop management adapted to the general level of education and field conditions of drug shops to ensure its professionalization and the systematic collection of data from the private sector. This data would lead to the national quantification of essential medicines.

2 Determining the Conditions Under which Medicinal Products Intended for Humans are Used and Determining the Allowed Number of Drug Shops by Locality. Ministerial Decree 11092/2016, (2016): Chapter IV, Article 20. Issued by Ministry of Public Health, Madagascar.

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Tapping into innovation for family planning: applying drone technology to bring contraceptives to remote Communities in Madagascar

Although more women in Madagascar are using modern contraceptives than ever before, their use has hovered at approximately 35 percent. Certainly, modest improvements in addressing the unmet needs of contraceptive use have been hailed across the country. But for women and girls living in remote communities of the country, it is a different story. Women and girls suffer from a double burden given the limitations posed by their physical locations, as well as the interruptions posed to supply chains. The need for improving access to family planning in rural communities presents the greatest challenges; and in turn, warrant innovative strategies to help expand access in remote areas. In response, the USAID IMPACT Project has begun to explore the use of drone technology to deliver family planning resources to respond to this very issue.

In October 2019, the IMPACT project began exploring how drone technology could be used to improve access to essential drugs to communities in need. By rolling out drone technology, the IMPACT project has been successful in maximizing efficiencies to respond to stock out challenges at supply points. Before, it would take 2 to 3 months to make contraceptives available; but now, the drone technology delivers products in just one hour. After seeing the pilot experience through the drone use video, the GESI Specialist, Malanto Rabary, realized the potential that drones could offer in facilitating access to contraceptives for excluded community in remote areas. The use of drone by itself is indeed reaching four critical objectives (i) expanding the distribution of health commodities among target groups, (ii) addressing a gender and social inclusive balanced approach, (iii) promoting family planning health among women, girls and whole community in rural areas and (iv) helping to fill the market in social marketing sector. As the project continues to test out new ways of using drone technology more consistently in the supply chain, stakeholder partners and rural communities themselves will stand to benefit from expanded access for priority medications for women in remote, including family planning and medications for maternal and child health.

At this year’s celebrations of International Women’s Day in Tulear, IMPACT collaborated with the Ministry of Population and the National Women’s Council to showcase the opportunities that drone technology offers to remote communities. The IMPACT team showed a video which explained how drones could fill a critical gap in access to health products for marginalized populations in remote communities. Senior representatives from the Ministry of Population as well as the Chairwoman of the National Women’s Council were very interested in the potential that the drone technology offered, particularly to give women and girls access from remote communities. Senior level officials shared, “It is good to know that women from remote areas could get now contraceptives with the use of this drone. Thanks to IMPACT as it helps improving health status in Madagascar”.

Through the IMPACT project’s signature commitment to gender and social inclusion, interventions continue to be designed with an express goal of addressing gender-specific dimensions to help strengthen the supply chain systems for U.S.-funded maternal and child health, malaria, and family planning activities. IMPACT and the GESI team will continue to collaborate to unlock the solutions to addressing the most critical needs in maternal and child health, malaria and family planning, so that health services and access can continue to grow more equitable for all.

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ANNEX E – STOCK INVENTORY AS OF MARCH 2020 (USAID AND PMI funded)

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MALARIA COMMODITIES (SALAMA)

Quantity Expiry date PRODUCTS Quantity Treatment/Kit/Vial (dd/mm/yy) packs /tablet Sulfadoxine/Pyrimethamine 500/25 mg Tablet, 150 1-Apr-22 6,000 900,000 Tablets Sulfadoxine/Pyrimethamine 500/25 mg Tablet, 150 1-Aug-21 4,513 676,950 Tablets Sulfadoxine/Pyrimethamine 500/25 mg Tablet, 150 1-Aug-21 6,994 1,049,100 Tablets TOTAL QUANTITY 2,626,050 Artesunate/Amodiaquine 100/270 mg Tablet, 25 x 3 1-Dec-20 172 4,300 Blister Pack Tablets TOTAL QUANTITY 4,300 Artesunate/Amodiaquine 100/270 mg Tablet, 25 x 6 1-Dec-20 2,301 57,525 Blister Pack Tablets TOTAL QUANTITY 57,525 Artemether/Lumefantrine 20/120 mg Dispersible Tablet, 30 x 6x2 Blister Pack Tablets 1-Apr-21 896 26,880 Artemether/Lumefantrine 20/120 mg Dispersible Tablet, 30 x 6x2 Blister Pack Tablets 1-Jul-21 2,160 64,800

