Quarterly Performance Report from April 01, 2018 to June 30, 2018

DEFEAT MALARIA

Defeat Malaria Quarterly Performance Report From April 01, 2018 to June 30, 2018

Submission Date: July 31, 2018

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

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

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

Table of Contents List of Tables ------iii List of Figures ------iv ACRONYMS AND ABBREVIATIONS ------v Executive Summary ------7 Defeat Malaria Goal and Objectives ------8 Summary of Key Achievements (From April 2018 to June 2018) ------10 Interventions and Achievements on Core Areas of Strategic Focus ------12 1. Achieving and sustaining scale of proven interventions through community and private sector engagement ------12 2. Use of strategic information to adapt to changing epidemiology ------22 3. Progress of malaria elimination activities in three pilot townships in Southern Rakhine State ------22 4. Improving Myanmar’s capacity to collect and use information ------30 5. Building capacity and health systems strengthening ------36 6. Strengthening capacity of the NMCP and Ethnic Health Organizations (EHOs) ------39 Challenges ------42 Annexes ------43 Annex 1 – Case Finding and Management ------43 Annex 2 – Active case detection by mobile team ------44 Annex 3 – Monthly meeting ------45 Annex 4 – Supervision and monitoring ------46 Annex 5 – Reporting status of VMWs/PPs ------47 Annex 6 – Clinical audit ------48 Annex 7 – Stock out monitoring at the time of monitoring visits ------49 Annex 8 – Capacity building ------51 Annex 9 – BCC ------52 Annex 10 - Study tour to Sampov Loun District, Battambang Province in Cambodia ------53 Annex 11 – Performance Indicators ------54

List of Tables Table 1: Project area coverage as of June 30, 2018 ...... 9 Table 2: Summary of case finding and management by different case detection agents (April to June 2018) ...... 13 Table 3: State/Region wise summary of case finding and management (From April to June 2018) ...... 13 Table 4: Summary of DOT (from April to June 2018) ...... 14 Table 5: State/Region wise LLIN mass distribution at village-level (from April to June 2018) .... 18 Table 6: LLIN distribution at worksites (from April to June 2018)...... 19 Table 7: Monitoring of LLIN coverage and utilization (from April to June 2018) ...... 19 Table 8: Risks among different groups ...... 22 Table 9: Conducting Malaria Elimination Advocacy Meeting and Quarterly MECC Meeting ...... 23 Table 10: Capacity Building Training for Malaria Elimination in Three Pilot Townships ...... 23 Table 11: Reporting status of all reporting units (villages/worksites) in Toungup, Munaung, and Ramree Townships, Jan – June 2018 ...... 25 Table 12: Surveillance report – Case detection, notification, investigation, and classification in Toungup Township (Jan – Jun 2018) ...... 27 Table 13: Surveillance report – Case detection, notification, investigation, and classification in Ramree Township (Jan – Jun 2018) ...... 27 Table 14: Surveillance report – Case detection, notification, investigation, and classification in Munaung Township (Jan – Jun 2018) ...... 28 Table 15: Provider based surveillance report (Jan – June 2018) ...... 29 Table 16: LLIN distribution in Elimination Townships from April to June 2018 ...... 29 Table 17: Gender related indicators and their current status...... 35 Table 18: Summary of QAQI activities and actions to be taken (From April to June 2018) ...... 36 Table 19: Township wise summary of case finding and management by different case detection agents (from April to June 2018) ...... 43 Table 20: Summary of active case detection in project villages and work sites (from April to June 2018) ...... 44 Table 21: Summary of active case detection in non-project villages and work sites (from April to June 2018) ...... 44 Table 22: Summary of VMW/PP monthly meeting (from April to June 2018) ...... 45 Table 23: Summary of supervision and monitoring visits to VMWs/PPs (from April to June 2018) ...... 46 Table 24: Reporting status of VMWs/PPs (from April to June 2018) ...... 47 Table 25: Summary of clinical audit (from April to June 2018) ...... 48 Table 26: Summary of stock out monitoring at the time of monitoring visits and on-site data collection (from April to June 2018) ...... 49 Table 27: Summary of stock out monitoring at monthly meeting (from April to June 2018)...... 50 Table 28: Number of VMWs/PPs trained on case management (from April to June 2018) ...... 51 Table 29: Number of VMWs/PPs trained on diagnosis (from April to June 2018) ...... 51 Table 30: Number of people reached through IPC and Group Health Talks by Mobile Team, VMWs and PPs (From April to June 2018) ...... 52

iii

Table 31: Number of people reached through IPC and Group Health Talks by Private Providers only (From April to June 2018) ...... 53 Table 32: Performance Indicators Tracking Table (From April to June 2018) ...... 54

List of Figures Figure 1: Map showing coverage of Defeat Malaria ...... 9 Figure 2: Number of people disaggregated by gender, reached through IPC by VMWs/PPs (From April to June 2018) ...... 17 Figure 3: Message about malaria elimination on Defeat Malaria Facebook Page ...... 17 Figure 4: Focus Group Discussion with Karen forest goers at Arr Mo village close to Thailand border, Dawei Township ...... 20 Figure 5: PMI/ USAID Senior Malaria Advisor’s visit to Defeat Malaria Elimination Office, Toungup Township ...... 29 Figure 6: National Technical Officer-WHO, facilitated data summarization and analysis by the appropriate utilization of data elements, indicators, and reporting generated by DHIS2 ...... 31 Figure 7: DQO cross-checked stock data for Routine Data Quality Assessment at Dawei Office ...... 32 Figure 8: Quarterly RDQA and OSDV coverage, Oct 2017-Jun 2018...... 32 Figure 9: Proportions of malaria treatment seeking behaviors ...... 34 Figure 10: PMI Malaria Advisor visits Sakhanmaw village and meets with malaria case to understand local epidemiology ...... 35 Figure 11: State/Region wise Defeat Malaria VMW by gender ...... 36 Figure 12: mHealth and Research Officer demonstrated ODK application during supervision at Kyauk Tan Chay village, Sittwe Township...... 38 Figure 13: Project Manager of MHAA presents progress and challenges of Buthidaung, Rathedaung and Maungdaw Townships ...... 38 Figure 14: mHealth and Research Officer provided GIS reorientation training at Sittwe Township ...... 39 Figure 15: Defeat Malaria staff and trainers at the Master Mentor Training for Integrated Community Malaria Volunteers ...... 40 Figure 16: Second dose of VMW training at Launglon Township...... 40 Figure 17: Malaria supervisor, District VBDC team, Myawaddy coached ICMV from Apyinmaekanal village, Myawaddy in filling of carbonless register ...... 41 Figure 18: Assessing RDT testing of VMW at Gwa Township ...... 41 Figure 19: Sub-Grant Manager and Finance Manager of URC visits MHAA office, Yangon for strengthening collaboration ...... 41

ACRONYMS AND ABBREVIATIONS ABER Annual Blood Examination Rate ACD Active Case Detection ACT Artemisinin-based combination therapy ANC Antenatal care API Annual Parasite Incidence ARC American Refugee Committee BCC Behavior Change Communication BHS Basic Health Staff CMEP Cambodia Malaria Elimination Program CNM Cambodia National Malaria CPIR Commodity Procurement Information Request COP Chief of Party DMR Department of Medical Research DMS Defense Medical Services DOT Directly observed treatment DQO Data Quality Officer EHO Ethnic Health Organizations EMMP Environmental mitigation and monitoring plan GAD Government Administrative Department GMS Greater Mekong Sub-region GTS Global Technical Strategy HMIS Health Management Information System ICMV Integrated Community Malaria Volunteer IEC Information, Education and Communication IPC Interpersonal Communication ITN Insecticide treated net KNU Karen National Union LCP Leprosy Control Program LDHF Low Dose High Frequency LLIN Long lasting insecticidal nets MECC Malaria Elimination Coordination Committee MHAA Myanmar Health Assistant Association MMP Migrants and mobile populations MNMA Myanmar Nurse and Midwife Association MOP Malaria Operation Plan M&E Monitoring and Evaluation NAP National AIDS Program NMCP National Malaria Control Program NSA Non-state actors NTG National Malaria Treatment Guidelines NTP National Tuberculosis Program ODK Open Data Kit OSDV On-site data verification PCR Polymerase Chain Reaction PMI President’s Malaria Initiative

PP Private Providers QA Quality assurance QAQC Quality assurance/quality control QAQI Quality assurance/quality improvement QI Quality Improvement RDQA Routine Data Quality Assessment RDT Rapid diagnostic tests RHC Rural Health Centers SOP Standard Operation Procedure TPR Test Positivity Rate TSG Technical Strategic Group UNOPS United Nations Office for Project Services URC University Research Co., LLC USAID United States Agency for International Development USG United State Government VBDC Vector Borne Disease Control VBS Village Based Stratification VMW Village Malaria Worker WHO World Health Organization

Executive Summary Myanmar’s National Malaria Control Program’s (NMCP) reported 85,019 malaria cases and 31 malaria deaths in 20171. This marks a decline of 83% in cases and 92% in deaths from 2012 to 2017. However, the malaria burden in Myanmar remains the highest among the six countries of the Greater Mekong Sub-region (GMS), accounting for about 51% of all cases. Significant challenges interfere with the implementation of the malaria control program, including weak health services in remote areas with high transmission, limited resources and manpower to expand and maintain quality malaria services, internal and cross-border migration, and evidence of spreading artemisinin resistance along the border (especially the Thai-Myanmar border). Under the NMCP, local and international organizations, including donor agency like the United States Agency for International Development (USAID), collaborate to identify gaps and implement solutions to address these challenges. The Defeat Malaria Activity (August 2016-August 2021), funded by the U.S. President’s Malaria Initiative (PMI) and USAID, is implemented by University Research Co., LLC (URC), in partnership with American Refugee Committee (ARC), Jhpiego and Duke University, Global Health Institute. Defeat Malaria’s local partners, Myanmar Health Assistant Association (MHAA) and Myanmar Nurse and Midwife Association (MNMA), deliver needed malaria services while contributing to local capacity building efforts. Defeat Malaria works with the NMCP to strengthen local health systems that are responsive and flexible and can respond appropriately to a changing malaria epidemiological situation and emerging threats, including multi-drug resistant P. falciparum and insecticide resistant vectors. Defeat Malaria promotes sustainable approaches to support malaria control activities, including community empowerment in malaria control and prevention, evidence-based decision making, engagement of the private sector, and building on existing efforts to engage other agencies and sectors. Because of the NMCP’s and implementing partners’ efforts, in all 17 townships of Rakhine State the malaria burden decreased from 123,814 cases in 2011 to 16,234 cases in 2017 (87% reduction). Thus, Defeat Malaria, in collaboration with the NMCP, initiated in January 2018 malaria elimination approaches in three pilot townships of Rakhine State: Munaung, Ramree and Toungup. Year 2 Quarter 3 (April - June 2018) Key Highlights include:  Increased geographic coverage of case finding and management service covering 31 townships with 1,330,203 people residing in 2,345 villages.  88,069 long lasting insecticidal nets (LLINs) distributed to vulnerable populations (489 pregnant women, 2,158 migrants and 161,743 people from worksites and villages, respectively)  54,646 people tested, 932 positive cases detected, among them 8 were referred and 924 were treated. Among treated cases, 98.1% (906 positive cases) were treated according to National Malaria Treatment Guidelines.

1 NMCP Annual Evaluation Meeting from 12th July 2018 to 15th July 2018 at Nay Pyi Taw

In Quarter 3, Defeat Malaria continued case finding and management and elimination refresher trainings, targeting 1,500 village malaria workers (VMWs)/Private Providers (PPs) and Basic Health Staff (BHS). The trained VMWs/PPs received rapid diagnostic tests (RDTs), antimalarial drugs, and patient registers. The VMWs/PPs and mobile teams provided case detection and management services in targeted areas. In areas where possible, directly observed treatment (DOT) to positive cases was provided by VMWs. Also, awareness campaigns such as interpersonal communication and group health talks were provided on malaria prevention and elimination messages to those 15 years and above who tested for malaria. Project staff were continuously performing data quality audits at different levels to improve data quality for planning, implementation and evaluation. In January 2018, with the permission from the Core Technical Strategic Group (TSG) and led by Deputy Director General (Disease Control), Department of Public Health, malaria elimination strategies were initiated by URC in Toungup, Ramree, and Munaung townships in Southern Rakhine State. Strategies for accelerated efforts to achieve elimination and core surveillance activities were introduced after capacity development of local health staff. For convenience in data collection, recording, analysis and better documentation, use of Open Data Kit (ODK) was initiated as a pilot during this quarter as a supervisory tool for VMWs’ field activities. To build capacity of the M&E and malaria surveillance system, Defeat Malaria’s M&E Team, led by the M&E Director, attended the workshop on “Surveillance and Malaria Database Management” on 18 May 2018 and a training for “Accelerating Malaria Case Reporting Across Implementation Partners” from 4-6 June 2018 steered by the NMCP with the support of UNOPS and WHO. To maintain motivation among VMWs amid decreasing malaria cases, the NMCP coordinated with the National Tuberculosis Program (NTP), National AIDS Program (NAP) and Leprosy Control Program (LCP) to expand VMW responsibilities and provide training on the prevention, early detection and referral of these 3 diseases. In addition, the NMCP included prevention of dengue haemorrhagic fever and filariasis, and now calling VMWs as Integrated Community Malaria Volunteers (ICMVs). Defeat Malaria is implementing the approach providing ICMV training to all VMWs (except those in pilot elimination areas) to safeguard good relationships between communities and VMWs.

