DEFEAT MALARIA

DEFEAT MALARIA ACTIV ITY

QUARTERLY PERFORMANCE REPORT

FISCAL YEAR 2019 QUARTER 2 (JANUARY 1, 2019 TO MARCH 31, 2019) 2019 QUARTER 2 PERFORMANCE REPORT

Submission Date: April 30, 2019

Agreement Number: AID-482-A-16-00003 Agreement Period: August 15, 2016 to August 14, 2021 AOR Name: Dr. Feliciano Monti Submitted by: May Aung Lin, Chief of Party University Research Co., LLC. Room 602, 6th Floor, Shwe Than Lwin Condominium New University Ave. Rd., BahanTownship Yangon, Myanmar Email: [email protected]

CONTACT INFORMATION

Dr. May Aung Lin, Chief of Party, Defeat Malaria [email protected] Office Phone/Fax: + 95 1 559 593, + 011 220 658, Mobile: + 959 7324 1930 Dr. Saw Lwin, Regional Technical Director, Defeat Malaria [email protected] Office Phone/Fax: + 95 1 559 593, + 011 220 658, Mobile: + 959 5014 887

THIS DOCUMENT WAS PRODUCED BY UNIVERSITY RESEARCH CO., LLC (URC) FOR REVIEW AND APPROVAL BY THE UNITED STATES AGENCY FOR INTERNATIONAL DEVELOPMENT (USAID). DEFEAT MALARIA

Defeat Malaria is a USAID-funded project with the goal to reduce the malaria burden and control artemisinin- resistant malaria in the targeted areas, thereby contrib- uting to the long-term national goal of eliminating ma- laria in Myanmar. Defeat Malaria has four core objec- tives, including:

 Objective 1: Achieve and maintain universal cover- age of at-risk populations with proven vector control and case management interventions, while pro- moting the testing of new tools and approaches.

 Objective 2: Strengthen the malaria surveillance sys- tem to comprehensively monitor progress and in- form the deployment and targeting of appropriate responses and strategies.

 Objective 3: Enhance technical and operational ca- pacity of the NMCP and other health service provid- ers at all levels of service provision.

 Objective 4: Promote the involvement of communi- ties, private healthcare providers, private companies and state-owned enterprises in malaria control and elimination initiatives. DEFEAT MALARIA FY2019 Q2 OUTCOMES

Testing & Case Finding 61,817 people were tested for malaria Health Communication 46,468 people, including 7,422 of whom migrants, were reached through 721 were positive cases interpersonal communication

Total Positivity Rate: 1.17%

Treatment Completion Preventive Commodities

510 individuals were Distributed 80,515 LLINs enrolled in DOT treatment; to villages, worksites, and 97.8% of enrolled cases women attending completed DOT treatment ante-natal care clinics

Diagnostic and Treatment Commodities Capacity Building Distributed 114,175 RDTs 2,022 health workers and 8,144ACTs received refresher to Defeat Malaria storage trainings on malaria sites to safeguard diagnostics and case continuous and on-time management delivery of malaria health care services DEFEAT MALARIA QUARTERLY PERFORMANCE REPORT FY2019 Q2

Table of Contents ACRONYMS AND ABBREVIATIONS ...... II EXECUTIVE SUMMARY ...... 1 INTRODUCTION...... 2

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...... 4 OBJECTIVE 2: STRENGTHEN THE MALARIA SURVEILLANCE SYSTEM TO COMPREHENSIVELY MONITOR PROGRESS AND INFORM THE DEPLOYMENT AND TARGETING OF APPROPRIATE RESPONSES AND STRATEGIES...... 12 OBJECTIVE 3: ENHANCE TECHNICAL AND OPERATIONAL CAPACITY OF THE NMCP AND OTHER HEALTH SERVICE PROVIDERS AT ALL LEVELS OF SERVICE PROVISION ...... 15 OBJECTIVE 4: PROMOTE THE INVOLVEMENT OF COMMUNITIES, PRIVATE HEALTHCARE PROVIDERS, PRIVATE COMPANIES AND STATE- OWNED ENTERPRISES IN MALARIA CONTROL AND ELIMINATION INITIATIVES ...... 18 ANNEXES ...... 21

ANNEX 1: SITUATION IN RAKHINE STATE ...... 21 ANNEX 2: SUCCESS STORIES ...... 22 ANNEX 3: ENTOMOLOGICAL SURVEY ON PERSISTANT MALARIA TRANSMISSION METHODS AND FINDINGS ...... 25 ANNEX 4: CASE FINDING AND MANAGEMENT ...... 26 ANNEX 5-A: ACTIVE CASE DETECTION BY MOBILE TEAM (PROJECT VILLAGES) ...... 28 ANNEX 5-B: ACTIVE CASE DETECTION BY MOBILE TEAM (NON-PROJECT VILLAGES) ...... 29 ANNEX 6: MONTHLY MEETINGS ...... 30 ANNEX 7: SUPERVISION AND MONITORING ...... 32 ANNEX 8: REPORTING STATUS OF VMWS/PPS ...... 33 ANNEX 9: CLINICAL AUDIT ...... 35 ANNEX 10: STOCK OUT MONITORING AT THE TIME OF MONITORING VISITS ...... 37 ANNEX 11: CAPACITY BUILDING ...... 39 ANNEX 12: BEHAVIOR CHANGE COMMUNICATION ...... 41 ANNEX 13: ADVOCACY MEETINGS ...... 43 ANNEX 14: STRATEGIES TO ADDRESS MID-TERM EVALUATION RECOMMENDATIONS ...... 44 ANNEX 15: PERFORMANCE INDICATORS ...... 48

Figure 1: Geographic spread of Defeat Malaria activities in Myanmar as of March 2019 ...... 2 Figure 2: RDT Distribution from the Central Warehouse to State/Region and EHO (Jan-Mar 2019) ...... 4 Figure 3: ACT Distribution from the Central Warehouse to State/Region and EHO (Jan-Mar 2019) ...... 4 Figure 4: Reporting status of VMWs/PPs by State and Region ...... 8 Figure 5: Malaria testing and diagnosis by source for FY19 Q2 ...... 9 Figure 6: Routine Data Quality Assessment Status, Jan-March 2019 ...... 13 Figure 7: Foci Classification based on 2018 surveillance data ...... 15

Table 1: Project area coverage as of September 30, 2018 ...... 3 Table 2: Long lasting insecticide net (LLIN) distribution at villages (Jan-Mar 2019) ...... 6 Table 3: LLIN distribution at worksites (Jan-Mar 2019) ...... 6 Table 4: LLIN Coverage and Utilization by Defeat Malaria State/Region (Jan-Mar 2019) ...... 7 Table 5: Malaria testing by Defeat Malaria covered state/region (Jan-Mar 2019) ...... 9 Table 6: Findings of hsRDT study in Rakhine State ...... 11 Table 7: Malaria Elimination Capacity Building Training ...... 16

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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 ASTMH American Society of Tropical Medicine and Hygiene BCC Behavior Change Communication BHS Basic Health Staff BPHWT Back Pack Health Worker Team CBO Community based organization CDC Centers for Disease Control and Prevention COP Chief of Party cRDT Conventional rapid diagnostic test CSG Community Support Group C-sum Cumulative sum DHF Dengue Hemorrhagic Fever DMR Department of Medical Research DOT Directly Observed Treatment DQO Data Quality Officer EHO Ethnic Health Organization EID Emerging infectious diseases ELISA Enzyme-linked immunosorbent assay ESPT Entomological Surveillance Planning Tool FDA Food and Drug Administration FETP Field Epidemiological Training Program GMS Greater Mekhong Subregion hsRDT Highly-sensitive rapid diagnostic test ICMV Integrated Community Malaria Volunteers ICRC International Committee of the Red Cross IEC Information, education and communication INGO International Non-Government Organization IPC Interpersonal communication IRS Indoor Residual Spray ITN Insecticide treated net Jhpiego Johns Hopkins Program for International Education in Gynecology and Obstetrics KDHW Karen Department of Health Welfare KNU Karen National Union LLIN Long-lasting insecticidal nets M&E Monitoring and Evaluation MECC Malaria Elimination Coordination Committees

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MHAA Myanmar Health Assistant Association MIMU Myanmar Information Management Unit MNMA Myanmar Nurse and Midwife Association MoHS Ministry of Health and Sports MRCS Myanmar Red Cross Society NGO Non-Government Organization NFPP Non-formal private provider NMCP National Malaria Control Program NRS Northern Rakhine State NSP National Strategic Plan NTG National Malaria Treatment Guidelines NTP National Tuberculosis Program OMW Outreach Malaria Worker OSDV On-site data verification PCR Polymerase Chain Reaction PMI President’s Malaria Initiative PP Private providers QA Quality Assurance QC Quality Control QI Quality Improvement RDQA Routine Data Quality Assessments RDT Rapid diagnostic tests RHC Rural Health Centers SMT Senior Management Team SRS Southern Rakhine State TPR Test positivity rate TSG Technical strategic group UCSF University of California, San Francisco UN United Nations UNDSS United Nations Department of Safety and Security UNOPS United Nations Office for Project Services URC University Research Co., LLC USAID United States Agency for International Development USG United State Government usPCR Ultra-sensitivepolymerase chain reaction VBDC Vector Borne Disease Control VBS Village Based Stratification WFP World Food Program VMW Village Malaria Worker WHO World Health Organization

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Executive Summary Myanmar’s National Malaria Control Program (NMCP) reported 85,019 malaria cases and 30 malaria deaths in 2017. This marks a decline of 82.3% 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 almost 45% of the total cases among the GMS countries in 2017. The Defeat Malaria Activity, funded by the U.S. President’s Malaria Initiative (PMI) and USAID, runs from 15th August 2016 to 14th August 2021 and is implemented by University Research Co., LLC (URC), in partnership with American Refugee Committee (ARC), Jhpiego and Duke University, Global Health Institute. Defeat Malaria also involves local partner organizations to deliver needed malaria services while contributing to local capacity building efforts, including the Myanmar Health Assistant Association (MHAA) and Myanmar Nurse and Midwife Association (MNMA). 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 resistance and insecticide resistance. 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. The project focal states and regions where Defeat Malaria works in collaboration with the NMCP have seen a reduction of malaria cases in the last few years. Between 2015 and 2017, the malaria burden went from 10,852 to 4,118 cases (62% reduction) in Tanintharyi Region, from 34,459 to 15,195 cases (56% reduction) in Rakhine State, and from 24,642 to 15,080 (39% reduction) in Kayin State. Because of efforts by the NMCP and implementing partners, the malaria burden has decreased from 102,237 cases reported in 2011 to 15,195 cases in 2017 (85% reduction) in all 17 townships of Rakhine State. Thus, Defeat Malaria, in collaboration with the NMCP, has been conducting malaria elimination approaches in three pilot townships: Munaung, Ramree and Toungup townships since January 2018. In addition, based on the experiences gained from three pilot townships, Defeat Malaria is extending our technical and operational support to increase the number of elimination areas and further realize Myanmar’s malaria elimination goals. As 2019 is the 3rd year of 5-years Defeat Malaria project, we will expand the focus on village-based stratification for field activities and promote successful, appropriate interventions including (1) conducting routine malaria surveillance, (2) promotion of access to malaria health services by vulnerable, hard-to- reach populations including mobile migrant workers and conflict affected population, (3) engaging community and private sector stakeholders for strengthened involvement for sustainability, and (4) strengthening continuous ethnic health organization (EHO) engagement in order to promote equity of healthcare services. Project Year 3 Quarter 2 Key Highlights (January 2019 - March 2019) • As of March 2019, overall coverage of Defeat Malaria beneficiaries included around 1,503,648 population from 2,733 villages of Rakhine and Kayin States, and Tanintharyi and Sagaing Regions. • Defeat Malaria teams conducted active case detection (ACD) activities through special mobile mechanisms in 141 project villages and 155 non-project villages in project townships. • We continued to strengthen private sector engagement by working closely with private companies to encourage malaria testing and notification at their clinics, facilitating public private dialogue, and conducting non-formal health care providers assessment in three townships piloting malaria elimination.

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• Defeat Malaria submitted 6 abstracts to the American Society of Tropical Medicine and Hygiene (ASTMH) 2019 annual meeting to learn from our colleagues based on the achievements of Defeat Malaria project. • All Defeat Malaria partners strive to achieve significant changes by appropriate interventions upon great consideration of local epidemiology and context, with the documented successful events on intensifying high malaria burden reduction, detailed investigation and tailed approach for heterogeneously high and persistent malaria transmission areas, and continuous learning and sharing to promote pilot malaria elimination activities. • The URC team used the opportunity to reflect on the findings and recommendations of the Defeat Malaria Midterm Evaluation, conducted in November 2018, and build responsive activities into the project plan for FY2019. Introduction Defeat Malaria coverage as of March 2019 Defeat Malaria currently covers two States (Rakhine in the west and Kayin in the south-east) and two Regions (Tanintharyi in the south-east and Sagaing in the north-west) of Myanmar. Rakhine State is one of the highest malaria burden states/regions in Myanmar (NSP, 2016-2020) and has deep forested mountain ranges. Dawna Mountain Range in Kayin State extends southward, merging with the northern part of Tanintharyi Hill. Sagaing Region stood fourth in high malaria occurrences after Chin, Rakhine and Kayin States in 2017. Deeply forested areas provide favourable conditions for mosquitoes’ receptivity and contribute to a high prevalence of malaria. In addition, the difficult terrain is a significant barrier to access health services in these remote areas. Table 1 provides a summary of villages and populations covered by Defeat Malaria. By the end of March 2019, the Defeat Malaria project is implementing activities in 36 townships, including five new townships in Sagaing which were initiated this quarter through advocacy to local health departments and community engagement for proper village malaria worker (VMW) selection. Defeat Malaria continuously engages with the national program and other implementing partners to ensure universal coverage of malaria prevention, Figure 1: Geographic spread of Defeat Malaria activities diagnosis and case management services, targeting in Myanmar as of March 2019 hard-to-reach population residing in high malaria risk areas. Malaria services are reaching beneficiaries through a network of 2,022 VMWs, private providers (PPs), and township mobile teams. Our efforts extend to 2,733 villages and worksites. Currently, Defeat Malaria’s overall population coverage is around 1,503,000 beneficiaries.

