Accessible Continuum of Care and Essential Services Sustained (Access) Activity

ACCESSIBLE CONTINUUM OF CARE AND ESSENTIAL SERVICES SUSTAINED (ACCESS) ACTIVITY

Quarterly Progress Report: January – March 2019

May 10, 2019

John Yanulis

This report was made possible through support provided by the United States Agency for International Development (USAID), under the terms of Cooperative Agreement No. 72068718CA00003. The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of USAID.

ACCESS Activity Management Sciences for Health 200 Rivers Edge Drive Medford, MA 02155 Telephone: (617) 250-9500 www.msh.org 1

QUARTERLY

REPORT

ACCESSIBLE CONTINUUM OF CARE AND ESSENTIAL SERVICES (ACCESS)

Submitted by John Yanulis, Chief of Party Management Sciences for Health 6ème Etage, Immeuble Fitaratra Ankorondrano, 101 Antananarivo MADAGASCAR

This document was produced for review by the United States Agency for International Development. It was prepared by Management Sciences for Health for the USAID ACCESS Program, NOFO 72068718CA00003.

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TABLE OF CONTENTS

TABLE OF CONTENTS 2 LIST OF ACRONYMS 3 ACCESS OVERVIEW 5 RESULTS FRAMEWORK 6 AT A GLANCE 7 PROGRESS TOWARDS THE PROGRAM OBJECTIVES 8 MONITORING, EVALUATION, AND LEARNING (MEL) 24 COMMUNICATIONS 25 MANAGEMENT 26 FY19 Q2 FINANCIAL REPORT Error! Bookmark not defined. SUCCESS STORY: MEASLES RESPONSE IN MAHJANGA I 32

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LIST OF ACRONYMS

AAP American Academy of Pediatricians ACCESS Accessible Continuum of Care and Essential Services Sustained ACNM American College of Nurse Midwives ACOG American College of Obstetricians and Gynecologists AOR Agreement Officer Representative APPH Advancements in Postpartum Hemorrhage Care ASOS Action Socio-Sanitaires Organisation Secours CCDS Comités Communaux De Développement De Santé CCNT National Technical Coordination Cell CHD Centre Hospitalier de District CHV Community Health Volunteer CLA Collaborating, Learning, and Adapting CLTN Community-Led Total Nutrition CLTS Community-Led Total Sanitation COSAN Comités De Santé CRS Catholic Relief Services CSB Centre de Santé de Base CVC Community Surveillance Monitoring Committee CVF Fokontany Surveillance Monitoring Committee DCA Development Credit Authority DDS Direction des Districts Sanitaires DDSB Direction de Soins de Santé de Base DEP Direction de l’Etude et de la Planification DEPSI Direction de l’Etude de la Planification et du Système d’Information DGFS Director General for Health Facilities DHIS-2 District Health Information System II DPEV Direction du Programme Elargi de Vaccination DPS Direction de la Promotion de la Santé DPLMT Direction de la Pharmacie, des Laboratoires, et de la Médecine Traditionnelle DRSP Direction Régionales De La Santé Publique DSI Direction des Systèmes d'Information DVSSER Direction de Veille Sanitaire, Surveillance Épidémiologique, et Riposte EMAD Equipe de Management de District EMAR Equipe de Management de Région EPI Expanded Programme on Immunization EMOI Equipment, Materials, Tools, and Other Inputs EU The European Union FFSDP Fully Functional Service Delivery Point FP Family Planning FY Fiscal Year HEARD Health Evaluation and Applied Research Development HIS Health Information System HP+ Health Policy Plus IDSR Integrated Disease Surveillance and Response IMCI Integrated Management of Childhood Illnesses IMPACT Improving Market Partnerships and Access to Commodities Together IP Implementing Partner IT Information Technology

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IUD Intrauterine Device JHU-CCP Johns Hopkins Center for Communication Programs KAP Knowledge, Attitudes, and Practices LARC Long-acting Reversible Contraceptives LDP+ Leadership Development Program Plus LiST Lives Saved Tool LMG Leadership, Management, and Governance LoA Letter of Authorization MCSP Maternal and Child Survival Program M&E Monitoring and Evaluation MEL Monitoring, Evaluation, and Learning MELP Monitoring, Evaluation, and Learning Plan MNCH Maternal, Neonatal, and Child Health MOPH The Ministry of Public Health MSH Management Sciences for Health NGO Non-governmental Organization PBF Performance-Based Financing PhaGis Pharmacie de Gros du District PPH Postpartum Hemorrhage PLGHA Protecting Life in Global Health Assistance PMI The President’s Malaria Initiative PNLP Programme Nationale de Lutte contre le Paludisme PNSC Politique Nationale de Santé Communautaire PROGRES Program for Organizational Growth, Resilience, and Sustainability PSBI Possible Serious Bacterial Infction PSI Population Services International PTF Partenaires Techniques et Financiers Q1 Quarter 1 Q2 Quarter 2 Q3 Quarter 3 RH Reproductive Health RMACom Community Monthly Activity Report SBC Social and Behavior Change SDSP Service de District de Santé Publique SCM Service de la Communication et Media SBU-GHI Stony Brook University Global Health Institute SILC Savings and Internal Lending Communities SMS Short Message Service STTA Short-Term Technical Assistance TWG Technical Working Group UNFPA The United Nations Population Fund UNICEF The United Nations Children’s Fund URC University Research Co USAID United States Agency for International Development USG United States Government WASH Water, Sanitation, and Hygiene WHO The World Health Organization

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ACCESS OVERVIEW

Activity Name Accessible Continuum of Care and Essential Services Sustained (ACCESS)

Start and End Date September 27, 2018 – September 26, 2023

Name of Prime Management Sciences for Health (MSH) Implementing Partner

Cooperative 72068718CA00003 Agreement Number

Name of Sub- Action Socio-Sanitaires Organisation Secours (ASOS) Awardees American Academy of Pediatricians (AAP) American College of Obstetricians and Gynecologists (ACOG) American College of Nurse Midwives (ACNM) Catholic Relief Services (CRS) Dimagi Johns Hopkins Center for Communication Program (JHU-CCP) Stony Brook University Global Health Institute (SBU-GHI)

Main Counterpart Ministry of Public Health (MOPH), Madagascar

Geographic Coverage Thirteen Regions in Madagascar: Atsinanana, Vatovavy Fitovinany, Vakinankaratra, Amoron’I Mania, Haute-Matsiatra, Atsimo Andrefana, Menabe, Melaky, Boeny, Sofia, Analanjirofo, Diana, Sava.

Goal and Purpose The goal of the program is to accelerate sustainable health impacts for the Malagasy people–as measured by sustained reductions in maternal and child mortality and morbidity–in 13 regions of the country.

The purpose of the program is to build the capacity of MOPH actors at the district level and below in all districts in the implementation regions, to design, develop, manage, deliver, monitor, and evaluate health services and programs in their catchment areas.

Objectives 1) Quality health services are sustainably available and accessible to all Malagasy communities in the target regions 2) Health systems function effectively to support quality service delivery 3) The Malagasy people sustainably adopt healthy behaviors and social norms

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RESULTS FRAMEWORK

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AT A GLANCE

This progress report summarizes the technical and management activities that took place in the second quarter (Q2) of Fiscal Year 2019 (FY19)—January 1- March 31, 2019—and the planned activities for the third quarter (Q3) of the ACCESS Health Activity—hereafter referred to as “the ACCESS Program,” “ACCESS,” or “the program.”

During Q2 FY19, ACCESS conducted technical orientations with ACCESS staff (which is an activity that is ongoing as new staff continue to join the program); worked alongside the MOPH to develop and validate national technical strategies, policies, and tools; enhanced coordination mechanisms with other implementing partners and USAID programs; applied a collaborating, learning, and adapting (CLA) approach to ACCESS interventions and innovations before initiating roll out or scale up; technically and financially supported the MOPH’s response to the measles outbreak; and finalized the baseline study protocol. Additionally in Q2, the ACCESS FY19 Workplan and the Monitoring, Evaluation, and Learning Plan (MELP) were approved by the United States Agency for International Development (USAID).