Defeat Malaria Goal and Objectives The overall goal of the Defeat Malaria Activity is to reduce the malaria burden and control artemisinin-resistant malaria in targeted areas, contributing to the long-term national goal of eliminating malaria in Myanmar. This will be achieved by expanding coverage of community- based prevention and case management services, prioritizing highly endemic for further burden reduction of malaria, hard-to-reach and Non-State Actor areas and covering mobile and migrant populations (MMPs). Defeat Malaria strengthens the capacity of local partners to manage and implement interventions effectively to achieve the goal of malaria elimination. The

8 malaria surveillance system is strengthened to collect quality data, use of data-for-decision making, and developing appropriate strategic interventions. Defeat Malaria works with the NMCP and key partners to achieve the following objectives: Objective 1: Achieve and maintain universal coverage of at-risk populations with proven vector control and case management interventions, while promoting the testing of new tools and approaches. Objective 2: Strengthen the malaria surveillance system to comprehensively monitor progress and inform the deployment and targeting of appropriate responses and strategies. Objective 3: Enhance technical and operational capacity of the NMCP and other health service providers at all levels of service provision. Objective 4: Promote the involvement of communities, private healthcare providers, private companies and state-owned enterprises in malaria control and elimination initiatives. Defeat Malaria is currently covering two States (Rakhine and Kayin States) and one Region (Tanintharyi). Rakhine State has the highest malaria burden in Myanmar (source; NSP, 2016 -2020) due to high receptivity. In addition, difficult terrain is a significant barrier to providing health services in remote areas. Table 1 provides a summary of villages and populations covered by Defeat Malaria as of June 2018. Figure 1: Map showing coverage of Defeat Malaria

Table 1: Project area coverage as of June 30, 2018 Total Total Total % of State & Region Covered Covered Total Population Covered Population Townships Villages Population Covered Tanintharyi 10 587 1,408,401 313,711 22.27% Northern Rakhine 10 565 1,108,828 439,509 39.64% Southern Rakhine 7 1,003 740,797 443,218 59.83% Kayin 4 190 1,297,935 133,765 10.31% Total 31 2,345 4,555,961 1,330,203 29.20% As shown in Table 1, as of FY18 Q3, 31 townships are covered with 1,330,203 beneficiaries in 2,345 villages. The volunteer network has 1,717 VMWs/PPs to provide quality malaria health care services. Unfortunately, MHAA could not begin activities in Maungdaw Township, Northern Rakhine State, because of conflict, in spite of series of discussions with local authorities including local

9 health department. However, they could initiate field activities in Buthidaung township since last quarters. Summary of Key Achievements (April 2018 to June 2018)  Training activities - In targeted townships, refresher trainings were conducted for 208 VMWs and PPs on malaria case diagnostics and management.  54,646 people were tested for malaria through VMWs, private providers, and Defeat Malaria mobile outreach teams (in all covered townships). In three pilot elimination townships, activities were carried out in alliance with the NMCP.  932 positive cases were detected and, among them, 8 were referred to hospitals. The remaining 924 positive cases were treated with 906 (98.1%) treated according to National Treatment Guidelines.  To prevent onward transmission, artemisinin resistant malaria and relapsing, DOT were provided to total 559 positive cases and among them, 99.1% (554 cases) were completed to take full course of antimalarials.  Interpersonal communication – Defeat Malaria reached 44,463 people (21,826 males, 22,637 females) through interpersonal communication (IPC) including 5,493 migrants. 643 group health talks were conducted covering 13,137 people (5,708 males and 7,429 females) including 1,568 migrants in project areas.  88,069 LLINs were distributed in 261 villages and 17 worksites including distribution of LLINs to 489 pregnant women attending ANC visits in 39 sub-centers.  Defeat Malaria introduced the innovative low dose high frequency training approach in Integrated Community Malaria Volunteer (ICMV) training for all VMWs in project areas (except the 3 elimination townships). An “ICMV Master Mentor Training” was conducted from 20-22 June 2018 at Defeat Malaria’s Yangon office covering 19 Defeat Malaria central and field staff.

Interventions and Achievements on Core Areas of Strategic Focus This section covers the following core strategic focus areas: (1) Achieving and sustaining scale of proven interventions through community and private sector engagement (2) Adapting to changing epidemiology based on strategic information (3) Initiating malaria elimination approaches in three pilot townships in Southern Rakhine State (4) Improving Defeat Malaria staffs’ capacity to collect and use information (5) Building capacity and strengthening health systems (6) Strengthening capacity of the National Malaria Control Program and Ethnic Health Organizations (EHOs) 1. Achieving and sustaining scale of proven interventions through community and private sector engagement 1.1 Capacity building for VMWs/PPs on malaria diagnosis and case management Capacity building for VMWs and private providers was conducted to provide quality malaria diagnosis and case management services covering 183 VMWs (M-102, F-81) and 25 PPs (M-17, F-8) for 4-days. The training also covered provision of IPC, stock management, and data collection and reporting for case management. (Details in Annex 8). 1.2 Distribution of commodities to all project townships and villages From April to June 2018, 77,525 RDTs and 1,390 ACTs were distributed from the central warehouse (Yangon) to commodity storage sites at the township level to ensure continuous uninterrupted treatment services for targeted communities. Then, the commodities were distributed to service and delivery points (VMWs or PPs) working there. In FY18Q3, 53,645 RDTs and 1,223 ACTs were distributed to VMWs/PPs from township storage sites. Stock outs were monitored during field supervisory visits and monthly VMW/PP meetings. Replenishments were usually done during monthly meetings. 1.3 Ensure early diagnosis and appropriate treatment through different approaches Community-based malaria diagnosis and treatment services are run by trained VMWs, PPs and mobile teams run by Defeat Malaria staff at village level, and volunteers of some employers from private companies to provide services for at-risk populations including MMPs and pregnant women. Case detection and treatment of positive cases (Testing and Treating) were reported during VMW/PP monthly meetings at the end of the month. Initiation of testing of suspected malaria cases and reporting by general practitioners (GPs) started in April 2018 in elimination townships. In FY18Q3, reporting showed 54,646 people tested and 932 positive cases including 423 P. falciparum, 393 P. vivax and 15 mixed infections. The Test Positivity Rate (TPR) was 1.71%. Because of severe symptoms, 8 cases were referred to hospitals and the remaining 924 positive cases (98.9%) were treated by project staff/volunteers. Among treated cases, 98.1% were treated according to NTGs (Annex 1). More detail case detection and treatment status in

12 elimination townships can be seen in elimination section. (see in Progress of malaria elimination activities in three pilot townships in Southern Rakhine State). Table 2: Summary of case finding and management by different case detection agents (April to June 2018) Total Approach Tested Pf Pv Mix TPR% Positive Mobile Teams 6,686 45 15 30 0 0.67% VMWs 35,840 727 321 395 11 2.03% PPs 3,849 94 36 56 2 2.44% GPs 16 0 0 0 0 0.00% NMCP (collaborative activity in 8,255 66 51 13 2 0.80% elimination townships) Total 54,646 932 423 393 15 1.71%

Table 3: State/Region wise summary of case finding and management (From April to June 2018) Total State / Region Tested Pf Pv Mix TPR% Positive Tanintharyi Region 14,818 357 72 283 2 2.41% S. Rakhine State 19,274 169 143 23 3 0.88% N. Rakhine State 16,890 291 199 85 7 1.72% Kayin 3,664 115 9 103 3 3.14% Total 54,646 932 423 494 15 1.71%

1.4 Active Case Detection (ACD) Defeat Malaria teams continued conducting special mobile activities through active case detection (ACD) in 80 project villages and 51 non-project villages in 21 townships. During this reporting period, mobile teams tested 6,356 in project and non-project villages and detected 42 positive cases (12 Pf, 30 Pv, and 0 mixed) including 27 positive cases (9 Pf, 18 Pv) among 1,221 tested in non-project villages, and 15 positive cases (3 Pf, 12 Pv) among 5,135 tested in project villages. As there might be service gaps and remoteness, the TPR in non- project villages (2.21%) was higher than TPR in project villages (0.29%). For more detail, please see Annex 2. 1.5 Directly Observed Treatment (DOT) 554 cases (99.1%) of 559 positive cases enrolled under DOT completed the full course of antimalarials under monitoring.

Table 4: Summary of DOT (from April to June 2018)

Pf Pv Mixed Total Total positive enrolled in DOT 295 255 9 559 Completed DOT 295 250 9 554 Incomplete DOT (lost to follow up*) 0 5 0 5 Total positive cases under ongoing DOT 8 123 2 133 % of enrolled completed DOT 100% 98% 100% 99.1% * Lost to follow up means patients couldn't continue to take treatment or VMW/PP couldn't continue to monitor treatment and does not include positive cases which receive ongoing monitoring under DOT. 1.6 VMW monthly meetings 93.7% (1,571 out of 1,676 VMWs/PPs) in April, 95.4% (1,556 out of 1,631 VMWs/PPs) in May, and 97.1% (1,592 out of 1,639 VMWs/PPs) in June attended monthly meetings. Due to remoteness, activities with other jobs and/or lack of interest, some VMWs/PPs didn’t take part in the monthly meetings. Defeat Malaria staff monitored VMWs/PPs reporting performance (timeliness and completeness), verified reported data and randomly checked data, replenished commodities and refreshed case management capacity (Annex 3). If a VMW/PP was absent from the meeting and did not report, project staff enquired why and tried to motivate the VMW/PP. In a few cases, replacements need to be considered. 1.7 Supervision and monitoring Supportive supervisory visits improve the capacity and effectiveness of VMWs/PPs’ performance. During supervisory visits, Defeat Malaria staff, either the Team Assistant or Health Facilitator, perform on-site data verification, assess monthly performance and achievements and stock outs, ensure timely and complete reports, assess performance on case detection and correct prescription of positive cases, ensure adequacy of stock supplies and treatment adherence through appropriate practice of DOT, and preventive practices. In FY18Q3, total 904 supervision visits (251 visits in Tanintharyi Region, 322 visits in Southern Rakhine State, 191 visits in Northern Rakhine State, and 140 visits in Kayin State) and averagely 0.54 visit/volunteer were conducted by township project staff by using standardized supervisory checklists (Annex 4) and this was averagely. Till now, supervision visits could not be conducted in Buthidaung and Maungdaw townships in Northern Rakhine State due to security. 1.8 Reporting status: improve data management capacity In addition to supervisory visits, VMW/PP activities are monitored during monthly meetings. If a VMW/PP missed two consecutive meetings, the field team visited their village to discuss the reasons for missing and encourage them to perform assigned activities. Replacements will be considered if the VMW/PP is no longer willing to participate. In FY18Q3, 53 replacements were made. Performance of VMWs/PPs is closely monitored through blood examination rates, clinical

14 audits, DOT completeness, data completeness and accuracy, and prevention activities performed. In Northern Rakhine State, 98.4% of VMWs/PPs reported (1,501 out of 1,525 reports) and 100% of them were on time, despite conflicts in the region. Overall, 98.7% reported and 99.5% were on time Annex 5. 1.9 Clinical audit on treatment of positive cases according to National Malaria Treatment Guidelines (NTGs) Quality of health service provision by VMWs/PPs was ensured through initial and refresher trainings emphasizing treatment of malaria cases in line with NTGs. Safety of patients and quality of malaria health care services were continuously monitored through clinical audits at monthly meetings and field supervision visits. In Q3, 906 out of 924 positive cases (98.1%) were treated according to NTGs (Annex 6). VMWs are instructed to use job aids for malaria treatment and receive strong messaging on following NTGs. 1.10 Monitoring stock out of RDTs and first line antimalarials (ACT) To ensure continuous quality of malaria services for communities, Defeat Malaria regularly checks stock outs of commodities, including RDTs and first line antimalarials (ACTs), at service delivery points. To prevent stock outs, regular replenishment of RDTs and ACTs is provided during monthly meetings and monitoring visits. From April to June 2018, VMWs/PPs received monitoring 5,576 times (5,168 times for VMWs and 408 times for PPs) during either monthly meetings or monitoring visits. RDTs were delayed in arriving at the central warehouse due to the approval long process for the import permit and customs clearance from Myanmar Customs and prolonged lead time by Chemonics/PSM. To strengthen on-time delivery of commodities, Defeat Malaria is performing CPIR in advance and buffer stocks and is requesting quarterly updates from Chemonics. Due to this, 13 VMWs in April and 33 VMWs in May from Tanintharyi Township faced RDT stock outs but these were replenished at monthly meetings. However, in Q3 99.1% of VMWs/PPs reported no RDT stock outs and 99.9% of VMWs/PPs reported no ACT stock outs. (See in Annex 7) 1.11 Strengthen Behavior Change Communication (BCC) The Defeat Malaria BCC team, led by the Senior Technical Director, produced biweekly reports on: a. A field trip of PMI’s Malaria Operation Plan (MOP) Team to Defeat Malaria project townships b. PMI Thematic Workshop c. Bed net distribution to pregnant women in high transmission areas d. Defeat Malaria tests innovative diagnostic tools in FY18Q3

Additionally, four factsheets summarizing activities implemented and results obtained by Defeat Malaria in the 3 focus states/regions and overall were developed and produced. Defeat Malaria utilized several communication channels to achieve strong coverage of most vulnerable communities, including IPC (a key approach for malaria BCC among key affected communities), updating project and activity status on the project’s Facebook page, and distribution of printed materials (e.g., posters and information leaflets). IPC VMWs and PPs conduct IPC activities during case finding and management activities to disseminate malaria preventive messages and promote LLIN use and care to at-risk populations. From April to June 2018, 44,463 people (in which 50.9% were female), including 5,493 migrants, were reached by IPC in villages and worksites (including 3,694 people (in which 49.2% were female) by PPs). Annex 9 shows the total number of people, disaggregated by sex, reached through IPC with malaria preventive messages. Additionally, group health talks were conducted to share malaria preventive messages and increase utilization of LLINs while mobile teams performed case finding and management activities and before LLIN distribution. In Q3, 643 group health talks were held in Defeat Malaria villages and work sites, reaching 13,137 people (in which 56.6% were female), 1,568 of whom were migrants (Figure 2). Health education sessions were also organized at worksites to share malaria prevention information with MMPs. From April to June 2018, 106 health education sessions were conducted at 54 worksites and 1,417 migrants (837 males and 580 females) received malaria preventive messages.

