Quarterly Progress Report - Year 4, Quarter 1 October - December 2019

CAMBODIA MALARIA ELIMINATION PROJECT

Cambodia Malaria Elimination Project

Submission Date: 30th January 2020

Contract Number: AID-442-C-17-00001 Contract Period: October 26, 2016 to October 25, 2021 COR: Rida Slot Alternate COR: Bunna Sok

Submitted by: Sharon Thangadurai, Chief of Party University of Research Co., LLC. #31, St 352, Sangkat Beugkengkang 1, Khan Chankamon, Phnom Penh Email: [email protected]

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

TABLE OF CONTENTS

Acronyms ...... iii

1. Introduction ...... 1

2. Progress Toward achieving CMEP OBJECTIVES ...... 2 2.1 Objective 1: Develop a scalable, evidence-based elimination model in SPL OD and support its dissemination and replication for malaria elimination in Cambodia...... 2 2.2 Objective 2: Support scale-up of high quality malaria control and prevention interventions in five to eight ODs, where gaps in coverage or quality exist...... 8 2.3 Objective 3: Strengthen national malaria surveillance systems and M&E appropriate for malaria elimination and control activities ...... 12 2.4 Objective 4: Build capacity of Ministry of Health (MOH) to manage, intensify, and sustain malaria control and elimination efforts particularly at the OD level ...... 14

3. Project Management ...... 15 Oversight and Coordination ...... 15 Procurement ...... 18 Financial Management ...... 18 Human Resource Management ...... 19

4. RESOLVING CHALLENGES FROM FY19 Q4 ...... 19

5. CHALLENGES AND ACTIONS TAKEN OR PROPOSED ...... 20

6. PLANS FOR NEXT QUARTER AND UPCOMING EVENTS ...... 20 ANNEX 1 CSO FY20 Q1 RESULTS TABLES ...... 21 ANNEX 2 LAB QA/MICROSCOPY TRAINING TABLES ...... 26 ANNEX 3 CMEP PV RADICAL CURE IMPLEMENTATION Q1 ...... 27

ACRONYMS

ABER Annual Blood Examination Rate ACT Artemisinin-based Combination Therapies AFRIMS Armed Forces Research Institute of the Medical Sciences AHEAD Action for Health Development (CSO in Cambodia) AOP Annual Operational Plan APMEN Asia Pacific Malaria Elimination Network ASMQ Artesunate + Mefloquine BKN Bakan BTB Battambang CHAI Clinton Health Access Initiative CMEP Cambodia Malaria Elimination Project CBO / CSO Community Based Organization / Civil Society Organization CDC Centers for Disease Control and Prevention CM Case Management CNM Cambodia National Malaria Center CO Contracting Officer COP / DCOP Chief of Party /Deputy Chief of Party COR Contracting Officer’s Representative CPIRS Commodity Procurement Information Requests cRDT Conventional Rapid Diagnostic Tests CRS Catholic Relief Services DBS Dried Blood Spot EDAT Early Diagnosis and Treatment ELIZA Enzyme Linked Immunosorbent Assay G6PD Glucose 6 Phosphate Dehydrogenase GF Global Fund HC, HF Health Centre, Health Facility hsRDT Highly-Sensitive Rapid Diagnostic Tests IDQA Internal Data Quality Assessment IEC Information, Education and Communication IP Intensification Plan IP2 Intensification Plan 2 IPC Interpersonal Communication IRB Institutional Review Board ITN Insecticide-Treated Net KRK Krakor LLIN / LLIHN Long Lasting Insecticidal Net / Hammock Net M&E Monitoring and Evaluation MEAF Malaria Elimination Action Framework 2016-2020 MIS Management Informationn System MMP Mobile and Migrant Populations MMW Mobile Malaria Worker MPR Malaria Program Review MoH Ministry of Health MORU Mahidol Oxford Tropical Research Unit MRS Maung Russey MSF Medecins Sans Frontieres NCA National Competency Assessment NECHR National Ethics Committee Health Research NTG National Treatment Guidelines NSP National Strategic Plan OD / ODMS Operational Health District / OD Malaria Supervisor

III

ODTL/ODTLA Operational District Team Leader / OD Assistant TL OEC Operation Enfant Cambodge (CSO in Cambodia) OR Operational Research PCR Polymerase Chain Reaction PHD / PMS Provincial Health Department / Provincial Malaria Supervisor PFDA Partner For Development in Action (CSO in Cambodia) PKV Phnom Kravanh PLN Pailin PMI President’s Malaria Initiative PMS Provincial Malaria Supervisor POC Point of Contact PP Private Provider PPM Private Public Mix PQ Primaquine PSI Population Services International PSM Procurement and Supply Management PSWGME Provincial Special Working Group Malaria Elimination QA Quality Assurance Re-ACD Reactive Case Detection RDT Rapid Diagnostic Tests SBCC Social and Behavior Change Communication SLDPQ Single Low Dose Primaquine SOP Standard Operating Procedure SPL Sampov Loun SPM Sampov Meas STA Senior Technical Advisor TA Technical Assistance TMK Thmar Kaul TPR Test Positivity Rate UNOPS United Nations Office for Project Services URC University Research Co., LLC USAID United States Agency for International Development VMW Village Malaria Worker WHO World Health Organization WMD World Malaria Day

1. INTRODUCTION The USAID | PMI Cambodia Malaria Elimination Project (CMEP), 2016-2021, was launched on October 26, 2016 to support the Cambodian National Center for Malaria Control, Parasitology and Entomology (CNM) to reduce malaria morbidity and mortality and contribute towards malaria elimination goals nationwide by 2025. To reach this goal, the project has set up four strategic objectives to: 1. Develop a scalable, evidence-based elimination model in Sampov Loun OD and support its dissemination & replication for malaria elimination in Cambodia. 2. Support scale-up of high-quality malaria control and prevention interventions in five to eight ODs, where gaps in coverage or quality exist. 3. Strengthen national malaria surveillance systems and monitoring and evaluation (M&E) appropriate for malaria elimination and control activities. 4. Build capacity of malaria program to manage, intensify, and sustain malaria control and elimination efforts particularly at the OD level. For this FY20 Q1 report it should be noted that 2 CMEP ODs transitioned to elimination ODs, namely Bakan and Sampov Meas and therefore the new makeup of the CMEP ODs in FY20 Q1 is 7 elimination and 2 transitional ODs.

CMEP conducted the following key activities in FY20 Q1:- . 34,176 of suspected cases tested with 1,150 positive cases confirmed and all cases received appropriate treatment according to National Treatment Guidelines . Among the 7 elimination ODs in Battambang and Pailin province and two ODs in Pursat, 77 % of all cases were notified within 1 day, 67 % investigated within 3 days, and 71 % responded to within 7 days . CMEP response to the increase in cases in Pursat ODs in FY20 Q1 continued and included monitoring daily/weekly cases, intensifying services at all points of care, and the continued setup and support of touchpoint/peer educator volunteers (there are now 6 touch point volunteers in KRK, 22 in PKV ODs, 5 touch point volunteers in KRK, 9 in PKV ODs) . In the 7 elimination ODs, CMEP deployed 16,867 ITNs as buffer stock to HFs and VMWs in Q1 (target=10,950). Through VMW outreach activities, 2,817 ITNs were distributed (target=9,438) to local recidents and 344 ITNs (target=417) were distributed to PPMs through MMWs at big farms and MMP locations . In the 2 transitional ODs, 1,500 ITNs were deployed as buffer stock (target was 4,400) to HF and VMW levels. 1,989 ITNs were distributed to local residents (target=3,800) . Supported CNM technical units to conduct 35 planned supervision visits (target=35). . Regarding CMEP’s radical cure implementation, at the end of Q1, 42 Pv cases were enrolled, 40 G6PD RDTs were used to test 34 patients (some doubted the required retesting), all 34 tested resulted in normal status of G6PD and these received 14 days PQ treatment (of which 33 cases completed 3 days follow up, 30 completed 7 days follow up and 23 completed 14 days follow up). No adverse events were reported.