While technical activities ramped up in Q2, ACCESS continued to focus on start-up activities related to program management. In particular, during this quarter the program hired an additional 57 staff-- including the Deputy Chief of Party, Performance Improvement and the Director of Finance and Administration (both key personnel positions); secured office space in 13 regions; finalized five out of eight of the consortium sub-award contracts; initiated the procurement of vehicles; and established sound financial and operational procedures to ensure compliance policies are in place. Furthermore, the new Minister of Public Health and his appointees assumed office during Q2. ACCESS made concerted efforts to establish formal relationships with the new MOPH and continued to provide uninterrupted support to the national, regional, and district MOPH in both technical and operational activities.

Additionally, on October 26, 2018, the MOPH declared a measles outbreak and mobilized all partners in a national response. The ACCESS Program has been an active partner to the MOPH in the implementation of the response plan, particularly by supporting two vaccination campaigns during Q2.

This report begins with a review of activities specific to each of the three objectives that were implemented by ACCESS in Q2. The rest of the report reviews the managerial, operational, and financial activities and status by the end of Q2.

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PROGRESS TOWARDS THE PROGRAM OBJECTIVES

OBJECTIVE 1: QUALITY HEALTH SERVICES ARE SUSTAINABLY AVAILABLE AND ACCESSIBLE TO ALL MALAGASY COMMUNITIES IN THE TARGETED REGIONS

Major Q2 activities and key achievements

Objective 1.1: Quality community health services are available as first point of contact with the health system

● Worked with the MOPH to develop the strategic plan to reinforce Madagascar's community health system. In Q2, ACCESS worked alongside the MOPH and other partners (the World Health Organization [WHO], the United Nations Children’s Fund [UNICEF], the United Nations Population Fund [UNFPA], Health Policy Plus [HP+], Mahefa Miaraka, and Action Socio-Sanitaires Organisation Secours [ASOS]) to develop a strategic plan to reinforce and refine Madagascar’s community health strategy (PNSC). As a result, ACCESS has aligned its workplan with the MOPH, particularly in regard to its community-level capacity building approaches. The future community health coaches to be hired in ACCESS’s zones of interventions will be officially called community health aides (Accompagnateurs en Santé Communautaires). One of major responsibilities of the community health coaches will be to identify the best performing CHVs and train, accompany, and help them to become peer mentors after two years. Therefore, the CHV coach position is temporary and designed to strengthen local capacities without creating a new position that could deepen dependency to project. The District Development Directorate of the MOPH is in agreement with this approach. ACCESS will continue to support the MOPH to refine the job description and develop the hiring strategy for this position in quarter three (Q3). This co-design further ensures sustainability and MOPH ownership.

Objective 1.2: Quality health services are available at the centres de santé de base (CSBs) and district hospitals

● Co-conducted a needs assessment of medical equipment, instruments, and materials in CSBs and district hospitals. ACCESS partnered with Project C.U.R.E to implement an assessment of 22 facilities in 13 districts (Toamasina 1, Toamasina 2, Fenerive Est, Soanierana Ivongo, Miandrivazo, Mahabo, Morondava, Antsiranana 1, Antsiranana 2, Ambilobe, Ifanadiana, Manakara, and Vohipeno) across five regions (Vatovavy Fitovinany, Diana, Atsinanana, Analanjirofo, and Menabe) to determine equipment needs, such as stethoscopes, beds, blood pressure cuffs, IV poles, scales, etc. The facilities included in this assessment were selected to be representative of the majority of facilities within the ACCESS areas of intervention, as Project C.U.R.E is unable to visit each facility to conduct unique assessments. Project C.U.R.E. has budgeted for 16 40-foot containers to be shipped to Madagascar containing needed medical instruments and equipment. Following the needs assessment, Project C.U.R.E will share with ACCESS an allocation and sequencing strategy to determine what items from each container will be allocated to each facility and in what order the shipments will be deployed. This will then be discussed with the MOPH’s Director General for Health Facilities (DGFS) to finalize the list of materials and the distribution strategy.

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● Facilitated the preliminary visit of Breakthrough RESEARCH and Health Evaluation and Applied Research Development (HEARD) projects for the initiation of their Advancements in Postpartum Hemorrhage Care (APPHC) study in Madagascar. As part of this USAID- funded study on the obstacles in the prevention and management of postpartum hemorrhage (PPH) in Madagascar, a team from the Population Council-implemented Breakthrough RESEARCH project and the University Research Co. (URC)-implemented HEARD project travelled to Madagascar in March 2019 to conduct a scoping visit, which included several stakeholder consultations. ACCESS helped to facilitate these stakeholder meetings and contributed to the discussions around PPH barriers and current prevention and management activities.

● Operationalized mobile clinics in seven regions. In quarter one (Q1), ACCESS subcontracted Population Services International (PSI) to manage the program’s family planning (FP) mobile outreach clinics in seven regions. In January, five mobile clinics were operational (Boeny, Diana, Sava, Analanjirofo, and Sofia). The remaining two mobile clinics in Menabe and Melaky began operations in mid-February. The main activities provided by the mobile clinics include: insertion and removal of long-acting FP methods (implant or intrauterine device [IUD]), provision and referrals to CSBs for short-acting methods (Depo Provera, Sayana Press, condoms, oral contraceptive pills), and client follow-up. In Q2, the seven mobile clinics served a total of 2,439 unique clients at 162 sites, 92 of which were located next to CSBs during the day of visit and offered services not usually available in CSBs (see Table 1 and Figure 1).

Table 1: Monthly evolution of mobile clinic clients, per region

Region January February March Total

Analanjirofo 35 404 289 728

Boeny 21 197 272 490

Diana 9 156 220 385

Melaky - 67 91 158

Menabe - 40 131 171

Sava 34 94 160 288

Sofia 25 101 93 219

Total 124 1,059 1,256 2,439

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Figure 1: Monthly evolution of mobile clinic clients

Almost all mobile clinics demonstrated a continuous increase in FP clients between January and March. The exceptional decrease in number of clients seen in the region of Analanjirofo can be attributed to the fact that the zones this mobile clinic served in March were very remote, and therefore there was less client demand.

Furthermore, as illustrated in Figure 2, the regions of Analanjirofo and Boeny served the most number of clients in Q2, representing 50% of the quarter’s mobile clinic beneficiaries. The number of clients served is mostly influenced by the population density in the mobile clinic zone, the security of the zone, and the demand for the services generated by community health volunteers (CHVs) supported by the Mahefa Miaraka project, who promote the mobile clinics within their communities.

Figure 2: Breakdown of mobile clinic service provision by region

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Overall, these results demonstrate that the mobile clinic activities are off to a strong start and that promotion and communication efforts to generate demand for their services are effective.

Further disaggregation by type of service indicates that insertion of implants was the most frequently provided service by these mobile clinics in Q2 (see Table 2).

Table 2: Number of mobile clinic beneficiaries per type of service

Type of client and service provided # of beneficiaries

Clients seeking Insertion (NU and Implants 1,802 services for RU combined) long acting IUD 142 methods Removal of long Implants 30 acting methods IUD 5

Clients have Provided short Depo-Provera 14 not chosen acting methods at long acting mobile clinics Sayana Press 0 methods Oral contraceptives 1

Condom 10

Referred to CSB for short acting methods 78

Clients seeking Because suspected pregnancy 130 services for long acting Because close appointment for injectable 28 methods but contraceptive not eligible Other non-eligibility criteria 40

Clients coming for follow-up visits 159

TOTAL 2,439

Consistent with the fact that one of the main functions of the mobile clinics is to provide long-acting FP methods to women who are unable to receive them at CSBs, implant insertion and removal represented over 75% of mobile clinic services in Q2 (see Table 2). In Madagascar, the implant tends to be the most accepted method of long-acting FP for several reasons: it is widely available, it is available at a low cost, and the procedure is easy and painless. On the other hand, IUDs are generally not as well accepted by the Malagasy population because of the reluctance of providers to offer them, frequent stock outs of IUDs, and a scarcity of trained providers on IUD insertion and removal. Over the life of the program, ACCESS will increase awareness of the advantages of IUDs as an FP method, improve clinical capacities of providers on IUD insertions and removals, improve provider attitudes around IUDs, and work in close coordination with the Improving Market Partnerships and Access to Commodities Together (IMPACT) Project and PSI to reduce stock outs and ensure continued availability of IUDs.