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Table 1: Project area coverage as of September 30, 2018 State & Region Total Total Total Total % of Covered Covered Population Covered Population Townships Villages Population Covered Tanintharyi 10 592 1,408,401 309,166 21.95% Northern Rakhine 10 698 1,298,458 473,357 36.46% Southern Rakhine 7 1,050 803,656 469,814 58.46% Kayin 4 229 1,008,001 151,055 14.99% Sagaing 5 164 747,114 100,256 13.42% Total 36 2,733 5,265,630 1,503,648 28.56% During this quarter, Defeat Malaria has also taken the opportunity to strengthen key project activities, based on the recommendations of the independent mid-term evaluation. Specific activities and desirable outcomes have been developed for each recommendation (SeeAnnex 14). Defeat Malaria is collaborating with the NMCP and other implementing partners to increase VMWs/PPs coverage in the geographically hard-to-reach areas by supporting the malaria implementing partners mapping workshop, which will help Defeat Malaria and other stakeholders realize the mandate for universal coverage of malaria service among hard-to-reach and at-risk populations. Defeat Malaria provides not only a series of malaria elimination, surveillance trainings to VBDC and BHS, but also supports a cascade of training skills, malaria technical skills and ICMV trainings in collaboration with the Regional Technical Director and team and Jhpiego. Moreover, Defeat Malaria is striving to improve the health system by empowering communities, engaging with the private sector, integrating malaria services into primary health care activities, piloting malaria elimination activities for nation-wide application, and developing innovative approaches for applicability, all of which lay the groundwork for sustainable comprehensive malaria services. Work in Northern Rakhine was first restricted in January 2019 as the situation became less stable and secure. The challenges in Rakhine have limited Defeat Malaria’s ability to effectively work in sites there. While the team remains committed to supporting the local populations, our priority for field staff is their safety. Further information on this situation and Defeat Malaria’s response can be found in Annex 1. FY2019 Quarter 2 Summary of Key Achievements ✓ Training activities - In targeted townships, refresher trainings were conducted for 2,022 VMWs and PPs on malaria case diagnostics and management. ✓ 61,817 people were tested for malaria through VMWs, private providers and mobile outreach teams. ✓ 721 positive cases were detected and, among them, 706 out of 712 treated cases (99.2%) were in line with National Treatment Guidelines. The other 9 cases were referred to health facilities for further appropriate treatment to be given by township health staff. ✓ Under the DOT strategy, enrollment of positive cases was 510 (70.74%) DOT cases among 721 positive cases and 499 (97.84%) of 510 enrolled DOT cases completed the treatment courses. ✓ Interpersonal communication – Defeat Malaria reached 46,468 people (23,071 males and 233,97 females) through interpersonal communication (IPC) including 7,422 migrants. 345 group health talks were conducted reaching 6,664 people (3,060 males and 3,604 females) including 2,380 migrants in targeted areas. ✓ A total of 80,515 LLINs were distributed in 213 villages and 21 worksites, including 462 pregnant women attending ante-natal clinics, and to positive patients. ✓ Baseline assessment was conducted in 30 villages of 5 townships of Sagaing Region.

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Fiscal Year 2019, Quarter 2: Activities By Objective 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. ❖ Ensure the distribution of LLINs, diagnostics, and quality-assured medicines to the beneficiary populations, health services and collaborating VMWs in the targeted areas Commodity distribution and stock monitoring For malaria case management and uninterrupted treatment services for targeted communities, 114,175 rapid diagnostic tests (RDTs) and 8,144 first line antimalarials (ACTs) were distributed to established commodity storage sites of Defeat Malaria partners and sub grants from the central warehouse in Yangon (See Figures 2 & 3). From those township level storage sites, commodities (66,519 RDTs and 2,473 ACT strips plus 6 ACT tablets) were delivered to respective village level service delivery points i.e., VMWs/PPs during VMW monthly meetings and monitoring and supervision visits ifnecessary. The distributed commodities were provided based on anticipated use for each site and VMW/PP, calculated from data on monthly commodity utilization over the past project years.

Figure 2: RDT Distribution from the Central Warehouse to State/Region and EHO (Jan-Mar 2019)

Figure 3: ACT Distribution from the Central Warehouse to State/Region and EHO (Jan-Mar 2019)

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To provide better malaria services to communities without interruptions, Defeat Malaria regularly monitors commodity stock-outs – including RDTs and ACTs at service delivery points – by checking the commodity balances of VMWs/PPs at monthly meetings and during monitoring visits. Stock-outs are defined as when a service delivery point runs out of stock or has had any expired commodities for one week or longer during last 3 months. Regular replenishment of RDT and ACT were practiced during monthly meetings and monitoring visits to prevent stock-outs. During Q2 FY2019, VMWs/PPs received stock-out monitoring at the monthly meetings and the supervision visits 5,908 times 5,492( times for VMW and 416 times for PP). Among them, two VMWs from Hlaingbwe had experienced RDT stock-outs, however they borrowed RDTs from nearby VMWs and case finding activities were not affected. ❖ Optimize coverage and promote use of proven vector control interventions Strengthening Behavior Change Communication (BCC) Interpersonal Communication From January to March 2019, a total of 46,468 people (50% female), including 7,422 migrants, were reached through interpersonal communication (IPC) activities to share key malaria preventive messages during case management in villages and worksites from VMWs. Within the IPC activities, private providers reached 3,492 people (50.7% female). Moreover, group health talks were conducted to share malaria preventive messages and to increase utilization of LLINs during mobile team case finding and before LLIN distribution. In Q2 FY2019, 345 group health talk sessions were conducted in Defeat Malaria covered villages and work sites, reaching 6,664 people (54.1% female), 2,380 of whom were migrants. Distribution of printed materials During this reporting period, 20,520 pamphlets were distributed to targeted populations in project areas to promote their malaria control and elimination knowledge, attitudes and practices to prevent transmission. Printed digital media and Defeat Malaria on Social Media The Defeat Malaria team leverages social media 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. Our Facebook page (“Defeat Malaria Myanmar”) is routinely updated with relevant information and successes and reached 17,676 people during FY2019 Quarter 2. The Facebook content includes photos that showcase Defeat Malaria’s strategies and activities, Defeat Malaria technical support to Ministry of Health and Sports, vacancy announcements, and global technical strategies for malaria. BCC Assessment for improvement of communication to the community The Defeat Malaria team has been preparing for a BCC assessment to be conducted in FY2019. The BCC approaches will be assessed for continuous quality improvement and updated according to the findings, segmental analysis, and dose-response review to improve communicationoutcomes in communities. The team has developed assessment tools and is preparing to conduct the BCC assessment in the next quarter. Long-lasting insecticide net distribution Mass distribution of LLINs LLIN distribution is a key vector control mechanism and, under Defeat Malaria, LLIN distribution is prioritized in high malaria transmission areas and high-risk groups such as migrants and pregnant women. The team utilizes multiple distribution approaches, including distribution/top up at the village level, distribution/top up to migrant population at work sites, distribution in antenatal careservices, and distribution through ethnic health organizations (EHOs). LLINs were distributed per village-based stratification and always accompanied by appropriate behavior change communication activities.

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In total, 78,557 LLINs were distributed in 213 villages through mass and top up distribution. We based distribution on the norm “2 persons per one LLIN”, thus providing protection for at least 142,838 people from 29,282 households. Both household and population coverage were 100% of the target. Average population per LLIN is 1.82. Table 2 shows mass LLIN distribution/top up at village level by state/region. Table 2: Long lasting insecticide net (LLIN) distribution at villages (Jan-Mar 2019) Indicator Mass Distribution Top Up Grand Total # of Villages 200 13 213 # of Households (HHs) present at time of distribution 28,370 912 29,282 # of HHs covered 28,370 912 29,282 # of Population present at time of distribution 139,411 3,427 142,838 # of Population covered 139,411 3,427 142,838 Total LLINs distributed 76,682 1,875 78,557 % of HHs covered 100% 100% 100% % of Population covered 100% 100% 100% Net Ownership (Persons/LLIN) 1.82 1.83 1.82

LLIN distribution to migrants and mobile populations in collaboration with employers In all activities, Defeat Malaria provides targeted support for mobile and migrant populations (MMP). In order to reach migrants preventive methods, LLINs were distributed at work sites. During Q2FY2019, a total of 1,496 LLINs were distributed in 21 work sites to 2,613 MMPs. All households and populations were covered in worksites reaching 100% coverage and average population per LLIN with 1.75 (see Table 3).

Table 3: LLIN distribution at worksites (Jan-Mar 2019) Mass distribution Top up Grand total # of worksites 18 3 21 # of Households (HHs) present at time of distribution 827 70 897 # of HHs covered 827 70 897 # of Population present at time of distribution 2,417 196 2,613 # of Population covered 2,417 196 2,613 Total LLINs distributed 1,398 98 1,496 % of HHs covered 100% 100% 100% % of Population covered 100% 100% 100% Net Ownership (Persons/LLIN) 1.73 2.0 1.75

LLIN distribution to pregnant women during Antenatal Care (ANC) in high transmission areas Defeat Malaria continued distributing LLINs to pregnant women by targeting ANC visits in Ann, Gwa, Thandwe, and Toungup townships. This activity could not also be initiated in Kyauktaw and Minbya townships as planned because of political instability in Northern Rakhine State. During this reporting period, LLIN were distributed to 462 pregnant women who took their first ANC within those townships. Monitoring on LLIN coverage and utilization Defeat Malaria conducts LLIN coverage and use monitoring in the villages where the CAP-Malaria/Defeat Malaria projects have distributed LLINs since 2015. In this quarter, LLINs were monitored in 280 villages; we found only 61% of villages had an acceptable level of coverage (at least 15 out of 21 households monitored owning enough LLINs to adequately cover 2 people per LLIN) and 68% of villages met acceptable level of high utilization (70% utilization). Defeat Malaria will work closely with the NMCP and other partner organizations to conduct mass distribution activities in 2019 to improve coverage. Our BCC assessment in FY19 Q3 will help identify successful methods to promote LLIN utilization.

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Table 4: LLIN Coverage and Utilization by Defeat Malaria State/Region (Jan-Mar 2019) State / # Villages Village LLIN Coverage acceptability Village LLIN Utilization Acceptability Region monitored # (%) villages with # villages with # (%) villages with # villages with acceptable LLIN unacceptable LLIN acceptable LLIN unacceptable LLIN coverage coverage utilization utilization Tanintharyi 98 75 (77%) 23 57 (58%) 41 Southern 141 79 (56%) 62 106 (75%) 35 Rakhine Northern 1 0 (-) 1 0 (-) 1 Rakhine Kayin 40 17 (43%) 23 27 (68%) 13 Grand Total 280 171 (61%) 109 190 (68%) 90

❖ Ensure early diagnosis and appropriate treatment of all clinical malaria cases Capacity building of VMWs/PPs on diagnosis and case management, RDT use and correct prescription of ACTs: To provide quality malaria health care services to targeted communities, trainingsfor VMWs and PPs were conducted in newly expanded areas from Sagaing Region and refresher trainings were conducted in some townships of Tanintharyi Region and Southern Rakhine State in this reporting period. A total of 305 VMWs (61.6% female) and 28 PPs (35.7% female) received training on malaria diagnosis and case management through the Integrated Community Malaria Volunteer (ICMV) approach, how to conduct IPC, stock management, and data collection. VMW support and supervision Meetings with VMWs and PPs have been conducted monthly since November 2016 for routine performance supervision, data verification for accuracy, and necessary stock replenishment. In this reporting period, attendance records logged 93.6% of VMWs/PPs cumulatively attended these meetings (the target for monthly meeting attendance is set at 90%). The Defeat Malaria team has continued supportive supervisory visits with on-site data verification, routine monthly meetings, regular mobile phone communication, and ad hoc supervisor visits for special situations (with the exemption of some Northern Rakhine Townships in conflict). Supportive supervisory visits improve the capacity and effectiveness of VMWs/PPs and facilitate on-site data verification, especially on case surveillance data, completeness of data, commodity stock out monitoring, and on the job training. During these visits, VMWs and private providers were monitored, supervised and their patient’s register were checked on completeness, timeliness of reporting, data accuracy, clinical audit (whether positive cases were treated according to treatment guideline or not), stock out andalso provided on the job trainings. During this reporting period, Defeat Malaria conducted total 786 supervision visits, however this only included 8 visits in the newly expanded areas of Sagaing Region. Through the rest of FY19, Defeat Malaria will use supervision data recorded on mobile tablets to implement a more efficient and effective system. Currently, the field team needs to reserve 6 to 10 days for supervision, which can hinder their ability to conduct other activities. Defeat Malaria will discuss this with PMI and may propose that VMWs with excellent performance will be moved to a once a year schedule, as most of the VMWs have been supervised for over 2 years of project implementation. The reporting status for VMWs/PPs was continuously monitored to supervise their reporting performance, ensure the inclusions of all reporting units for effective surveillance, and to use as a proxy indicator for continuous supply mechanism ensuring no stocks-out of RDT and ACTs for VMWs/PPs. During

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the reporting period, 5,535 (98.3%) out of total 5,628 reports expected to be submitted by VMW/PP were received and, of these, 5,521 reports (99.7%) were received in a timely manner (see Figure 4).

2,500 100.0%

2,000 95.0% 1,500 90.0%

1,000 Percent 85.0% 500

- 80.0% Taninthar Southern Northern Cumulative number of reports of number Cumulative Kayin Sagaing yi Rakhine Rakhine # of VMW/PP reports to be 1,470 1,453 1,920 644 141 submitted # of VMW/PP reported 1,408 1,451 1,904 640 132 # of VMW/PP reported timely 1,396 1,451 1,903 639 132 % of reporting 95.8% 99.9% 99.2% 99.4% 93.6% % of timely reporting 99.1% 100.0% 99.9% 99.8% 100.0%

Figure 4: Reporting status of VMWs/PPs by State and Region Clinical audit on treatment of positive cases according to National Malaria Treatment Guidelines (NTG) A clinical audit was carried out by Defeat Malaria township teams on monthly basis to assess the quality of malaria health care service provided by VMWs/PPs to targeted communities. The treatment provided for positive cases was verified to assess the percentage of cases treated according to NTG. According to findings of the Q2 FY2019 clinical audit, 706 (99.2%) among 712 treated cases received correct antimalarial treatment (according to NationalT reatment Guidelines, NTG) and 9 cases were referred to health facilities for further appropriate treatment. VMW/PP who treated not according to NTG received on-job training for malaria diagnosis and case management during monthly VMW meetings. This audit is part of a safety monitoring plan, which will be coupled with coaching for VMWs/PPs in the next quarter. Active case detection From January to March 2019, Defeat Malaria teams conducted active case detection (ACD) activities through special mobile mechanisms in 141 project villages and 155 non-project villages in project townships. For project villages, ACD was intended to promote community awareness to utilize VMWs’ service at the time of fever and to understand local epidemiology. These wereconducted in project target areas with the following criteria: • No health facility or volunteer services, • Recruiting VMWs is impractical due to high costs and inability to attend monthly meetings and submit reports regularly due to remoteness, • Malaria reduction is needed in identified high burden areas, • Reactive case detection is conducted among household members surrounding the positive index case during case investigation, • Proactive case detection in epidemiological assessments of persistent malaria transmission areas. Moreover, Defeat Malaria field teams conducted ACD activities through mobile case finding and management in non-project areas requested by the NMCP to assess the malaria situation (high, moderate, low, or no transmission). If we identified a high/moderate TPR in non-target villages with malaria service gaps, intensified burden reduction activities were initiated.