Myawaddy 794 975 363 537 Hpa-an 799 1500 284 418 Sittwe 367 485 746 848 Ponnagyun 377 387 426 493 Myebon 550 608 332 319 Minbya 167119 1279 1272 Buthidaung 4033 1597 811 747 Thandwe 1550 1811 541 619 Kyaukpyu 518 621 952 1038 Ann 1013 866 598 954 Thayetchaung 577 918 438 415 Palaw 510 688 498 1117 Launglon 200 372 770 994 Kawthoung 1163 910 443 380 Bokpyin 727 629 0 1000 2000 3000 4000 5000 6000 Male Female

Figure 2: Number of people disaggregated by gender, reached through IPC by VMWs/PPs (From April to June 2018) Distribution of printed materials Defeat Malaria distributed 39,218 pamphlets and other information, education and communication (IEC) materials to share core malaria preventive messages to targeted populations during LLIN distribution and ACD during Q3. Facebook page To strengthen online communication and disseminate project achievements, reach local people and groups, and advocate for donor and stakeholder interest and investment in malaria elimination, the content of the Facebook page: http://www.facebook.com/defeatmalariamyanmar is updated weekly by the BCC team with malaria Figure 3: Message about malaria elimination on prevention methods and photos, including Defeat Defeat Malaria Facebook Page Malaria’s slogan.

1.12 Optimize coverage and promote use of proven vector control interventions Mass Distribution/top up distribution of LLINs in villages From April to June 2018, 84,556 LLINs were distributed in 242 villages in seven townships of Tanintharyi Region, three townships in Southern Rakhine State and four townships in Kayin State and 1,812 LLINs were topped up in 19 villages in five townships of Tanintharyi Region based on the standard “2 persons per 1 LLIN”, thus providing protection for 161,743 people from 38,222 households. LLIN distribution was mainly guided by timelines (those due for LLIN distribution) but also in areas with an unusual increase in cases and LLIN monitoring. Both household and population coverage was 100%. Average population per LLIN is 1.87. Table 5 shows mass LLIN distribution and topping up at the village level by state/region. Table 5: State/Region wise LLIN mass distribution at village-level (from April to June 2018)

Mass distribution Top up Southern Southern Taninthar Kayin Total Rakhine Rakhine Kayin State yi Region State State State # of Villages 25 195 22 17 2 261 # of Households 3,852 31,886 1,514 833 137 38,222 (HHs) present # of HHs covered 3,852 31,886 1,514 833 137 38,222 # of Population 18,584 131,600 8,748 2,071 740 161,743 present # of Population 18,584 131,600 8,748 2,071 740 161,743 covered Total LLINs 10,299 69,614 4,643 1,442 370 86,368 Distributed % of HHs covered 100% 100% 100% 100% 100% 100% % of Population 100% 100% 100% 100% 100% 100% covered Net Ownership (Pop 1.80 1.89 1.88 1.44 2.00 1.87 per LLIN)

LLIN distribution/top up distribution to migrants and mobile populations in collaboration with employers Defeat Malaria seeks to prevent migrants from getting malaria through a focus on worksites by distributing and topping up LLINs. 17 worksites were covered during this reporting period and 1,212 LLINs were distributed and topped up to 2,158 MMPs (Table 6). All worksite households and populations were 100% covered with an average population per LLIN of 1.78.

Table 6: LLIN distribution at worksites (from April to June 2018) Mass distribution Top up Indicator Grand Total Tanintharyi Region Tanintharyi Region

# of Worksites 11 6 17 # of Households (HHs) present 447 154 601 # of HHs covered 447 154 601 # of Population present 1,761 397 2,158 # of Population covered 1,761 397 2,158 Total LLINs Distributed 1,005 207 1,212 % of HHs covered 100% 100% 100% % of Population covered 100% 100% 100% Net Ownership (Pop per LLIN) 1.75 1.92 1.78

LLIN distribution to pregnant women during antenatal care (ANC) visits in high transmission areas To promote and increase utilization of LLINs among pregnant women, LLIN distribution through ANC services to pregnant women in high transmission areas were conducted in 3 Rural Health Centers (RHC) in Ann Township, 2 RHCs in Toungup Township, at 1 RHC in Gwa and 1 RHC in Thandwe. From April to June 2018, 489 LLINs were distributed to pregnant women at their first ANC visit in 39 sub-centres at 7 RHCs in four townships. Monitoring LLIN coverage and utilization From April to June 2018, LLIN monitoring was conducted in 28 Defeat Malaria villages where LLIN distribution was done in 2015 during the USAID | PMI Control and Prevention of Malaria (CAP-Malaria) project. According to the LLIN Monitoring Standard Operation Procedure (SOP), based on Lot Quality Assurance System, eligible respondents from 21 households in each village were interviewed. Findings are in Table 7.

Table 7: Monitoring of LLIN coverage and utilization (from April to June 2018)

LLIN ownership LLIN utilization Total no. No. of No. of No. of villages No. of villages # Townships of villages villages at villages at not at not at assessed acceptable acceptable acceptable level acceptable level level level 1 Bokpyin 5 0 5 0 5 2 Palaw 1 0 1 1 0 3 Tanintharyi 3 3 0 3 0 4 Yebyu 1 1 0 0 1 5 Thandwe 6 6 0 6 0 6 Myawaddy 12 10 2 11 1 Grand Total 28 20 8 21 7

Villages at an unacceptable level of coverage will be included in LLIN top-up distribution in FY18 Q4. BCC campaigns (individual and group health talks) with a focus on the importance and use of LLINs will follow to increase utilization among the community. 1.13 Implementation and assessment of acceptability and utilization of forest goers’ package (Activity: 1.2.7) Defeat Malaria is prioritized for hard-to-reach and marginalized populations, and forest goers are at risk due to their geographic location, nature of work, economic opportunity, poor income, displacement given long-standing armed conflict, and hunting in the forest. An assessment was conducted on the acceptability and utilization of the forest goers’ package by the central M&E team and respective field staff in 9 targeted villages in Tanintharyi Region and Kayin State in May and June 2018. Survey methodology training was provided to 19 Defeat Malaria staff (6 staff in Dawei, 5 staff in Palaw, 4 staff in Kyunsu, 4 staff and 2 VMWs in Myawaddy). The forest goers’ package assessment collected information from 377

Figure 4: Focus Group Discussion with Karen forest goers at Arr Mo participants in Karen ethnic areas in village close to Thailand border, Dawei Township Dawei, Palaw and Kyunsu Townships in Tanintharyi Region, and Myawaddy Township of Kayin State with persistent malaria transmission. The villages of Dawei and Myawaddy are close to the Thai border and some forest goers access cross-border clinics for health care. Six focus group discussions (FGDs) were conducted with 8-10 participants for each session to explore typologies of forest goers and their characteristics, lifestyle, working nature, seasonality of work, knowledge, attitude and preventive behaviour towards malaria, accessibility to malaria services, and acceptability and utilization pattern of forest goers’ kit items. Currently, data is being cleaned and verified post-entry into the electronic database. Data was transcribed and translated. Further data analysis, quantitate-qualitative triangulation and report development will be in FY18Q4.

1.14 Operational research to pilot new tools and approaches to reduce malaria transmission (Activity: 1.5.1) Progress of Evaluation of the performance of hsRDT versus cRDT compared with Polymerase Chain Reaction (PCR) in Rakhine State Starting in October 2017, Defeat Malria is implementing an innovative study on “Evaluation of the performance of an hsRDT versus cRDT compared with PCR as the gold standard, in reactive case detection of malaria infections in Rakhine State”. At the end of June 2018, the survey team met the adequate blood sample size by collecting 1,991 samples from contacts (neighbours from the nearest 10 households or co-workers) of 51 P. falciparum cases passively identified by VMWs or BHS in 50 targeted villages under Sakhanmaw areas in Ann Township, Rakhine State.

Innovative Operational Knowledge Evidence-based Strategic Action Research Integration decision

All the blood samples were transferred to the Department of Medical Research at the end of June 2018, and the confirmatory PCR results will be available August 2018. Data analysis, interpretation and report preparation will be undertaken by Duke Global Health Institute expected to be available in October 2018. The results will be presented at the Malaria Technical Strategic Group meeting and recommendations will be applied for malaria elimination. Findings will be submitted at the American Society for Tropical Medicine and Hygiene Meeting for international dissemination. 1.15 RDT QA/QC Defeat Malaria tested samples of RDT lots from peripheral and local storage for quality assurance/quality control (QA/QC). Results were used to improve procurement, storage and the supply system to reduce poor quality RDTs. RDT and artemisinin-based combination therapy (ACT) quality were tested at the Department of Medical Research (DMR). Eight boxes of malaria RDTs (SD Bioline Antigen Pf/Pv) from villages in Rakhine State (2 from Kyauktaw and 2 from Rathedaung), Kayin State (1 from Myawaddy) and Tanintharyi Region (2 from Kyunsu and 1 from Tanintharyi) were sent to DMR in January 2018 for quality assessment from 21 February to 12 March 2018. Results showed one box from Myawaddy Township, Kayin State (05DDC004A), one box from Tanintharyi Township, Tanintharyi Region (05DDB004A), and one box from Kyauktaw Township, Rakhine State (05DDC010A) were not recommended for use although control lines in the devises were working.

2. Use of strategic information to adapt to changing epidemiology 2.1 Assessment of different malaria risk groups Defeat Malaria routine case finding and management data (not from the three elimination townships) were analyzed to assess risk groups. According to findings, the male population is more vulnerable to malaria infection than the female population (TPR 2.36% vs 1.33%). Also, the migrant population had a much higher TPR than the resident population (5.07% vs 1.46%). Residents and women tend to stay behind in the village, while migrants and men live and work in forested areas. Another vulnerable group is children under 5 (<5 years TPR 2.67% vs ≥ 5 years TPR 1.77%) but risk levels between pregnant and non-pregnant women were similar as shown in Table 8.

Table 8: Risks among different groups

Risk Group Test Positivity Rate (%) from April 2018 to June 2018 Male 2.36% Female 1.33% <5 years 2.67% ≥5 years 1.77% Pregnant 0.82% Non-pregnant 1.06% Migrant 5.07% Resident 1.46%

3. Progress of malaria elimination activities in three pilot townships in Southern Rakhine State With the permission of the core TSG members, Defeat Malaria, exclusively URC, is allowed to implement malaria elimination approaches in Toungup, Ramree, and Munaung townships in Rakhine State. URC is the first implementation partner, with the NMCP, allowed to implement malaria elimination activities in Myanmar. 3.1 Strengthening the enabling environment

During the first three months of implementation, Defeat Malaria emphasized preparation of the health system requirements for an enabling environment in line with the WHO’s Global Technical Strategy (GTS) for Malaria Elimination. A series of advocacy meetings was conducted in the first three months as described in Table 9. Defeat Malaria organized Township Malaria Elimination Coordination Committees (MECCs) during advocacy meetings in the three elimination townships with quarterly MECC meetings at the township level. Two quarterly MECC meetings were conducted in Toungup Township in Jan – June 2018. At the meetings, discussions included engagement of informal PPs and general practitioners. Table 9 includes the date and number of participants of advocacy and MECC meetings.

Table 9: Conducting Malaria Elimination Advocacy Meeting and Quarterly MECC Meeting

Township Date Meeting Male Female Total Toungup 1 Feb 2018 Advocacy Meeting and Formation of MECC 46 17 63 Toungup 15 Feb 2018 Advocacy Meeting with village chief 89 14 103 Ramree 24 Mar 2018 Advocacy Meeting 31 13 44 Munaung 29 Mar 2018 Advocacy Meeting and Formation of MECC 43 15 58 Ramree 4 Apr 2018 Formation of MECC 24 6 30 Toungup 27 Mar 2018 Quarterly MECC Meeting 14 3 17 Toungup 22 May 2018 Quarterly MECC Meeting 19 2 21

3.2 Capacity building Malaria elimination is a new concept for health staff. Therefore, Defeat Malaria developed a training approach based on provider category (Category A: Medical Officer, Township Health Assistant, Health Assistant 1, Township Health Nurse, Health Assistant, Lady Health Visitor, and Public Health Supervisor Grade 1; Category B: Midwife and Public Health Supervisor Grade 2 and Category C: volunteers) in its Malaria Elimination Plan of Action 2018. From Jan – Jun 2018, Defeat Malaria, in collaboration with the NMCP, conducted rounds of training for health staff and volunteers with financial support from PMI/USAID and Global Fund. The trainings are delineated in Table 10.