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In cases where the client is not eligible for a long-acting method (for example, because she may be pregnant or have a sexually transmitted infection) or chooses not to use one, the mobile clinic will refer the client to the FP provider at the CSB to receive a short-acting method, a service usually available at the same time when the mobile clinic operates at the CSB. However, when the client is unable to go to a CSB for these services (ie geographic remoteness when the mobile clinic operates outside a CSB, or for personal reasons), the mobile clinic will offer short-acting FP methods, including injections (Sayana Press and Depo Provera) and condoms. In Q2, mobile clinics saw 198 clients not receiving a long-acting method. In Q3, ACCESS will work with PSI to develop a stronger follow-up approach for these non-eligible clients.

Objective 1.3: Functional continuum of care across service delivery channels is provided throughout the district

● Oriented ACCESS team members to the program’s activities related to clinical capacity building along the continuum of care. ACCESS conducted a series of six orientations, which focused on the FY19 workplan activities; the referral and counter-referral system; quality improvement approaches at CHV, CSB, and district hospital levels; new approaches to malaria management; maternal, neonatal, and child health (MNCH); post-abortion care; FP; immunization, particularly related to the measles outbreak response campaign; and nutrition. While these orientations were targeted to Objective 1 technical staff, they included staff from across the program in order to reinforce the integrated nature of ACCESS’s implementation strategy.

● Collected information to sharpen ACCESS’s capacity building strategy and implementation plan. Based on the FY19 workplan’s main objectives and indicator targets, the ACCESS team developed a data collection tool to assess the availability of qualified human resources (ie the number of trained providers). The objectives of the assessment are to establish the primary capacity building needs at the community, CSB, and hospital levels, to use the data to refine the content of the different trainings, and to inform workplan implementation.

● Supported the Programme Nationale de Lutte Contre le Paludisme (PNLP) to develop the Malaria Elimination Plan 2019-2022. ACCESS will continue working with the MOPH on the malaria elimination strategy in Q3, and anticipates that the Plan will be validated in Q3.

Challenges

● The change of teams and leadership within the MOPH resulted in the delays of some planned activities. However, ACCESS intends to continue being flexible and adapting its support to the evolving structure and needs of the MOPH. ● Many capacity building documents (training curricula, policies) are not yet validated by the MOPH, hampering full roll out of related activities. ACCESS will work with the MOPH to validate these documents in the coming quarters.

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Major activities planned for Q3 In Q3, ACCESS will: ● Support World Malaria Day events and co-host a national-level Malaria Scientific Conference ● Work with the MOPH and other implementing partners to initiate roll out of the rectal artesunate plan ● Collect and analyze data on the training needs and the equipment, materials, tools, and other inputs (EMOI) needs of CHVs in Atsinanana, Atsimo Andrefana, and Vatovavy Fitovinany, as well as of CSBs and district hospitals within the other ten regions of intervention. ● Meet with all the different technical directors of the MOPH to coordinate workplan activities and identify priority interventions. ● Develop a guideline on minimum standards for CHVs. ● Conduct an evaluation of the quality of care provided by the mobile clinics. ● Scale up ACCESS technical activities at the commune and district levels. ACCESS will launch capacity-building activities in the field (commune and district levels) after completing the necessary preparatory steps with the program’s national counterparts. Integrated Management of Childhood Illnesses (IMCI) and possible serious bacterial infection (PSBI) are integral parts of the training package planned for roll out. ● Finalize MNCH and integrated FP training curricula. ● Conduct an orientation for national trainers on ACCESS’s continuum of care approach and on updates to revised curricula (child health, MNCH, integrated FP, and malaria)

OBJECTIVE 2: HEALTH SYSTEMS FUNCTION EFFECTIVELY TO SUPPORT QUALITY HEALTH SERVICES

Major Q2 activities and achievements

Objective 2.1 Service quality at the community and CSB is maintained through appropriate management, governance, supervision, oversight, and motivation mechanisms

● Prepared reporting tools and technical documents to support the Equipes de Management de Région (EMARs) and the Equipes de Management de District (EMADs) in monitoring the activities of Comités Communaux De Développement De Santé (CCDS), and Comités De Santé (COSAN). The ACCESS team began initially drafting these management tools, and will work with the MOPH to design and validate them in Q3.

● With the MOPH, adapted the Program for Organizational Growth, Resilience, and Sustainability (PROGRES) tool to the Malagasy context. PROGRES is a tool and process for an organization or unit to self-assess its capacity and performance according to international norms and standards. The tool has been used in many other countries, including in Madagascar under the USAID Mikolo Project. To adapt it to the Malagasy MOPH, certain changes needed to be made. For example, given the major challenges in the continuous availability of health commodities and the importance of the communication within and between different levels of the health system, integrated management of drugs and supplies and social and behavioral change were added as mandatory components of the tool. ACCESS plans to roll out the PROGRES tool in four MOPH directorates in the coming months: the Direction de Soins de Santé de Base (DDSB), the Direction de l’Etude de la Planification et du Système d’Information (DEPSI), the Direction de la Pharmacie, des Laboratoires, et de la Médecine Traditionnelle (DPLMT), and the PNLP.

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● Oriented ACCESS staff on the Leadership Development Program (LDP). ACCESS shared the concept of the LDP and its different steps with program staff and helped the team understand how it will help improve the management and implementation of health programs in Madagascar. ACCESS plans to work with the MOPH to adapt the LDP to Madagascar in Q3, and will initiate LDP implementation in Q3 and Q4 of FY19 with the DDSP, the DEPSI, the DPLMT, and the PNLP units of the MOPH.

● Initiated the adaptation of the Fully Functional Service Delivery Point (FFSDP) for Madagascar. ACCESS began a review of the FFSDP quality standards in the context of Madagascar’s current norms and standards. ACCESS plans to share the approach and discuss the needed adaptations with the MOPH in Q3, and aims to roll out FFSDP implementation in FY20, after it has been validated by the MOPH.

● Joined the National Committee on Maternal and Neonatal Health to revitalize the maternal death review (audit) committees. ACCESS participated in meetings led by the MOPH’s Maternal and Neonatal Health Committee in order to support the establishment and scaling up of the death reviews (audits) at the national, regional, and district hospital levels in FY19.

Objective 2.2: Quality data is available at the CSB and district level, is used for decision making, and is integrated into the national HMIS

● Analyzed mHealth application use data. Under the USAID Mikolo Project, 600 users were trained in the CommCare mHealth application (385 of the 600 users are in ACCESS regions). In Q2 FY19, ACCESS conducted an analysis of application use by the 600 users between March 2018 and March 2019, when there was no project support provided to the initiative (USAID Mikolo activities had ended; ACCESS mHealth activities had yet to begin). The assessment found that over 60% of the 600 users are still actively using the application, with a rate of data completeness between 78 and 84%, and data timeliness between 68% and 79%. ACCESS also conducted a focus group with 11 users (9 CHVs, 1 CSB Chief, and 1 EMAD) in the commune of Anjeva Gara to collect their feedback, which will help inform application scale up strategies during ACCESS. ACCESS also began to contact the 40% of inactive users to re-engage them and encourage continued use.

● Worked with MOPH to identify community-based health information system (HIS) needs, particularly using mobile technology. ACCESS attended a meeting with the former Direction des Systèmes d'Information (DSI), Direction de la Veille Sanitaire et de la Surveillance Épidémiologique (DVSSE), and Direction de l’Etude et de la Planification (DEP) directors to compile their feedback on the draft CommCare expansion plan. These meetings continued with the new DEPSI and Direction de Veille Sanitaire, Surveillance Épidémiologique, et Riposte (DVSSER) directors. The main needs identified were to provide access to disaggregated and individual-level data beyond the aggregated data that CommCare already provides via the District Health Information System II (DHIS-2); to transition the storage of data to a MOPH CommCare instance after five years (when the ACCESS Program ends), resulting in the cancellation the monthly Dimagi subscription cost; to integrate content and modules into the application to support community-based surveillance; and to explore the possibility of generating offline short message service (SMS) alerts from CommCare (which would facilitate offline data reporting when CommCare users do not have internet access). ACCESS has incorporated these needs into the mHealth planning documents (scale up and SECOND QUARTERLY REPORT ACCESS PROGRAM PAGE 14

sustainability plans), and the program has also initiated a costing analysis of the CommCare initiative.