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During this reporting period, 61,817 people were tested through approaches such as Testing and diagnosis of malaria by source 569 VMW community-based malaria diagnosis 45,000 1.6% positive and treatment, Defeat Malaria staffmobile 1.4% teams, and private sector engagement. We 1.2% 30,000 identified 721 positive cases (276 P. 108 1.0% falciparum, 439 P. vivax and 6 mixed). The positive 0.8% overall Test Positivity Rate (TPR) was 1.2% 32 12 0.6% (See Table 5). More specifically, mobile 15,000 positive positive 0.4% teams tested 9,468 people in project and 0.2% non-project villages, VMWs tested 39,857 people, private providers tested 3,423 - 0.0% people, and all other providers tested Mobile VMWs PP Others 9,069 people; VMWs had the highest TPR Total Tested TPR% of all provider (see Figure 5). In non-project villages, only 47 positive cases (24 Pf, 22 Pv, Figure 5: Malaria testing and diagnosis by source for FY19 Q2 and 1 mixed) were found among 3,058 tested, and in project villages, 61 cases (15 Pf, 46 Pv, and 0 mixed) were found among 6,410 tested. The TPR in non-project villages was 1.54% but TPR in project villages was much less as compared and only 0.95%. Among positive cases, 98.8% were treated and the remaining 9 cases were referred. Among cases treated, 99.2% received the treatment according to the national treatment guideline. Table 5: Malaria testing by Defeat Malaria covered state/region (Jan-Mar 2019) State / Region Tested Total Positive Pf Pv Mix TPR% Tanintharyi Region 17,428 309 63 246 0 1.8% S. Rakhine State 16,747 62 51 10 1 0.4% N. Rakhine State 21,973 284 161 118 5 1.3% Kayin 4,473 65 1 64 0 1.5% Sagaing 1,196 1 0 1 0 0.1% Total 61,817 721 276 439 6 1.2%

Directly Observed Treatment (DOT) and patients’ compliance to DOT DOT is conducted according to Standard Operation Procedures approved by PMI to prevent the spread of artemisinin resistant malaria and ensure full adherence to the antimalarial treatment achieving radical cure and to prevent onward transmission in malaria elimination. Cases are eligible for DOT if confirmed by a parasitological examination using RDT, and fulfil the following criteria: • Uncomplicated malaria cases manageable by VMWs; • The VMW is available and capable of observing treatment (e.g. he/she has no plan to travel during the DOT period); • The visit schedule by the VMW is agreed and accepted by the patient or guardian; and • The patient or guardian is willing and able to report incomplete doses with reason. From January to March 2019, 510 out of the 721 (70.74%) individuals diagnosed with malaria were enrolled in DOT and 499 out of 510 (97.84%) patients enrolled in DOT fully adhered to their treatment.

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❖ Strengthen and expand the network of VMWs to improve access to basic diagnostics and treatment services (RDTs and ACTs), particularly for high-risk and hard-to-reach populations Malaria implementation partners mapping Mapping of Implementing Partners is an important activity for efficiently utilizing resources for national program effectiveness. In March 2017, Defeat Malaria supported a malaria implementation partners mapping workshop for Taninathryi Region. In this reporting period, we conducted a second implementing partner mapping exercise to update the disappearance of some small and unstable settlements and to assess universal malaria service coverage in hard-to-reach areas. In March 2019, the Defeat Malaria M&E Technical Advisor Malaria implementation partners mapping conducted at District met with Regional Health Director and Health Department of Myeik, Tanintharyi Region in March 2019 Regional Officer of Vector Borne Disease Control (VBDC) to discuss the mapping approach and malaria service extension to fill identified gaps. Defeat Malaria worked with Data Assistants for systematic arrangement of mapping files and distribution of tasks within 10 townships of Tanintharyi Region. The M&E Technical Advisor also presented on previous mapping methodology, lessons learned, and the updated approach to be applied in the 2019 workshop. For example, in the previous mapping exercise we could not capture malaria service coverage from nearby villages, mobile visits of IPs for small and unstable settlements, and military dispensaries providing for their military camps. Mapping updates were conducted by the leadership of VBDC with technical support from seven malaria implementation partners – including Defeat Malaria – in coordination with local Township Medical Officers, basic health staff, township VBDC focal staff, and ethnic health organizations (EHO). The mapping identified a total of 1,930 settlements (villages/ worksites) and, according to the preliminary results, 324 settlements (17%) have health facilities in their villages and receive health care from the BHS. An additional 1,210 settlements (63%) have no health facility but village malaria workers are deployed to provide malaria prevention and control activities. Of the remaining 396 settlements (20%) with structural gaps indicating no BHS/VMW in their settlements, 345 settlements have easy access to malaria services at nearby villages (within 1-2 kilometers distance) and some areas receive regular mobile health visits of implementing partners. Defeat Malaria has submitted the drafted mapping file to regional NMCP for review and to develop the strategy for the unsupported 51 settlements (2.6% of all settlements). With the success of the implementation mapping exercise in Tanintharyi, the project is advocating for the NMCP to support similar mapping workshops in Rakhine and Kayin States; the NMCP will set the dates to be conducted in next quarter. Baseline assessment in Sagaing Region During this reporting period, a baseline assessment was conducted by applying multistage cluster sampling method at five expansion townships of Sagaing Region to explore the current malaria situation and prepare resources for effective and efficient activity implementation. A total of 422 households from 30 villages were interviewed with standard questionnaires toassess the knowledge, attitude and practice of the community towards malaria. The central M&E team with the lead of mHealth and Research Officer

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synchronized assessment tools into a mobile device-based application which allowed us to skip manual data entry and thus avoid unnecessary data entry errors and improve the data cleaning process. The M&E team recruited and trained 12 data collectors to advocate to the village chiefs of assessed villages, appropriately select households for sampling, and conduct the assessment. Following this, the data collection process began in February 2019 and was completed in March 2019. Data cleaning process is ongoing, and data analysis and interpretation will be completed in the coming quarters. ❖ Conduct operational research to pilot promising new tools and approaches to reduce malaria transmission as directed by NMCP, in consultation with the PMI/USAID Operational Research on innovative tool for malaria diagnosis using highly sensitive RDT (hsRDT) URC is collaborating with our partner, the Duke Global Health Institute (DGHI), in the implementation of an operational research study entitled “Evaluation of the performance of a hsRDT versus cRDT compared with PCR as the gold standard, in reactive case detection of malaria infections in Rakhine State”. A total of 51 index cases and 1991 contact cases were included in the study. Index cases were identified using Standard conventional RDT (cRDT) while contacts were evaluated by both cRDT and highly sensitive RDT (hsRDT). Dried blood spot samples were collected from all study participants for ultra-sensitive PCR (usPCR) analysis at Department of Medical Research (DMR) Myanmar lab and quality control (QC) at DGHI lab of Duke University. A severe fungus infection was detected in the last batch of samples from the field due to severe weather conditions, which delayed the study timeline; data analysis and interpretation began after this reporting period, in April 2019. During FY19 Q2, 20% of the total sample size (all positive and randomly selected negative samples) were analysed (this being higher than the standard 10% could be due to the high rate of contamination). The overall concordance rate was 91.3% (93.9% for P. falciparum, and 97.4% for P. vivax), which is above the pre-specified cut-off value, and is considered adequate and satisfactory. These values are equivalent to kappa of 0.86 (Std. Error of 0.015). Table 6 highlights the results from each testing kit, including that while hsRDT can only test for P. falciparum, the cRDT testing kit only identified one of the P. vivax cases. The results will be presented and discussed with other hsRDT studies conducted in Myanmar, and we aim to include the results in the agenda for the May 2019 PMI Thematic Workshop to discuss with the MoHS, WHO, UNOPS, SCI, PSI, and other malaria implementing partners. Community feedback will be provided at Ann township in June 2019 where studies have been conducted and community representatives, basic health staff and the participants will be shared about the study results and its utility. Table 6: Findings of hsRDT study in Rakhine State Types of Species/ infection # (%) of diagnostic results among 2,042 participants (51 index cases and 1,991 contacts) cRDT (Pf and Pv) hsRDT (Pf only) usPCR (Pf and Pv)

P. falciparum mono-infection 79 (3.9) 129 (6.3) 216 (10.6) P. vivax mono-infection 1 (0.05) n/a 128 (6.3) Mixed infection 0 n/a 37 (1.8) Negative 1,962 (96.1) 1,913 (93.7) 1,661 (81.3) Total 2,042 (100.0) 2,042 (100.0) 2,042 (100.0) Operational Research on extended malaria services for forest workers According to anecdotal evidence, forest goers are more vulnerable and higher-risk for malaria infection, especially in high and persistent malaria transmission areas, and they are in need of appropriate extended malaria service. The initial pilot assessment on malaria prevention service package also revealed high acceptability and utilization towards the items in the packages. In FY2019 Q2, Defeat Malaria prepared

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for an operational research study on “Impact of using mosquito topical repellents and extended standard interventions on malaria prevention in Myanmar”. It is currently being submitted to Ministry of Health and Sports (MoHS) for approval to conduct the study in collaboration with National Malaria Control Program after the technical inputs and policy clearance of PMI. The proposed study targets in Bokpyin and Tanintharyi Townships of Tanintharyi Region and Ann, Kyauktaw and Minbya Townships of Rakhine State. The study will take 27 months to accomplish and will allow us to further explore innovative and integrated approaches to reach vulnerable and hard-to-reach forest goers with the necessary malaria services.

Objective 2: Strengthen the malaria surveillance system to comprehensively monitor progress and inform the deployment and targeting of appropriate responses and strategies. ❖ Strengthen the malaria surveillance system in line with malaria elimination, improve data management capacity at all levels of the health system, from village to central level, and support appropriate information technology to facilitate data collection, reporting, and use in both public and private sectors Workshops, trainings and advocacy meetings Advocacy meetings Advocacy meetings were conducted at newly extended townships of Banmauk, Indaw, and Pinlebu in Sagaing Region to orientate local stakeholders about the goals, objectives, and planned activities of Defeat Malaria to be implemented in FY 2019. It was participated by 302 attendants (68.5% female) from local administrative departments, township health departments, private companies and worksite representatives and village chiefs. Defeat Malaria Quarterly Review Meetings The Quarterly review meeting was conducted at Defeat Malariaoffice , Yangon in January 2019 for central level Defeat Malaria partners to review the current project achievements and discuss the priority and catch-up activities based on the Year 3 workplan. One of the main discussions was how to support and collaborate with NMCP for effective LLIN distribution. Other specific activities discussed included VMW supply stocking and supervision with mHealth tools, capacity building and M&E trainings, activities for community support group establishment, private sector engagement, malaria service provision, project expansion, and team safety and security. Some activities were postponed to Q3 FY2019 in consideration of the budget transfer transition period. Following this, the Field Operation Director and partners focal staff communicated with all township team leaders by skype calls and phone calls for to disseminate the decisions of the meeting and discuss upcoming activities to be accomplished in timely manner. Routine Data Quality Assessment (RDQA) The M&E Director and Documentation Officer conducted RDQAs at Kyauktaw and Mrauk-U Townships of Northern Rakhine State during FY19 Q2 to assess data management flow, township level M&E M & E Director and Documentation Officer conducted on-site data verification during RDQA visit at Mrauk-U township

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system, and to provide hands-on experiences for on-site data verification and promote the attitudes towards the importance of quality of reported data. The Central M&E team noted the challenges of conducting VMWs supervision activities in such areas with rising conflict situation and restriction of field activities. In this quarter, RDQA could not be conducted at 2 townships of Taninathryi Region, one township of Figure 6: Routine Data Quality Assessment Status, Jan-March 2019 Southern Rakhine State and one township of Northern Rakhine State. Activities in Munaung in Southern Rakhine are carried out by BHS in collaboration with the NMCP without VMWs. It was difficult to conduct on-site data verification (OSDV) in Northern Rakhine State with security conditions. In Q3 we will strengthen data recording and reporting for townships with poor RDQA status (see Figure 6). We will prioritize the implementation and regular updates of the new village-based malaria stratification framework, mapping high-risk areas and populations and use of data to better plan and target control interventions. ❖ In persistent residual malaria transmission areas, to determine reasons for persistent transmission and implement appropriate intervention based on assessment findings especially in elimination townships and border townships. Entomological assessments were conducted at two persistent malaria transmission sites (Htauak Kyant Taw village of Ramree township and Lower Kyauk Ta Gar village of Toungup township) during March 2019 by two entomology consultants and the Defeat Malaria team to monitor vector bionomics, behavior, and potential breeding sites for supporting entomological information and further effective intervention. Entomological assessments were also conducted at logging worksite (A1 worksite) near Htauk Kyant Taw village (A1 village) and Thit Shi Camp (A2 worksite) near Lower Kyauk Ta Gar village (A2 village) as these sites were the sources of infection. The methods for entomological survey and findings are described in Annex 3. The primary, secondary and suspected Anopheles (Cellia) vectors were stored in micro- centrifuge tubes to proceed for ELISA method for the detection of circum sporozoites. For ELISA, 156 samples were stored from Htauk Kyant Taw and nearby worksite, and 497 samples were stored from Lower Kyauk Ta Gar village and Thit Sin Camp. It was recommended that the team practice environmental manipulation by leveling of unused domestic-water collection pits at the bank of stream, strengthening LLIN taken to the forest and utilization, and use mosquito repellents at night-time before sleep. Vigilance on increased occurrences of malaria cases In January 2019, the team introduced systematic notification and regular analysis of disease trend with the support of conditional formattingby easily detection of outliers using cumulative sum (C-sum) method in selected areas to remain vigilant on increased occurrences of malaria cases. All Defeat Malaria partners are engaged, collaborating with the NMCP to use surveillance data and make appropriate actions if increased malaria occurrences are detected. During FY19 Quarter 2, VMWs/PPs from 15 no/low/very low villages were notified and 20 cases were investigated by respective township field teams in collaboration with township NMCP staff.