Table 10: Capacity Building Training for Malaria Elimination in Three Pilot Townships

Conducted by No. of Category of Township Date Topic whom (NMCP/ Remarks participants participants Defeat Malaria)

Malaria Financial support by 24 Mar Township/ Station Elimination Global Fund and Ramree 35 NMCP 2018 Hospital Staffs Orientation technical support by Training Defeat Malaria Malaria Financial support by 27 Mar Township/ Station Elimination Global Fund and Toungup 54 NMCP 2018 Hospital Staffs Orientation technical support by Training Defeat Malaria Malaria Financial support by 28 Mar Township/ Station Elimination Global Fund and Munaung 17 NMCP 2018 Hospital Staffs Orientation technical support by Training Defeat Malaria Training in Kyauk Ni Maw. Training was conducted separately 12 – 16 because these Ramree 7 Volunteers ICMV Training NMCP May 2018 volunteers are Muslim. Financial support and technical support by Defeat Malaria Diagnosis, Financial and technical 8 – 11 Ramree 38* Volunteers Case Defeat Malaria support by Defeat May 2018 Management, Malaria (*F Indicator)

Conducted by No. of Category of Township Date Topic whom (NMCP/ Remarks participants participants Defeat Malaria)

IPC, and Reporting

Diagnosis, Case Financial and technical 8 – 11 Toungup 31* Volunteers Management, Defeat Malaria support by Defeat May 2018 IPC, and Malaria (*F Indicator) Reporting Diagnosis, Case Financial and technical 8 – 11 Toungup 16* Private Providers Management, Defeat Malaria support by Defeat May 2018 IPC, and Malaria (*F Indicator) Reporting Financial support by Transmission 23 – 24 Basic Health Staffs Global Fund and Ramree 61 reduction and NMCP June 2018 (BHS) technical support by elimination Defeat Malaria Financial support by Transmission 25 – 26 Basic Health Staffs Global Fund and Ramree 58 reduction and NMCP June 2018 (BHS) technical support by elimination Defeat Malaria Case investigation Financial and technical 30 June Basic Health Staffs form and Toungup 107 Defeat Malaria support by Defeat 2018 (BHS) malaria case Malaria classification calculator 3.3 Initiation of core intervention on elimination specific surveillance As one of the pillars of GTS for Malaria Elimination, transformation of surveillance into a core intervention has a substantial role to play in progressing toward malaria elimination. Timely and regular reporting, adequacy of blood testing, all-inclusiveness of reporting from public and private sectors, defense medical services, VMWs, etc., and all possible approaches (PCD, ACD, RACD, and PACD) for case detection, notification, investigation, classification, and responses are vital components of surveillance in malaria elimination. Following a continuum approach, Defeat Malaria introduced case notification, investigation, and response to routine case detection as the initial steps of elimination specific surveillance in April 2018. 3.4 Reporting status All suspected malaria cases must be tested by surveillance agents in all reporting units to prove one of the elimination requirements, “Interruption of local human malaria parasite by Anopheles mosquitoes”. Table 10 describes the reporting status of all reporting units (all villages and worksites) in the three townships. Based on the Implementation Partners’ Mapping Report, Defeat Malaria updated the villages and worksites included in the Government Administrative Department (GAD in the list of) and those not included in the GAD list. These updated villages and worksites are identified as reporting units for universal coverage of malaria

elimination activities. In Ramree Township, three new villages were updated for a total of 227 reporting units in June 2018. Table 11: Reporting status of all reporting units (villages/worksites) in Toungup, Munaung, and Ramree Townships, Jan – June 2018

Toungup Ramree Munaung

* *

€ € €

µ µ µ

Month

/ Worksites) Worksites) /

“Reported” “Reported” “Reported” “Reported”

“Not Reported" “Not

“Not Reported” Reported” “Not Reported” “Not

– – –

worksites) worksites) worksites) worksites)

–

– –

Units Units Units Units

Units Units

Units Units Units

Total Number Total Reporting of Number Total Reporting of Number Total Reporting of Number Total Reporting of Number Total Reporting of Number Total Reporting of Number Total Reporting of Number Total Reporting of Number Total Reporting of

Units (Villages/ Worksites) (Villages/ Units

Units (Villages Units Worksites) (Villages/ Units

(including Zero tested villages/ villages/ (includingZero tested villages/ (includingZero tested villages/ (includingZero tested

Jan 241 161 80 224 159 65 139 67 72

Feb 241 170 71 224 147 77 139 77 62

March 241 163 78 224 159 65 139 78 61 Average (Jan – Mar 241 165 76 224 155 69 139 74 65 2018) April 241 205 36 224 198 26 139 122 17

May 241 207 34 224 180 44 139 134 5

June 241 213 28 227 209 18 139 137 2 Average (April – 241 208 33 225 196 29 139 131 8 Jun 2018) * Total number of reporting units – all updated villages and worksites (GAD and non-GAD lists) € Total number of reporting units that submitted all reporting (and have blood testing) µ Total number of reporting units not reported. Villages reporting “zero tested cases” are counted as not reporting as all suspected cases must be tested in elimination settings.

Case detection reports from all surveillance agents in elimination areas are distributed to reporting units after data entry at the end of the month. Table 11 represents total township data, NMCP and Defeat Malaria, in the three elimination townships. From January-June 2018, availability of reports and blood testing in all reporting units is gradually increasing. If reporting units have not submitted a report or blood testing data each month, the field implementation team encourages all surveillance agents to conduct blood tests in all reporting units. Information on villages with no blood testing or surveillance reports was given to the Assistant Director of VBDC (Rakhine State) and Township Medical Officer to provide appropriate instructions to all surveillance agents every month. As mentioned earlier, the average number

25 of reporting units reporting or providing blood test data is improving. There is still room for improvement for blood testing and timely reporting especially in Toungup and Ramree Townships. 3.5 Monthly surveillance activities

Table 12, 13, and 14 summarize case detection, notification, investigation, and classification in the three elimination townships. The baseline situational analysis showed all three elimination townships have inadequate ABER at the village level. NMCP and Defeat Malaria emphasized a target of 10% ABER at the village level to adequately assess the malaria situation in 2018. In April 2018, the NMCP and Defeat Malaria started elimination surveillance and identified surveillance agents for case detection. The number of blood testing is increasing with more cases found in April – Jun 2018. This likely coincides with the malaria transmission season. All positive cases need to be notified to the Malaria Inspector/Supervisor (NMCP) and Elimination Coordinator/Team Leader/Medical Officer (Defeat Malaria) at the township level who is responsible for case investigation and response. To manage the caseload, not all positive cases are investigated in the elimination areas. The positive cases in villages/worksites with an API > 20 per 1,000 population based on 2017 micro- stratification data are excluded from case investigation because it is not manageable at this stage. In Toungup Township, case investigations for all positive cases from January to March 2018 were done in April 2018 with data entry in May 2018. There were 14 notified cases out of 19 total cases in Toungup Township in April 2018. Among the 14 notified cases, only 10 cases were eligible for investigation and 9 out of 10 were investigated. In May and June 2018, 70 notified cases were investigated and classified which indicates substantial progress for surveillance activities. The high number of locally contracted malaria cases, especially indigenous cases, compared to other cases found in Toungup Township is a challenge which needs to be addressed for malaria elimination. In Munaung and Ramree Townships, the number of positive cases detected is very low even though the rate of blood testing has been noticeably increasing since April 2018. This allowed all positive cases to be notified, investigated, and classified in Ramree and Munaung Townships. In May 2018, there was a mixed case found in Munaung Township. Munaung was previously assumed to be a no malaria transmission area although there was inadequate ABER. The Munaung Township team intensively investigated and classified the case as a cryptic case (isolated indigenous case) since the patient had no travel history in the past two weeks and no history of malaria in the last three years. There were no other positive cases prior to this patient, and they had no history of blood transfusions. The response team tested family members, neighboring households, and co-workers immediately at the time of case investigation and again at the time of possible onward transmission from the patient (index case) but no additional positive cases were detected.

Table 12: Surveillance report – Case detection, notification, investigation, and classification in Toungup

Township (Jan – Jun 2018)

case

Month

cases

Cases

Mixed

Tested

Positive

Relapse case Relapse

Inducedcase

Importedcase

Indigenous caseIndigenous

Introducedcase

Indigenous case)Indigenous

to be investigated be to

Number of notified Numbernotified of

Recrudescence Recrudescence

Cryptic case (Isolated Crypticcase (Isolated

Number of investigated Numberof investigated Number of eligible cases Number of eligible

Jan 872 60 51 7 2 - - 5 5 ------

Feb 991 42 35 6 1 1 - 5 3 - 2 - - - -

March 867 3 3 ------

April 2,100 19 14 5 - 14 10 9 5 - 3 1 - - -

May 1,676 26 21 4 1 22 26 22 8 - 13 1 - - -

Jun 2,402 49 44 5 - 48 49 48 12 - 36 - - - -

Total 8,908 199 168 27 4 85 85 89 33 - 54 2 - - -

Table 13: Surveillance report – Case detection, notification, investigation, and classification in Ramree

Township (Jan – Jun 2018)

Month

cases

Cases

Mixed

Tested

Positive

Relapse case Relapse

Inducedcase

Importedcase

Indigenous caseIndigenous

Introducedcase

Indigenous case)Indigenous

Number of eligible Numberof eligible

Number of notified Numbernotified of

Recrudescence case Recrudescence

Cryptic case (Isolated Crypticcase (Isolated

casesto investigated be Numberof investigated

Jan 852 2 - 2 - 2 2 2 1 - 1 - - - -

Feb 783 ------

March 883 ------

April 1,306 2 - 2 - 2 2 2 1 - - 1 - - -

May 1,027 ------

Jun 1,270 ------

Total 6,121 4 - 4 - 4 4 4 2 - 1 1 - - -

Table 14: Surveillance report – Case detection, notification, investigation, and classification in Munaung

Township (Jan – Jun 2018)

Month

Cases

Mixed

of notified cases notified of

Tested

Positive

Relapse case Relapse

Inducedcase

Importedcase

be investigated be

Indigenous caseIndigenous

Introducedcase

Indigenous case)Indigenous

Recrudescence case Recrudescence

Cryptic case (Isolated Crypticcase (Isolated

Number of investigated Numberof investigated

Number Number of eligible cases Numberto of eligible

Jan 160 ------

Feb 204 ------

March 166 ------

April 733 ------

May 950 1 - - 1 - 1 1 ------1

Jun 877 ------

Total 3,090 - - - 1 - 1 1 ------1

3.6 Provider-based surveillance In malaria elimination, ensuring regular and adequate testing and case detection by all health care providers from the public sector including Defense Medical Services, private sector (both formal and informal), and VMWs are essential components of an effective surveillance system to show documentation for interruption of local human transmission by Anopheles mosquitoes. In April 2018, the NMCP and Defeat Malaria started encouraging all health care providers from different sectors to perform blood testing to meet an ABER of 10% as a baseline for 2018. The engagement of different sectors, especially hospital and the formal private sector such as general practitioners, progressed in FY18Q3 after advocacy meetings and formation of township MECCs. Case detection in these sectors is improving and some providers detected positive cases. Defeat Malaria trained informal PPs as volunteers and received regular monthly case detection reports from them. However, case detection reports are still lacking from Defense Medical Services (DMS). A medical officer from DMS submitted case detection reports from his private clinic as a general practitioner. The NMCP and Defeat Malaria addressed timely reporting from DMS in June 2018 and upcoming reports are expected from DMS.

Table 15: Provider based surveillance report (Jan – June 2018) Toungup Ramree Munaung Jan – March April – Jun Jan – March April – Jun Jan – March April – Jun Type of 2018 2018 2018 2018 2018 2018 Provider Test Posi Teste Positi Test Positi Posi Test Positi Posi Tested Tested ed tive d ve ed ve tive ed ve tive

Basic Health Staff 1,066 62 2,054 33 237 1 1,165 0 481 0 2,500 0

Hospital 34 1 109 7 23 0 80 0 49 0 37 1 General 0 0 169 3 0 0 12 0 0 0 0 0 Practitioner Private Provider 118 3 446 3 158 0 114 0 0 0 0 0 (Informal) Village Malaria 1,480 39 1,649 34 2,100 1 2,030 2 0 0 0 0 Worker Defense Medical 0 0 0 0 0 0 0 0 0 0 0 0 Services Mobile (Response 31 0 1,752 14 0 0 202 0 0 0 23 0 Team) Total 2,729 105 6,179 94 2518 2 3,603 2 530 0 2,560 1

3.7 Universal coverage for malaria prevention In April – June 2018, Defeat Malaria distributed LLINs for universal coverage for malaria prevention given the receptivity of the area. With LLINs supported by NMCP and logistics by Defeat Malaria, 5,809 LLINs were distributed in Toungup Township. In Ramree Township, Defeat Malaria distributed 31,603 LLINs to 136 villages covering a population of 58,977 fully supporting LLIN and logistics costs. LLIN distribution in elimination townships is detailed in Table 15. Table 16: LLIN distribution in Elimination Townships from April to June 2018 # of # of # of # of # of Total LLIN Township HHs HHs population population Remarks villages distributed present covered present covered Defeat Malaria supported both Ramree 136 14,315 14,315 58,977 58,977 31,603 LLIN and logistics costs (*F indicator) NMCP supported LLINs and Def. Toungup 49 2,765 2,765 11,327 11,327 5,809 Mal. logistics costs for distribution 3.8 Monitoring and Supervision by Defeat Malaria’s Central Team and PMI/USAID’s Senior Malaria Advisor As Defeat Malaria’s pilot elimination activities are in the beginning stages, central level monitoring and supervision is mandatory and will be conducted regularly. The Regional Technical Director and Technical and Program Management Coordinator from Figure 5: PMI/ USAID Senior Malaria Advisor’s visit to Defeat Malaria Elimination Office, Toungup Township

Defeat Malaria’s central team conducted rounds of supervision and monitoring visits to elimination implementation areas. From Jan-Jun 2018, the Defeat Malaria central team conducted five supervision and monitoring visits to pilot elimination areas. The team visited elimination areas every month except April 2018 because of government holidays. During the visits, operational and technical issues were found and appropriate instructions and recommendations were provided to field implementation teams for follow up. In May 2018, the Senior Malaria Advisor from PMI/USAID visited Toungup Township and joined the quarterly MECC meeting. The Senior Malaria Advisor joined the supervision visit to Let Pan village where a formative assessment on persistent malaria transmission was conducted. To share information on the updated Defeat Malaria Elimination Plan, the Technical and Program Management Coordinator presented on progress of activities at the URC-ADB dissemination workshop at Ngapali, Thandwe Township on 26 May 2018. 3.9 Study tour to Sampov Loun District, Battambang Province in Cambodia To assist further development of malaria elimination work plans, the Technical and Program Management Coordinator, Field Directors from Tanintharyi and Southern Rakhine and M&E Director went to Cambodia to learn from the Cambodia Malaria Elimination Program (CMEP). The team visited Sampov Loun District, Battambang Province, Cambodia from 7-11 May 2018. During the visit, the Defeat Malaria Team (Myanmar) met with URC’s Regional Director, CMEP’s Chief of Party, Program Director and M&E Team and malaria focal persons from the Cambodia National Malaria Program (CNM) of Bour Health Center and Operational District Health Center in Sampov Loun. CMEP’s Program Director explained the project and presented activity progress. CNM staff from the Bour Health Center and the Technical Chief from the OD Health Center presented activities and progress of the program. CNM staff, CMEP staff and the Defeat Malaria Team (Myanmar) discussed the activities, tools used, and documents developed to support certification of malaria elimination. The Defeat Malaria Team (Myanmar) suggested how to complete the gaps and recommended: 1) Annual Blood Examination Rate (ABER) 2) Documentation on full information of active foci 3) Case investigation and 4) Documentation on “existence of a central repository of information on entomological surveillance” For more details about the trip and technical feedback, please refer to Annex 10. 4. Improving Myanmar’s capacity to collect and use information 4.1 Workshop on surveillance and malaria database management (18 May 2018) The M&E Director and M&E Coordinator attended a workshop on surveillance and malaria database management organized by the NMCP on 18 May 2018. They presented the Data Management and Surveillance System (collection, validation, verification, entering, aggregation,