● Supported MEASURE Evaluation and the MOPH in the development and implementation of a standardized system in which data reports are harmonized at the community level. The MOPH requested ACCESS’s technical assistance in revising the community monthly activity report (RMACom). The validation workshop is being planned with Mahefa Miaraka and DEPSI for Q3, in parallel with the technical review of and update to the relevant community registers.

● Provided support to train the Direction de la Promotion de la Santé (DPS) and six Services de District de Santé Publique (SDSPs) in Boeny on the utilization of DHIS-2. ACCESS supported the training of HIS managers and data clerks in the DPS and six SDSPs (Mitsinjo, Soalala, Mahajanga I, Mahajanga II, Ambato Boeny, and Marovoay) of Boeny region (where Mahefa Miaraka is not present) in DHIS-2. This activity is part of the scaling up of DHIS-2 to improve the quality, timeliness, and completeness of data to make the information accessible in real-time and usable by all actors for effective decision-making. As a result, the DPS and SDSP teams in Boeny are able to analyze and use the data entered into DHIS-2. The teams of the four SDSPs not supported by Mahefa Miaraka were also equipped with a modem and credit from ACCESS to allow them apply the acquired skills and be operational immediately.

● Conducted an assessment of information technology (IT) equipment (smartphones, computers, etc.) and infrastructure (ie connectivity) in all 13 program regions, the results of which will inform the program’s strategy for support to the MOPH’s HIS.

● Joined the monthly HIS working groups. ACCESS actively participated in and contributed to monthly coordination meetings with implementing partners, which mainly focused on the processes for strengthening Madagascar’s HIS.

● Participated in the development and implementation of the DHIS-2 Management and Transition Plan and the electronic integrated disease surveillance and response (IDSR) module with the DVSSER, PSI, and MEASURE Evaluation. The integration of disease surveillance into Madagascar’s DHIS-2 is an integral part of strengthening the national HIS. The transition pilot phase supported by PSI proved successful, and the transition of the management of the disease surveillance platform to the DVSSER is currently ongoing.

● Supported the revision and finalization of DHIS-2 parameters. Following an initial testing of the DHIS-2 MOPH instance, there were a number of findings and configuration issues identified by users of DHIS-2 (formula errors, absence of usual indicators related to RMAs, etc.). Consequently, the DEPSI team organized a meeting to identify solutions. ACCESS offered technical assistance to the DEPSI team to help resolve many of these issues.

● Contributed to a workshop for developing an epidemics preparedness and response monitoring and evaluation (M&E) plan, adapted to the context of IDSR. The workshop was hosted by the DVSSER and MEASURE Evaluation to develop the M&E plan to ensure that the monitoring of the IDSR strategic plan and relevant IDSR data are collected and submitted through the HIS. The key points discussed during the workshop include M&E in the context of SMIR, the outline of the M&E Plan, and the required operational tools. SECOND QUARTERLY REPORT ACCESS PROGRAM PAGE 15

● Participated in a training on the Lives Saved Tool (LiST). ACCESS joined USAID’s implementing partners on a training on the use of the LiST modelling tool, which resulted in the production of national and sub-national analyses for Madagascar. The analysis of the LiST indicators will help USAID and its partners estimate the impact of interventions supported through USAID-supported projects (ACCESS, IMPACT, Vector Link, Mahefa Miaraka, MCSP) and to measure the results of health and nutrition interventions on maternal, child, and newborn mortality.

● Contributed to the development of the MOPH’s February and March surveillance bulletins. ACCESS worked with the MOPH on content development, particularly in relation to analysis of data during the measles outbreak.

● Participated in trainings on performance-based financing (PBF) conducted by the National Technical Coordination Cell (CCNT) of PBF in the district of Vohipeno. The ACCESS team in Vohipeno will now be able to assist the district’s six CSBs in PBF implementation, supported by the World Bank through the PARN Project. While ACCESS does not directly support these PBF activities, other aspects of the PBF process are complementary and relevant for the program’s activities, including culture of performance monitoring, data processing and use, teamwork, and accountability. ACCESS’s innovative approaches (LDP, PROGRES, and FFSDP) will help EMADs and health facilities reach PBF targets. Monthly coordination meetings between ACCESS and the CCNT will begin in Q3.

Objective 2.3: Health commodities continuously available at CSBs and CHVs

● Worked with the MOPH and the IMPACT Project in strengthening the public sector supply chain. ACCESS assisted the MOPH and IMPACT in defining improved mechanisms to transport pharmaceutical and health commodities from the Pharmacie de Gros du District (PhaGDis) to the CSB level, and established primary information on the availability of key commodities in ACCESS intervention districts. Currently, HIV, TB, and malaria commodities—including artemisinin-based combination therapy and rapid diagnostic tests— are not included in the FAMOME system. That means that while these products arrive at the PhaGDis level free of charge, there currently is no budget to pay for their transportation the CSBs. This problem contributed to the frequent stockouts seen at CSB and CHV levels. With support from ACCESS and IMPACT, the Unité de Gestion des Programmes of the MOPH agreed to provide a standard fee per kilogram per kilometer to cover the cost of transportation of these products. The mechanism is in the implementation phase.

● Participated in a meeting organized by the European Union (EU) for the mapping of Partenaires Techniques et Financiers (PTF) interventions for the management of health commodities. The aim of this mapping exercise was to identify gaps in health commodity management and supply chain, in order to help guide future EU activities.

● Provided technical assistance to the PNLP in the preparation of malaria program data to be presented to the Global Fund. The March 28 meeting with the Global Fund focused on identifying the reasons behind over- and under-stocked malaria commodities at the central and district levels between December 18, 2018 and February 19, 2019. During this time, the central level experienced stock outs, whereas the district levels reported overstocks. This meeting discussed the reasons for this, and resulted in a commitment to hold a quantification workshop to avoid further stock-out and overstock situations. SECOND QUARTERLY REPORT ACCESS PROGRAM PAGE 16

● Started planning initial data collection for the feasibility study for the transport of health commodities/pharmaceuticals with drones. In Q2, ACCESS drafted a list of indicators and data points to be collected for this feasibility study. The assessment, which will begin in April 2019, will be focused on community-level stock outs, similar drone experiences in Madagascar, and necessary protocols and regulations.

Challenges

● The restructuring of the MOPH delayed the start of some ACCESS activities, including the adoption and introduction of PROGRES and LDP. The ACCESS team is collaborating closely with the new MOPH teams and still plans to roll out PROGRES and LDP activities in FY19. ● This restructuring of the MOPH also resulted in a delay in validating the RMACom, which slowed down the introduction of the Community DHIS-2 instance and data collection. ACCESS anticipates that the DEPSI will validate the RMACom in Q3. ● Community-level surveillance data is not routinely being reported into the DVSSER data management system, hence the reporting rate of community surveillance data remains almost zero. One solution proposed is to integrate a disease surveillance module into the CommCare application, which will automatically upload data into the national HIS server. ● The remoteness of some CSBs, the problems encountered with the completeness of necessary supporting documents, and the non-admissibility of some of the supporting documents provided has resulted in delays and blocking of payments for the transport health commodities, which could have major consequences to the supply chain (including stock-outs of malaria commodities at CSB and CHV levels). To overcome this challenge, ACCESS will work closely with the IMPACT team and the Procurement Supply Management Committees at the district level to track order placements of health commodities by CSBs to PhaGDis. ACCESS will also ensure the supply of logistics management tools for CSBs and CHVs in order to ensure quality commodity data is being reported on time. ● MOPH understaffing at the district level has resulted in delays in entering data into GESIS, which is contributing to low data completeness levels at district, regional, and central levels. Furthermore, during the transition period between the GESIS and DHIS-2, MOPH staff have to enter data into both GESIS and DHIS 2, further compounding the data entry challenges. To overcome this challenge, ACCESS is supporting the DEPSI to activate the current version module of RMACom into DHIS-2, which helps the SDSPs to better capture community-level data.