Figure 1 provides an infographic summary of CMEP progress in FY20 Q1. Progress against each performance indicator is presented in the file attached.

PITTFY20Q1.XLSX

Figure 1. CMEP Summary of Activity Progress (October-December 2019)

2. PROGRESS TOWARD ACHIEVING CMEP OBJECTIVES 2.1 Objective 1: Develop a scalable, evidence-based elimination model in SPL OD and support its dissemination and replication for malaria elimination in Cambodia. Task 1. Pre-implementation situational analysis of current malaria elimination operations in SPL: Rapid Situational Analysis and Needs Assessment Report1: Task 2. Sustain universal long-lasting insecticidal net (LLIN) coverage: Mass distribution: There was no mass distribution activity in FY20 Q1 for Objective 1. Ensure continuous distribution of LLINs: In line with the updated list of villages for ITN distribution, CMEP’s target for continuous LLIN distribution was 154 villages in the 7 elimination ODs [Act 1.2.3]. Of these 7 elimination ODs, CMEP deployed 16,807 ITNs as buffer stock to HFs and VMWs in Q1 (10,950 planned). CMEP will further deploy ITNs in

1 Activity 1,1.1. was completed in Year 1 and Year 2 is not applicable to the FY20 Q1 reporting period

Q2, (using USG-purchased ITNs). CMEP distributed 2,817 ITNs (9,438 planned) to target populations during outreach and response activities [Act 1.2.5] and another 344 ITNs (target=417) were distributed to MMPs at big farms and MMP locations [Act 1.2.5.a]. Net top up and malaria education to households: : In the 7 elimination ODs, VMWs conducted 861 visits (target=1,165) to households/farms for net use monitoring, net top-up and health education [Act 1.2.6]. The number of supervision visits increased significantly due to the number of VMW visits increasing to up to 5 per month. Visits to HH members/farm workers included health education for malaria prevention/LLIN use. There were 4 monitoring & supervision visits conducted from CNM ITN Unit to elimination ODs in Q1 [Act 1.2.7]. Task 3. Ensure Early Diagnosis and Treatment (EDAT) and follow up: For the 7 elimination ODs, CMEP activities covered 438 points of care in Q1 (106 public health facilities and 332 VMWs/MMWs) in Q1 (this figure does not include private providers as they are now not allowed to perform malaria tests and treatment) [Act. 1.3.1]. 14,360 of 14,771 (97 %) suspected malaria cases received a parasitological test. 52% of individuals were tested by VMWs and 48% by HFs. Out of all the individuals tested, 160 cases were confirmed positive. All 160 cases were enrolled in the system and 121 have travel history information. (See Figure 2 for a table of case classification and OD case distribution maps for Q1). Further analysis showed that 93 cases (77%) were imported from Pursat, 1 (1%) from Thailand and the remaining 27 cases (22%) from other provinces in Cambodia. There were no local cases (L1, L2, L3) for Pf/Mix identified in this quarter in the 7 elimination ODs. Figure 2. Map of case classification in table for 7 ODs and reported malaria cases by origin Oct-Dec 2019 Battambang Mong Russei Pailin Sampov Luon Thma Koul Sampov Meas Bakan Species L1 L2 L3 L4 Imported Unclassified L1 L2 L3 L4 Imported Unclassified L1 L2 L3 L4 Imported Unclassified L1 L2 L3 L4 Imported Unclassified L1 L2 L3 L4 Imported Unclassified L1 L2 L3 L4 Imported Unclassified L1 L2 L3 L4 Imported Unclassified Pv 31012 0 0 00041 0 1 2004 0 0 00013 0 0 0006 0 0 00027 0 29 0017 1 8 Pf 00000 0 00000 0 00000 0 00000 0 00000 0 00020 1 00000 0 Mix 0000 0 0 0000 0 0 0000 0 0 0000 0 0 00000 0 0000 0 1 00000 0

Out of 160 positive cases reported in FY20 Q1, 4 (2.5%) were Pf/mixed and 156 (97%) were Pv. Figure 3 provides the cases breakdown for Q1 and the cases trend since January 2017. Figure 3. Number of confirmed malaria cases in 7 ODs per species in Jan 2017-Dec 2019 (source MIS/PMIS)

Of the total 160 cases, 4 were Pf/mixed and all these cases were reached through reminder messages via the mHealth application and automatically transferred to a response team to conduct 28-day follow up. 3 patients out of 4 (75%%) received 28-day follow-up (for the remaining case, the patient moved to another area in Cambodia and follow up was not possible) [Act. 1.3.3]. Figure 4 summarizes the implementation of DOT for confirmed cases in the 7 CMEP elimination ODs. Figure 4. Implementation of DOT in 7 ODs per species

In FY20 Q1, zero patients were hospitalized for second line treatment in the 7 elimination ODs. [Act 1.3.6]. CMEP provided orientation training to government staff and continued emphasizing the use of single low dose primaquine (SLDPQ) in monthly meetings with VMWs and HF staff since FY18. All 4 Pf/mixed cases diagnosed in the 7 ODs in Q1 were eligible for SLDPQ (weight ≥ 20kg) and 100% of these received SLDPQ, CNM Pharmacy, Lab and Diagnosis and Treatment units completed 7 supervision visits (7 planned visits) during FY20 Q1. [Act. 1.3.10]. Task 4. Malaria case reporting, investigation, and response For 7 ODs, in Q1, 123 out of 160 cases (77%) were notified within 1 day via the SMS Day-0 mHealth system, 107 cases (67%) were investigated within 3 days, and for 113 (71%) the response was provided within 7 days [Act.1.4.1-1.4.3]. All HFs/VMWs followed the established 1-3-7 surveillance practice. It should be noted that these reporting, investigation and response percentages are quite lower than compared to FY19 Q4, mainly due to BKN and SPM transitioning to elimination ODs in FY20 Q1 (for the 5 elimination OD scenario’ in FY20 Q1 (BTB, MRS, PLN, SPM, TMK ODs), the percentages were: 1 day 99%, 3 days 98% and 7 days 99% respectively). Among all 160 confirmed cases, 37 cases (23 %) were not notified within 24 hours. This late notification was mainly due to limitations of internet connection, tablets and smartphones (which were not functioning well) and also due to HF staff/VMWs being busy. For the investigation within 3 days, 53 cases (33%) were investigated later than 3 days or were not investigated due too late notification or no notification being done or due to patient movements. For response within 7 days, 47 cases out of 160 cases (29%) were not responded too or were responded too later than 7 days, mainly due to no notification, late notification, or HF staff being busy [Act.1.4.1-1.4.3].