30 analysis, interpretation, dissemination and follow up actions on results), Defeat Malaria’s M&E System and lessons learned from past years to the NMCP and implementing groups. 4.2 Training for accelerating malaria case reporting across implementation partners Defeat Malaria’s M&E Coordinator, mHealth and Research Officer, and M&E Assistant attended the training for “Accelerating malaria case reporting across implementation partners” provided by the NMCP with the support of UNOPS and WHO from 4-6 June 2018 in Nay Pyi Taw. The malaria information system is a part of the NMCP’s strengthening of surveillance and Figure 6: National Technical Officer-WHO, facilitated data monitoring and evaluation systems to meet summarization and analysis by the appropriate utilization malaria elimination. The core malaria indicators of data elements, indicators, and reporting generated by DHIS2 are generated at township level and aggregated in DHIS2. The NMCP needs to integrate the national Health Management Information System (HMIS) and ATM DHIS2 system, which is a data warehouse. The training created a shared understanding of the data processing, management and reporting system of the NMCP, an enhanced data management and reporting system in line with the NMCP system, strengthened communication and coordination between the NMCP and malaria partners and accelerated malaria data reporting across all implementation partners to gain a full understanding of malaria epidemiology across the country. 4.3 Malaria data management and encoding training at Myeik, Tanintharyi Region Defeat Malaria is supporting the NMCP to strengthen their data management and surveillance systems and improve of data utilization. Defeat Malaria provided laptops and internet package charges to all townships and the regional level in Tanintharyi to facilitate data management in 2017. The Malaria Team Leader discussed the need for refresher trainings for previously trained data encoders. Defeat Malaria supported a “Training for malaria data management and encoding” as a refresher course conducted from 9-13 May 2018 in Myeik Town. Twenty-eight participants attended including 24 malaria focal staff (data encoders) from the NMCP and 4 Data Assistants from URC. It was facilitated by four central NMCP trainers. The central NMCP trainer expressed great appreciation to Defeat Malaria for the financial support to conduct this training, and Defeat Malaria’s Field Director to support computer maintenance in Launglon and monthly internet charges. 4.4 Management of Data Quality Provision of Routine Data Quality Assessments (Activity 2.1.5) An RDQA tool was updated to include a data utilization component (now inclusive of 6 components). After pilot testing in Q2, the new RDQA tool was applied in Q3.

Strengthening data quality at the village level was conducted by township staff at monthly meetings and supervision visits. Promoting data quality at the township level was continuously supervised by Data Quality Officers (DQOs)/partner focal staff through quarterly routine data quality assessment visits to all townships. Overall data quality assurance was monitored by the central M & E Team under the guidance of the M & E Technical Advisor. Monthly telecommunication between the Central M & E team and State/Region DQO/partner focal staff were actively verified and data quality issues and challenges encountered at RDQA and on-site data verification (OSDV) visits were discussed. Building the capacity of partners in conducting RDQAs and OSDV through an M & E Technique Figure 7: DQO cross-checked stock data for Routine Data training and joint assessments between focal staff Quality Assessment at Dawei Office and the Central M & E team increased RDQA coverage (Figure 8). In Q3, RDQAs were done in 25 out of 31 townships. Six townships could not receive RDQAs due to DQOs and Township Team Leader gaps. All these positions were recruited and paused activities in Maungdaw due to conflict recently restarted. In Q3, M&E capabilities were strengthened by encouraging DQOs/Team Leaders to deliver a 3- day M & E orientation package for newly recruited staff, promotion of utilizing standard data collection tools, strengthened data management processes by following back-up procedures, post-data entry verification procedures, and keeping written document for data verification. The central M & E team will provide a data utilization technique workshop in FY2019.

Figure 8: Quarterly RDQA and OSDV coverage, Oct 2017-Jun 2018

100% 86% 90% 80% 77% 76%

80% 70% 60% 50% 40% 40% 30% 20%

20% Covered Townships) 10%

0% Coverage Coverage (Assessed Townships/ % Oct-Dec'2017 Jan-Mar'2018 Apr-Jun'2018

RDQA Coverage OSDV Coverage

4.5 Assessment of residual transmission areas in the focus of Sa Htone Village of Toungup Township and appropriate response based on findings In Q3, an assessment of persistent malaria transmission was conducted in Sa Htone Village, Toungup Township, Southern Rakhine State as positive cases were increasing (API increased from 20.3/1,000 population (FY2016) to 41.5/1,000 population (FY2017)) despite good coverage of vector control measures and malaria case treatment services since CAP-Malaria. Sa Htone village is located under Letpan Sub-center, Ma Ei RHC in Toungup Township with 603 residents living in 180 households with an 30 to 45 minutes’ drive by motorbike from Ma Ei. The village is in a foothills/forested area surrounded by Gyoke Chaung and Thit Yinn Chaung streams with Sa Htone Chaung stream running through it. No streams dried up, even during the summer, however, old shallow wells were seen which may be breeding sources for mosquitoes. Three different population groups (1) villagers, (2) seasonal agricultural workers and (3) wood cutters/timber extractors were identified, with different intensities of risk of malaria infection in areas where they are exposed. All residents are Rakhine nationality, and most are farmers with some forest related workers such as timber extraction There is a Timber extraction worksite, Thit Yinn Chaung, a two-hour walk from Sa Htone village. On the way from Sa Htone village to the Timber extraction worksite, there are about 10 seasonal farm huts with rubber, ground nut and corn plantations. At the Timber extraction work sites, groups of timber extractors (about 10 persons) stay together in a hut which does not have proper walls to protect the entrance of mosquitoes so Indoor Residual Spaying (if NMCP consider) will not work as a preventive measure and about 20% of the village population usually work there except in raining season. Malaria transmission was present in the forested foot-hills of the Thit Yinn Chaung Tiber extraction worksite. The ratio of malaria cases among farmers and wood cutters is 1:4-5 according to Key Informants Interviews. Wood cutters/timber extractors are the highest risk group with the remaining groups contributing very few positive cases. To provide qualified malaria health care services in the village, a VMW was recruited and trained in July 2013 and is well trained, well stocked and functioning well. A midwife is present at the nearby Letpan Sub-center. There is a doctor and an informal private provider who usually refers all suspected cases to the hospital.

When assessing preventive measures, 60% of total households (109) were selected by convenient sampling. The assessment found 245 LLINs were distributed over the past three years covering a population of 385. According to a household level analysis of LLIN coverage, fully protected population coverage was only 57.1% based on quality and availability of LLINs. Utilization of LLINs is low with only 16.4% of fully protected population sleeping under an LLIN the previous night. Respondents said LLINs were tough and very rigid. For malaria treatment seeking behavior, 53% of interviewees responded they went and see a VMW when suffering symptoms of malaria.

A parasitological survey was conducted during VMW the assessment with 234 patients tested and 13% two positive cases (all Pf and male) were 9% Self-medication found. Disaggregation of residents vs migrants showed the 2 positive cases were detected 53% 25% among 27 forest goers. They were contracted Quack from the Thit Yinn Chaung worksite. Entomological findings supported that the Doctor or BHS main vector, An. minimus species, is present at the worksites, where secondary vectors like An. sundaicus and An. maculatus are present

Figure 9: Proportions of malaria treatment seeking in the village. behaviors

According to the assessment, 182 people stayed outside the house from 6 PM to 9 PM mainly to visit to neighbors’ houses. Actions to be taken  Advocacy for people based specific findings rather than general health education messages.  Provision of “mosquito repellent” as a preventive measure. (Villagers prefer repellent to prevent small insect bites in the forest, primary intention is not for prevention of mosquito bites)  Record surveillance data (tested and positive, case classification) by category of risk group to get documentation on high risk transmission areas and classify cases for evidence of transmission  Promote community involvement in filling old small shallow wells which are no longer used; sustain the water flow of streams near the village.  Test all suspected malaria cases, especially those who stayed overnight in forested areas and recently returned.  Explore how to involve the medical doctor and informal private provider (Quack) practicing in the community in malaria elimination in Sa Htone village  Regularly monitor case response and malaria epidemiology and report to central level

4.6 Monitoring visit from U.S. PMI Senior Advisor and Defeat Malaria M&E Technical Advisor to Sakhanmaw Village, Ann Township The PMI Advisor and the Defeat Malaria Team visited Sakhanmaw village in Ann Township, Rakhine State on May 24, 2018. They met with malaria patients to enquire about potential risk factors and basic health staff to learn about prevailing health problems and the local epidemiology of malaria. Malaria cases were commonly found among forest goers working in the farm near the forest about a 2 to 3 hour walk from the village. Some were miners working outside of the township and returned after getting malaria. LLINs cannot provide full protection due to night time work hours. The PMI Advisor supervised the hsRDT survey activities focusing on data protection measures, proper storage of hsRDTs, consent and interview procedures, blood sample collection, storage and transfer processes to the reference laboratory. They provided motivational support to successfully accomplish field survey activities. 4.7 Gender mainstreaming Defeat Malaria systematically identifies gaps in gender equality and prioritizes gender specific concerns, Figure 10: PMI Malaria Advisor visits Sakhanmaw needs and experiences which are integral to policies, village and meets with malaria case to understand programs and projects to benefit women and men local epidemiology equally. Defeat Malaria participated in Myanmar Women’s Day 2018 promoting gender awareness discussions at the Defeat Malaria office in Yangon attended by 12 women and 12 men. Gender related indicators were reviewed (Table 17). Table 17: Gender related indicators and their current status

Gender Related Indicators Status 1. Recruitment of village malaria workers 1. More female village malaria workers are involved for Defeat Malaria activities (52%) in Defeat Malaria activities 2. Access to malaria preventive services 2. Higher access to women including special approaches by women in Defeat Malaria areas for ANC for pregnant women 3. Access to malaria diagnosis and 3. Higher access to malaria diagnosis by women and treatment services for women directly observed treatment was received equally 4. Gender based violence incidents 1. Nil since Defeat Malaria activities

5. Gender discrimination 2. Not seen

At the same time, malaria occurs more among male forest workers. Defeat Malaria staff discussed promotion measures for reaching men with malaria services through women. In Myanmar, women usually play a pivotal role in family health and share important health messages to all family members. Women are also decision makers for accessing health care if someone in the family is sick and take care of family members for treatment adherence. Prevention against violence for female staff was discussed as they are working in the field. Use of motorbikes is encouraged as well as traveling to the field with a colleague and returning to Figure 11: State/Region wise Defeat Malaria VMW by gender township no later than 5:00 pm. All forms of gender violence are to be notified immediately to URC Headquarters hotline which are provided in all Defeat Malaria offices. The Senior Management Team takes full responsibility for gender-based violence through a confidential complaint mechanism and immediate actions for psycho-social counselling and support, prevention of unwanted pregnancy, and post-exposure prophylaxis for HIV is provided.

5. Building capacity and health systems strengthening 5.1 Quality Assurance/Quality Improvement (QA/QI) review of current Defeat Malaria Activities Table 18: Summary of QAQI activities and actions to be taken (From April to June 2018)

Issue Activity Status/Actions to be taken Conceptual framework of quality QI Director presented framework 1. Senior Management Team (SMT) improvement for defeat malaria that identifies six dimensions to guide the QI activities activities 1. effectiveness; 2. Concept of quality improvement 2. efficiency; to be embedded in program 3. accessibility (both timely and implementation: central and field geographically); team 4. patient-centered approach; 5. equity of malaria services does not vary in quality; and, 6. safety to minimize risks and harm to both service providers and patients. Malaria Commodities Logistics QI Director developed and 1. In draft form and operation, Management and Monitoring presented a draft guide for a logistics and M&E teams to provide System framework for LLIN distribution inputs collectively mechanisms and delivery strategy 2. After the guide is approved for mass distribution in the training will be provided to the staff communities from different levels

BCC messages QI director informed Defeat BCC team to produce IEC Malaria Management about materials sensitive to conflict community wide awareness situations and ethnic differences activities and disseminating materials sensitive to conflict situations and ethnic differences. Defeat Malaria on URC website QI director informed the Chief of 1. BCC focal person to inform HQ Party (COP) and BCC focal person to update the website, and provide to update the website since it necessary information and activity shows activity photo from CAP photos malaria 2. COP to follow up http://www.urc- chs.com/projects/defeat-malaria- activity Considering gender mainstreaming QI Director presented central staff 1. Central office staff to share the in Defeat Malaria activities integration of gender into climate information to field team change programming along with a 2. Integrate gender issues in plan for implementation and project activities and include in monitor gender issues reports (implementation and monitoring) Defeat Malaria environmental The QI Director gave trainings to 1. Defeat Malaria activities mitigation and monitoring plan central and field teams on EMMP to potentially have negative impact on (EMMP) ensure incorporation of field visits the environment and are and consultations with recommended for Negative Implementing Partners, periodic Determination with Conditions assessment of the environmental threshold determination as defined impacts of on-going activities, by 22 CFR 216 associated mitigation measures and 2. Field team to conduct regular minimizing risks and harm to both monitoring and central team to service providers such as VMWs report environmental compliance and beneficiary communities Capacity-building support to sub- QI Director provided information 1. SMT to decide on organization grantees to Sub-grant Manager about capacity assessment (OCA) organizational assessment to 2. Design and provide inform SMT about capacity building Organizational Development plan for sub-grantees, EHOs trainings Defeat Malaria Sub-grant process QI director developed and 1. SMT meetings to decide sub- presented Defeat Malaria sub- grant selection and award process award/sub-grant management 2. Establish a robust sub-grant system appropriate for the conflict monitoring mechanism with affected non-state actors (NSA) programmatic, technical and areas compliance standpoints reflecting USAID rules and regulations before giving sub-awards to EHOs Costing of Defeat Malaria QI director provided trainings on Defeat Malaria SMT to consider prevention and control activities mathematical modeling of malaria operational research in year 3; e.g., and basic principles of cost analysis 1. cost analysis of village malaria of health projects workers (VMWs) in malaria control activities, 2. Benefits and lessons learned from LLIN mass distribution campaigns 3. Application of Mathematical models for MMPs in malaria transmission

5.2 Use of OpenDataKit (ODK) for a mobile device-based supervision tool The application of ODK was used for a supervision tool to support supervision of VMWs by supervisors. Defeat Malaria township staff usually monitor all villages where VMWs are performing malaria prevention, diagnosis and case management activities through performance indicators. Supervision continuously identifies reporting performance, meeting attendance, monthly blood Figure 12: mHealth and Research Officer examination rates, occurrence of malaria cases, clinical demonstrated ODK application during supervision at Kyauk Tan Chay village, Sittwe audits, DOT completeness, IPC activities, stock-out Township conditions, and promotes accountability and guidance to VMWs on their performance.