Major activities planned for Q3

In Q3, ACCESS will: ● Initiate PROGRES implementation within four MOPH directorates. ACCESS will first present the PROGRES tool to the MOPH and demonstrate how it works. Then, the program will collaborate with the technicians to refine it, make sure the content is relevant to the context of the four target directorates (DDSB, DEPSI, DPLMT, and PNLP), and adapt the materials and training tools. Finally, ACCESS will assist the directorates in performing their assessments, identifying areas for improvement, and developing corrective action plans. ● Finalize the adaptation of the LDP. ● Present ACCESS’s plans to redynamize maternal death reviews (audits) in national committee strategy meetings.

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● Orient CCDS and COSAN on their roles and responsibilities in the implementation of the National Health Policy and PNSC. ● Complete the adaptation of the FFSDP and seek approval from the MOPH to roll out and scale up the tool in FY20. ● Conduct a scoping mission in the ACCESS intervention regions to develop a roadmap for the implementation and scale up of CommCare interventions over the life of the project. ● Hold working sessions with the DEPSI and DVSSER technical teams to understand the DHIS-2 roadmap and interoperability with CommCare and further define the needs for health surveillance and electronic community surveillance. ● Conduct a two-day training on the CommCare application development with MOPH technical staff. ● Continue to support the transition of the management of the disease surveillance platform to the DVSSER. ● Participate in the evaluation of the pilot study conducted by PSI on the use of DHIS-2 for the surveillance of 28 priority diseases. ● Support the MOPH to make management tools available at CSB and community levels. ● Train PhaGDis in the integrated management of health inputs. ● Initiate the drone feasibility study. ● Support the DEPSI on the workshop to validate RMACom.

OBJECTIVE 3: THE MALAGASY PEOPLE SUSTAINABLY ADOPT HEALTHY BEHAVIORS AND SOCIAL NORMS Major Q2 activities and key achievements

Objective 3.1: The Malagasy people demonstrate knowledge and practice of healthy behaviors

● Supported the MOPH in the development and validation of several SBC communication plans, including malaria and maternal and child health. In particular, the MOPH organized a series of meetings in order to publish the Malaria Communications Plan 2019-2022. The first occurred between January 7 and 9 and focused on content development. The second and third both occurred in late January with the aim of validating the Plan. After this, ACCESS provided feedback and additional research documents to help strengthen the communications strategies. The document will be validated in Q3. ACCESS also suggests supporting each region to develop a region-specific operational plan to realize the communication plan.

In Q2, ACCESS also contributed the validation of the Maternal and Child Health Communications Plan and the National Policy on Youth Health. These plans and strategies will help guide ACCESS’s social and behavior change (SBC) strategies.

● Assisted the MOPH in organizing World Health Days. World Health Days provide ACCESS the opportunity to sensitize the public on a national scale on important health issues, work in close coordination with the MOPH, and collaborate with other implementing partners. Specifically during Q2, ACCESS supported the MOPH in the organization of International Women’s Day, which was celebrated on March 8 in Mahjanga. At this event, ACCESS had a stand where the team presented on the program’s activities and strategies. Moreover, ACCESS assisted in the planning of World Health Day, World Malaria Day, and Maternal and Child Health Week, which will all occur in Q3.

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● Supported the MOPH in the revitalization of the 910 hotline/call center and the MOPH’s Facebook page. The hotline and the Facebook page were mainly revitalized as a way to reach the population about important information regarding measles prevention and management during the outbreak. ACCESS conducted a training with the MOPH on managing both the hotline and the Facebook page and how to maximize their impact during a national epidemic. ACCESS’ support included ensuring that accurate and correct messaging was being communicated to the public through these channels.

Objective 3.2: Communities and institutions support healthy behaviors

● Began implementing water, sanitation, and hygiene (WASH) activities. ACCESS prepared tools for Clean Clinic Approach trainings and introduced the program's WASH activities to the Regional Directorate of the Ministry of Energy, Water, and Hydrocarbons in the regions of Diana, Boeny, and Analanjirofo. The Clean Clinic Approach workshop is being planned with the MOPH and is slated for Q3.

● Developed an implementation strategy for Community-Led Total Sanitation (CLTS) and Community-Led Total Nutrition (CLTN). After orienting ACCESS staff to the CLTS and CLTN approaches, the program began developing the strategy and implementation guidelines for CLTN and CLTS, which will be rolled out beginning in Q3.

Objective 3.3: Barriers to healthy and health-seeking behaviors for the poor and underserved populations are reduced

● Developed the operational plan and budget for Savings and Internal Lending Communities (SILC). SILC activities were moved from Catholic Relief Services (CRS)’s scope of work to MSH’s. This process necessitated a review of the SILC FY19 workplan, as well as its associated budget.

● Participated in two meetings with Banyan Global on Development Credit Authorities (DCAs). Through DCAs, SILC groups, CHVs, and CSBs could have greater access to credit opportunities, increasing their motivation and quality of service delivery. This strategy will continue to be discussed in Q3.

● Held working sessions to begin discussing SILC-related cash transfers using mobile phones. This meeting included staff from ACCESS, CRS, Dimagi, and the Network of Savings Groups Promoters in Madagascar. At the end of the meeting, in which SILC groups and mobile money processes were discussed, it was decided that Dimagi would share a concept note for a possible pilot in April.

Challenges

● A challenge faced in Q2 was determining the best way to decide in which intervention areas SILC and CLTS should be focused in order to achieve maximum coverage of interventions and to ensure complementarity between other projects and stakeholders. ● ACCESS is also determining how best to integrate WASH and nutrition interventions into other program activities. This will be addressed through coordination and strategy development workshops in Q3.

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Major activities planned for Q3

In Q3, ACCESS will: ● Organize six (6) major workshops: 1. An SBC inventory workshop to identify all resources and materials available for each health area; 2. A Health Champion Workshop with the MOPH and other implementing partners to discuss, update and revise the Champion Household, Commune, and Fokontany approaches, as well as the possibility of adding Champion Providers and Gender Champions; 3. A Youth Summit, in order to help develop a youth SBC strategy; and 4. A National Leadership and Innovative Approaches in Strategic Communications for Public Health workshop, which will engage the MOPH (DPS and Service de la Communication et Media [SCM]) at the national, regional, and district levels as the leaders of communications strategies. Following this workshop, ACCESS will work with the MOPH DPS to develop the overarching SBC strategy, including the identification of segmented target audiences, key messages to be disseminated and the channels to be used to promote health behaviors among target audiences. 5. Organize a national workshop and trainer of trainers on the Clean Clinic Approach. 6. Hold workshop to develop a SILC health promotion strategy. ● Organize a Malaria Scientific Conference to celebrate World Malaria Day. ● Participate in World Health Day celebrations. ● Update and order SBC tools and job aids for CHVs. ● Finalize and validate the CLTS and CLTN strategies. ● Purchase materials for WASH infrastructure and initiate Computer Aided Design activities in preparation for latrine construction.

MEASLES OUTBREAK RESPONSE After noting a sudden spike in measles cases throughout the country in September and October 2018, the MOPH officially declared a measles epidemic on October 26. As of the end of March, 140,935 cases of measles have been recorded, which have resulted in 902 deaths.

The MOPH organized a response plan and mobilized partners to help implement priority response efforts, including a series of vaccination campaigns targeting children aged nine months to nine years in 107 out of Madagascar’s 114 districts. Two of these campaigns occurred in Q2 FY19. ACCESS’s main responsibilities during this quarter were to support the MOPH in the technical, operational, and financial implementation of the response plan.

Major Q2 activities and key achievements

● Vaccination Campaigns. The first campaign took place between January 14 and 18 in 25 high-priority districts in 13 regions. ACCESS participated in the supervision of the campaign in five districts: Toamasina I, Toamasina II, Toilara I, Marovoay, and Mahajanga I. This support from ACCESS included on-site supervision of vaccinators, sensitizing parents to the vaccination, meeting with parents and schools who refuse to have children vaccinated, orienting social mobilizers, participating in advocacy meetings with those responsible for local television and radio programming, and transporting vaccinators.