Task 5. Strengthen case management, reporting, and response to all malaria cases in the private sector CMEP proposed and got the approval of PP not to do testing and treating and thus the previous indicator has been removed from this quarter but the referral and supervision indicator still is being tracked and reported. In Q1 there were 171 malaria suspected patients referred from PPs to public health facilities, 77 % of PPs (149/193) attended the PP meetings in elimination ODs [Act 1.5.3]. PPs who were absent from quarterly meetings were either busy with other tasks or did not consider the meetings relevant as they realize PPs are no longer able to test or treat. Those PPs who were absent received data collection visits from PHD/OD or from CMEP staff to ensure all PPs were continuing to provide health education and referrals for suspected malaria patients for all target populations. Semesterly supervision visits were also conducted to provide technical feedback on referrals and to improve SBCC initiatives. 99 PP visits were accomplished during supervision visits (276 planned) in Q1 [Act 1.5.4]. 5 supervision visits (target=5) from CNM’s PPM unit were conducted in Q1 [Act 1.5.6]. Task 6: Build capacity and strengthen systems to manage elimination activities Supporting VMW monthly meetings: Monthly meetings continued in Q1 to support capacity building of VMWs. Meetings were held during the fourth week of October, November, and December. In Q1, for the 7 ODs, 818 VMWs attended meetings versus 846 planned (97 %) [Act 1.6.1]. The VMWs who did not attend the meeting were notified as first time absent, and CMEP along with HF staff will now monitor the VMWs for the 2nd and 3rd month, and if found consecutively not attending for 3 months, CMEP and the OD will ensure the replacement of VMWs as per CNM guidance. CMEP OD teams visited 207 absent VMWs to review progress and provide mentoring [Act 1.6.2]. Reasons mentioned for VMWs being absent included attending to economic activites and being away from the OD. Integrated supervision from ODs to HFs: 103 supervision visits were conducted to 88 HFs in the 7 elimination ODs using the CNM supervision checklist (target=104) [Act 1.6.3]. Data verification on total tests, total confirmed cases and total treated cases was performed during the visits. No artemisinin-based combination (ACT) stock outs or potential stock outs were detected at the time of supervision (further data verification during the visits confirmed this). Stock monitoring: CMEP continued to provide monthly RDT and ACT (ASMQ) stock status reports to CNM and all partners including UNOPS and updates from all HFs in the 9 target ODs. Overall, stocks of tests and drugs in CMEP areas was secured for the period of October- December 2019; there was no stockout and the few places that did identify any potential stockout were immediately fixed. There was no reallocation of drugs between Elimination ODs during Q1. CMEP staff also visited key HCs, reviewed/monitored the stock levels and verified the consumption against the allocation. Visit to selected VMW’s from CNM VMW Unit: There was no visit planned in this quarter. [Act 1.6.6]. District Special Working Group for Malaria Elimination: 6 meetings were conducted in Q1 in the elimination ODs. The meetings enabled updates on the malaria situation and knowledge sharing for participants. Provincial Special Working Group for Malaria Elimination There was 1 PSWGE meeting conducted in Pursat in Q1 which included the new BKN and SPM elimination ODs. [Act 1.6.8]. Task 7. Social and Behavior Change Communication (SBCC) for malaria elimination In the 7 elimination ODs, 14,360 individuals tested for malaria received IPC for malaria education (target=8,934, was over target mainly due to VMWs/HFs increasing their number of tests and increased CSO activity) [Act 1.7.1]. In addition to malaria patients, IPC was provided to 9,671 people (5,858 sessions were carried out at SPL, BTB, TMK, MRS,PLN, SPM, and

BKN) from high-risk groups during case response activities within the village and farms [Act 1.7.2]. At the farms, VMWs organized small group education sessions to deliver key malaria messages. As a result, 2,709 MMPs were reached at farms with malaria outreach educational activities. CNM Health Education Unit made 5 visits to the elimination ODs in Q1 (target=7 ) [Act 1.7.3]. Task 8. Support civil society organizations (CSOs/CBOs) to complement malaria elimination activities: In Q1, AHEAD continues to work closely with the local health system (PHDs, ODss and HC), village volunteers, local authorities and CMEP team to scale up malaria services to mobile/migrant population in the remote/annex villages. In early Q1, AHEAD consulted with OD counterparts, HC staff and CMEP to select 123 remote villages (including 53 annex villages) to implement the activities in its 4 target ODs (BTB, THK and SPL for BTB Province and PLN OD for PLN Province). During Q1, AHEAD developed an annual work plan and submitted it sto CMEP, conducted 75 village campaigns which reached 2,411 MMPs and residents who live in isolated areas. AHEAD also worked with CMEP team and village malaria workers to distribute 1,328 ITNs to MMPs. At the same time, AHEAD collaborated with local authorities to map 80 MMP locations/settlements to identify required services that AHEAD could support. Also, AHEAD has empowered contact points to identify 183 suspected malaria patients for referring to VMWs/HFs; 183 (100%) of the referred patients reached the mentioned service delivery points. Additionally, AHEAD keeps following up on the malaria situation in its areas, strengthens good collaboration with all relevant stakeholders and shares its results with partners though organizing meetings with OD and HC staff and also participated in meetings organized by ODs and PHDs. A summary of Q1 AHEAD results are provided in Annex 1, Table 1. In Q1, OEC submitted its work plan to CMEP and worked closely with local health structures, local authorities, village volunteers (contact points) and CMEP staff in MRS OD to identify high risk areas/villages and conducted 15 sessions of health education campaigns which reached 326 MMPs. OEC worked with CMEP/VMWs to distribute 264 ITNs to the at risk population. 14 mobile/migrant settlements were mapped, and at the same time OEC team and OEC’s contact points identified and referred 149 malaria suspected cases to VMWs/HFs. This resulted in 100% of the referred patients reaching VMWs/HFs. OEC organized and attended meetings with HCs, OD and PHD to strengthens its collaboration and get participatory implementation. A summary of OEC Q1 results are provided per in Annex 1, Table 2. However with these work that OEC has performed there ahs been major concerns by CMEP monitoring team about the quality of OEC work and their relation with ODs and PHDs. CMEP will undertake a thorough review of OEC performance and thus will decide in their future engagement in CMEP Project. In Q1, PFDA continues to implement its activities in 4 ODs (KRK, PKV, SPM and BKN ODs) in Pursat Province. During Q1, SPM and BKN ODs transitioned to malaria elimination ODs. In Q1 PFDA submitted its year 4 work plan to CMEP, and continues its good collaboration with OD counterparts, health center staff, local authority, village volunteers and CMEP team to execute activities in the workplan to support the malaria elimination interventions in these two ODs. The activities included organizing 16 health education campaigns in the remote villages which reached 510 MMPs, distributing 441 ITNs, mapping 4 MMP settlements, referring 149 suspected malaria patients of whom 100% of reached VMWs/HFs. Also, PFDA organized and attended meetings with OD and PHD teams regularly to share PFDA activities and progress. A summary of PFDA Q1 results are provided in Annex 1, Table 3. Task 9. Conduct operational research in the context of malaria elimination Continuing from FY19, CNM, CMEP, sub-contractor (Institute Pasteur in Cambodia or IPC)