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Temporary hut used by forest workers at the worksite near Htauk Kyant Taw village of Ramree township

In addition, regarding the routine analysis of disease trend by practicing C-sum method, Defeat Malaria field teams from 5 project townships identified raised disease trends beyond the threshold lineof3 project years (October 2015 to September 2018) in 25 villages. Among those 25, 3 villages from Dawei township and 1 village from Palaw township reported raised disease trends for 3 consecutive months. According to the findings, Defeat Malaria township field teams conducted immediate and further responses including analyzing existing data with the addition of weekly information, reactive case detection, case investigation, management of possible source of infection, and fulfilling the possible service gaps (health care service, LLINs coverage, BCC etc.). The field teams work closely with the higher- level teams and local stakeholders for feedback and follow-up actions. ❖ To initiate an elimination strategyfor target elimination areas, pilottest and scale-up a system for rapid detection and notification of malaria cases, case and contact investigations, and prompt deployment of appropriate response interventions in three townships in Southern Rakhine State, by improving and strengthening the surveillance system Scale-up the system for rapid detection and notification of malaria cases, case and contact investigation, and prompt deployment of appropriate response interventions Since January 2018, Defeat Malaria initiated pilot malaria elimination activities in Toungup, Ramree, and Manaung townships in collaboration with NMCP in Myanmar. Along with WHO Global Technical Strategy 2016-2030, NMCP plays a crucial role in piloting elimination model and further countrywide implementation. Annual evaluation of malaria elimination in Ramree Township On 8 March 2019, the Annual Evaluation Meeting of Malaria Elimination was held in Ramree Township Hospital Meeting Hall. Township Malaria Elimination Coordination Committee members, basic health staff, NMCP officials, volunteers and Defeat Malaria staffs attended the meeting. Defeat Malaria’s Regional Technical Director presented achievements, challenges and the plan for the upcoming year. The General Administrative Department invited Defeat Malaria to share one-year experiences on malaria elimination activitieswith community representatives atthe monthly village chief meeting. The remaining two annual evaluation meetings will be conducted in Toungup and Munaung townships next quarter. All-inclusiveness in transforming surveillance into core intervention The private sectors (both formal and non-formal) have important roles to play in the various facets of elimination. Based on 2018 surveillance data and private provider census data, Defeat Malaria selected non-formal private providers from the villages where indigenous cases were found in 2018. These selected providers and respective village chiefs were invited to discuss early referral of patients with suspected for malaria on March 5th, 2019 at Toungup Defeat Malaria Office. This resulted in increased

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commitment from the stakeholders, with attending providers agreeing to refer suspected malaria cases to BHS or VMW and send the referral reports to township malaria elimination committees through respective village chiefs at the end of each month. The Defeat Malaria team will coordinate with both sides and monitor routine referral data to ensure this goes smoothly. Strategic partnerships across sectors It is unlikely that malaria elimination will be achieved only through the conventional health system, and many parts of government and society will have to work together. While approaching to elimination, malaria transmission becomes more heterogenicity in nature and cases are often found only in highly vulnerable groups. Migrant workers play a crucial role in driving malaria transmission intensity because of the nature of their work. In Toungup Township, there are mobile road construction worksites under the Road and Construction Department of Local Government, and it is important that malaria services are available and that the situation is continuously monitored. The Defeat Malaria team is developing a relationship with the Officer-in-Charge of Road and Construction Departmentand will continue to pursue avenues to provide malaria services for the construction workers. Identification and classification of malaria focus based on 2018 surveillance data According to the requirement of WHO 300 malaria elimination certification, five years of 241 227 220 full information of active focus from the last 250 200 159 indigenous case need to be properly 139 139 documented. At the end of 2018, Defeat 150 Malaria identified the malaria foci in the 100 68 three elimination townships based on case 50 14 2 5 0 0 classification results from that year (see (Foci) villages of No. 0 Figure 7). During early stages of elimination, Toungup Ramree Munaung Defeat Malaria operationalizes malaria focus Village Total Active foci as the whole village where indigenous Residual Non-active foci Unclassified due to ABER<7% malaria cases are identified in the recent year (active foci) or in the previous one to three Figure 7: Foci Classification based on 2018 surveillance data years (residual non-active foci). While approaching to elimination, the more circumscribed well-defined areas of the village will be identified as focus of malaria infection.

Objective :3 Enhance technical and operational capacity of the NMCP and other health service providers at all levels of service provision ❖ Improve skills and job performance of staff involved in malaria control, particularly on epidemiology, surveillance, entomology and vector control, through supportive supervision and training at peripheral and national levels After reviewing and updating training manual and curriculums for Master Mentors in this reporting period, 38 Defeat Malaria staff (34 males and 4 females) and 19 NMCP staff (12 males and 7 females) from Central and State/Region VBDC were provided Master Mentor trainings focusing on malaria elimination and other vector borne diseases (DHF and Filariasis). Regarding trainees from NMCP, 16 participants were representatives from State/Region level, and 3 participants were from central NMCP. All 38 Defeat Malaria staff received training skills and as technical skill trainings, but 19 NMCP staff received training skills training only in this quarter, and the remaining technical skill training will be provided in next quarter.

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According to the capacity building cascades, the trained 40 master mentors are expected to support and capacitate 74 general trainers, who in turn will conduct on-site trainings to 400 VMWs/ICMVs in FY 2019 at the states/regions and township levels where Defeat Malaria activities are implementing. In this quarter, seven of the 40 master mentors were supervised, including four during the general trainer training conducted at Training skill training provided for 19 NMCP staff at Mingalar Thiri Myawaddy township, and three during Hotel, Nay Pyi Taw by Jhpiego Expert and Defeat Malaria Facilitators their on-site trainings provided to VMWs at Minbya township. The annual target for supervision to trained master mentors is set at 50%; as they have now all completed trainings, we anticipate achieving this target in Q3 and Q4 of FY19. Regarding on-site trainings, 79 VMWs (40.5% female) from Toungup and Ramree townships, and 110 ICMVs (57.3% female) from Ann, Dawei and Tanintharyi townships received technical knowledge and skills on clinical diagnosis and management of malaria, data management, IPC, and other communicable diseases (Tuberculosis, Leprosy, HIV/AIDS, DHF and LymphaticF ilariasis) for five-day course sessions. ❖ Strengthening surveillance system by supporting NMCP on tools, equipment, telecommunication cost, capacity building and HR development Table 7: Malaria Elimination Capacity Building Training for NMCP and malaria Implementation Partners No. of Category of Lead Date participants Remarks participants Organization (% female) 7-9 Jan VBDC staff (Southern Financial support by GFATM and 47 (27.7%) NMCP 2019 Shan State) technical support by Defeat Malaria 15-17 Jan JHPIEGO (Defeat Financial and technical support by 36 (11.1%) Defeat Malaria staff 2019 Malaria) Defeat Malaria 4-5 Mar VBDC staff (Northern Financial and technical support by 33 (0%) Defeat Malaria 2019 Rakhine State) Defeat Malaria 12-14 Mar VBDC staff (Kayin Financial support by GFATM and 78 (75.6%) Defeat Malaria 2019 State) technical support by Defeat Malaria Regional Malaria Technical Director with the support of Technical and Program Management Coordinator provided capacity building trainings to VBDC staff of Rakhine (Southern and Northern) and Kayin States about malaria elimination training. The elimination training was also provided to Defeat Malaria staff in collaboration with Jhpiego. ❖ Support NMCP for entomological training, entomological field assessments and other gaps at the different levels Training on entomological surveillance in elimination settings and foci investigation In November 2018, multiple stakeholders, including 12 entomologists, 4 malaria staff from VBDC of Thandwe and Toungup townships and 5 Defeat Malaria staff participated in a comprehensive malaria foci investigation UCSF, PMI and Defeat Malaria facilitators in 4 villages of Toungup township. The report on this assessment became available in FY19 Q2. In Taung Pauk, the team used light traps, animal baited net traps, and human landing to collect specimens in- and outdoors; a larvae survey was also conducted. In

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Gwa Sone and Ka Mar, rapid entomological assessments and larvae surveys were conducted. The fourth, in Pauk Pyin, included a focus investigation without entomological assessment and was limited because the location of worksites are secret. The team concluded that malaria transmission was occurring outside the villages. Two worksites outside of the villages, where transmission had likely occurred, were visited, although an additional worksite was an inaccessible forest site. The foci investigations revealed several barriers to Investigation of mosquitoes by Chief Entomologist, CDC-Atlanta progress towards malaria elimination in in Toungup township, Rakhine State Toungup and a set of recommendationswere developed from these findings. Most malaria risk occurs in forest populations and seasonal farm hut dwellers. While the focus investigation occurs in the village, the actual events of transmission are elsewhere, either near a farm hut or in the deep forest. Reservoirs of parasites in forest/forest fringe, in mosquitoes and people working there, were identified as the main drivers of malaria transmission in the areas investigated. Infectious bites in the forest, with limited or absent vector protection and away from prompt access to malaria services, fuel the persistent transmission and pose a high risk of reintroduction and outbreaks in the receptivenearby villages. The investigation team recommended supplying adequate RDT and ACTs to VMWs for the villages served as home-base for forest goers or farm population, to recruit outreach malaria workers for forest goers, to provide mosquito repellents, LLINs and modified BCC to increase LLIN use among forest goers, and habitat modification and larvicide application in active foci reduce An. minimus productivity in accessible transmission sites. ❖ Knowledge transition of Defeat Malaria Activities Submission of abstracts to major conferences For appropriate data utilization, knowledge sharing, synthesis and integration, Defeat Malaria submitted 6 abstracts to 68th Annual Meeting of American Society of Tropical Medicine and Hygiene. The topics included cost analysis of Defeat Malaria activities for further projection and efficient utilization of resources for malaria elimination activities, acceptability of malaria prevention service package to forest goers for suggesting extended services and approaches development, utility of malaria case classification calculator of Defeat Malaria innovative tool for supporting malaria elimination activities, patients perspectives on 8 weeks of Primaquine regimen for advocating to strengthen adherence of Primaquine treatment with shorter duration, and two more abstracts relating with effectiveness of capacity building trainings to basic health staff and Defeat Malaria staff. Moreover, the abstract on “collaborative malaria service mapping aiming towards universal health coverage in Myanmar” was submittedto 2020 Prince Mahidol Award Conference. The abstract was based on Defeat Malaria’s experience on supporting malaria implementing partners mapping workshop conducted in Tanintharyi Region in Q2 FY2019. The theme of the conference for this year is “accelerating progress towards universal health coverage” and is relevant with Defeat Malaria’s primary objective of achieving and maintaining universal coverage of malaria at risk population for vector control and case management interventions.

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Objective 4: Promote the involvement of communities, private healthcare providers, private companies and state-owned enterprises in malaria control and elimination initiatives ❖ Build the organizational and technical capacity of Universities related to health, CBOsand ethnic health organizations (EHO). Engagement with non-formal private health care providers in the pilot elimination townships Non-formal private providers (NFPP) mappings were conducted at 3 elimination townships (Toungup, Ramree, Manaung), in December 2018. Based on the results, Defeat Malaria organized and conducted advocacy meeting with 16 NFPPs from high-burden areas of Toungup township with the involvement of village leaders and township administrator in March 2019. Regional Technical Director of Defeat Malaria explained about project activities, commitment of malaria elimination in Myanmar, and importance of involvement of NFPP in malaria elimination. In this meeting, NFPPs were encouraged for referring suspected for malaria and febrile cases to nearest health facilities and requested to support referral lists to the elimination project via villages’ leader. At the end of March 2019, among 16 NFPPs in Toungup township, 9 NFPP reported the referral of 9 suspected for malaria cases to nearest VMWs. Promote engagement of private companies in malaria control and elimination Regarding engagement with private companies, Defeat Malaria facilitated public private dialogue between the Regional Health Director, Manager and Medical Superintendent from private companies and PPM expert at Kawthoung Township, Tanintharyi Region in January 2019. It was attended by 40 participants from Regional/District Health Departments, WHO, local authorities, private companies, Dawei Special Economic Zone development committee, and implementing partners. The objectives of the workshop were to promote awareness on the importance of public-private coordination and partnership in malaria control and elimination activities. As a result of advocacy meeting with private sector, Yuzana Oil Palm company requested Defeat Malaria to provide necessary malaria services and commodities. Defeat Malaria provided Integrated Community Malaria Case Management training for health staff of company, provided LLINs for their migrant workers, and supported RDTs, ACTs and other necessary stocks. In this quarter, Defeat Malaria engages with 41 companies and tested 4,317 people suspected for malaria and treated 17 malaria cases (2 P.f cases and 15 P.v cases) in 7 townships of Tanintharyi Region and Rakhine State. Regarding malaria prevention, 1,179 LLINs were distributed and 113 health education sessions were conducted. Defeat Malaria has been recruited and working with 139 Private Providers (PPs)

Meeting with community at Naung Ei Khant Village, Meeting with community at Thit War Village, Hpa-An Kawkareik Township on March 21, 2019 Township on March 21, 2019

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who were actively participated in malaria control and elimination activities. In the 3 pilot malaria elimination townships, Defeat Malaria was collaborating with 24 village-based private providers, 22 General Practitioners, and 30 drug sellers, and tested 658 people suspected for malaria but no case was detected in this quarter. Senior Management Team (SMT) meeting The Quarterly SMT meeting was conducted at Defeat Malaria Office on February 14, 2019 involving all Defeat Malaria senior management level staff from all partners. To ensure the accomplishment of overall Defeat Malaria’s commitments, make effective coordination and communication among Defeat Malaria partners, and provide the best appropriate rational decision making by involving all partners. Core discussion points included: • Management issues relating with compliance of volunteers’ payments by all partners, handover of 23 villages of other project of MHAA to Defeat Malaria, and the transformation of VMWs meeting from monthly into quarterly for the areas with very low and no malaria transmission. It was agreed to pilot in this quarter without affecting monthly reporting of VMWs data and suggested VMWs from the villages where malaria transmissions are still active in the recent and current year. • Recruitment of Outreach Migrant Workers for reaching malaria services to forest worksites. URC shared the experiences of pilot activities at Toungup township. • Application of mobile tablet in supervision activities were discussed and MNMA requested and agreed to provide mobile tablets for Thandwe and Gwa townships. • Provision of staff safety and security trainings for NRS staff (URC and MHAA), and Field Operation Coordinator and Sub-Grant manager will work with Admin/Finance Director for further implementation of safety trainings. • Operationalization of ICMV activities at field level and the potential of proposing donor level coordination meeting especially with Access to Health Fund and other disease control partners.