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ACCESS also participated in M&E activities, including data collection, validation, and analysis. Logistically, ACCESS provided nine vehicles for the transportation of four MOPH supervisors and five ACCESS supervisors. ACCESS also transported vaccines, other commodities, communications materials, and management tools, according to the needs of the five districts. During this first campaign, 299,164 children aged nine months to nine years old received a measles vaccine in the five districts of ACCESS intervention, achieving a 94% coverage rate for those districts.

The second campaign occurred between February 18 and 25 in 17 districts across Atsimo Andrefana, Androy, and Diana. ACCESS ensured the transportation of vaccines from the district level to community level for 176 CSBs in the 104 communes of all eight districts of Atsimo Andrefana. During this campaign, 1,184,450 children aged nine months to nine years old received a measles vaccine in the 17 districts of ACCESS intervention, achieving a 102% coverage rate for those districts (population data [the denominator in this rate calculation] is based on projections and was underestimated by the MOPH).

● Surveillance. Beginning in January, ACCESS, as part of the Surveillance Committee, focused on assuring the quality of data shared in the weekly measles bulletin. This has been achieved by automating compiled data for fast and efficient processing. ACCESS also proposed to separate the data of the 25 campaign districts in order to conduct post-campaign monitoring. Furthermore, ACCESS created a projection for the evolution of simple and complicated measles cases over the next three and six months, including forecasting commodity needs.

Additionally, in three regions--Atsinanana, Atsimo Andrefana, and Vatovavy Fitovinany-- ACCESS coordinated with EMARs and EMADs on reinvigorating and motivating mayors, CSB chiefs, Fokontany leaders, and CHVs to conduct routine health surveillance activities and to immediately report suspected cases. These routine surveillance activities are part of the national system set up by the DVSSER for timely reporting of cases and events related to 28 target diseases at the CSB level. ACCESS specifically reinvigorated the system during the measles epidemics, and supported actors at all levels of the health system to report the “line list” according to the national guidelines.

As soon as the community monitoring system is well defined, ACCESS will work with the EMADs and EMARs in these regions to engage and re-activate disease monitoring committees at the community and Fokontany levels (CVCs and CVFs, respectively), which were set up and supported, with USAID Mikolo assistance, during the 2017-2018 pneumonic plague outbreak. These committees served as an important component of community-level surveillance and helped with identifying, treating, and preventing cases of plague. ACCESS will help expand their mandate to cover the nationally required notification package, including death, symptoms of cholera, meningitis, plague, and risk of food poisoning, rabies, zoonosis, and flaccid paralysis, as well as other unusual events. They will be trained on an approximately three to five day curriculum to be developed in coordination with the DVSSER. ACCESS will integrate this activity into the national disease surveillance strategy and use the CommCare application.

ACCESS also provided assistance to preparatory activities for measles death audits, which will occur in April 2019. The audits will include verbal autopsies at the community level, and will be jointly conducted with a team from the Case Management Commission.

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● Case management and treatment. ACCESS provided advice to the MOPH and partners on the need to share the causes of death at the hospital and health center levels to better understand the situation and to strengthen the measles case management capacity of providers.

Furthermore, ACCESS, with the heads of the Expanded Programme on Immunization (EPI) activities at the Directions Régionales De La Santé Publique (DSRPs), collected and submitted data regarding measles cases and stock levels every two days in order to support national-level efforts to review and manage the supply chain for measles commodities. ACCESS, along with IMPACT, also supported EMADs in cold chain management for planning vaccination campaigns and routine vaccination activities.

At the beginning of March, ACCESS supported EMARs and EMADs in budgeting for measles-related trainings that will be carried out in all of Madagascar’s 22 regions in Q3.

● Community mobilization. As part of the Social Mobilization Committee for the response to the measles outbreak, ACCESS participated in the establishment of five sub-committees: media and press, rumor mitigation, school strategy (and other sectors), community mobilization, and communication support. ACCESS supported the finalization of the response communication plan. Since January, ACCESS participated in the technical development and validation of television and radio spots about measles prevention and treatment, and financed the diffusion of 384 television spots about the measles campaign on four national and local channels.

In Q2, ACCESS also worked with the MOPH to reinvigorate the 910 hotline (a phone number people can call to receive information about prevention and treatment of measles), and the MOPH’s Facebook page. On February 8, ACCESS supported an emergency training with 18 responders on correctly answering hotline caller questions and concerns about measles. Between March 4 and 7, ACCESS supported a workshop for developing training manuals for these informational platforms.

ACCESS worked with the MOPH and implementing partners to develop training tools for measles response actors at the regional, district, and community levels. The elements included in these materials are clinical signs and symptoms, modes of transmission, prevention efforts, health behaviors, referral information and forms for identified or suspected cases, and monitoring and reporting on activities and cases. Finally, ACCESS supported the Committee in developing informational materials designed specifically for parents about measles, the vaccination, and dispelling rumors.

Major activities planned for Q3

In Q3, ACCESS will: ● Support the implementation of the third vaccination campaign. ● Continue to provide technical leadership to the national steering committee and to the national commissions: Surveillance, Case Management, Epidemic Response, Logistics, Community Mobilization, and Communications ● Work with the MOPH and other implementing partners to improve community-, district-, regional-, and national-level outbreak surveillance and preparedness systems. In particular, ACCESS will: SECOND QUARTERLY REPORT ACCESS PROGRAM PAGE 22

● Evaluate the campaigns’ effectiveness in controlling the epidemic. ● Participate in a Think Tank focused on improving routine vaccination activities. ● Contribute to a post-campaign survey within a month after this last campaign. This survey will provide an independent verification of immunization coverage. ● Support districts that need further assistance in controlling the measles epidemic. A joint MOPH and ACCESS team will travel to the districts to conduct surveillance activities and contribute to additional prevention and control measures. ● Continue to support the DVSSER in the transition of DHIS-2 surveillance activities. ● Develop a document containing all communications strategies implemented during the campaigns.

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MONITORING, EVALUATION, AND LEARNING (MEL)

Major Q2 activities and key achievements

● Development of the MELP. Based on feedback received from USAID in January 2019 following the submission of the MELP on December 27, 2018, ACCESS finalized and submitted the program’s MELP to USAID on March 1st, which was approved by USAID on March 7th. This included the M&E Plan, PMP indicator table, and the Performance Indicator Reference Sheets (PIRS). The program started developing guidelines and tools for the orientation and the roll out of the MELP to ACCESS staff at national, regional, and district levels.

● Initiated activities to setup the program’s DHIS-2 instance. The ACCESS DHIS-2 instance will include data elements from monthly activity reports from CHVs (RMACom), CSBs, and district hospitals. ACCESS plans to pull data needed for Project reporting to USAID directly from the MOPH’s DHIS-2 instance through an automatic process in order to avoid a parallel system. For data elements that are specific to the program and not already a part of the MOPH’s DHIS-2 instance, ACCESS will enter the data directly into program’s DHIS-2 instance.

● Developed a draft of the program’s baseline study and related tools. ACCESS will establish a baseline related to indicators in the PMP table. Targets will be set for many service delivery indicators in the PMP once the baseline data has been collected. The purpose of this baseline study, which will begin in Q3, is to define the points of reference from which the performance of the program will be measured, as well as to define realistic targets for the life of the program. The results of the study will also allow ACCESS to better define the program’s interventions and target areas by identifying what gaps exist where.

The study will include the collection of routine service statistics, as well as a mapping and inventory at the health facility and district levels; Knowledge, Attitudes, and Practices (KAP) surveys; client satisfaction surveys; health provider and CHV capacity assessments; and focus group discussions at community level. Data collection will begin in April and continue through June. A final report will be ready before the end of the fiscal year, with targets being integrated into the Project’s PMP.

Major activities planned for Q3

In Q3, ACCESS will: ● Finalize MEL tools and standard operating procedures. ● Roll out ACCESS' MELP, including staff orientations ● Finalize indicator targets for the indicators that are part of routine service statistics. ● Finalize baseline study protocol and tools. ● Issue a request for proposals for data collectors. ● Start baseline study implementation. ● Set up the ACCESS DHIS-2 instance.