The mHealth and Research Officer provided a training on use of the ODK application, uploading data to Google drive, data configuration and export from the web browser to 15 Defeat Malaria staff on 30 May 2018 in Sittwe. Field tests of the application were conducted with two VMWs in two villages in Sittwe Township. The ODK application trainings will be done in Tanintharyi Region, Southern Rakhine and Kayin States next quarter after fixing identified bugs and weaknesses. The application will be rolled out in all townships in FY2019. 5.3 Quarterly review meeting Monthly progress, monitoring and surveillance data were verified and analyzed monthly at the township level and data from the townships are again verified and combined at the central level. Data are compiled analyzed, interpreted and shared at quarterly review meetings with technical and M & E staff from the central, State/Region and Township teams, and all Defeat Malaria partners. The Q3 Quarterly Review Meeting was from 25-27 April 2018 at the Chatrium Hotel. Defeat Malaria achievements, progress and challenges were reviewed by State and Region Figure 13: Project Manager of MHAA presents progress and teams and partner organizations. It was noted challenges of Buthidaung, Rathedaung and Maungdaw activities could extend into 1,696 villages from Townships 1,363 villages. Suggestions included strengthened engagement with EHOs, prioritized LLIN distribution to high transmission areas prior to rainy season, provision of LLIN top-up and promotion of utilization upon LLIN monitoring results, enforce DOT activities in 3 townships (Ann, Hlaingbwe, Palaw), closely supervise VMWs in 5 townships (Bokpyin, Kyunsu, Myebon, Hlaingbwe, Myawaddy) to be in line with National Treatment Guidelines, conduct RDQAs for

38 all townships quarterly, and support adequate buffer for conflict affected areas in Buthidaung not to face stock-outs again. To be more efficient, village-based stratification and appropriate intervention measures should be informed to all field staff. Supervision through the use of mobile phones (ODK application) and the M & E dashboard (using Tableau) for data utilization, and the malaria calculation calendar were introduced to field staff for further application. 5.4 GIS Capacity building of central and township level staff The mHealth and Research Officer continued reorientation on production of GIS maps to 13 Defeat Malaria staff in Sittwe on 28 May 2018 during the visit for ODK application training. The objectives were to promote data utilization through GIS maps, standardize the maps produced by Defeat Malaria, increase user friendliness by providing respective Township, State, Region shapefiles and reorient the GIS application. On 29 May 29 2018, all participants practiced and produced maps for Defeat Malaria project areas, village-based Figure 14: mHealth and Research Officer provided GIS reorientation training at Sittwe Township stratification maps, and quarterly malaria

case occurrence maps. 5.5 Improved surveillance through mHealth Update Defeat Malaria Dashboard A web-based Defeat Malaria Dashboard was developed by the mHealth and Research Officer together with the Central M&E Team using Tableau for better visualization and internal monitoring and is updated monthly by the mHealth and Research Officer with case detection data. 6. Strengthening capacity of the NMCP and Ethnic Health Organizations (EHOs) 6.1 TOT of ICMV approach The NMCP coordinated with the National Tuberculosis Program (NTP), National AIDS Program (NAP) and Leprosy Control Program (LCP) to provide training to VMWs on the prevention, early detection and referral of these diseases. In addition, the NMCP included prevention of dengue hemoragic fever and filariasis now calling VMWs Integrated Community Malaria Volunteers (ICMVs).

Defeat Malaria is implementing the innovative approach providing ICMV training to all VMWs (except those in pilot elimination areas) to safeguard good relationships between communities and VMWs. An “ICMV Master Mentor Training” was conducted from June 20 - 22, 2018 at Defeat Malaria’s Yangon office. Focal persons from several national programs (NMCP, NTP, NAP and LCP) provided training covering: (1) ICMV role and responsibilities; (2) Epidemiology, prevention, control, treatment guidelines and referral methods for Dengue, Filariasis, Tuberculosis, HIV and Leprosy; and, (3) Behavior Change Communication Figure 15: Defeat Malaria staff and trainers at the Master activities in field practice Mentor Training for Integrated Community Malaria Volunteers Nineteen Defeat Malaria central and field staff (URC, Jhpiego, ARC, MHAA and MNMA) attended the training with three facilitators from the central Defeat Malaria office and six facilitators from respective programs. These Master Mentors will conduct training for Defeat Malaria General Trainers in Taninthayi, Kayin, and Rakhine Field Offices. The General Trainers will then provide trainings to VMWs who will become Integrated Community Malaria Volunteers. General Trainers will complete training of ICMVs by the end of FY2018. 6.2 On-site trainings of VMWs (ADAF/LDHF approach for volunteers) In Q3, Jhpiego provided technical support to ICMV training conducted by the NMCP through a community based intervention approach at the township level. In collaboration with the NMCP, eleven “first dose” on-site trainings for ICMVs were conducted in two sessions in Toungup, Buthidoung and Minbya Townships and one session in Gwa township in Rakhine State and Kyainseikgyi, Hpa-an, Hlaingbwe and Kawkareik Townships in Kayin State facilitated by Jhpiego staff in April and June 2018. Total 493 VMWs have received a one-time update on clinical diagnosis and management of malaria, form completion, performance of different BCC topics and RDT testing using different teaching aids, including case studies and group exercises. Figure 16: Second dose of VMW training at 97 VMWs (47 VMWs from Launglone, Tanintharyi Launglon Township Region and 50 VMWs from Toungup, Rakhine State) received a “second dose” of the same topics by General Trainers facilitated by Jhpiego Staff at the township level. Jhpiego facilitated a VMW training in coordination with ARC in Kawthoung Township in Tanintharyi Region and Hlaingbwe Township in Kayin state.

6.3 Conduct post training assessment and joint supportive supervision with project staff and BHS In Q3, Jhpiego conducted joint supportive supervision visits led by District and Township VBDC teams with ICMVs from Apyinmaekanal, Pharchaung, Pwitlinayemyaing villages in Myawaddy Township and Daung shaung, Mel Aone Nauk and Inngyi villages to improve capacity of malaria staff and ICMVs on malaria case management and prevention after training. Volunteers received quick refreshers on the importance of RDT testing and health education for community health. Individual Figure 17: Malaria supervisor, District VBDC assessments/on-the-job performance through role play was team, Myawaddy coached ICMV from done and monthly Apyinmaekanal village, Myawaddy in filling of carbonless register reports were checked. Based on results , individual feedback was provided. Jhpiego worked with URC and MNMA to assess VMWs from Palaw and Gwa, respectively, who were receiving three doses of training via the Low Dose High Frequency (LDHF) approach in FY17. They assessed Figure 18: Assessing RDT testing of VMW at Gwa volunteers knowledge, attitude and skills in malaria Township epidemiology, case management and interpersonal communication via a knowledge assessment questionnaire, RDT checklist and supervision check list. 6.4 Capacity building of partner organizations Defeat Malaria worked harmoniously with all partners and the Sub-Grant Manager and Finance Manager visited MHAA office in Yangon on 14 May 2018 to strengthen collaboration. The URC team met with 8 MHAA staff including the chairman, secretary, project manager, senior finance manager, admin manager and M & E officer. MHAA is doing all they can to reach people affected by conflict in Buthidaung and Rathedaung and discussed possible revitalization of activities in Maungdaw. Twenty-one villages will be revitalized pending approval of the Rakhine State Coordination Committee. The URC team discussed Defeat Malaria financial procedures, strengthening data Figure 19: Sub-Grant Manager and Finance Manager of URC verification at the field level prior to financial visits MHAA office, Yangon for strengthening collaboration reporting, cross-checking with source

41 documents, purchase order processes, counter-checked, use of stamps and signatures of the MHAA Finance Manager in the final cash book. The Chairman and Finance Manager expressed great appreciation for the visit of lead partners.

Challenges  Temporary interruption of activities in Maungdaw and Buthidaung villages due to conflict – Defeat Malaria targeted villages in Buthiduang and Maungdaw Townships were severely affected by conflict. Starting from the early weeks of October 2016 and last weeks of August 2017, unstable security conditions occurred in Northern Rakhine State causing interruption of Defeat Malaria field activities. Activities can re-start in Buthidaung Township but not Maungdaw Township.  Difficulty in finding malaria cases – Due to aggressive and universal coverage of prevention and case management by all implementing partners, malaria incidence has reduced in most geographical areas. This led to low detection of positive malaria cases. In most of the potential expansion townships, other implementing partners are already conducting activities. Duplication of case detection services is seen because of overlap in implementation areas by more than one partner. Even if Defeat Malaria expands to new areas, there may not be more malaria positive cases as most villages with no volunteer services don’t have malaria.  Expecting rebound effect of malaria - In most existing Defeat Malaria villages, malaria prevalence is decreasing. It is important to sustain the zero-malaria positive status in some villages and further reduce malaria transmission in very low prevalence villages. If malaria transmission free status or further improvement of malaria transmission is not sustained, a rebound effect can occur especially due to changing climatic conditions. In 2018, there is heavy rains and flooding in most project areas leading to an increase in breeding places. Increasing humidity led to an increase in longevity of mosquitoes, reducing time intervals for maturation of eggs inside the mosquito (gonotrophic cycle) that may lead to epidemics in some areas.  Delay in Procuring ACTs and RDTs – Delayed procurement of malaria commodities is still a challenge. Expansion in project year 3 depends on the expected arrival of the commodities. Before arrival, field implementation can’t start in new areas without antimalarials. However, staff recruitment, capacity building in malaria prevention and control, and data management can be initiated.  Supporting EHOs - Per discussion between ARC’s Defeat Malaria Project Manager and the Karen National Union (KNU) Brigade-5, the KNU focal point of Hpa-Pun Township confirmed that they won’t accept Defeat Malaria activities in their areas. Thus, ARC stopped activities in Hpa-pun and Kyainseikgyi Townships in January 2018. Possible services or interventions will be explored like capacity building and support of commodities for future cooperation in malaria health services in project year 3.

Annexes Annex 1 – Case Finding and Management Table 19: Township wise summary of case finding and management by different case detection agents (from April to June 2018)

# Township Tested Total Positive Pf Pv Mixed TPR% 1 Bokpyin 1,114 53 2 51 0 4.76% 2 Dawei 1,081 47 3 44 0 4.35% 3 Kawthoung 2,054 21 10 10 1 1.02% 4 Kyunsu 2,557 19 5 14 0 0.74% 5 Launglon 664 0 0 0 0 0.00% 6 Myeik 1,581 2 0 2 0 0.13% 7 Palaw 1,441 111 39 71 1 7.70% 8 Tanintharyi 778 39 12 27 0 5.01% 9 Thayetchaung 1,578 56 1 55 0 3.55% 10 Yebyu 1,970 9 0 9 0 0.46% Tanintharyi Total 14,818 357 72 283 2 2.41% 11 Ann 2,233 68 61 6 1 3.05% 12 Gwa 1,203 4 3 1 0 0.33% 13 Kyuakpyu 792 0 0 0 0 0.00% 14 Munaung 2,560 1 0 0 1 0.04% 15 Ramree 3,603 2 0 2 0 0.06% 16 Thandwe 2,705 0 0 0 0 0.00% 17 Toungup 6,178 94 79 14 1 1.52% Southern Rakhine 19,274 169 143 23 3 0.88% Total 18 Buthidaung 5,494 70 43 25 2 1.27% 19 Kyauktaw 4,224 112 82 28 2 2.65% 20 Minbya 471 52 42 8 2 11.04% 21 Mrauk-U 391 18 13 5 0 4.60% 22 Myebon 1,582 6 4 2 0 0.38% 23 Pauktaw 1,368 2 2 0 0 0.15% 24 Ponnagyun 1,236 23 11 11 1 1.86% 25 Rathedaung 1,135 3 2 1 0 0.26% 26 Sittwe 989 5 0 5 0 0.51% Northern Rakhine 16,890 291 199 85 7 1.72% Total 27 Hlaingbwe 694 10 3 7 0 1.44% 28 Hpa-an 1,168 12 5 6 1 1.03% 29 Kawkareik 866 14 1 13 0 1.62% 30 Myawaddy 936 79 0 77 2 8.44% Kayin Total 3,664 115 9 103 3 3.14% Grand Total 54,646 932 423 494 15 1.71%

Annex 2 – Active case detection by mobile team

Table 20: Summary of active case detection in project villages and work sites (from April to June 2018)

# Township Total villages Total Tested Pf Pv Mixed 1 Bokpyin 5 160 1 2 0 2 Dawei 6 330 1 5 0 3 Kawthoung 1 47 0 0 0 4 Kyunsu 4 400 0 1 0 5 Launglon 1 34 0 0 0 6 Myeik 9 437 0 1 0 7 Palaw 4 187 0 1 0 8 Thayetchaung 8 386 0 2 0 9 Yebyu 7 564 0 0 0 Tanintharyi Total 45 2,545 2 12 0 10 Ann 1 1 0 0 0 11 GWA 3 123 0 0 0 12 Ramree 2 202 0 0 0 13 Thandwe 8 889 0 0 0 14 Toungup 7 471 0 0 0 Rakhine (South) Total 21 1,686 0 0 0 15 Kyauktaw 1 200 0 0 0 16 Rathedaung 1 56 0 0 0 Rakhine (North) Total 2 256 0 0 0 17 Hpa-An 1 223 1 0 0 18 Kawkareik 1 107 0 0 0 19 Myawaddy 10 318 0 0 0 Kayin Total 12 648 1 0 0 Grand Total 80 5,135 3 12 0