Regional Health Director of Tanintharyi Region delivered M & E Technical Advisor facilitated at panel discussion an opening speech at private sector engagement on the importance of private sector involvement in workshop at Kawthoung, Tanintharyi malaria and elimination at Kawthoung, Tanintharyi

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❖ Strengthen BCC and community mobilization activities to promote the sustained use of preventive methods, the timely use of community and facility-based health services, the adherence to prescribed treatment, and the collaboration in the testing of new tools and approaches Engagement with community for establishment of community support groups (CSG) In this quarter, Defeat Malaria-ARC team met with community representatives at 25 villages of 5 townships of Kayin State (Hpa An – 6 villages, Hlaingbwe – 2 villages, Kawkareik – 8 villages, Myawaddy – 7 villages, Bokpyin – 2 villages). The main points of discussion were: • Community involvement in health care and community support groups • Functional status and challenges of CSGs if the villages had already formed and established • Community interest on revitalization or establishment of community support groups Some villages already had health emergency referral support activities initiated by other INGOs such as Save The Children, ADRA, and etc. The current community groups among the villages have various levels of functionality and most of them were supportive of proposed activities to revitalize community support functions. It was discussed that Defeat Malaria was also willing to facilitate for the development of Community Support Group in a standard procedure and improving systems for empowering communities. It is currently drawn up the CSG forming procedures referencing previous village health committee establishment experiences of 3MDG project in Myanmar and other donor models to be tailored with local context and situation.

The URC Defeat Malaria Team assisting ARC in integrating the mobile-based supervision tool for VMW supervision

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Annexes Annex 1: Situation in Rakhine State According to the conflict situation updates and the order issued by Rakhine State Coordination Committee dated on January 10th 2019, all UN/ INGO/ NGO (except ICRC and WFP) are restricted to work only at the urban town and not allowed to go villages and field sites in Rathedaung, Buthidaung, Maungdaw, Ponnagyun and Kyauktaw Townships. (Ref: Rakhine State Coordination Committee Issue Order, Letter No. 0040/Admin/CC/2019 Rakhine) As the situation progresses, other enhanced security measures likely include checkpoints, roadblocks, and ID checks. Authorities are also likely to conduct more intense screenings of foreign visitors at Sittwe Airport (AKY). Increased security could result in localized disruptions and travel delays. Travel advisories were issued upon the armed hostilities continuation and the US Embassy in Myanmar warned its citizens against traveling to Buthidaung, Kyauktaw, Maungdaw, Minbya, Mrauk- U, Ponnagyun, and Rathedaung townships in Rakhine State on March 29th, 2019. (Ref: Worldcue Alert @ www.worldaware.com ) Defeat Malaria set up weekly situation report of Rakhine updates to Chief of Party, and daily updates are communicated with field offices as necessary to take immediate and appropriate actions for staff safety and security. In this quarter, all 38 URC staff (24 Rakhine native and 14 Rakhine non-native) from NRS have been provided United Nations Department of Safety and Security (UNDSS) online training through the access to https://training.dss.un.org. The trainings were facilitated by Field Operation Coordinator and Township Team Leaders for successful accomplishment of online course available in English version for all Township Assistants, Health Facilitators, and office staff. All 52 URC staff from SRS have accomplished the safety and security trainings including BSAFE, Information Security Awareness and Preparing and Responding to Active Shooter incidents. BSAFE is the new online security awareness training which replaces both Basic Security in the Field ((BSITF) and Advanced Security in the Field (ASTIF). BSAFE is mandatory for all UN personnel including intern and consultants. At the quarterly review meeting, the Sub-Grant Manager discussed the security trainings to be provided to all MHAA and URC staff who are working in Northern Rakhine State, and proposed online course of United Nations Department of Safety and Security (UNDSS) Training through the access to https://training.dss.un.org. It was agreed to provide safety and security training to all staff especially working in Northern Rakhine State, and it would need the supports of Field Director, Field Operation Coordinator, and Township Team Leaders for successful accomplishment of online courses which are available in English version. The Rakhine State Director of URC is scheduling field visits to Buthidaung, Rathedaung and Maungdaw townships on April 2nd to 5th 2019 to provide safety and security trainings to MHAA partner staff. All staff in NRS are remaining vigilant to the situation for the safety and security of staff and strictly follow the safety procedures and alert system. Local security condition of March 2019 was yellow alert in all three townships under curfew order. The URC team will continue to monitor the situation and adapt our approach in Northern Rakhine State as necessary.

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Annex 2: Success Stories Approach for Intensifying Malaria Burden Reduction in Ann Township, Rakhine State According to the Myanmar National Malaria Control Program (NMCP) data, Rakhine State had the highest number of malaria occurrences in 2016 and the second highest in 2017, ranked third for annual parasitic incidence that year. University Research Co. (URC) has implemented malaria burden reduction activities in Ann township since July 2013 under CAP-M project and has continued these activities under the Defeat Malaria project starting from October 2016. One of the areas we work within Rakhine is Ann Township; according to a malaria implementing partners mapping conducted in 2017, 216 Village Malaria Workers (VMWs) were implementing community-based malaria control and URC Team Leader and Assistant is drawing a micro-plan with prevention activities in 303 villages of Ann Malaria Supervisor of NMCP township that year, led by various stakeholders including the NMCP, URC, Myanmar Medical Association (MMA), and Myanmar Health Assistant Association (MHAA). URC has worked in close collaboration with the Township Health Departments (THD) – under the leadership of Team Leaders (Public Health Doctors) – to collect routine and targeted data, conduct data cleaning, compilation, analysis, select priority areas for additional support, and conduct targeted activities including joint visits, effective LLIN distribution and accelerated case finding. In 2017, Defeat Malaria progress data revealed that Ann township had the most malaria cases detected among 17 townships of Rakhine State. Darr Let and Ka Zu Kine Rural Health Centers (RHCs) were noted as the highest malaria transmission among 7 RHCs of Ann Township. During 2018, Defeat Malaria, in collaboration with the THD, conducted intensified malaria mobile visits for hard-to-reach areas of Dar Lett and Ka Zu Kine areas. The first visit was held in January 2018, reaching 26 villages, testing 1,969 people suspected for malaria, and treating all 17 malaria cases detected. The second mobile visit was in October 2018, reaching 53 villages, testing 4,505 people suspected for malaria, and treating 6 malaria cases detected. The same year, 52,130 LLINs were distributed for 11,156 people residing at 23,440 households in the 54 villages of Ann Township. VMW performance was continuously supervised for promoting passive case detection, provision of treatment according to national treatment guidelines, and ensuring treatment completeness by supporting directly observed treatment. At the end of 2018, malaria transmission in the Defeat Malaria targeted areas of Ann township reduced by 63% (781 cases in 2017 vs 278 cases in 2018) within a year. At the Defeat Malaria Annual Review Meeting, the Central M&E team presented that: “A dramatic reduction of malaria cases in Ann Township was noted in this 2018 and it might reflect the effective collaboration of NMCP with URC and other partners, appropriate resource mobilization to highly prioritized areas, and the high motivation of all care providers to work for marginalized hard-to-reach people.” We continue to apply best practices and lessons learned from these successes in our efforts to reduce the malaria burden. Defeat Malaria came to provide 25 VMWs more for malaria service coverage at additional 25 villages in Ann township, which were handed over due to phasing out of Myanmar Medical Association malaria project. Success story told by Malaria Inspector of Ann Township

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During a collaborative township review meeting, Mr. Thein Shwe, a Malaria Inspector of Ann Township said that “URC had been implementing malaria prevention and control activities in hard-to-reach areas and high malaria transmission areas of Ann Township since 2014. In 2015, URC, in collaboration with the NMCP, provided indoor residual spray and mass screenings of malaria activities for very high malaria transmission areas.” The Malaria Supervisor said “we follow the guidance of Sayagyi Dr. Saw Lwin (Regional Technical Director of Defeat Malaria) for proving intensified malaria case findings and prevention activities for high malaria burden areas”. “NMCP collaborated with partners and recruited more community-based VMWs to promote the accessibility of malaria services for every village with no malaria service gaps”. In the same meeting, basic health staff from Dar Let RHC voiced that more malaria cases were detected among villages of NMCP implemented areas following mobile visits and motivational support to village volunteers and provision of advocacy to village leaders and communities for early access to malaria diagnostics. NMCP and URC made a micro-plan for joint malaria mobile visits to provide intensified case finding activities for such areas, as well as education and distribution for effective LLIN coverage and utilization among communities including mobile migrant population. Forest goers were also found as more vulnerable and VMWs were encouraged for active fever surveillance and repeated testing of malaria diagnosis to forest goers. Story written, note taken and recorded by Dr. Thant Ko Ko Oo (Team Leader - Ann, URC) and reviewed by Dr. Thant Zin Aung (Field Director - Southern Rakhine State, URC)

Approach to Persistent Malaria Transmission Area of Let Pan Village in Toungup Township, Rakhine State Let Pan village is situated under Ma Ei Rural Health Center of Toungup Township with the Ma Ei river on the south-west side and paddy fields surrounding the area. As with other areas in Myanmar, University Research Co., LLC (URC) first began supporting Village Malaria Workers (VMWs) for malaria prevention and control activities in July 2013 under the CAP-Malaria project and has strengthened these activities under the Defeat Malaria project since October 2016. Using village-based stratification techniques allows the team to continuously analyze localized malaria transmission trends among villages that Defeat Malaria targets. Out of around 750 people in Let Pan village, the number of malaria cases detected has continued to increase from 13 in 2014 to 32 in 2017, revealing persistent malaria transmission despite of adequate LLIN distribution, high blood examination rates, and provision of standard treatment. In August 2017, the Defeat Malaria team conducted a demographic assessment, behavior survey, epidemiological assessment, and review of the quality of health services. Findings revealed that forest goers – mostly Chin ethnic minorities – were not accessing malaria preventive and other necessary services, and that although 410 LLINs were distributed adequately for 792 people in 2017, the LLIN utilization rate was only 62%. Based on these findings, Defeat Malaria developed targeted activities to address the core issues. In 2018, VMWs reached out to 89 forest goers for continuous engagement and key malaria preventive messages for sleeping under LLIN both at the village and at the forest worksite, as well as immediate testing for malaria diagnosis at the onset of fever or upon the Township Elimination Coordinator captured the story appearance of early malaria symptoms. Mosquito from Village Malaria Worker of Let Pan

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repellents were distributed to 23 night-time forest workers to be used during outdoor night-time works starting from August 2018. Following these interventions, there was a dramatic reduction of malaria transmission from 32 cases in 2017 to 6 cases in 2018 (81% reduction) in spite of adequate Annual Blood Examination Rate (28%). Case investigations and responses were undertaken and classified as 4 indigenous and 2 imported cases, all found among forest goers. There were 36 people tested for malaria between January and March 2019, and 2 imported cases were identified from forest workers who had not previously accessed VMW services. Following this success, in February 2019, the team conducted participatory discussions with Township Malaria Coordinator of URC captured the community stakeholders to explore the malaria story from a forest goer services reaching forest worksites and recruited 2 Outreach Malaria Workers among forest goers for improved support. Success Story told by Village Malaria Worker of Let Pan Ms. May Zin Tun, a VMW from Let Pan village, said that the malaria transmission in the village has been markedly reduced in 2018 by comparing with previous 3-4 years. Defeat Malaria supported many capacity building trainings to perform active fever surveillance, provide awareness raising of malaria knowledge and promote LLIN utilization among forest goers, immediately notify for malaria positive cases, and participation in case investigation and response activities. Ms. May uses village-level community meetings to share updated information about malaria including higher risk of malaria infection among forest goers, encourage seeking blood testing at the early onset of fever, promote LLIN utilization, and highlight the importance of taking complete course of anti-malaria treatment. Chin ethnic villagers are more vulnerable to malaria infection due to the nature of their work, such as farming in the mountainous areas, cutting trees by chain saws, and carrying woods by buffaloes from the forested areas. “It was discussed with my supervisor, Team Assistant of Defeat Malaria project, about malaria service provision to reach those scattered worksites, and now I received 2 Outreach Malaria Workers who were forest goers to provide malaria service for the remote forest worksites.” “We could prevent onward malaria transmission not only in the village but also in the worksites if one malaria case was detected.” Forest goers were also very pleased to receive mosquito repellents to be used during their night time works. Success Story told by the Forest Goer Mr. Zaw Min Thu, a 21 years old forest goer from Let Pan village, said that malaria related services are improving since URC project has been active in the village. He got malaria infection 2 times in the last 2 to 3 years and was cured with the support of VMWs providing medication. Previously, Mr. Zaw did not regularly use an LLIN when he stayed at forest worksite, but after engaging with VMWs and learning about their usefulness, he now strives to sleep under an LLIN every night. “VMW also instructed me to take blood test for malaria especially 2 weeks after coming back from the forest.” “I am very pleased to receive mosquito repellents as it helps me to minimize the nuisance of mosquito bites at my night-time work.

Notes taken and recorded by Dr. Ei Ei Win Aung and Dr. Hein Htet Lin Nyan, and the story written by Dr. Than Zin Aung (Field Director-Southern Rakhine State, URC).