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COMMUNICATIONS

Major Q2 activities and key achievements

● Created the program’s logo. ACCESS designed its official logo in close collaboration with USAID’s communications team to integrate the various aspects of the program’s interventions and impacts, and to create a unique identity.

● Created and promoted online channels. ACCESS created its Instagram page and YouTube account. Instagram is a social media platform that will help increase the project’s visibility with a rich photo gallery illustrating field interventions and impacts on target populations. The YouTube channel will be dedicated for video publications, which are instrumental for visual communications. Instagram page: https://www.instagram.com/usaidaccessprogram/ YouTube channel: https://www.youtube.com/channel/UCUtMuZEFVdsLOwuRqPLCaEg

● Developed communications materials. In Q2, ACCESS developed and designed its project factsheet, a two-pager that summarizes the key objectives and the technical approaches that will be implemented in the program’s target areas. ACCESS also produced rollup banners, oriflammes, and signs to maximize its visibility, especially during special events, meetings, and conferences.

● Promoted the program’s activities and celebrations of health days online. In Q2, ACCESS promoted various events on its social media pages, in coordination with USAID Madagascar and MSH’s communications team. The main health days included International Women’s day (March 8) and World Water Day (March 22).

Major activities planned for Q3

In Q3, ACCESS will: ● Organize and promote the project launch with USAID. ● Organize and promote a malaria scientific conference with the MOPH’s malaria control program and the President’s Malaria Initiative (PMI). ● Increase the program’s visibility with additional materials that include polo shirts, caps and vests for the staff, and signs and banners for regional and district offices ● Create and promote the ACCESS website. This activity has been scheduled for Q2 but has not yet been achieved due to procedural requirements and a delay in the production of the content. ● Finalize the program’s strategic communications plan. This activity has not yet been achieved yet, as the situational analysis to assess the current communications context and environment is still ongoing. ● Launch the development of a photo gallery. A photo hub will be created and shared with USAID for various communications needs, including the production of photo essays that depict the program’s interventions and health hero stories.

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MANAGEMENT

STAKEHOLDER MEETINGS AND TECHNICAL ASSISTANCE

Major Q2 activities and key achievements

● Participated in coordination and collaboration meetings with various stakeholders, including:

o Monthly meetings with the program’s Agreement Officer Representative o Presentation of ACCESS to USAID Implementing Partners (IPs) at the Hotel Carlton in February. o Introductory meetings with the MOPH, including the Minister of Public Health (with USAID), the MOPH Secretary General, and teams from the two Directors General (Preventive Medicine and Health Facilities). o Partner coordination meetings with Mahefa Miaraka, RANO WASH, IMPACT, MCSP, Mikajy, Peace Corps, the European Union, and InterAide. o The PMI quarterly meeting, which was hosted by ACCESS.

● Held the ACCESS Orientation and Alignment Workshop in February. ACCESS hosted an intensive five-day orientation workshop in Antananarivo between February 11 and 15. Over 100 people participated in the workshop, including ACCESS district-, regional-, and central- level staff; representatives from the ACCESS consortium partners (except Dimagi and Stony Brook University); and USAID and MOPH staff. The goals of the workshop were to align the team around a shared understanding of ACCESS goals, objectives, and technical strategies and approaches; jointly formulate a common vision and agree on operating principles; and orient the team to United States Government rules and regulations, including Protecting Life in Global Health Assistance, Thiart, procurement integrity, financial management, and others. This five-day off-site workshop was followed by two weeks of more in-depth technical orientations and planning at the ACCESS central office in Antananarivo.

● Hosted several short-term technical assistance (STTA) visits. The following STTAs occurred in Q2:

Organization Name Dates SOW

MSH Elke Konings January 27- ● Provide high-level technical support and February 16, supervision to the program 2019 ● Contribute to the ACCESS Orientation/Alignment workshop

MSH Aishling January 18- ● Contribute to ACCESS start-up activities Thurow February 16, ● Provide technical support to the 2019 production of the FY19 Q1 report ● Support the implementation of the Orientation/Alignment workshop

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MSH Laurence February 9- ● Contribute to the Orientation/Alignment Laumonier- March1, 2019 workshop and in-depth technical Ickx orientations of ACCESS staff

ACNM Kate McHugh February 7-20, ● Provide orientations and trainings on 2019 ACCESS’s clinical capacity building approaches

ACNM Renee February 7-21, ● Provide orientations and trainings on Fiorentino 2019 ACCESS’s clinical capacity building approaches

ACOG Gillian February 11- ● Provide orientations and trainings on Burkhardt 21, 2019 ACCESS’s clinical capacity building approaches

AAP Carlos Ramos February 11- ● Provide orientations and trainings on 19, 2019 ACCESS’s clinical capacity building approaches

JHU-CCP Shannon February 2- ● Provide orientation on ACCESS’s SBC McAfee February 16, approach and tools 2019

JHU-CCP Heather February 2- ● Provide orientation on ACCESS’s SBC Forrester February 22, approach and tools 2019

Major activities planned for Q3

In Q3, ACCESS will: ● Host, along with USAID and the MOPH, the program’s official launch in Antananarivo. ● Continue hosting and participating in routine meetings with the MOPH and other IPs to ensure harmonized activity implementation. ● Begin process for developing the FY 2020 Annual Workplan. ● Visiting Regional Offices of the Project and conducting supervision visits to the field.

HUMAN RESOURCES

Major Q2 activities and key achievements

● Recruitment of central-level office staff. Recruitment of staff for the Antananarivo office was in the final stages by the end of Q2, with only five positions remaining to be filled. All key personnel and senior staff positions were filled by end of March 2019.

● Ongoing regional- and district-level Recruitment. ACCESS made significant progress in Q2 in the recruitment of staff for the 13 regional offices. All regional offices have representatives and senior staff working with the regional MOPH counterparts. In total, 82 staff were hired by the end of March, with an additional 44 expected to be hired by Q3.

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● Orientation and onboarding at all levels. The human resources team has conducted orientation and onboarding sessions on a rolling basis with new staff arrivals in Q2, and will continue to do so in Q3.

● USAID Certifications. In Q2, all ACCESS Program staff completed their certifications in “Protecting Life in Global Health Assistance and Statutory Abortion Restrictions” and “United States Abortion and Family Planning Requirements.” These certifications have been recorded in both the human resources and the compliance program files. Major activities planned for Q3

In Q3, ACCESS will: ● Cascade district- and commune-level recruitment: as senior regional and district positions have been filled in Q2, ongoing recruitment and orientation of new staff will be conducted through a cascaded approach, where these regional and district staff will manage recruitment efforts with support from the central human resources team. This approach will rapidly scale up the recruitment of district and commune level positions. ● Ensure that all program employees complete the annual certification of the “Code of Business Ethics and Conduct.” This process is conducted in May of each year, and covers organizational policies on ethics, procurement integrity, anti-harassment, whistleblower protections, fraud, and corruption. ● Maintain all employee files in electronic format and on web-based platforms in both the Madagascar and United States offices. As with the office standards on financial and procurement documentation, this archiving approach is to ensure punctual compliance reviews and ensure availability of documentation in the future.

SUBCONTRACTS

Major Q2 activities and key achievements

● Fully engaged all ACCESS consortium partners. All ACCESS consortium partners were fully engaged and funded through Letters of Authorization (LoAs) by the end of Q2. Five sub-awards have been fully executed, with three sub-awards pending final signatures. All consortium partners with activities planned for FY19 Q2 were actively implementing their approved activities.

● Engaged PSI to manage mobile clinic operations. With the approval of the Mobile Outreach Clinic subcontract with PSI at the end of Q1, PSI began operationalizing mobile clinic activities in the seven approved regions in Q2.

Major activities planned for Q3

In Q3, ACCESS will: ● Initiate FY20 workplanning processes: all partners will be directly involved in the preparation and creation of the FY20 workplan for the ACCESS Program. This process will span both Q3 and Q4 of FY19. ● Conduct cost share training in Q3, focusing on eligible costs, documentation requirements, and verification processes for cost share reporting. Each consortium partner will be required to report on cost share on a quarterly basis.