7 and relevant PHDs/ODs/HFs of Battambang, Pailin and Pursat coninued the study to evaluate the use of highly sensitive Rapid Diagnostic Tests (‘hsRDTs’) versus conventional RDTs (‘cRDTs’), compared with a Polymerase Chain Reaction (PCR) as the gold standard in reactive case detection, to identify additional malaria infections amongst at risk population especially asymptomatic people. By 31st December 2019, 77 Pf cases were enrolled in the study. From these, 77 index cases and another 270 individuals (family members, co-travelers/ co-workers and surrounding families) were screened/tested with 4 tests as mentioned in the protocol (cRDT, 2 hsRDTs: Alere & Global Good, and DBS for PCR). There were 5 cases of the index cases that Alere-hsRDT detected negative, while many others were found to be negative by the Global Good-hsRDT. As a result, confirmation will be given by PCR that will be analyzed soon. The above results showed cases were predominantly found in Pursat (78%) rather than Battambang and Pailin even though Pursat commenced 10 months after these provinces. Task 10. Refine existing malaria elimination tools, SOPs, and guidelines CMEP team joined a meeting with CNM, WHO, UNOPS and other partners and discussed (i) progress of malaria elimination implementing in the first 6 provinces including Battambang and Pailin; (ii) proposed some revision on technical guidance in the future in terms of testing/ABER/TPR, case notification, simplified investigation, Re-ACD, foci investigation/management, data analysis, update/shared MIS and especially surveillance in the non-endemic ODs; and (iii) moving entire country to malaria elimination in 2020, with a plan to initiate training early in 2020 to the remaining 7 provinces. Follow up meetings will be required. Summary of Pv Radical Cure progress in Q1 After training in September 2019 and equipment/supply of G6PD RDTs, PQ (15 mg & 7.5 mg) and other supporting tools in November 2019, CMEP in Battambang and Pailin provinces initiated radical treatment with G6PD testing and 14 days PQ administration for Pv male patients of 20 Kg and above. As of 31st December 2019, 42 Pv cases were enrolled, 40 G6PD RDTs were used to test 34 patients (some doubt led to retesting), all 34 tested resulted in normal status of G6PD and received 14 days PQ treatment (of which 33 cases completed 3 days follow up, 30 completed 7 days follow up and 23 completed 14 days follow up). No adverse events were reported. Annex 3 provides the summary of results in the Battambang and Pailin ODs for FY20 Q1.

2.2 Objective 2: Support scale-up of high quality malaria control and prevention interventions in five to eight ODs, where gaps in coverage or quality exist Task 1. Rapid Situational Analysis and Needs Assessment Report - There was no activity on this task during FY20 Q1. Task 2. Ensure universal coverage with LLINs Mass distribution: There was no mass distribution activity in FY20 Q1 for Objective 2. Continuous LLIN distribution and top up monitoring: Initially, there was no plan to deploy ITNs to VMWs/MMWs in Q1 given the mass distribution campaign. However, since CNM revised targets for ITN mass distribution for only villages with an API ≥5, CMEP deployed ITNs to villages that were not covered by the mass campaign. Therefore, 1,500 (34%) ITNs were deployed as buffer stock at the HC and VMW level (4,400 planned). During Q1, CMEP distributed 1,989 (52%) ITNs (3800 planned) to target populations during outreach and response activities during October to December 2019. The actual result was lower than planned due to a relatively low need for ITNs after the mass distribution event [Act 2.2.5]. MMWs distributed zero ITNs at big farms and MMP locations in Q1 (160 targeted) [2.2.6]. VMWs/MMWs conducted outreach visits to households and farms to top up ITNs using

8 remaining nets from the previous deployment, along with providing SBCC activities and EDAT services, when required. 477 visits were accomplished (473 planned) by VMWs to households and farms for ‘use monitoring’ and health education [Act 2.2.7]. 7,325 individuals received malaria education through IPC. [Act 2.2.8]. Task 3. Ensure EDAT and follow up Provide ongoing support in malaria diagnosis and treatment: CMEP activities covered 236 Point of Care units in Oct-Dec 2019 for its 2 transitional ODs (19 HFs and 217 VMWs). PPs are now excluded as they are not allowed to test and treat [Act 2.3.1]. In the 2 transitional ODs, 19,816 individuals were tested, 990 were confirmed with malaria and 990 cases were treated in Q1 (Figure 5 shows the trend in confirmed malaria cases from 2017 to 2019). For confirmed cases, 68 cases (7 %) were Pf/mixed and 922 cases (93%) were Pv. Three-day DOT was provided to 37 Pf/mixed cases by VMWs (73% of the total 51 VMW Pf/Mix cases) [Act. 2.3.2]. During Q1, there were no severe malaria cases [Act. 2.3.4]. Figure 5. Confirmed malaria cases in 2 transitional ODs (April January 2017 to Dec 2019)

Table 1 provides a breakdown of the confirmed malaria cases by species in the 2 transitional ODs. Overall, there has been a significant increase in Pf and Pv cases since 2017 in PKV and KRK ODs (see Figure 6), although there has been a decline in the past year. Table 1. Breakdown of confirmed malaria cases by species in 4 ODs OD Name Species Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Pf 198 179 208 321 347 418 380 242 196 157 128 67 54 77 39 33 28 29 99 37 20 34 6 7 Kravanh Pv 343 382 465 574 861 945 928 853 740 669 644 545 517 415 365 323 331 320 480 290 222 252 170 135 Mix 24 19 49 28 33 31 26 7 18 11 15 10 11 6 2 4 4 8 4 1 3 1 2 1 Pf 56 67 47 72 82 115 73 81 47 47 48 26 25 16 9 8 9 19 46 15 6 3 7 6 Krakor Pv 167 138 167 215 196 317 246 308 205 231 216 165 195 137 120 130 119 144 218 132 108 165 109 91 Mix 6 310 5 21211 7 43 2 2 4 1 0 0 4 3 1 2 1 1 0 0

Figure 6. Monthly malaria cases in Kravanh and Krakor ODs

Outreach activities: Among all confirmed malaria cases, 608 (61%) were in PKV, and 382

(39 %) were in KRK ODs (see Figure 7 for maps showing village incidence in PKV and KRK ODs). Although there were some changes in the number of cases identified in individual villages, the general areas of concern remain the same, with most representing areas being near the forest. For 9 selected high incidence villages in PKV, there were 38 cases in Oct and 24 cases in Dec 2019. For 12 selected high incidence villages in KRK OD, there were 56 cases in Oct and 32 cases in Dec 2019. Figure 7. Village incidence in PKV and KRK ODs