TOTAL QUANTITY 91,680 Artemether/Lumefantrine 20/120 mg Dispersible Tablet, 30 x 6x1 Blister Pack Tablets 1-Aug-21 976 29,280 TOTAL QUANTITY 29,280 Malaria Rapid Diagnostic Test (RDT), pack of 25 Tests 1-Oct-21 11,481 287,025 TOTAL QUANTITY 287,025

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MNCH COMMODITIES (SALAMA)

Quantity Expiry date COMMODITIES Quantity Treatment/Kit/Vi (dd/mm/yy) packs al/tablet GENTAMICINE 10MG/ML INJ - AMP 2ML - (20MG) - 1-mai-21 522 52,200 Box/100 - GENTAMICINE 10MG/ML INJ - AMP 2ML - (20MG) - 1-juin-21 320 32,000 Box/100 - TOTAL QUANTITY 84,200 GENTAMICINE 40MG/ML INJ - AMP 2ML - (80MG) Box/100 1-févr.-21 149 14,900 - GENTAMICINE 40MG/ML INJ - AMP 2ML - (80MG) Box/100 1-nov.-20 210 21,000 - TOTAL QUANTITY 35,900 MAGNESIUM SULFATE 50% INJ.AMP.10ML - Box/10 1-févr.-21 1,612 16,120 MAGNESIUM SULFATE 50% INJ.AMP.10ML - Box/10 1-mai-21 1,098 10,980 TOTAL QUANTITY 27,100 OXYTOCINE 10UI/ML INJ. AMP. 1ML - Box/10 1-mai-21 12,386 123,860 OXYTOCINE 10UI/ML INJ. AMP. 1ML - Box/10 1-juin-21 75,180 751,800 OXYTOCINE 10UI/ML INJ. AMP. 1ML - Box/10 1-juin-21 33,440 334,400 TOTAL QUANTITY 1,210,060

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ANNEX F – STOCK STATUS BY END OF MARCH 2019

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Dashboard- stock status of malaria commodities- end of March 2020 Stock on Hand Central MOS Procurement Warehouse AMC Estimated Products by Shipment Agency/ Donor (PMI and (Quantification) arrival date AMC funding Global Fund stocks) 34,350 PSI/ Global Fund 31-May-20 ASAQ 2 - 11 64,300 PSI/ Global Fund 30-Jun-20 months, tablet, 11,800 19,324 0.6 52,350 GHSC-PSM/PMI 14-May-20 treatment 5,250 GHSC-PSM/PMI 7-Sep-20 187,650 PSI/ Global Fund 30-Sep-20 75,000 PSI/ Global Fund 31-May-20 75,000 PSI/ Global Fund 30-Jun-20 ASAQ 1- 5 50,650 GHSC-PSM/PMI 21-Jul-20 years, tablet, 0 107,677 0.0 496,750 GHSC-PSM/PMI 14-May-20 treatment 717,450 PSI/ Global Fund 30-Sep-20 386,000 GHSC-PSM/PMI 7-Sep-20 21,225 GHSC-PSM/PMI 21-Jul-20 ASAQ 6- 13 192,500 GHSC-PSM/PMI 14-May-20 years, tablet, 52,745 58,265 0.9 91,600 GHSC-PSM/PMI 7-Sep-20 treatment 527,525 PSI/ Global Fund 30-Sep-20 106,125 GHSC-PSM/PMI 21-Jul-20 ASAQ 14 years 80,400 GHSC-PSM/PMI 14-May-20 and above, 82,925 60,231 1.4 301,625 GHSC-PSM/PMI 21-Jul-20 treatment 495,475 PSI/ Global Fund 30-Sep-20 25,000 GHSC-PSM/PMI 22-Apr-20 Artesunate 53,336 47,685 1.1 142,000 PSI/ Global Fund 31-Jul-20 injectable, vial 333,300 PSI/ Global Fund 30-Sep-20 1,000,000 GHSC-PSM/PMI 7-Jul-20 Rapid 1,290,325 GHSC-PSM/PMI 4-Sep-20 diagnostic test - 2,198,675 591,781 3.7 2,852,625 PSI/ Global Fund 31-Aug-20 kit 3,459,325 PSI/ Global Fund 30-Sep-20 SP 8,700,150 335,937 25.9 1,500,000 GHSC-PSM/PMI 15-Dec-21 189,000 PSI/ Global Fund 30-Apr-20 QUININE tablet 314,900 35,854 8.8 126,000 PSI/ Global Fund 1-Dec-20 Artesunate 12,672 PSI/ Global Fund 31-Jul-20 11,520 2,664 4.3 suppositories 84,500 PSI/ Global Fund 30-Sep-20 Primaquine 0 5,888 - 125,000 PSI/ Global Fund 30-Apr-20 AL 1x6 33,841 19,324 1.8 AL 2x6 97,640 107,677 0.9 AL 3x6 34,350 58,265 0.6 64,800 GHSC-PSM/PMI 1-May-20 AL 4x6 32,970 60,231 0.5