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FACILITIES

Major Q2 activities and key achievements

● Fully operationalized the program’s central Antananarivo office. The ACCESS Program’s central office is fully operational. With the addition of the 4th floor office space, ACCESS has installed a fiber-optic internet connection to support program activities and communications.

● Established offices in all 13 program regions. In Q2, ACCESS successfully negotiated with the MOPH to embed 10 of the 13 regional teams in MOPH regional offices. The Ministry has highly appreciated the operational approach to integrate program and MOPH staff in the same working environment. In the three regions where there was not sufficient space in the MOPH regional office, ACCESS has rented office space.

● Began refurbishments of regional office space. In three of the 13 regions, where the space available in MOPH offices is limited to rooms or buildings that require minor repair, the ACCESS Program initiated contracts with local vendors to repair working areas for the ACCESS team. This renovation work will continue into Q3, but is not expected to expand into additional offices at the regional level.

Major activities planned for Q3

In Q3, ACCESS will: ● Continue to negotiate with the MOPH at the district level to embed program staff. As with the regional offices, it is possible that office space will be limited or require repair. In these cases, leasing office space and renovations of Ministry office space will be reviewed on a case-by- case basis. ● ACCESS will enter into agreements with each regional and district office where the program team is embedded and shares office space and services with the MOPH. This agreement will specify what costs will be borne by the program, and what costs or services will be provided by the MOPH office. These agreements will specify opportunities for cost share, as well as confirm that supporting documentation will be provided by the MOPH in order to verify and confirm the reported cost share expenses.

PROCUREMENT

Major Q2 activities and key achievements

● Fully furnished and equipped offices. The central office was fully furnished and equipped by the end of Q2, and procurements of computer equipment, furniture, supplies, and materials for each of the 13 regional offices were initiated. Delivery of goods was adjusted to meet individual office start dates and staffing needs, with some deliveries continuing into early Q3.

● Coordinated with USAID on the two-vehicle limit for duty free importation. The ACCESS Program met with USAID in March 2019 to discuss the constraints encountered by the program related to the two-vehicle limit for duty free importation of vehicles set by the Government of Madagascar. Given the need to procure 11 vehicles in FY19, and an additional 14 scheduled for procurement at the end of FY20, this two vehicle limit requires the ACCESS Program to support program activities through the use of long-term rental of

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vehicles. USAID has confirmed that this issue is well known, and that USAID will initiate diplomatic discussions with the government of Madagascar to resolve the issue. As agreed with the USAID team in the March meeting, the ACCESS Program will request USAID approval in Q3 for long-term transportation services contracts with local vendors in order to maintain program activities until the issue has been resolved.

Major activities planned for Q3

In Q3, ACCESS will: ● Initiate large procurements of both goods and services for technical activities. These procurements include data collectors for the baseline survey and equipment for digital health activities. In addition, the bulk procurement of CHV supplies and materials will be completed before the end of Q3. ● Expand the present electronic request and approval system to include the segregation of duties between procurement team members in the various offices. This approach will accelerate and ensure compliance of procurements in the regional offices, through remote review of competition and vendor selection in offices where operations staff are limited. ● Submit documentation for customs clearance for the two duty free vehicles to USAID. ● Request approval from USAID in Q3 to procure 60 motorcycles to support activities in remote and rural areas.

OPERATIONS AND FINANCE SYSTEMS

Major Q2 activities and key achievements

● Established operations and finance systems at the central level. During Q2, all ACCESS operations and finance systems were established and finalized in the central office, according to MSH policy and USAID regulations. These systems will be expanded to the regional offices in Q3.

● Conducted compliance checks. The ACCESS Program’s Compliance Officer began compliance checks of ACCESS’s finance and operations systems in Q2. The results of these compliance checks have been used to finalize the Compliance Officer’s orientation and onboarding, and will be used to support a compliance review by MSH Internal Audit in mid- June 2019.

● Completed the Humentum anti-fraud course. During March 2019, the finance and administration managers and the Compliance Officer participated in the Humentum Anti- Fraud course. This training provided key lessons learned and tools for the identification of fraud, and the internal control systems necessary to mitigate the risk of fraud in development and humanitarian programs. This course will be provided to additional members of the team in Q3, and regional staff will be provided with an internal course based on the Humentum curriculum.

● Completed the inventory of the central office. Inventories of individual regional offices will be completed in Q3 on a rolling basis in order to finalize the program-wide inventory required for compliance reporting.

Major activities planned for Q3

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In Q3, ACCESS will: ● Conduct compliance reviews of financial and procurement transactions, as well as regional office operations in Q3. These reviews will include field visits, spot check verifications, and on-site verifications of technical activities. ● Regional offices will receive inventory training and conduct initial inventories of equipment and furniture assets in Q3. These inventories will be reviewed by central office operational staff and the Compliance Officer prior to inclusion in the final ACCESS Program Inventory.

FINANCIAL REPORTING

Major Q2 activities and key achievements

● Initiated Electronic Archiving of Financial and Procurement Transactions. In order to integrate the documentation and archiving needs of the finance and procurement teams, and to facilitate compliance reviews in Madagascar and globally, all finance and procurement documentation have been maintained on a web-based portal. This archiving approach was initiated during the first days of start up in order to ensure that document retrieval and compliance reviews can be done on a punctual basis in hand with financial reporting.

● Established bank accounts for regional offices. The ACCESS Program has created ten sub- accounts to the primary BNI account in Antananarivo, in order to maximize efficiency in funding transfers, account balance control, and centralized review of regional transactions. The three remaining regions will be reviewed over time to confirm whether financial activity is sufficient to merit individual accounts, or whether financial transactions will be managed from the central office.

● Trained regional staff on QuickBooks Online. All regional finance staff recruited have been trained in QuickBooks Online during Q2. The use of a web-based finance software allows for financial monitoring, capacity building, and compliance reviews in real-time. In coordination with the electronic filing and banking approaches listed above, the ACCESS Program will mitigate the risks of errors or fraud in financial reporting and documentation.

Major activities planned for Q3

In Q3, ACCESS will: ● Require regional office teams to formally request the future funding needs for their individual office on a monthly basis, with each monthly forecast separated into weekly or bi-weekly tranches in order to ensure that appropriate funding levels for regional activities are available in the regional bank sub-account. These accounts will be monitored, in tandem with the QuickBooks Online accounts, to ensure that excess funds are not maintained in the sub- accounts and that all expenses are appropriately documented. ● Require regional and district teams to coordinate phone and contact information for the MOPH and local partners who may participate in ACCESS Program activities. The central office team will manage a web portal with a mobile money provider to ensure that payments at the district and commune level (whenever possible) are made through mobile money transfers.

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SUCCESS STORY: MEASLES RESPONSE IN MAHJANGA I

During the second measles vaccination campaign implemented by the MOPH in 25 districts between January 14 and 18, one of the main challenges faced by the campaign teams was parents refusing to vaccinate their children due to fears about the vaccination, fueled by misconceptions and myths.

Rakotomanga Harisoa Farida, a mother living in Mahajanga I, was one of those parents. She heard a rumor that the measles vaccine will actually make the child sick, and, as a result, she would not let her two children get vaccinated.

With support from ACCESS, the MOPH campaign supervisors and vaccinators joined up with the children's school administrators, and, equipped with communications materials related to measles and the vaccine, met with Harisoa Farida and discussed the benefits of the measles vaccine and dispelled the myths and rumors that were causing her concern. After this conversation, she immediately brought her two children, aged seven and nine, to the nearest vaccination site to receive the measles vaccine.

These dialogues between the campaign Children being vaccinated against measles at the Public implementers and parents proved to be a Primary School in Amborovy, Mahajanga. successful strategy in increasing measles vaccination rates during the campaign. In fact, the Director of the Public Primary School in Amborovy gained the support of all parents, resulting in a 100% vaccination rate at his school.

This highlights the importance of inter-sectoral collaboration (in this case, between health actors and education actors) in implementing a successful vaccination campaign. Additionally, measles informational materials should be targeted to parents, and it is important to not only include information on the vaccine and its benefits, but also on dispelling common misconceptions and rumors.

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