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Annex 3: Entomological survey on persistent malaria transmission methods and findings Locations Methods Findings 1. Human landing outdoor. 1. An. dirus, An. minimus and An. maculatus and man biting rates were 0.17-0.33 per man/night in 2nd and 3rd quarter of the night. 2. Light trap collection (indoor) 2. An. maculatus & An. Vagus 3. Animal baited net traps 3. An. dirus, An. minimus, An. maculatus, and An. Sundaicus 1. Larval collection (Source: Seepage 1. Average 1.8 larvae per dip in 72 dips, and stream with vegetation, clear water identified larvae of 3 An. minimus, 6 An. having pH7) maculatus and 2 An. aconitus. 2. Larval collection (Source: Seepage 2. Average 0.9 larvae per dip in 30 dips, and

Htauk Kyant (A1 Taw village) with vegetation, not clear water but identified 3 An. Vagus and 2 An. barbirostris pH7 1. Human landing outdoor. 1. An. dirus, and An. minimus and man biting rates were 0.16 per man/night for both 2. Light trap collection (indoor) 2. No Anopheles mosquito was identified. 3. Animal baited net traps 3. Six Anopheles species were identified including An. minimus, An. maculatus (+++),

worksite) and An. aconitus (+) Worksite (A1Worksite Larval collection (Source: hand 1. No Anopheles larva was collected. scooped-hole for water) 1. Human landing outdoor. 1. An. minimus, An. maculatus and An. vagus, and man biting rates were 0.02-0.13 per man/night 2. Light trap collection (indoor) 2. An. maculatus 3. Light trap collection (outdoor) 3. An.culicifacies 4. Animal baited net traps 4. Six anopheles species including An. minimus (0.05%), An. maculatus (9%), and An. culicifacies (43%), and An. Jamesii (36%). Larval collection 1. Larvae of An. jamesii and An. culicifacies (Source: Toungup stream and edges

LowerKyauk (A2 village) Gar Ta of stream) 1. Human landing outdoor. 1. An. maculatus and man landing rate was

0.013 per man/night 2. No Anopheles collected 2. Human landing indoor 3. No Anopheles collected 3. Light trap indoor and outdoor 4. Six anopheles (C) species and one (A) species 4. Animal baited net traps including An. maculatus (44%), and An. stephensii (19%), An. Jamesii (19%), and An.

culicifacies (7%), An. minimus (6.4%), and An. Vagus (4,3%) 5. Indoor space spray collection 5. No Anopheles collected Thit Sin Thit Camp worksite) (A2 Larval collection (Source: Stream of 1. Larvae of An. maculatus Thit Sin)

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Annex 4: Case Finding and Management No Township Tested Total Positive Pf Pv Mixed TPR% 1 Bokpyin (ARC) 982 34 7 27 0 3.46% 2 Dawei (URC) 1881 60 4 56 0 3.19% 3 Kawthoung (ARC) 1932 1 0 1 0 0.05% 4 Kyunsu (URC) 3832 40 0 40 0 1.04% 5 Launglon (URC) 979 0 0 0 0 0.00% 6 Myeik (URC) 943 6 5 1 0 0.64% 7 Palaw (URC) 2423 101 43 58 0 4.17% 8 Tanintharyi (ARC) 1037 12 4 8 0 1.16% 9 Thayetchaung (URC) 1688 55 0 55 0 3.26% 10 Yebyu (URC) 1731 0 0 0 0 0.00% Tanintharyi 17,428 309 63 246 0 1.77% 11 Ann (URC) 1861 46 40 6 0 2.47% 12 Gwa (MNMA) 920 0 0 0 0 0.00% 13 Kyuakpyu (URC) 693 0 0 0 0 0.00% 14 Munaung (URC) 3066 1 0 1 0 0.03% 15 Ramree (URC) 4432 1 0 1 0 0.02% 16 Thandwe (MNMA) 1308 0 0 0 0 0.00% 17 Toungup (URC) 4467 14 11 2 1 0.31% Southern Rakhine 16,747 62 51 10 1 0.37% 18 Buthidaung (MHAA) 6392 51 26 22 3 0.80% 19 Kyauktaw (URC) 3929 85 48 36 1 2.16% 20 Maungdaw (MHAA) 784 2 2 0 0 0.26% 21 Minbya (URC) 1427 65 42 23 0 4.56% 22 Mrauk-U (URC) 2213 24 14 10 0 1.08% 23 Myebon (URC) 1920 16 13 3 0 0.83% 24 Pauktaw (URC) 1126 7 6 1 0 0.62% 25 Ponnagyun (URC) 1188 28 7 20 1 2.36% 26 Rathedaung (MHAA) 1444 1 0 1 0 0.07% 27 Sittwe (URC) 1550 5 3 2 0 0.32% Northern Rakhine 21,973 284 161 118 5 1.29% 28 Hlaingbwe (ARC) 769 13 0 13 0 1.69% 29 Hpa-an (ARC) 1335 7 0 7 0 0.52% 30 Hpa-pun (ARC) 0 0 0 0 0 - 31 Kawkareik (ARC) 1337 12 1 11 0 0.90% 32 Kyarinseikgyi (ARC) 0 0 0 0 0 - 33 Myawaddy (ARC) 1032 33 0 33 0 3.20% Kayin 4,473 65 1 64 0 1.45% 34 Banmauk (URC) 0 0 0 0 0 - 35 Homalin (URC) 628 0 0 0 0 0.00% 36 Indaw (URC) 0 0 0 0 0 -

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37 Pale (URC) 568 1 0 1 0 0.18% 38 Pinlebu (URC) 0 0 0 0 0 - Sagaing Total 1,196 1 0 1 0 0.08% DEFEAT MALARIA TOTAL 61,817 721 276 439 6 1.17%

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Annex 5-A: Active case detection by mobile team (Project Villages) # of Project Total Total No. Township Pf Pv Mixed TPR% Villages Tested Positive 1 Bokpyin 4 7 0 0 0 0 0.00% 2 Dawei 6 1105 3 20 0 23 2.08% 3 Kawthoung 1 55 0 0 0 0 0.00% 4 Kyunsu 4 1005 0 6 0 6 0.60% 5 Launglon 0 0 0 0 0 0 0.00% 6 Myeik 4 173 1 0 0 1 0.58% 7 Palaw 13 907 4 6 0 10 1.10% 8 Tanintharyi 2 74 0 0 0 0 0.00% 9 Thayetchaung 4 507 0 12 0 12 2.37% 10 Yebyu 2 75 0 0 0 0 0.00% Tanintharyi Total 40 3908 8 44 0 52 1.33% 11 Ann 6 79 3 0 0 3 3.80% 12 Gwa 0 0 0 0 0 0 0.00% 13 Kyaukpyu 0 0 0 0 0 0 0.00% 14 Munaung 0 0 0 0 0 0 0.00% 15 Ramree 43 130 0 0 0 0 0.00% 16 Thandwe 0 0 0 0 0 0 0.00% 17 Toungup 12 155 0 0 0 0 0.00% Rakhine (South) Total 61 364 3 0 0 3 0.82% 18 Buthidaung 0 0 0 0 0 0 0.00% 19 Kyauktaw 8 582 1 1 0 2 0.34% 20 Maungdaw 0 0 0 0 0 0 0.00% 21 Minbya 0 0 0 0 0 0 0.00% 22 Mrauk-U 0 0 0 0 0 0 0.00% 23 Myebon 1 170 3 0 0 3 1.76% 24 Pauktaw 1 91 0 0 0 0 0.00% 25 Ponnagyun 0 0 0 0 0 0 0.00% 26 Rathedaung 1 111 0 0 0 0 0.00% 27 Sittwe 0 0 0 0 0 0 0.00% Rakhine (North) Total 11 954 4 1 0 5 0.52% 28 Hlaingbwe 0 0 0 0 0 0 0.00% 29 Hpa-an 3 210 0 0 0 0 0.00% 30 Hpapun 0 0 0 0 0 0 0.00% 31 Kawkareik 12 618 0 0 0 0 0.00% 32 Kyainseikgyi 0 0 0 0 0 0 0.00% 33 Myawaddy 14 356 0 1 0 1 0.28% Kayin Total 29 1184 0 1 0 1 0.08% GRAND TOTAL 141 6410 15 46 0 61 0.95%

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Annex 5-B: Active case detection by mobile team (Non-Project Villages) # of Non-project Total Total No. Township Pf Pv Mixed TPR% Villages Tested Positive 1 Bokpyin 10 104 1 6 0 7 6.73% 2 Dawei 11 89 0 0 0 0 0.00% 3 Kawthoung 1 25 0 0 0 0 0.00% 4 Kyunsu 2 842 0 4 0 4 0.48% 5 Launglon 0 0 0 0 0 0 0.00% 6 Myeik 0 0 0 0 0 0 0.00% 7 Palaw 2 42 0 1 0 1 2.38% 8 Tanintharyi 2 2 0 0 0 0 0.00% 9 Thayetchaung 1 1 0 0 0 0 0.00% 10 Yebyu 0 0 0 0 0 0 0.00% Tanintharyi Total 29 1105 1 11 0 12 1.09% 11 Ann 4 12 1 2 0 3 25.00% 12 Gwa 0 0 0 0 0 0 0.00% 13 Kyaukpyu 0 0 0 0 0 0 0.00% 14 Munaung 0 0 0 0 0 0 0.00% 15 Ramree 68 155 0 0 0 0 0.00% 16 Thandwe 0 0 0 0 0 0 0.00% 17 Toungup 21 155 0 0 0 0 0.00% Rakhine (South) Total 93 322 1 2 0 3 0.93% 18 Buthidaung 0 0 0 0 0 0 0.00% 19 Kyauktaw 7 810 15 6 1 22 2.72% 20 Maungdaw 0 0 0 0 0 0 0.00% 21 Minbya 5 487 7 1 0 8 1.64% 22 Mrauk-U 0 0 0 0 0 0 0.00% 23 Myebon 0 0 0 0 0 0 0.00% 24 Pauktaw 1 3 0 0 0 0 0.00% 25 Ponnagyun 9 178 0 2 0 2 1.12% 26 Rathedaung 0 0 0 0 0 0 0.00% 27 Sittwe 0 0 0 0 0 0 0.00% Rakhine (North) Total 22 1478 22 9 1 32 2.17% 28 Hlaingbwe 0 0 0 0 0 0 0.00% 29 Hpa-an 0 0 0 0 0 0 0.00% 30 Hpapun 0 0 0 0 0 0 0.00% 31 Kawkareik 0 0 0 0 0 0 0.00% 32 Kyainseikgyi 0 0 0 0 0 0 0.00% 33 Myawaddy 11 153 0 0 0 0 0.00% Kayin Total 11 153 0 0 0 0 0.00% GRAND TOTAL 155 3058 24 22 1 47 1.54%

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Annex 6: Monthly Meetings VMW / PP Posts Sr % of VMWs/PPs Township have to attend Male Female Total attended the meeting No. the meeting 1 Bokpyin 175 34 139 173 98.9% 2 Dawei 63 10 45 55 87.3% 3 Kawthoung 169 89 55 144 85.2% 4 Kyunsu 185 47 133 180 97.3% 5 Launglon 99 10 76 86 86.9% 6 Myeik 90 12 78 90 100.0% 7 Palaw 159 37 108 145 91.2% 8 Tanintharyi 181 41 126 167 92.3% 9 Thayetchaung 93 15 74 89 95.7% 10 Yebyu 199 42 139 181 91.0% Tanintharyi Total 1413 337 973 1310 92.7% 11 Ann 262 161 83 244 93.1% 12 Gwa 195 79 111 190 97.4% 13 Kyaukpyu 150 107 39 146 97.3% 14 Munaung 0 0 0 0 - 15 Ramree 228 152 75 227 99.6% 16 Thandwe 354 113 241 354 100.0% 17 Toungup 264 127 113 240 90.9% Southern Rakhine Total 1453 739 662 1401 96.4% 18 Buthidaung 426 398 27 425 99.8% 19 Kyauktaw 270 85 114 199 73.7% 20 Maungdaw 63 58 3 61 96.8% 21 Minbya 124 79 43 122 98.4% 22 Mrauk-U 196 107 29 136 69.4% 23 Myebon 237 114 120 234 98.7% 24 Pauktaw 126 72 51 123 97.6% 25 Ponnagyun 160 72 64 136 85.0% 26 Rathedaung 195 79 113 192 98.5% 27 Sittwe 123 30 93 123 100.0% Northern Rakhine Total 28 Hlaingbwe 158 29 124 153 96.8% 29 Hpa-an 258 50 205 255 98.8% 30 Hpapun 0 0 0 0 - 31 Kawkareik 147 65 65 130 88.4% 32 Kyainseikgyi 0 0 0 0 - 33 Myawaddy 68 18 50 68 100.0%

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Kayin Total 631 162 444 606 96.0% 34 Banmauk 0 0 0 0 - 35 Homalin 48 26 21 47 97.9% 36 Indaw 0 0 0 0 - 37 Pale 93 27 59 86 92.5% 38 Pinlebu 0 0 0 0 - Sagaing Total 141 53 80 133 94.3% GRAND TOTAL 5558 2385 2816 5201 93.6%

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Annex 7: Supervision and monitoring

Total # of VMWs and PPs Sr No. Township # of VMWs supervised # of PPs supervised supervised 1 Bokpyin 25 4 29 2 Dawei 11 1 12 3 Kawthoung 32 4 36 4 Kyunsu 30 4 34 5 Launglon 11 0 11 6 Myeik 13 2 15 7 Palaw 25 6 31 8 Tanintharyi 24 0 24 9 Thayetchaung 7 5 12 10 Yebyu 38 0 38 Tanintharyi Total 216 26 242 11 Ann 39 8 47 12 Gwa 34 0 34 13 Kyaukpyu 44 4 48 14 Ramree 48 1 49 15 Thandwe 70 0 70 16 Toungup 27 12 39 Southern Rakhine Total 262 25 287 17 Buthidaung 0 0 0 18 Kyauktaw 7 0 7 19 Maungdaw 0 0 0 20 Minbya 12 0 12 21 Mrauk-U 17 8 25 22 Myebon 33 2 35 23 Pauktaw 15 5 20 24 Ponnagyun 2 0 2 25 Rathedaung 1 0 1 26 Sittwe 13 0 13 Northern Rakhine Total 100 15 115 27 Hlaingbwe 30 0 30 28 Hpa-an 60 4 64 29 Kawkareik 31 2 33 30 Myawaddy 14 1 15 Kayin Total 135 7 142 GRAND TOTAL 713 73 786