Forest interventions The interventions have been managed along with an intensification plan (IP & IP2) introduced by CNM and aim to pro-actively increase malaria services coverage for forest workers, particularly in PKV and KRK ODs where population movement into the forest areas is still very dynamic. In FY20 Q1, 42 MMWs (designated as either ‘touch points’ or ‘peer volunteers’) have been maintained in the above 2 ODs. They contacted and encouraged forest goers/workers to conduct malaria testing, provided treatment for confirmed cases, provided health education via IPC, and distributed treated nets and SBCC materials (as the touch points are entry points, they come into contact with forest goers while they pass through the touch points into the forests, wheras the peer educators get into contact with the forest goers when visiting the work sites inside the forest). The MMWs regularly joined monthly meetings with VMWs (under the same catchment areas of relevant HFs). Results showed that the MMWs conducted site visits to meet with forest workers and tested 3,939 suspected malaria patients. 162 patients (142 Pv, 20 Pf/Mix) or 4.11% who tested positive received treatment as per NTG. 786 LLIHNs were distributed (many of the forest goers already have nets from previous distribution events) and health education sessions were conducted (which reached 4,294 forest workers). In addition, 1,066 forest packs were distributed to forest goers. With recent village map/remapping following the analysis of MIS data and CNM’s recommendation new MMWs will be setup leading to 49 MMWs available for interventions in IP2 for PKV and KRK ODs. Capacity building: In Q1, 51 VMWs received Case Management trainings in the transitional ODs (there were no Case Management trainings conducted for newly recruited touch point volunteers and peer educators). Technical supervisions were conducted by technical units from CNM, as well as PHDs/ODs to respective target ODs and HFs/VMWs. CNM supervision: There were no planned supervision visits from the laboratory unit of CNM to the transitional ODs (target=0). 1 supervision visits from CNM pharmacy unit were made to transitional ODs (target=1) [Act 2.3.10]. Task 4. Strengthen case management and reporting in the private sector: Private Provider Mapping: The CMEP contract modification was approved in Q1, and resulted in PPs only formally now being able to refer patients. 1 quarterly meeting (2 planned) was held in the 2 ODs (PPM tasks are no longer a priority for the Government staff and PPMs are less motivated to attend). [Act 2.4.3]. 30 PPs attended the quarterly meetings (122 planned), and

10 typically, the main questions were around why PPs are being asked to stop testing/treating and when this situation might change. Supervision visits: During Q1, there were no planned supervision visits from CNM PPM unit to CMEP transitional ODs [Act. 2.4.5]. Task 5. Build capacity and strengthen systems to manage malaria control activities: CMEP Support to VMWs/MMWs: In total, 589 (278 in KRK; 311 in PKV) VMWs/MMWs (target 542) attended monthly meetings from Oct to Dec 2019 (109 %) [Act 2.5.1]. During these meetings, VMWs reported information on malaria cases; received RDTs/ACTs from health center staff; and, received on the job training for case management, SBCC, case registration/reporting, and ITN monitoring/top-up reports. VMWs also shared challenges which included difficulties with DOT completion among MMPs and forest-related workers, poor road conditions, long distances to travel and some demands of topping up ITNs among the residents. During Q1, CMEP OD teams visited 90 absent VMWs to review progress and provide mentoring [Act 2.5.2]. During FY20 Q2, CMEP teams at OD level will continue to work with VMWs to encourage them to attend meetings to share experiences and build knowledge, and will work with ODMS to ensure that the attendance of VMWs in meetings increases. Integrated supervision from OD to HFs [Act 2.5.3]: 18 supervisory visits were accomplished during Q1 (86 % against 21 planned). Build capacity and strengthen systems to manage malaria commodities: CMEP provided support in stock monitoring and management to the nine target ODs during Q1. CMEP used the mHealth application (via laptops) [Act 2.5.4-2.5.5] which automatically geotags facilities and locations to allow close monitoring of places visited. ACT distribution:No ACT and/or RDT stock out/potential stockout were reported for 9 ODs in Q1. Table 2 provides a summary of ACT and RDT stock monitoring in all CMEP ODs. Table 2. Q1 ACT and RDT stock monitoring in all ODs Operational # of HFs ACT RDT District monitored Potential Stock Out Potential Stock Out SPL 10 0 0 0 0 BTB 28 0 0 0 0 PKV 8 0 0 0 0 KRK 8 0 0 0 0 TMK 18 0 0 0 0 MRS 15 0 0 0 0 PLN 6 0 0 0 0 BKN 11 0 0 0 0 SPM 12 0 0 0 0

Total 116 0 0 0 0

Provincial special working group for malaria elimination [Act 2.5.7]: There was 1 PSWGE meeting conducted in the transitional ODs during Q1 (in Pursat for KRK and PKV ODs). Visits to selected VMWs from CNM VMW Unit: In Q1, there were no planned visits from CNM’s VMW Unit to CMEP transitional areas [Act. 2.5.6]. Task 6. Strengthen BCC interventions for intensified malaria control IPC to tested malaria cases and high-risk groups: During Q1, 19,816 (target 8,400) suspected malaria patients were tested and received IPC through VMWs and HCs [Act 2.6.1]. For the

11 high risk groups in KRK and PKV ODs, 14 peer educators and 28 touch points provided 2,801 health education sessions to 4,294 MMPs (target=1950) [Act 2.6.2]. Malaria education campaigns at schools: There were no CMEP activities for this in Q1. Teachers at the schools in PKV and KRK ODs who had previously taken part in CMEP education interventions are routinely passing on and reminding students on malaria messages. Task 7. Support civil society and community-based organizations (CBOs) to implement Provide support to selected CSO partners & Implement sub-grant activities [Act 2.7.2]: Due to the malaria burden in PKV and KRK ODs remaining high, these ODs have not yet moved to elimination stage. Considering the malaria situation PFDA prepared a Year 4 work plan which allocated more resources and efforts to extend malaria services to the hard-to-reach populations. With good collaboration with all relevant stakeholders, PFDA organized 47 health education campaigns in the selected areas which involved the participation of 1,443 forest workers/forest goers, distributed 2,335 ITNs to high risk groups through campaigns, monitored ITN use activity, mapped 5 MMP settlements, referred 444 suspected malaria patients to VMWs/HFs and followed up all referred cases. Additionally, PFDA met with OD and the PHD regularly to strengthen collaboration, engage their participation and share progress of the implementation. Annex 1, Table 4 provides the results for PFDA in KRK and PKV ODs in Q1.

Task 8. Operational research- CMEP Q1 Operational Research activity is covered under Objective 1.

2.3 Objective 3: Strengthen national malaria surveillance systems and M&E appropriate for malaria elimination and control activities

Task 1. Refine and harmonize M&E reporting forms and support consistent use by public and private healthcare providers Work with CNM and partners to harmonize M&E reporting forms: Technical supervision procedures continued to be revised for HF/RH/ODs in FY20 Q1. [Act 3.1.1] Support consistent use of the harmonized forms by providers: CMEP regularly ensures consistency of the forms (including recent visits/spot checks from key staff that check for this) Some inconsistent elimination forms were identified in the ODs in Q1 by the CMEP team. OD teams were urged to always use the required correct forms [Act 3.1.2]. Overall, during Q1, 92% of providers submitted surveillance data on time (100% from HFs and 91% from VMWs). Figure 8 provides submission percentages per OD since FY2018 Q3. Figure 8. Percentage of HFs, VMWs/MMWs in target transitional ODs submitting surveillance data on time per national guidelines (since FY2018 Q3)

Task 2. Provide technical assistance on data management and use Conduct IDQA at OD and selected HFs by ODMS/PMS and CMEP [Act 3.2.2]: The CMEP FY19 IDQA was required to be conducted in FY20 Q1 at one elimination and one transitional