General information on the stock status

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• There is a critical situation of stock of ACTs and RDTs at the central level. Districts and CSB are continuing the redeployment whenever necessary. The Committee GAS central level is rationing stock available and ship to districts only stock to raise district levels at a maximum of 2 months (instead of 6 months) • The AL are being distributed at the same time of AS/AQ • There is a planned shipment of ACTs expected to arrive in May 2020 that will solve the situation. The Committee GAS central level will work with SALAMA to ship in emergency malaria commodities starting June.

Dashboard – Stock status of MNCH commodities, end of March 2020

stock available at Projected AMC Month of COMMODITY SALAMA, end (demographic stock Stock status Recommended actions March 2020 data) available

IMPACT is planning with Gentamycin 10 DSFa a second 84,200 7,383 11.40 Normal Mg/ml, injectable, distribution to districts in vial of 2ml (80ml) the 78 supported districts

IMPACT is planning with Gentamycin 40 DSFa a second 35,900 3,033 11.84 Normal Mg/ml, injectable, distribution to districts in vial of 2ml (20ml) the 78 supported districts

IMPACT is planning with DSFa a second Sulfate de distribution to districts in 27,100 2,207 12.28 Normal magnesium 50%, the 78 supported districts injectable, vial of and other hospitals in 10 ml need

IMPACT is planning with DSFa a second distribution to districts in 1,210,060 32,123 37.67 Overstock the all 114 districts and Oxytocin 10U.I/ml, explore a possible injectable, transfer to another ampoule of 1ml country.

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ANNEX G - Descriptions of the seven quality dimensions for the RDQA

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Data Quality Parameter Descriptions The extent to which data and its supporting documentation are available. Review availability of the indicator source documents for the selected reporting period. 1- Availability Source documents depends on the indicator but will often refer to client intake forms, registers, cards redeemed vouchers, etc. Specify the name of the documents reviewed.

Complete means that the document contained all the required entries of the indicator as appropriate. 2-Completeness Review completeness of the indicator source documents for the selected reporting period.

The degree to which the data correctly reflects what they were intended to measure. 3-Accuracy It is also known as validity. Accurate data correctly measure actual events, cases, units, etc.

The extent to which data is up to date (current) and is made available on time. Review the timeliness of documents received from the site for the selected reporting 4-Timeliness period. Reports can either be summary reports or reports of aggregated data that is submitted to the next reporting level e.g. regional or district level.

The extent to which data is protected from unauthorized changes or manipulation. 5-Integrity Review the source document for any indication of unauthorized (accidental or deliberate) insertion, modification or destruction of data.

6-Confidentiality The extent to which information or data is protected and kept secure.

The extent to which data is collected with the level of detail required to measure the 7-Precision indicator e.g. disaggregation by commodity type, etc.

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ANNEX H – Call-Center Functioning

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The call center located at PSI office with unlimited and high-speed Internet connection available. The call center was created to strengthen the LMIS reporting rate from Pha-G-Dis to DPLMT (central office based in Antananarivo). The call center is used to remind the Pha-G-Dis providers on LMIS data submission as explained in the following process:

- The call center team checks the reporting rate using a dashboard presented in the IMPACT Intranet dashboard. - All Pha-G-Dis identified that did not submit LMIS data are called and reminded to submit data for the relevant period. - Challenges and barriers are managed as tickets and shared to the CHANNEL focal point at DPLMT and to RLA.

If the issues cannot be solved by the call center then field visits will be organized. It is noticed that the call center does not collect LMIS data but was set up to remind Pha-G-Dis provider to submit LMIS data extracted from CHANNEL (always using mail).

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