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Annex 8: Reporting status of VMWs/PPs Cumulative # # of # of % of of VMW/PP VMW/PP VMW/PP % of No State/Region Township timely reports to be reported (On reported reporting submitted time + Late) timely reporting 1 Tanintharyi Bokpyin 180 175 175 97.2% 100.0% 2 Tanintharyi Dawei 96 95 95 99.0% 100.0% 3 Tanintharyi Kawthoung 184 153 153 83.2% 100.0% 4 Tanintharyi Kyunsu 185 182 182 98.4% 100.0% 5 Tanintharyi Launglon 99 99 97 100.0% 98.0% 6 Tanintharyi Myeik 90 90 90 100.0% 100.0% 7 Tanintharyi Palaw 159 154 154 96.9% 100.0% 8 Tanintharyi Tanintharyi 181 174 167 96.1% 96.0% 9 Tanintharyi Thayetchaung 93 91 91 97.8% 100.0% 10 Tanintharyi Yebyu 203 195 192 96.1% 98.5% Tanintharyi Total 1470 1408 1396 95.8% 99.1% 11 Rakhine (South) Ann 262 262 262 100.0% 100.0% 12 Rakhine (South) Gwa 195 194 194 99.5% 100.0% 13 Rakhine (South) Kyaukpyu 150 150 150 100.0% 100.0% 14 Rakhine (South) Munaung 0 0 0 - - 15 Rakhine (South) Ramree 228 228 228 100.0% 100.0% 16 Rakhine (South) Thandwe 354 354 354 100.0% 100.0% 17 Rakhine (South) Toungup 264 263 263 99.6% 100.0% Southern Rakhine Total 1453 1451 1451 99.9% 100.0% 18 Rakhine (North) Buthidaung 426 426 425 100.0% 99.8% 19 Rakhine (North) Kyauktaw 270 268 268 99.3% 100.0% 20 Rakhine (North) Maungdaw 63 61 61 96.8% 100.0% 21 Rakhine (North) Minbya 124 124 124 100.0% 100.0% 22 Rakhine (North) Mrauk-U 196 196 196 100.0% 100.0% 23 Rakhine (North) Myebon 237 235 235 99.2% 100.0% 24 Rakhine (North) Pauktaw 126 123 123 97.6% 100.0% 25 Rakhine (North) Ponnagyun 160 156 156 97.5% 100.0% 26 Rakhine (North) Rathedaung 195 192 192 98.5% 100.0% 27 Rakhine (North) Sittwe 123 123 123 100.0% 100.0% Northern Rakhine Total 1920 1904 1903 99.2% 99.9% 28 Kayin Hlaingbwe 159 157 156 98.7% 99.4% 29 Kayin Hpa-an 270 269 269 99.6% 100.0% 30 Kayin Kawkareik 147 146 146 99.3% 100.0% 31 Kayin Myawaddy 68 68 68 100.0% 100.0% Kayin Total 644 640 639 99.4% 99.8%

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32 Sagaing Banmauk 0 0 0 - - 33 Sagaing Homalin 48 41 41 85.4% 100.0% 34 Sagaing Indaw 0 0 0 - - 35 Sagaing Pale 93 91 91 97.8% 100.0% 36 Sagaing Pinlebu 0 0 0 - - Sagaing Total 141 132 132 93.6% 100.0% DEFEAT MALARIA TOTAL 5628 5535 5521 98.3% 99.7%

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Annex 9: Clinical audit Total % of Positive Total Total positive Total % of treated patients who Positive Positive cases referred cases among was treated Sr.No. Township cases cases treated cases positive cases according to found treated according NTG to NTG 1 Bokpyin 34 34 34 0 100.0% 100.0% 2 Dawei 60 60 58 0 100.0% 96.7% 3 Kawthoung 1 1 1 0 100.0% 100.0% 4 Kyunsu 40 39 39 1 97.5% 100.0% 5 Launglon 0 0 0 0 - - 6 Myeik 6 6 6 0 100.0% 100.0% 7 Palaw 101 100 98 1 99.0% 98.0% 8 Tanintharyi 12 10 10 2 83.3% 100.0% 9 Thayetchaung 55 54 53 1 98.2% 98.1% 10 Yebyu 0 0 0 0 - - Tanintharyi Total 309 304 299 5 98.4% 98.4% 11 Ann 46 46 46 0 100.0% 100.0% 12 Gwa 0 0 0 0 - - 13 Kyaukpyu 0 0 0 0 - - 14 Munaung 1 1 1 0 100.0% 100.0% 15 Ramree 1 1 1 0 100.0% 100.0% 16 Thandwe 0 0 0 0 - - 17 Toungup 14 14 14 0 100.0% 100.0% Southern Rakhine Total 62 62 62 0 100.0% 100.0% 18 Buthidaung 51 51 51 0 100.0% 100.0% 19 Kyauktaw 85 83 83 2 97.6% 100.0% 20 Maungdaw 2 1 1 1 50.0% 100.0% 21 Minbya 65 65 65 0 100.0% 100.0% 22 Mrauk-U 24 24 24 0 100.0% 100.0% 23 Myebon 16 16 16 0 100.0% 100.0% 24 Pauktaw 7 7 6 0 100.0% 85.7% 25 Ponnagyun 28 27 27 1 96.4% 100.0% 26 Rathedaung 1 1 1 0 100.0% 100.0% 27 Sittwe 5 5 5 0 100.0% 100.0% Northern Rakhine Total 284 280 279 4 98.6% 99.6% 28 Hlaingbwe 13 13 13 0 100.0% 100.0% 29 Hpa-an 7 7 7 0 100.0% 100.0% 30 Kawkareik 12 12 12 0 100.0% 100.0% 31 Myawaddy 33 33 33 0 100.0% 100.0% Kayin Total 65 65 65 0 100.0% 100.0% 32 Banmauk 0 0 0 0 - -

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33 Homalin 0 0 0 0 - - 34 Indaw 0 0 0 0 - - 35 Pale 1 1 1 0 100.0% 100.0% 36 Pinlebu 0 0 0 0 - - Sagaing Total 1 1 1 0 100.0% 100.0% GRAND TOTAL 1205 1192 1184 13 98.9% 99.3%

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Annex 10: Stock out monitoring at the time of monitoring visits % of sites % of sites % of sites % of sites Total # Total which which which which No State/ of # of Township experience experience experience experience . Region visited visite d NO RDT d NO ACT d NO RDT d NO ACT VMW d PP stock out stock out stock out stock out Taninthary 1 Bokpyin 25 100.0% 100.0% 4 100.0% 100.0% i Taninthary 2 Dawei 11 100.0% 100.0% 1 100.0% 100.0% i Taninthary 3 Kawthoung 32 100.0% 100.0% 4 100.0% 100.0% i Taninthary 4 Kyunsu 30 100.0% 100.0% 4 100.0% 100.0% i Taninthary 5 Launglon 11 100.0% 100.0% - - - i Taninthary 6 Myeik 13 100.0% 100.0% 2 100.0% 100.0% i Taninthary 7 Palaw 25 100.0% 100.0% 6 100.0% 100.0% i Taninthary 8 Tanintharyi 24 100.0% 100.0% - - - i Taninthary 9 Thayetchaung 7 100.0% 100.0% 5 100.0% 100.0% i Taninthary 10 Yebyu 38 100.0% 100.0% - - - i Tanintharyi Total 216 100.0% 100.0% 26 100.0% 100.0% 11 Rakhine Ann 39 100.0% 100.0% 8 100.0% 100.0% (South) 12 Rakhine Gwa 34 100.0% 100.0% - - - (South) 13 Rakhine Kyaukpyu 44 100.0% 100.0% 4 100.0% 100.0% (South) 14 Rakhine Munaung ------(South) 15 Rakhine Ramree 48 100.0% 100.0% 1 100.0% 100.0% (South) 16 Rakhine Thandwe 70 100.0% 100.0% - - - (South) 17 Rakhine Toungup 27 100.0% 100.0% 12 100.0% 100.0% (South) Southern Rakhine Total 262 100.0% 100.0% 25 100.0% 100.0% 18 Rakhine Buthidaung ------(North) 19 Rakhine Kyauktaw 76 100.0% 100.0% - - - (North) 20 Rakhine Maungdaw ------(North)

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21 Rakhine Minbya 12 100.0% 100.0% - - - (North) 22 Rakhine Mrauk-U 66 100.0% 100.0% 19 100.0% 100.0% (North) 23 Rakhine Myebon 33 100.0% 100.0% 2 100.0% 100.0% (North) 24 Rakhine Pauktaw 15 100.0% 100.0% 5 100.0% 100.0% (North) 25 Rakhine Ponnagyun 13 100.0% 100.0% - - - (North) 26 Rakhine Rathedaung 1 100.0% 100.0% - - - (North) 27 Rakhine Sittwe 13 100.0% 100.0% - - - (North) Northern Rakhine Total 229 100.0% 100.0% 26 100.0% 100.0% 28 Kayin Hlaingbwe 30 100.0% 100.0% - - - 29 Kayin Hpa-an 60 100.0% 100.0% 4 100.0% 100.0% 30 Kayin Hpapun ------31 Kayin Kawkareik 31 100.0% 100.0% 2 100.0% 100.0% 32 Kayin Kyarinseikgy ------i 33 Kayin Myawaddy 14 100.0% 100.0% 1 100.0% 100.0%

Kayin Total 82 100% 100.0% 1 100.0% 100.0% GRAND TOTAL 842 100% 100.0% 84 100.0% 98.6%

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Annex 11: Capacity building Training on Integrated Community Malaria Volunteer (January 2019 – March 2019)

Village Malaria Workers Private Providers Sr trained trained Township Grand Total No. Sub- Sub- M F M F total total 1 Bokpyin 4 23 27 1 - 1 28 2 Dawei ------3 Kawthoung ------4 Kyunsu ------5 Launglon - 1 1 - - - 1 6 Myeik ------7 Palaw ------8 Tanintharyi 9 16 25 - - - 25 9 Thayetchaung ------10 Yebyu 4 7 11 - - - 11 Tanintharyi Total 17 47 64 1 - 1 65 11 Ann 18 7 25 10 1 11 36 12 Gwa ------13 Kyaukpyu ------14 Munaung ------15 Ramree ------16 Thandwe ------17 Toungup ------Southern Rakhine Total 18 7 25 10 1 11 36 18 Buthidaung ------19 Kyauktaw ------20 Maungdaw ------21 Minbya 23 26 49 - - - 49 22 Mrauk-U 15 8 23 - - - 23 23 Myebon ------24 Pauktaw ------25 Ponnagyun 9 19 28 - - - 28 26 Rathedaung ------27 Sittwe ------Northern Rakhine Total 47 53 100 - - - 100

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28 Hlaingbwe ------29 Hpa-an ------30 Kawkareik ------31 Myawaddy ------Kayin Total ------GRAND TOTAL 82 107 189 11 1 12 201

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Annex 12: Behavior Change Communication Individual IPC Group Health Talk Sr Township Migrants Sessions Migrants No. Male Female Total Male Female Total included # included 1 Bokpyin 645 593 1238 816 73 807 868 1675 842 2 Dawei 678 622 1300 219 0 0 0 0 0 3 Kawthoung 1084 917 2001 2001 68 320 374 694 694 4 Kyunsu 1088 1307 2395 36 0 0 0 0 0 5 Launglon 326 626 952 1 0 0 0 0 0 6 Myeik 419 525 944 34 2 128 92 220 158 7 Palaw 801 1090 1891 260 0 0 0 0 0 8 Tanintharyi 456 419 875 150 33 104 118 222 8 9 Thayetchaung 553 1025 1578 594 0 0 0 0 0 10 Yebyu 636 922 1558 190 0 0 0 0 0 Tanintharyi Total 6686 8046 14732 4301 176 1359 1452 2811 1702 11 Ann 885 711 1596 236 0 0 0 0 0 12 Gwa 810 873 1683 43 0 0 0 0 0 13 Kyaukpyu 433 536 969 50 0 0 0 0 0 14 Munaung 0 0 0 0 0 0 0 0 0 15 Ramree 514 559 1073 338 0 0 0 0 0 16 Thandwe 1102 1385 2487 107 0 0 0 0 0 17 Toungup 627 407 1034 246 0 0 0 0 0 Southern Rakhine Total 4371 4471 8842 1020 0 0 0 0 0 18 Buthidaung 4567 1712 6279 23 34 395 163 558 0 19 Kyauktaw 939 1309 2248 825 28 431 310 741 610 20 Maungdaw 406 280 686 19 6 19 25 44 0 21 Minbya 373 336 709 94 1 7 10 17 0 22 Mrauk-U 1007 936 1943 136 7 55 35 90 0 23 Myebon 575 617 1192 58 0 0 0 0 0 24 Pauktaw 441 411 852 77 3 16 39 55 8 25 Ponnagyun 370 358 728 152 1 6 0 6 6 26 Rathedaung 563 797 1360 0 0 0 0 0 0 27 Sittwe 462 544 1006 28 7 41 42 83 5 Northern Rakhine Total 9703 7300 17003 1412 87 970 624 1594 629 28 Hlaingbwe 356 450 806 36 5 131 131 262 0 29 Hpa-an 595 1060 1655 124 12 207 559 766 0 30 Hpapun 0 0 0 0 0 0 0 0 0 31 Kawkareik 419 719 1138 63 56 323 722 1045 24 32 Kyainseikgyi 0 0 0 0 0 0 0 0 0

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33 Myawaddy 574 822 1396 268 0 0 0 0 0 Kayin Total 1944 3051 4995 491 73 661 1412 2073 24 34 Banmauk 0 0 0 0 0 0 0 0 0 35 Homalin 184 242 426 127 9 70 116 186 25 36 Indaw 0 0 0 0 0 0 0 0 0 37 Pale 183 287 470 71 0 0 0 0 0 38 Pinlebu 0 0 0 0 0 0 0 0 0 Sagaing Total 367 529 896 198 9 70 116 186 25 GRAND TOTAL 23071 23397 46468 7422 345 3060 3604 6664 2380

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Annex 13: Advocacy meetings Sr. Date of Place of Male Female Total No State/ Region Township Advocacy meeting Attendant Attendant Attendant . Victoria Cliff 1 Tanintharyi Kawthoung 23-Jan-19 31 11 42 Hotel Tanintharyi Total 31 11 42 Township 2 Rakhine (North) Mrauk-U 3-Feb-19 33 91 124 Hospital Hall Township 3 Rakhine (North) Sittwe 30-Jan-19 16 87 103 Health Clinic Northern Rakhine Total 49 178 227 Township 4 Sagaing Banmauk 31-Jan-19 Hospital' 31 80 111 Meeting Room Township 5 Sagaing Indaw 30-Jan-19 Hospital' 27 51 78 Meeting Room Township Hospital's 6 Sagaing Pinlebu 28-Feb-19 37 76 113 Meeting Room, Pinlebu Sagaing Region Total 95 207 302