OD. Pailin and Bakan ODs were selected for the exercise (although BKN OD became an elimination OD in FY20 Q1, the data reviewed for the IDQA was for when it was still a transitional OD in FY19). Overall, the results were an improvement on the CMEP IDQA exercise conducted for FY18 and CMEP continues to improve its internal data quality. The FY19 IDQA report was submitted to COR on 30th December 2019. Provide TA to CNM on village-based stratification and facilitate use of stratification tools [Act 3.2.3]: CMEP has started developing the next administrative level/commune based stratification for all 9 ODs. Initial maps have been completed, and various parameters required for spatial analysis and stratification have been collected. CMEP has also analysed village wise data in PKV OD and developed initial maps and identified 22 villages that were reporting high prevelance of malaria cases since 2018. A similar trend was also observed during 2019. Based on the outcome of the activities village stratification processes will be continued to be carried out in all ODs from Q1 with geographical (‘geo’) maps. Provide TA to CNM on data visualization and outbreak module development for MIS The distribution of the CMEP OD Bulletins for FY 18/FY19 has contributed to the TA to CNM on data visualization. The bulletins provide useful visual representations of OD cases and species and are also provided in the local language. [Act 3.2.4] CNM supervision [Act 3.2.5]: During Q1, several visits were conducted by CNM technical units to CMEP target areas and overall 100% of planned visits were achieved. Table 3 summarizes these visits. Table 3. Summary of CNM Technical Unit visits in Q1 Unit from CNM Q1 Planned Q1 Actual Percentage ITN unit 4 4 100% Pharmacy unit 8 8 100% Laboratory unit 0 0 - PPM unit 5 5 100% VMW unit 0 0 - Health Education Unit 8 8 100% M&E unit 7 7 100% Epidemiology unit 3 3 100% Entomology 0 0 - Total 35 35 100%

Task 3. Support further development and implementation of electronic data reporting and use platform CMEP continues to monitor and follow up on the use of smartphones designated to VMWs and tablets designated to HF/OD staff that provide notification and reporting of malaria cases and stock status of malaria commodities. Task 4. Strengthen capacity to conduct entomologic monitoring Conduct entomology training for OD and PHD staff [Act 3.4.1.]: No activities related to entomology monitoring or entomology capacity building were planned for FY20 Q1. As per the CNM request, CMEP agreed to allow CNM entomology unit to complete the outstanding activities of Year 3. From the monthly entomological collections in Year 3, CNM/CMEP

13 collected 11,744 Anopheles mosquitoes. As per the Year 4 work plan, Sporozoite ELISA on 1000 selected mosquitoes were supposed to be completed and a summary of the results to be submitted by CNM Entomologist by 31st December 2019. Later, CNM requested a few more days to complete, and this will be submitted by 07th January 2020. The final report of the monthly entomological activities will be submitted by 31st January 2020, which will also include a detailed analysis on ELISA testing. A dissemination meeting will be held during February 2020 (the timeframe for activities was changed as per the CNM request). 2.4 Objective 4: Build capacity of Ministry of Health (MOH) to manage, intensify, and sustain malaria control and elimination efforts particularly at the OD level Task 1. Develop and implement a plan to strengthen technical and management capacity at National, PHD and OD levels2 OD AOP development [Act 4.1.4.]: During FY20 Q1, the AOPs were finalized in October in a meeting in Pursat with staff from CMEP, CNM and the 3 PHDs. The meeting objectives included (i) sharing CMEP Priorities for Year 4; (ii) finalizing the OD annual operation plans (AOPs) for Year 4; and (iii) to discuss how progress review will be conducted during OD AOP implementation. The OD AOPs were finalized during the meeting and submitted. Internal Competency Assessment (ICA) course for selected malaria microscopists [Act 4.1.7] There was no activity on this indicator during FY20 Q1. Laboratory quality assurance [Act 4.1.8]: From October to December 2019, the CMEP Lab Supervisor conducted Lab QA supervision and monitoring visits with the BTB/Pailin PLS’s to the HFs labs of 5 elimination ODs (BTB, SPL, TMK, MRS, and PLN) PLS. See Annex 2 for the results. According to the current policy of Operational Manual for QA of malaria diagnosis that was organized by WHO and CNM from 11-14/June/2019, microscope services are managed only at RHs (District/Provincial levels) and are not required for HCs, nevertheless QA for RDT is required at all POCs. Provide on the job training and mentoring by CNM units [Act 4.1.9]: There was no specific training provided for entomology during FY20 Q1; E-Payment [Act 4.1.10]: The e-payment system is used to pay per diems, transportation and other allowances through mobile payments. During Q1, CMEP did not implement any further e-payments for VMWs in the ODs. The plan is to extend e-payment to PKV, KRK, SPM and BKN ODs from Q2 in Y4 subject to the feasibility and assessment conducted by MMEP teams. Task 2. Support CNM and MOH to develop and maintain a system for on-going technical and management capacity development Provide feedback to HFs/OD/PHD by CNM technical units during supervisions [Act 4.2.1]: There were 34 technical feedback sessions held with participation of CMEP, CNM, OD and PHD staff at each OD (Aligned with supervision schedule) in Q1. Largely the feedback was more related to nonregistered PP conducting testing and treatment from private pharmacy, lack of rigorous follow up on IP2 implemention, imptove accurate reporting through tablets, and ensure VMWs notifying Pf cases within 24 hrs. CMEP progress review [Act 4.2.2.]: Central Progress review is planned twice a year and shall be conducted in Q2 of Y4. Task 3: Improve malaria policies and guidelines [Act 4.3.1]: During FY20 Q1, CMEP team

2 Activities 4.1.1-4.1.3 are not applicable to the reporting period

14 joined a workshop organized by CNM and WHO on “Strategic Framework Development 2021- 2025 National Strategic Plan (NSP)” reviewing the MEAF 2016-2020 implementation, recommendations from the malaria program review (MPR) and discussions on the development of a NSP/MEAF 2 (2021-2025). CMEP then joined a series of meetings with CNM to work on the different strategic interventions such as “Intensification Plan phase 2 (IP2)”, “Interventions to locate malaria foci and interrupt transmission of Pf, Review of evidence from recent and ongoing studies or operation” and the “The 2nd ‘National Advisory Malaria Elimination Task Force’ meeting that was held under the chairmanship of the Minister of Health”. CNM SBCC strategy development: [Act 4.3.1] The strategy book modification will now be finalized in Q1 (CMEP has been part of supporting CNM in drafting the strategy). 3. PROJECT MANAGEMENT Oversight and Coordination CMEP Field Visits: DCOP visited Pursat province on 9th October and met PKV, KRK, SPM ODTLs to analyze the current situation in the ODs. Advice was provided to PKV and KRK ODTLs to focus on villages where Pf cases have been reported (although it was noted there has been a drop in Pf cases in the past 3 months). The ODTLs developed a plan to visit work sites/entry/exit points to increase surveillance and EDTA, and also instructed the CSOs working in these areas to focus on hard to access locations through their contact points and MMWs (and to mainly to provide BCC). On 10th October 2019, the DCOP visited MRS ODTL and BTB ODTL and discussed increasing surveillance activities and case investigation. On 11th October 2019, DCOP visited BKN OD office with SPM ODTL to advise on the new elimination approach for BKN and the SPM ODTL was asked to provide more day to day guidance for BKN OD. On 4th November, the COP met the Pursat Deputy Governor with the Pursat PHD Director and CMEP ODTL (the meeting was a follow up on the Ministers meeting held on 22nd October, where it was requested by the Pursat Deputy Governor to have CMEP support developing actions to fight malaria at the border area of Kp Speu and Kp Channang, which was supported by the Minister). His Excellency Oeung Kim Leang, Dr. Khoy Dy and the COP discussed the issues and agreed to organize a high level meeting for the 3 provinces on the 12th of December (which was then postponed to 20th December 2019). The main objectives of the meeting were:- (1) discuss/solve main issues of the 3 provinces (technical and financial support required), (2) and to develop an action plan to fight forest malaria at the border of the 3 provinces. The output of the meeting was to develop a joint MOU on the establishment of interprovincial sub-working group for malaria interventions; PHDs to jointly deal to address challenges at the border and joint planning for the sub-working group. The next meeting was proposed to be held in Kp Speu province. On 22nd November the DCOP met all 4 Pursat ODTLs and discussed ways forward with the current situation and strengthening of ongoing activities to reduce the case load to a much lower level. Both KRK and PKV OD has shown marked decrease of malaria cases and the DCOP also instructed them to continue with case based surveillance and to focus on Pf case hotspots. On 26th November, the DCOP and CMEP team visited Prey Lang Wildlife Sanctuary with USAID team which was headed by Ms. Vina Reddy, USAID Mission Director. This event was also attended by many MoE and MoH Delegates, Parliamentarian Delegates, Senate Delegates, Kampong Thom administration, Forest Rangers and the community in the protected areas. The objective of this activity was the signing ceremony between Kbal Dauntey, Chom Mrech Community of Protected Areas (CPA) and H.E Nong Veasna, Governor. From the 12th-13th December, the CMEP all staff annual meeting was held in Phnom Penh. The Meeting began with by COP presenting Year 3 project highlights. This was followed by