Table 21: Summary of active case detection in non-project villages and work sites (from April to June 2018)

# Township Total villages Total Tested Pf Pv Mixed 1 Bokpyin 16 23 1 9 0 2 Dawei 4 11 0 0 0 3 Kawthoung 1 82 0 0 0 4 Kyunsu 2 359 0 1 0 5 Myeik 1 257 0 0 0 6 Palaw 6 138 1 4 0 7 Tanintharyi 1 46 0 0 0 8 Thayetchaung 3 110 1 2 0 Tanintharyi Total 34 1,026 3 16 0 9 Ann 8 52 2 1 0 10 Toungup 4 87 2 0 0 Rakhine (South) Total 12 139 4 1 0 11 Ponnagyun 3 51 2 0 0 Rakhine (North) Total 3 51 2 0 0 12 Kawkareik 2 5 0 1 0 Kayin Total 2 5 0 1 0 Grand Total 51 1,221 9 18 0

Annex 3 – Monthly meeting

Table 22: Summary of VMW/PP monthly meeting (from April to June 2018)

Number of VMW / Actual number of % of VMWs/PPs # Township PP Posted have to VMW/PP attended attended the attend the meeting Male Female Total meeting 1 Bokpyin 177 34 132 166 93.8% 2 Dawei 63 10 49 59 93.7% 3 Kawthoung 164 77 52 129 78.7% 4 Kyunsu 183 46 133 179 97.8% 5 Launglon 99 12 78 90 90.9% 6 Myeik 90 6 83 89 98.9% 7 Palaw 159 33 113 146 91.8% 8 Tanintharyi 175 36 122 158 90.3% 9 Thayetchaung 93 14 77 91 97.8% 10 Yebyu 212 39 145 184 86.8% Tanintharyi Total 1,415 307 984 1,291 91.2% 11 Ann 259 170 74 244 94.2% 12 Gwa 195 82 107 189 96.9% 13 Kyaukpyu 150 115 33 148 98.7% 14 Ramree 276 175 82 257 93.1% 15 Thandwe 354 113 241 354 100.0% 16 Toungup 266 141 109 250 94.0% Southern Rakhine Total 1,500 796 646 1,442 96.1% 17 Buthidaung 422 384 23 407 96.4% 18 Kyauktaw 250 148 102 250 100.0% 19 Minbya 71 54 16 70 98.6% 20 Mrauk-U 78 51 26 77 98.7% 21 Myebon 165 84 81 165 100.0% 22 Pauktaw 126 75 51 126 100.0% 23 Ponnagyun 120 62 49 111 92.5% 24 Rathedaung 193 83 102 185 95.9% 25 Sittwe 96 15 80 95 99.0% Northern Rakhine Total 1,521 956 530 1,486 97.7% 26 Hlaingbwe 113 18 94 112 99.1% 27 Hpa-an 207 43 156 199 96.1% 28 Kawkareik 123 61 62 123 100.0% 29 Myawaddy 67 18 48 66 98.5% Kayin Total 510 140 360 500 98.0% Grand Total 4,946 2,199 2,520 4,719 95.4%

Annex 4 – Supervision and monitoring

Table 23: Summary of supervision and monitoring visits to VMWs/PPs (from April to June 2018)

Total # of VMWs and # Township # of visits to VMWs # of visits to PPs PPs supervised 1 Bokpyin 35 2 37 2 Dawei 19 0 19 3 Kawthoung 11 0 11 4 Kyunsu 31 5 36 5 Launglon 21 0 21 6 Myeik 10 1 11 7 Palaw 25 1 26 8 Tanintharyi 32 0 32 9 Thayetchaung 17 4 21 10 Yebyu 37 0 37 Tanintharyi Total 238 13 251 11 Ann 49 18 67 12 Gwa 41 0 41 13 Kyaukpyu 51 6 57 14 Ramree 20 2 22 15 Thandwe 120 0 120 16 Toungup 11 4 15 Southern Rakhine Total 292 30 322 17 Kyauktaw 26 1 27 18 Minbya 17 0 17 19 Mrauk-U 14 3 17 20 Myebon 31 1 32 21 Pauktaw 24 7 31 22 Ponnagyun 24 3 27 23 Rathedaung 22 0 22 24 Sittwe 18 0 18 Northern Rakhine Total 176 15 191 25 Hlaingbwe 32 0 32 26 Hpa-an 46 3 49 27 Kawkareik 41 1 42 28 Myawaddy 17 0 17 Kayin Total 136 4 140 Grand Total 842 62 904

Annex 5 – Reporting status of VMWs/PPs

Table 24: Reporting status of VMWs/PPs (from April to June 2018)

Total Number Of Number of % of Timely cumulative # VMWs/PPs Timely % of Report of # Township Of VMWs/PPs Reported (On Report Reporting VMWs/PPs have to submit time report + submitted by Status among the report Late report) VMWs/PPs reported 1 Bokpyin 180 180 174 100.0% 96.7% 2 Dawei 96 95 95 99.0% 100.0% 3 Kawthoung 168 156 156 92.9% 100.0% 4 Kyunsu 183 181 179 98.9% 98.9% 5 Launglon 99 97 96 98.0% 99.0% 6 Myeik 90 90 90 100.0% 100.0% 7 Palaw 159 158 157 99.4% 99.4% 8 Tanintharyi 176 170 165 96.6% 97.1% 9 Thayetchaung 93 93 92 100.0% 98.9% 10 Yebyu 212 206 197 97.2% 95.6% Tanintharyi Total 1,456 1,426 1,401 97.9% 98.2% 11 Ann 259 257 257 99.2% 100.0% 12 Gwa 195 195 195 100.0% 100.0% 13 Kyaukpyu 150 150 150 100.0% 100.0% 14 Ramree 276 274 274 99.3% 100.0% 15 Thandwe 354 354 354 100.0% 100.0% 16 Toungup 266 260 260 97.7% 100.0% Southern Rakhine 1,500 1,490 1,490 99.3% 100.0% Total 17 Buthidaung 422 412 412 97.6% 100.0% 18 Kyauktaw 250 250 250 100.0% 100.0% 19 Minbya 73 70 70 95.9% 100.0% 20 Mrauk-U 78 78 78 100.0% 100.0% 21 Myebon 165 165 165 100.0% 100.0% 22 Pauktaw 126 126 126 100.0% 100.0% 23 Ponnagyun 120 120 120 100.0% 100.0% 24 Rathedaung 195 185 185 94.9% 100.0% 25 Sittwe 96 95 95 99.0% 100.0% Northern Rakhine 1,525 1,501 1,501 98.4% 100.0% Total 26 Hlaingbwe 113 113 113 100.0% 100.0% 27 Hpa-an 219 219 218 100.0% 99.5% 28 Kawkareik 123 123 123 100.0% 100.0% 29 Myawaddy 67 67 67 100.0% 100.0% Kayin Total 522 522 521 100.0% 99.8% Grand Total 5,003 4,939 4,913 98.7% 99.5%

Annex 6 – Clinical audit

Table 25: Summary of clinical audit (from April to June 2018)

Total % of % of Positive Total Total positive treated Total patients who Positive Positive cases cases # Township referred was treated cases cases treated among cases according to found treated according positive NTG to NTG cases 1 Bokpyin 53 53 53 0 100.0% 100.0% 2 Dawei 47 47 47 0 100.0% 100.0% 3 Kawthoung 21 21 21 0 100.0% 100.0% 4 Kyunsu 19 19 19 0 100.0% 100.0% 5 Launglon 0 0 0 0 - - 6 Myeik 2 2 2 0 100.0% 100.0% 7 Palaw 111 111 111 0 100.0% 100.0% 8 Tanintharyi 39 38 38 1 97.4% 100.0% 9 Thayetchaung 56 56 56 0 100.0% 100.0% 10 Yebyu 9 9 9 0 100.0% 100.0% Tanintharyi Total 357 356 356 1 99.7% 100.0% 11 Ann 68 67 66 1 98.5% 98.5% 12 Gwa 4 4 4 0 100.0% 100.0% 13 Kyaukpyu 0 0 0 0 - - 14 Munaung 1 1 1 0 100.0% 100.0% 15 Ramree 2 2 2 0 100.0% 100.0% 16 Thandwe 0 0 0 0 - - 17 Toungup 94 93 77 1 98.9% 82.8% Southern Rakhine 169 167 150 2 98.8% 89.8% Total 18 Buthidaung 70 68 67 2 97.1% 98.5% 19 Kyauktaw 112 112 112 0 100.0% 100.0% 20 Minbya 52 52 52 0 100.0% 100.0% 21 Mrauk-U 18 18 18 0 100.0% 100.0% 22 Myebon 6 6 6 0 100.0% 100.0% 23 Pauktaw 2 2 2 0 100.0% 100.0% 24 Ponnagyun 23 23 23 0 100.0% 100.0% 25 Rathedaung 3 3 3 0 100.0% 100.0% 26 Sittwe 5 5 5 0 100.0% 100.0% Northern Rakhine 291 289 288 2 99.3% 99.7% Total 27 Hlaingbwe 10 10 10 0 100.0% 100.0% 28 Hpa-an 12 11 11 1 91.7% 100.0% 29 Kawkareik 14 13 13 1 92.9% 100.0% 30 Myawaddy 79 78 78 1 98.7% 100.0% Kayin Total 115 112 112 3 97.4% 100.0% Grand Total 932 924 906 8 99.1% 98.1%

Annex 7 – Stock out monitoring at the time of monitoring visits

Table 26: Summary of stock out monitoring at the time of monitoring visits and on-site data collection (from April to June 2018)

% of sites % of sites % of sites % of sites Total # of Total # of Total # of Total # of Total # of which which which which VMW with VMW with Total # of PP with PP with # Township visited experienced experienced experienced experienced NO RDT NO ACT visited PP NO RDT NO ACT VMW NO RDT stock NO ACT stock NO RDT stock NO ACT stock out stock out stock out stock out out out out stock out 1 Bokpyin 35 35 100.0% 35 100.0% 2 2 100.0% 2 100.0% 2 Dawei 19 19 100.0% 19 100.0% - - - - - 3 Kawthoung 11 11 100.0% 11 100.0% - - - - - 4 Kyunsu 31 31 100.0% 31 100.0% 5 5 100.0% 5 100.0% 5 Launglon 21 21 100.0% 21 100.0% - - - - - 6 Myeik 10 10 100.0% 10 100.0% 1 1 100.0% 1 100.0% 7 Palaw 25 25 100.0% 25 100.0% 2 2 100.0% 2 100.0% 8 Tanintharyi 32 31 96.9% 32 100.0% - - - - - 9 Thayetchaung 17 17 100.0% 17 100.0% 4 4 100.0% 4 100.0% 10 Yebyu 38 38 100.0% 38 100.0% - - - - - Tanintharyi Total 239 238 99.6% 239 100.0% 14 14 100.0% 14 100.0% 11 Ann 49 49 100.0% 49 100.0% 18 18 100.0% 18 100.0% 12 Gwa 41 41 100.0% 41 100.0% - - - - - 13 Kyaukpyu 51 51 100.0% 51 100.0% 6 6 100.0% 6 100.0% 14 Ramree 31 31 100.0% 31 100.0% 3 3 100.0% 3 100.0% 15 Thandwe 120 120 100.0% 120 100.0% - - - - - 16 Toungup 11 11 100.0% 11 100.0% 4 4 100.0% 4 100.0% Southern Rakhine Total 303 303 100.0% 303 100.0% 31 31 100.0% 31 100.0% 17 Kyauktaw 26 26 100.0% 26 100.0% 1 1 100.0% 1 100.0% 18 Minbya 17 17 100.0% 17 100.0% - - - - - 19 Mrauk-U 14 14 100.0% 14 100.0% 3 3 100.0% 3 100.0% 20 Myebon 31 31 100.0% 31 100.0% 1 1 100.0% 1 100.0% 21 Pauktaw 24 24 100.0% 24 100.0% 7 7 100.0% 7 100.0% 22 Ponnagyun 32 32 100.0% 32 100.0% 4 4 100.0% 4 100.0% 23 Rathedaung 22 22 100.0% 22 100.0% - - - - - 24 Sittwe 18 18 100.0% 18 100.0% - - - - - Northern Rakhine Total 184 184 100.0% 184 100.0% 16 16 100.0% 16 100.0% 25 Hlaingbwe 32 32 100.0% 31 96.9% - - - - - 26 Hpa-an 46 46 100.0% 46 100.0% 3 3 100.0% 3 100.0% 27 Kawkareik 41 41 100.0% 41 100.0% 1 1 100.0% 1 100.0% 28 Myawaddy 17 17 100.0% 17 100.0% - - - - - Kayin Total 136 136 100.0% 135 99.3% 4 4 100.0% 4 100.0% Grand Total 862 861 99.9% 861 99.9% 65 65 100.0% 65 100.0%

Table 27: Summary of stock out monitoring at monthly meeting (from April to June 2018)