GRAND TOTAL 175 396 571

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Annex 14: Strategies to address Mid-term Evaluation Recommendations Desirable No. Recommendation Current Strategy and Actions Reinforcement Actions Outcomes

* Updated malaria implementing partners (Ips) mapping for Tanintharyi Region was facilitated by * Defeat Malaria facilitated malaria NMCP & Defeat Malaria in March 2019, and 51 out implementation partners (Ips) mappings and of 1,925 villages (2.6% of total villages/worksites) collaborated with Township/State and Region were identified as malaria service gap and it is now At least 95% of Health Department for the areas in gap for being discussed with NMCP for full areas coverage. geographically malaria service * In first quarter of 2019, Defeat Malaria has hard-to-reach areas Increase VMW/PP * Seasonal and small worksites are provided by recruited an additional 150 VMWs in Rakhine. are covered by coverage in the 1 mobile teams * Defeat Malaria will support malaria IPs mapping basic health staff or geographically hard- * According to 2017 malaria IPs mapping, 20% of updates for Rakhine and Kayin to ensure full malaria village health to-reach areas the villages/worksites revealed malaria service service coverage including hard-to-reach areas. volunteers or gaps. In response, Defeat Malaria recruited more * Starting in 2019, Outreach Malaria Workers are outreach service Village Malaria Workers (VMWs) in Rakhine being recruited to provide malaria services to H2R providers (from 861 to 1,118 VMWs) and in Kayin (from forest worksites especially around persistent 141 to 189 VMWs) within 2018. malaria transmission areas. We will work with the NMCP to determin the structure of their relationship with VMWs

* A series of elimination and surveillance trainings have been providing by Defeat Malaria in collaboration with NMCP and other funding agencies * Intensify collaboration and coordination with local More than 90% of * Malaria Elimination Coordination Committees BHS/VBDC for the involvement in malaria burden Township focal staff (multi-sectoral) have been established at three reduction and elimination activities by joint (VBDC & BHS) for Intensify efforts to pilot elimination townships supervision visits, case investigation and malaria will have 2 build VBDC * Training on entomological surveillance and foci coordination meetings received malaria capacity investigation to 12 Entomologists and 4 health * Regularly Malaria Elimination Coordination elimination and staff was supported by Defeat Malaria in Committee meetings will be continuously surveillance collaboration with University of California-Sans maintained involving all stakeholders. trainings Francisco,CDC and PMI in November 2018. * Jhpiego as a Defeat Malaria partner is providing a series of cascades of capacity building trainings by local and international trainers

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* Strengthening of ICMV activities * Continuous strengthening of private companies At least 80% of * Piloting Community Support Groups (CSG) for sustainable local partnerships and CSGs where Develop an exit VMWs/PPs establishment for relatively hard-to-reach areas feasible 3 strategy for activities are * Engagement with private companies for malaria * Defeat Malaria will collaborate with national VMWs/PPs sustained at end- control and elimination program for appropriate handover of VMWs/PPs line evaluation activities, based on the NMCP's decisions on the role of volunteer health workers

* Defeat Malaria is supporting Master Mentors * Requesting more collaboration at funding agencies At least 80% of Training and Training Skills Training at Central Develop a VMW to level such as support of Access to Health Fund for VMWs have been level, General Trainers at State/Region levels, 4 ICMV transition strengthening ICMV activities received ICMV and On-site Training at Township/Village Levels plan * Need to strengthen operationalization of trained trainings for ICMV activities ICMV * Most of VMWs have been trained for ICMV

At least 80% of Private companies are taking * Recruitment of private providers for private accountable roles * Strengthen existing private sector engagement Increase efforts to companies for their workers activities through public-private dialogue and 5 engage private * Collaborative malaria service provision for in health service multiple engagements at all levels companies employees of private companies provision * Promote to engage with 60 companies * 36 companies are currently engaged Effective, sustainable public- private mix * Utilization of Outreach Malaria Workers for Increase annual forest goers blood examination 6 *It is not feasible to calculate ABER for migrants * Greater linkages between OMWs and VMWs/PPs It is not applicable rate (ABER) for as the denominator cannot be determined. * Forest-goers oriented service provision by migrants conducting operational research

Revise BCC * BCC approach will be assessed in 2019 for * LLIN monitoring activities are continuing. messaging for LLIN continuous quality improvement and updated BCC assessment 7 * BCC assessment for improvement of utilization in high- according to the findings, segmental analysis, dose- report communication strategies are underway risk populations response review.

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* National program is piloting mHealth activities in All townships * Real-time notification through phone collaboration with WHO (Case-based mHealth) and Expand real-time targeted for malaria communication is going well in elimination SCI (Malaria Case Based Reporting) notification or elimination are 8 piloted areas and Defeat Malaria regularly * Beyond elimination areas, Defeat Malaria will increase frequency equipped with real- communicates with the NMCP about these expand mHealth activities established according to of notification time notification activities national platform if these activities are launched by system the national program. * Village-based stratification for appropriate intervention is applied. * LLIN coverage and utilization are continuously monitored for appropriate response at village level. * Clinical audits are continuously auditing to be in line with national guidelines. * Supervision activities are continuously analyzed by mHealth tool At least 3-5 papers * Inviting technical groups for sharing of are submitted at elimination experiences international and Knowledge * Malaria case classification calculators are being * Strengthen technical discussions at national and national conference translation to developed for appropriate case classification and international conferences and exchange visits 9 and seminars for support decision- decision for response * Community feedback will be strengthened during knowledge making * Continuous surveillance through early supervision visits advancement and detection system of unusual occurrences of supporting malaria technical brief * Tableau application is used for township level data visualization * Defeat Malaria Facebook is used for sharing Defeat Malaria updates * Operational research and assessments are performing according to program needs and presented at National Technical Strategic Group meetings and international conferences like ASTMH, Prince Mahidol Award Conference * Flexibility in registration status of organization, monitoring and reporting issues are recommending Engagement with Continued * Capacity building to Backpack Health Workers to PMI donor. EHOs can be 10 engagement and Team * For Kayin, we will engage KDHW in a step-wise sustained and advocacy to EHOs * LLIN, RDTs and ACTs support to EHOs approach from flexibility to compliance, and promoted. integration in 2019

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* Senior management team members involving key Build management positioned staff from all partners are collaborating and strategic * Collaboration with Defeat Malaria partners by actively in dealing with management issues through Improved of 11 planning capacity of participatory quarterly review on work-plans quarterly SMT meetings. partners' capacity sub-grantees to * Supervision and support by Sub-Grant Manager * Strategic planning and management capacity assessment ensure sustainability development plan for MHAA and MNMA will be clearly drawn-up in FY19 Q3.

* For Kayin, KDHW will be engaged with step-wise approach from flexibility to compliance, and * For staff security, online security trainings of integration. United Nations Department of Safety and * For NRS, 2 to 3 CBOs Rakhine native groups will Security (UNDSS) have been provided to Defeat be engaged to be mobilized for reporting, Malaria staff in NRS (URC & MHAA) and daily supervision, and coordination for conflict situation and weekly situation reports to COP for timely Risk mitigation plan and further sustainability. 12 decision. for NRS and Kayin * Alternative plan is to collaborate with Myanmar * BPHWTs have been continuously providing Red Cross Society for Defeat Malaria activities in with logistics and technical supports in Kayin. conflict affected areas as they are officially allowed * EHOs in Kayin are continuously engaged at to provide services everywhere in Myanmar cross-border collaboration meetings, malaria * Coordinate with Township Health Department mapping workshop, and other informal meetings. for joint provision of service to conflicted affected people

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Annex 15: Performance Indicators FY2019 Indicators Frequency Baseline Target Remarks Q2 (FY2019) IP 1: Annual Parasite Incidence (API) in Defeat Annual 8 (CAP-M Annual 4.0 Malaria villages PY4) indicator Number of confirmed malaria cases 721 Mid-year population at risk of targeted areas IP 2: Annual Blood Examination Rate Annual 6% in 2015 Annual 8% (National indicator M&E plan) Number of parasitological tests carried out in 61,817

Defeat Malaria target areas Mid-year population at risk in Defeat Malaria

targeted areas IP 3: Percent of indigenous cases among cases Quarterly 9% (from 7.69% 60% investigated (in elimination areas) National M&E plan) Number of case classified as indigenous 1 Number of cases investigated 13 IP 4: Percent of active foci among foci investigated Monthly N/A N/A 60% The activity is still in the technical piloting phase, (in elimination areas) as described in the report narrative. Defeat Malaria will report on these indicators once the Number of active foci investigated N/A activities are implemented more widely.

Number of foci investigated N/A IP 5: Proportion ofvillages with zero positive cases Annually 18.5% Annual in a fiscal year (CAP-M indicator database) OC 1.1 % of households in target areas that own at Baseline End line 85% least one ITN and end indicator line

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Number of households interviewed during NA household surveys in targeted village that own one LLIN. Total number of households interviewed during NA

household surveys in targeted village. OC 1.2 Percentage of households in target areas Baseline 47% in End line 80% that own at least one and end Rakhine indicator insecticide-treated net for every two persons line 60,2% in TNT 65.6% in Kayin from CAP-M Number of households interviewed during NA household surveys in targeted village that own LLINs to cover at least 2 persons for one LLIN. Total number of households interviewed during NA

household surveys in targeted village. OC 1.3 % of individuals in targeted areas who slept Baseline TBD after Endline 80% under ITN the previous night. (disaggregate by type and end baseline indicator of net, pregnant women, age and gender) line OC 1.4 % of service delivery points which report no Quarterly Minimum 100.0% >90% stock outs of RDTs lasting more than one week 85% (from during the past 3 months (disaggregate by type of CAP-M) SDP) OC 1.5 % of service delivery points which report no Quarterly Minimum 100.0% >90% stock outs of first line antimalarial medicines (ACT) 85% (from lasting more than one week during the past 3 CAP-M) months (disaggregate by type of SDP) OC 1.6 % of patients found positive who received Quarterly minimum 99.2% > 95% antimalarial treatment according to National 95% (from Malaria Treatment Guidelines CAP-M)

Number of patients found positive who received 706

antimalaria treatment according to NTG

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Number of patients found positive who received 712

antimalaria treatment OC 1.7 % of Malaria Positive cases with having Quarterly 25% (from 69.2% 60% completed the treatment under DOT CAP-M FY15 report) OP 1.1 Number of insecticide treated net Activity 92,986 80,515 300,000 purchased in any fiscal year with USG funds that implement (From CAP- were distributed in this quarter (PMI required ed months M PY5) indicator) OP 1.2 Number of artemisinin-based combination Quarterly NA 8,144 19,000 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 fiscal year Quarterly NA 114,175 300,000 with USG funds that were distributed (PMI required indicator)

OP 1.4 Number of individuals reached with malaria Quarterly 514,333 46,468 120,000 behavior change messages through interpersonal (from CAP- communication (individual talks) M PY5) 23,071 (M) 23,397 (F) OP 1.5 Number of health workers trained in case Quarterly 5,155 333 2,000 management with ACTs with USG funds (from CAP- (Disaggregated by male, female, and profession) M) (PMI required indicator) OP 1.6 Number of health workers trained in Month of 5,443 333 2,000 malaria laboratory diagnostics (rapid diagnostic training (from CAP- tests (RDTs) or microscopy) with USG funds M) (Disaggregated by male, female, and profession) (PMI required indicator)

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OP 1.7 % of VMWs/PPs in Defeat Malaria target Annual > 90% areas received at least two supervisory visits per Annually N/A indicator year OC 2.1 % of service delivery points in targeted 98.3% > 90% areas report monthly data of malaria cases Monthly ≥ 80% (disaggregate by type of SDP) OC 2.2 % of service delivery points in targeted 5,535 > 90% areas report monthly data of malaria cases on time Annually N/A (disaggregate by type of SDP) OC 2.3 % of positive cases notified within 24 hours Quarterly N/A 5,628 80% in elimination targeted townships

Number of positive cases notified within 24 hours 98.35%

in elimination targeted townships Number of positive cases notified in elimination 5,535

targeted townships OC 2.4 Foci investigation rate Quarterly N/A N/A 70% The activity is still in the technical piloting phase, as described in the report narrative. Defeat OC 2.5 Active focus response rate Quarterly N/A N/A 80% Malaria will report on these indicators once the activities are implemented more widely. OP 2.1 Number of townships that have been Quarterly NA N/A 31 The Village Based Stratification data (VBS) is developed and updated VBS annually and updated annually. Monthly and quarterly updates annually are conducted only for internal surveillance. OP 2.2 Number entomological surveys conducted Semi- N/A 2 3 in persistent transmission areas annual OP 3.1 % of targeted health services with Quality Annually TBD Annual 70% Assurance/Quality Control (QA/QC) system indicator received quarterly internal assessments of the QA system in collaboration with NHL/NMCP

OP 3.2 Number of trainings on malaria technical Quarterly NA 5 20 skill and training facilitation skill supported by Defeat Malaria

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OP 3.3 Number of trainers developed through Quarterly NA 38 Defeat Malaria OP 3.4 Number of people trained through on-site Quarterly 0 Although many VMWs received on-site training training supported by USG program (Defeat this quarter, the target was set only for NMCP’s Malaria) volunteers, according to the indicator’s definition, and weould c not count for URC trained VMWs. OP 3.5 Percentage of trainers supervised during Quarterly NA 18.42% 50% trainings OP 3.6 Percentage of master mentors retaining at Quarterly NA N/A 80% Master mentors were trained this quarter. Follow least 80% of acquired skills and knowledge up for master mentor knowledge retention will be measured through follow-up at about 6 months after master mentors training. OP 3.7 Number of joint supervision visits to VMW Quarterly NA 6 for data quality assessments

OP 4.1 Number of private companies and state- Annual N/A 41 60 owned enterprises involve in malaria activities OP 4.2 Number of health education sessions Monthly N/A 113 TBD conducted in the targeted areas with participation from collaborating companies and enterprises

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DEFEAT MALARIA PARTNERS University Research Co., LLC (URC) as a prime with partners: American Refugee Committee (ARC) | Myanmar Health Assistance Association (MHAA) | Myanmar Nurse and Midwife Association (MNMA) | JHPIEGO | International Global Health Maryland University of Baltimore (IGH -MUB)

Room 602, 6th Floor, Shwe Than Lwin Condominium New University Ave. Rd., Bahan Township Yangon, Myanmar

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