OD team presentations showing progress and challenges during Year 3. There were then sessions on communication, financial policy/procedures, procurement, administration, HR policy and procedures, and a whole session on compliance. A technical presentation was provided by the STA. The meeting was closed by COP giving a presentation on proposed Yr 4 activities and way forward towards reaching elimination targets by 2020 in all project ODs. On 17th Dec in Kep city in Kep province, a meeting was conducted to discuss CMEP technical support to 3 newly started elimination provinces of Kep, Kampot and Kohkong covering 5 malaria endemic ODs. There were 40 participants which included CNM team (director, deputy director and technical chief), technical chief/deputy of the 3 PHDs, PMSs, OD directors/deputies of 5 ODs (KEP, Kampot, Chhouk, Smach Meanchey and Sre-Ambel), ODMSs/OD malaria staff as well as donors and implementing partners (USAID/PMI, UNOPS, CMEP, PFD and MC). This kick off meeting was a result of CNM requesting CMEP to expand and provide Technical Assistance (TA) to an additional 3 coastal provinces in Cambodia. The TA support is to scale up the Sampov Loun model elimination package in the CNM elimination provinces which is currently supported by Global Fund. Sub-grant Oversight and Management: OD teams conducted monthly field visits to monitor activities by the CSOs and provided necessary technical support. CMEP OD team leaders organized routine monthly meetings with the CSOs to recieve updates on progess to discuss challenges and seek solutions to improve the implementation. On 9th Dec 2019, at Pursat PHD conference room, 1st quarterly meeting in Year 4 of CMEP sub-grantees was conducted with participation from CMEP PP team, all 9 CMEP OD TLs, 3 executive directors of 3 CSOs and their staff (AHEAD, PFDA & OEC). The meeting objectives were (i) to review progress; (ii) to discuss challenges and solutions; and (iii) to discuss contract and budget for future sub-grant implementation. The 3 sub-grantees demonstrated good achievement on their 3-month activities to be completed by end Dec 2019. CMEP team shared on its ongoing commitment to support all sub-grantees, to assist with identification of current and future gaps in service coverage, as well as prioritization of the identified gaps based on project resources and exit strategy/phase out plans. IEC/BCC materials were discussed, and orientation provided on how to prepare effective presentations. Meetings with USAID (including COR, PMI-USAID team): On 22nd October 2019, CMEP team and later IPC held a meeting with MOP team at USAID, Phnom Penh. CMEP shared a presentation updating the following areas: Introduction of the CMEP Project, Goals, Objectives and Tasks, Progress during the 3 years, Successes/Achievements, Challenges/Solutions and Ways Forward while IPC updated about hsRDT study and shared some OR topics relating to Pf drug resistance, Pv radical treatment. Minutes of the meeting and presentations are available. On 15th November 2019, all CMEP key staff, met with new USAID OPHE director, Dr. John Eyers, and CMEP COR team at CMEP office. COP made a presentation on CMEP activities, progress, challenges and way forward. OPHE director also mentioned that he would like to visit CMEP areas in future to see the activities. CMEP team attended the training organized USAID on the Environmental Procedure & Compliance in Sunway Hotel on 03rd December 2019. The training focused on environment procedure and compliance, environmental mitigation monitoring plan (EMMP) and Initial Environmental Examination (IEE) which emphasized on environmental impact. COP and CMEP team attended the USAID partner meeting on 5th December at the Sunway Hotel. The meeting focused on the USAID country development cooperation strategies 2020- 2025, OIG audit report findings, and results of a USAID youth assessment survey. On 17th December CMEP team attended the USAID partner reception with the new US Ambassador Mr. Patrick Murphy. This event was organized by USAID Cambodia. USAID

Mission Director Veena Reddy and several USAID and Embassy officials were also present. Secretary of Health and Director General of Ministry of Health along with other higher officials from other ministries were also present. All other USAID implementing partners attended and displayed their project activities in display units. The Ambassador also visited the CMEP display desk and was impressed with the CMEP elimination model, the CMEP implementation progress and how the elimination model has been expanded to other ODs. Meetings with CNM and Other Partners: On 6 Dec, CMEP team joined with CNM, WHO, UNOPS and other partners meeting at CNM to discuss (i) progress of malaria elimination implementation in the first 6 provinces including Battambang and Pailin; (ii) proposed revisions on technical guidance in the future in terms of testing/ABER/TPR, case notification, simplified investigation, Re-ACD, foci investigation/management, data analysis, update/shared MIS and especially surveillance in the non-endemic ODs; and (iii) moving the entire country to malaria elimination in 2020. On 20th Dec 2019 at Pursat PHD conference room, a joint meeting was conducted with 43 participants from CNM management team (director and 2 deputy directors), NGO partners (PMI-CMEP, PSI, CHAI, PFDA, HSD) and members of 3 provincial special working groups for malaria elimination (PSWGME) of Pursat, Kampong Chhnang and Kampong Speu provinces. The meeting was for interprovincial coordination for joint malaria interventions at bordering areas, previously called “Triangle area of Kravanh-Oral”. The meeting was co- chaired by the 3 provincial deputy governors and CNM director to discuss: (i) joint MOU on establishment of interprovincial sub-working group for malaria interventions; (ii) progress and challenges to be jointly dealt with by the 3 provinces and (iii) joint planning for the sub-working group. USAID/PMI CMEP provided technical and financial support to the meeting, covering all participants from CNM and Pursat provinces. Meeting with CNM on National Strategic Plan (NSP) and MEAF 2: CMEP team joined a workshop organized by CNM and WHO on “Strategic Framework Development 2021-2025 National Strategic Plan (NSP)” in Phnom Penh on 9-10 Oct 2019. The workshop was the follow up of the MEAF 2016-2020 implementation, recommendations from the malaria program review (MPR) and discussions on the development of a national strategic plan for malaria elimination 2021-2025. The outcome of the workshop included: (i) new goals with zero local Pf by 2020 and zero local Pv by 2025; (ii) the restructuring of 4 new strategic objectives: a) combined case management, prevention with vector control and IEC/BCC, b) intensification response to hotspot/high risk areas, c) surveillance and M&E, and d) enabling environment. Further follow up meetings were planned to complete the work during Q1. CMEP team joined series of meetings at CNM to work in detail on the different strategic objectives of NSP/MEAF 2 (2021-2025): Vector control & BCC on 18th Oct; Case management on 21st Oct; Surveillance on 24th Oct. Meeting with CNM on Intensification Plan: CMEP team joined the meeting on the progress of the intensification plan at CNM on 2nd Oct 2019. Overall, it looks quite promising in terms of the reduction of cases in the target areas. 3 areas for CMEP to improve: (i) testing rate at HF; (ii) ACD visit of MMW to ensure 100% achieved in some of the HF catchment areas and (iii) distributed forest packs for MMPs to be entered into the MIS system. CMEP PP team and OD team from PKV & KRK ODs) joined a meeting organized by CNM regarding the “Kick-off meeting of Intensification Plan 2 (IP2)” at SOKHA Hotel in Phnom Penh on 11 Oct 2019. The meeting highlighted the IP2 strategy that will include intensified efforts for village selection, an enhanced role of MMWs, improving targeting of forest goers and having clear road maps on the entry and exits to the forest areas. The role of MMWs was extensively discussed including on how they will perform their activities in conjunction with neighboring VMWs and HCs. The IP2 will commence from October 2019. CMEP will work