% of sites % of sites % of sites % of sites Total # of Total # of Total # of Total # of Total # of which which which which VMW with VMW with Total # of PP with PP with # Township visited experienced experienced experienced experienced NO RDT NO ACT visited PP NO RDT NO ACT VMW NO RDT stock NO ACT stock NO RDT stock NO ACT stock stock out stock out stock out stock out out out out out 1 Bokpyin 155 155 100.0% 155 100.0% 11 11 100.0% 11 100.0% 2 Dawei 55 55 100.0% 55 100.0% 4 4 100.0% 4 100.0% 3 Kawthoung 120 120 100.0% 120 100.0% 9 8 88.9% 8 88.9% 4 Kyunsu 122 122 100.0% 122 100.0% 19 19 100.0% 19 100.0% 5 Launglon 90 90 100.0% 90 100.0% - - - - - 6 Myeik 69 69 100.0% 69 100.0% 16 16 100.0% 16 100.0% 7 Palaw 115 115 100.0% 115 100.0% 28 28 100.0% 28 100.0% 8 Tanintharyi 158 112 70.9% 158 100.0% - - - - - 9 Thayetchaung 73 73 100.0% 73 100.0% 18 18 100.0% 18 100.0% 10 Yebyu 184 184 100.0% 184 100.0% - - - - - Tanintharyi Total 1,141 1,095 96.0% 1,141 100.0% 105 104 99.0% 104 99.0% 11 Ann 182 182 100.0% 182 100.0% 62 62 100.0% 62 100.0% 12 Gwa 189 189 100.0% 189 100.0% - - - - - 13 Kyaukpyu 130 130 100.0% 130 100.0% 18 18 100.0% 18 100.0% 14 Ramree 251 251 100.0% 251 100.0% 6 6 100.0% 6 100.0% 15 Thandwe 354 354 100.0% 354 100.0% - - - - - 16 Toungup 186 186 100.0% 186 100.0% 64 64 100.0% 64 100.0% Southern Rakhine Total 1,292 1,292 100.0% 1,292 100.0% 150 150 100.0% 150 100.0% 17 Buthidaung 407 407 100.0% 405 99.5% - - - - - 18 Kyauktaw 222 222 100.0% 222 100.0% 6 6 100.0% 6 100.0% 19 Mrauk-U 65 65 100.0% 65 100.0% 12 12 100.0% 12 100.0% 20 Myebon 147 147 100.0% 147 100.0% 18 18 100.0% 18 100.0% 21 Pauktaw 96 96 100.0% 96 100.0% 30 30 100.0% 30 100.0% 22 Ponnagyun 92 92 100.0% 92 100.0% 16 16 100.0% 16 100.0% 23 Rathedaung 185 185 100.0% 185 100.0% - - - - - 24 Sittwe 95 95 100.0% 95 100.0% - - - - - Northern Rakhine Total 1,379 1,379 100.0% 1,377 99.9% 82 82 100.0% 82 100.0% 25 Hlaingbwe 112 110 98.2% 111 99.1% - - - - - 26 Hpa-an 199 198 99.5% 199 100.0% - - - - - 27 Kawkareik 120 120 100.0% 120 100.0% 3 3 100.0% 3 100.0% 28 Myawaddy 63 63 100.0% 63 100.0% 3 3 100.0% 3 100.0% Kayin Total 494 491 99.4% 493 99.8% 6 6 100.0% 6 100.0% Grand Total 4,306 4,257 98.9% 4,303 99.9% 343 342 99.7% 342 99.7%

Annex 8 – Capacity building

Table 28: Number of VMWs/PPs trained on case management (from April to June 2018)

Village Malaria Workers Private Providers Grand # Township M F Sub-total M F Sub-total Total 1 Kawthoung 4 3 7 1 - 1 8 Tanintharyi Total 4 3 7 1 - 1 8 2 Ramree 27 11 38 - - - 38 3 Toungup 17 14 31 11 5 16 47 Southern Rakhine Total 44 25 69 11 5 16 85 4 Buthidaung 8 1 9 - - - 9 5 Kyauktaw 4 6 10 - - - 10 6 Minbya 3 1 4 - - - 4 7 Mrauk-U 24 9 33 5 3 8 41 8 Myebon 11 19 30 - - - 30 9 Pauktaw - 3 3 - - - 3 10 Ponnagyun 2 3 5 - - - 5 11 Sittwe - 1 1 - - - 1 Northern Rakhine Total 52 43 95 5 3 8 103 12 Hlaingbwe 2 10 12 - - - 12 Kayin Total 2 10 12 - - - 12 Grand Total 102 81 183 17 8 25 208

Table 29: Number of VMWs/PPs trained on diagnosis (from April to June 2018)

Annex 9 – BCC Table 30: Number of people reached through IPC and Group Health Talks by Mobile Team, VMWs and PPs (From April to June 2018)

Individual IPC Group Health Talk # Township Migrants Sessio Migrants Male Female Total Male Female Total included ns # included 1 Bokpyin 727 629 1,356 838 71 635 561 1,196 666 2 Dawei 443 380 823 172 3 78 44 122 43 3 Kawthoung 1,163 910 2,073 2,073 66 292 301 593 593 4 Kyunsu 770 994 1,764 81 1 35 30 65 1 5 Launglon 200 372 572 35 8 304 1,349 1,653 0 6 Myeik 498 1,117 1,615 55 6 211 207 418 0 7 Palaw 510 688 1,198 86 1 17 47 64 0 8 Tanintharyi 438 415 853 133 54 229 184 413 156 9 Thayetchaung 577 918 1,495 397 5 122 233 355 0 10 Yebyu 598 954 1,552 222 2 57 85 142 0 Tanintharyi Total 5,924 7,377 13,301 4,092 217 1,980 3,041 5,021 1,459 11 Ann 1,013 866 1,879 27 23 254 431 685 1 12 Gwa 952 1,038 1,990 72 2 29 51 80 0 13 Kyaukpyu 518 621 1,139 1 0 0 0 0 0 14 Ramree 541 619 1,160 7 1 24 37 61 0 15 Thandwe 1,550 1,811 3,361 104 20 510 850 1,360 0 16 Toungup 811 747 1,558 1 0 0 0 0 0 Southern Rakhine 5,385 5,702 11,087 212 46 817 1,369 2,186 1 Total 17 Buthidaung 4,033 1,597 5,630 2 158 1,446 636 2,082 7 18 Kyauktaw 1,279 1,272 2,551 287 30 151 201 352 60 19 Minbya 167 119 286 51 1 8 4 12 0 20 Mrauk-U 332 319 651 67 5 50 41 91 2 21 Myebon 550 608 1,158 51 2 9 1 10 0 22 Pauktaw 426 493 919 124 4 53 58 111 17 23 Ponnagyun 377 387 764 96 5 17 47 64 0 24 Rathedaung 746 848 1,594 0 0 0 0 0 0 25 Sittwe 367 485 852 83 25 54 132 186 2 Northern Rakhine 8,277 6,128 14,405 761 230 1,788 1,120 2,908 88 Total 26 Hlaingbwe 284 418 702 36 6 50 196 246 0 27 Hpa-an 799 1,500 2,299 116 10 185 455 640 3 28 Kawkareik 363 537 900 51 122 565 1,091 1,656 17 29 Myawaddy 794 975 1769 225 12 323 157 480 0 Kayin Total 2,240 3,430 5,670 428 150 1123 1,899 3,022 20 Grand Total 21,826 22,637 44,463 5,493 643 5,708 7,429 13,137 1,568

Table 31: Number of people reached through IPC and Group Health Talks by Private Providers only (From April to June 2018)

Individual IPC Group Health Talk # Township Migrants Sessio Migrants Male Female Total Male Female Total included ns # included 1 Bokpyin 62 82 144 93 4 38 60 98 43 2 Dawei 13 13 26 0 0 0 0 0 0 3 Kawthoung 275 195 470 470 15 100 106 206 206 4 Kyunsu 128 171 299 7 0 0 0 0 0 5 Myeik 125 185 310 10 0 0 0 0 0 6 Palaw 94 113 207 41 0 0 0 0 0 7 Thayetchaung 138 174 312 140 0 0 0 0 0 Tanintharyi Total 835 933 1,768 761 19 138 166 304 249 8 Ann 306 256 562 11 0 0 0 0 0 9 Kyaukpyu 93 87 180 1 0 0 0 0 0 10 Ramree 56 53 109 0 0 0 0 0 0 11 Toungup 220 136 356 0 0 0 0 0 0 Southern Rakhine 675 532 1,207 12 0 0 0 0 0 Total 12 Kyauktaw 28 35 63 0 0 0 0 0 0 13 Mrauk-U 35 56 91 4 0 0 0 0 0 14 Myebon 48 58 106 29 0 0 0 0 0 15 Pauktaw 126 114 240 45 0 0 0 0 0 16 Ponnagyun 68 62 130 32 0 0 0 0 0 Northern Rakhine 305 325 630 110 0 0 0 0 0 Total 17 Hpa-an 41 18 59 7 0 0 0 0 0 18 Kawkareik 7 8 15 2 2 6 16 22 1 19 Myawaddy 12 3 15 5 0 0 0 0 0 Kayin Total 60 29 89 14 2 6 16 22 1 Grand Total 1,875 1,819 3,694 897 21 144 182 326 250

Annex 10 - Study tour to Sampov Loun District, Battambang Province in Cambodia Trip Report

180531_Trip Report_Elimination Study Tour to SPL.pdf

Technical Feedback

Technical Feedback on the trip to Cambodia Malaria Elimination Project.docx.pdf

Annex 11 – Performance Indicators

Table 32: Performance Indicators Tracking Table (From April to June 2018)

Actual Annual Indicators Frequency Baseline Achievem Target ents (FY2018) IP 1: Annual Parasite Incidence (API) in Annual 8 (CAP-M N/A 5.5 Defeat Malaria villages FY15 progress report) IP 2: Annual Blood Examination Rate Annual 6% in 2015 N/A 7% (from National M&E Plan) IP 3: Percent of indigenous cases among Quarterly 9% in 2015 NA 80% cases investigated (in elimination areas) (from National M&E Plan) IP 4: Percent of active foci among foci Quarterly N/A NA 80% investigated (in elimination areas) IP 5: Proportion of villages with zero positive Annually 18.5% (CAP-M N/A 23% cases for at least last three consecutive years database) OC 1.1 % of households in targeted areas Baseline and NA NA that own at least one insecticide treated net end line (ITN) OC 1.2 % of households in targeted areas 47% (in NA NA that own at least one ITN for every two Rakhine), persons 60,2% (in Tanintharyi), 65.6% (in Kayin) - from CAP-M End line Household Surveys OC 1.3 % of individuals in targeted areas NA NA who slept under ITN the previous night. (disaggregate by type of net, pregnant women, children under 5 OC 1.4 % of service delivery points which Quarterly Minimum 85% 99.1% ≥ 80% report no stock outs of RDTs lasting more (from CAP-M) than one week during the past 3 months (disaggregate by type of SDP) OC 1.5 % of service delivery points which Quarterly Minimum 85% 99.9% ≥ 80% report no stock outs of first line antimalarial (from CAP-M) medicines (ACT) lasting more than one week during the past 3 months (disaggregate by type of SDP) OC 1.6 % of patients found positive who Quarterly Minimum 95% 98.1% ≥ 95% received antimalarial treatment according to (from CAP-M National Malaria Treatment Guidelines FY15 progress report)

Actual Annual Indicators Frequency Baseline Achievem Target ents (FY2018) OC 1.7 % of Malaria Positive cases with Quarterly 25% (from 99.1% 50% having completed the treatment under DOT CAP-M FY15 progress report) OP 1.1 Number of insecticide treated net Quarterly 92,986 (From 88,053 70,900 purchased in any fiscal year with United State CAP-M FY16 Government (USG) funds that were progress distributed in this quarter report) OP 1.2 Number of artemisinin-based Quarterly NA 1,390 32,400 combination therapy (ACT) treatments purchased in any fiscal year with USG funds that were distributed in this reported fiscal year (PMI required indicator) OP 1.3 Number of RDTs purchased in any Quarterly NA 77,525 465,000 fiscal year with USG funds that were distributed (PMI required indicator) OP 1.4 Number of individuals reached with Quarterly 514,333 (from 44,463 100,000 malaria behavior change messages through CAP-M 5 year interpersonal communication (individual progress talks) report) OP 1.5 Number of health workers trained in Month of 5,155 (from 208 1,500 case management with ACTs with USG funds training CAP-M 5 year VMWs/PPs (Disaggregated by male, female, and progress profession) (PMI required indicator) report) OP 1.6 Number of health workers trained in Month of 5,443 (from 208 1,500 malaria laboratory diagnostics (rapid training CAP-M 5 year VMWs/PPs diagnostic tests (RDTs) or microscopy) with progress USG funds (Disaggregated by male, female, report) and profession) (PMI required indicator) OP 1.7 % of VMWs/PPs in Defeat Malaria Annually N/A N/A ≥ 80% target areas received at least two supervisory visits per year OC 2.1 % of service delivery points in Monthly ≥ 80% (from 98.7% ≥ 80% targeted areas report monthly data of CAP-M 5 year malaria cases (disaggregate by type of SDP) progress report) OC 2.2 % of service delivery points in Monthly N/A 99.5% ≥ 80% targeted areas report monthly data of malaria cases on time (disaggregate by type of SDP) OC 2.3 % of positive cases notified within 24 Monthly N/A NA 70% hours in elimination targeted townships OC 2.4 Foci investigation rate Monthly N/A NA 60% OC 2.5 Active focus response rate Monthly N/A NA 70%

Actual Annual Indicators Frequency Baseline Achievem Target ents (FY2018) OP 2.1 Number of townships that have Annually N/A NA 33 developed and updated Village Based Stratification (VBS) annually OP 2.2 Number entomological surveys Semiannual N/A 0 3 conducted in persistent transmission areas OP 3.1 % of targeted health services with Annually N/A 0% 60% Quality Assurance/Quality Control (QAQC) system received quarterly internal assessments of the QA system in collaboration with NHL/NMCP OP 3.2 Number of trainings on malaria Quarterly by N/A 3 20 technical skill and training facilitation skill Jhpiego supported by Defeat Malaria OP 3.3 Number of trainers developed Quarterly by N/A 0 72 through Defeat Malaria Jhpiego OP 3.4 Number of people trained through Quarterly by N/A 97 360 on-site training supported by USG program Jhpiego (Defeat Malaria) OP 3.5 Percentage of trainers supervised Quarterly by N/A 13% 50% during trainings Jhpiego OP 3.6 Percentage of master mentors Quarterly by N/A 0% 80% of master retaining at least 80% of acquired skills and Jhpiego mentors acquired skills knowledge and knowledge OP 3.7 Number of joint supervision visits to Quarterly by N/A 8 6 VMW for data quality assessments Jhpiego OP 4.1 Number of private companies and Annual N/A 34 60 state-owned enterprises involve in malaria activities OP 4.2 Number of health education sessions Quarterly N/A 106 300 conducted in the targeted areas with participation from collaborating companies and enterprises