17 closely with ODs and PHDs to ensure that the IP2 is well implemented. On 4 Nov 2019, CMEP team attended a meeting at CNM with malaria donors and implementing partners to discuss how IP2 that is expected to start in October 2019 will continue from IP1. The meeting provided a refresh/clarification on MMW selection, training/equipment and the provision of services by MMWs including outreach service. Implementing partners were asked to continually update on IP2 progress. For CMEP, the transition from IP1 to IP2, the target area will cover 2 ODs of PKV and KRK in 6 HCs catchment areas with 49 MMWs. Participation in Foci Investigation field testing with CNM/Other Partners: A 1-day meeting was organized by CNM, MORU and WHO on “Interventions to locate malaria foci and interrupt transmission of Pf, Review of evidence from recent and ongoing studies or operation” in Phnom Penh on 25th Oct 2019. Presentations included (i) mobile services for hard to reach communities; (ii) mapping malaria hotspots; (iii) tracking malaria inside forest areas; (iv) active screening with RDT & hsRDT; (v) ACD with MMWs/Strengthening VMWs/MMWs in hotspot areas; (vi) targeted malaria elimination (TME)/Mass drug administration (MDA); and (vii) anti-malaria drugs for prophylaxis, MDA, screening efficacy, safety, tolerability and resistance. Although there was considerable useful discussion, there was no real decision made during the meeting on possible future interventions. Meeting with IPC/Partners: CMEP and IPC team prepared a progress report on the hsRDT study on 2nd Oct and sent it to CDC (following the CDC reporting template). Both parties updated the modified contract for expansion and extension of the study which was signed first by URC HQ (4th Oct 2019). The amended contract was then given to IPC for signature. Meeting with MOH: The 2nd ‘National Advisory Malaria Elimination Task Force’ meeting was held on 22nd October under the chairmanship of the Minister of Health. The meeting was attended by all key national and subnational heads of department, province, donors and CSOs (international and national). Presentations were made by PHD representatives from Pursat, Kp Speu and Mondulkiri. The focus was mainly on forest interventions, case based surveillance and vector control. The plenary session covered on how to better target and tackle forest malaria. The Pursat deputy governor specifically requested more intense efforts in Pursat province specially in PKV OD. The minister requested PMI to support the Pursat suggestion, and it was agreed that CMEP shall meet the PHD and the Pursat Deputy Governor to better learn and understand how to plan and address the situation of malaria in the forest areas. Procurement In FY20 Q1, there was no significant procurement conducted by CMEP. Financial Management

Human Resource Management At the end of FY19 Q4, CMEP had 68 staff on board (with an approved total of 71 staff). For FY20 Q1, CMEP had 64 staff on board (4 Staff left the project in Q1, M&E Manager in Battambang, M&E Officer in Phnom Penh, 1 ODTL Assistant in Pailin and 1 ODTL Assistant in Krakor). In Q1, 1 staff was promoted from Finance Assistant to Finance Officer in the PP office. For FY20, the management team decided to phaseout 3 positions (1 HF Coordinator in Pailin, 1 Finance Assistant in Phnom Penh and 1 Admin and Logistic officer in Phnom Penh). 4. RESOLVING CHALLENGES FROM FY19 Q4 The efforts made to implement Pv radical cure were somewhat delayed due to some procurement issues and the late arrival of G6PD tests and refrigerators. However, the other processes were completed by CMEP/CNM team including training and field visits to assess hospital capacity. CMEP regularly followed up with CNM and also with the drugs stores to allocate the PQ 7.5 mg and the G6PD tests. It was then at the beginning of Year 4 Q1 that the commodities were able to be disbursed to respective ODs and CMEP then started the radicial cure activity with regular follow up and supervision. The major challenge that arose from FY19 Q4 was around implementation of the SOP for foci investigation process and protocol. CMEP with WHO, CNM and other partners were able to provide ample opportunity and support to accommodate the request for field testing and implementation. After the national level training, CMEP carried out training for their specific eliminaton ODs to make sure that the trainings are well cascaded to the health functionaries who will carry out the foci investigation at their respective ODs. The challenge of convincing and influencing SPM and BKN ODs to move into elimination was an internal struggle, CNM preferred to move all 4 ODs in Pursat to elimination whereas the PHD and OD functionaries were not in favour of moving all of them. CMEP along with CNM met several times with

19 the PHD and OD and provided case burden reduction data analysis and thus were then all able to agree to move only SPM and BKN at this time to elimination stages. The challenge of capturing the testing and treatment data for PP was not possible due to the PRAKAS and thus the indicator in CMEP project went unreported for the whole of FY19. This issue was discussed with COR and other CNM functionaries and thus CMEP was able to propose for an appropriate PP modification which was approved by CO USAID in FY20 Q1. 5. CHALLENGES AND ACTIONS TAKEN OR PROPOSED The challenges and actions taken or proposed in this reporting period included- The IP2 implementation as planned looks promising however the old hotspots are no longer relevant and thus new locations need to be identified in PKV. There are difficulties in getting the committed MMWs identified in these new hotspots as there is not much incentive too motivate them. CMEP is making considerable efforts to train them and provide a platform to meet, share and be recognized and thus anticipating that MMWs may continue to work for a longer time and become more interested to work in the new hotspots. Reporting on PP on referrals may be considered as a major challenge as the PPs are no longer motivated to attend meetings and accept supervision visits. CMEP will work with PHD and ODs to make sure the registered PPs are the ones who could be held accountable to refer cases, and hence ensuring supervision and also any malpractice of testing and treating will be reported to the PHD which can then have implications for the PP registration. Scaling up of the PV radical cure to other potential ODs after the pilot may present some challenges due to the procurement issues of G6PD testing tools and the shelf value of the existing ones. Currently, there are no clear indications on the way scaling up may progress and CNM has not yet provided a plan for scale up. CMEP plans to influence CNM to at least allow CMEP to do PV radical treatment in other CMEP elimination ODs. It remains a major challenge to make sure the G6PD tests are made available in time and the 14 days follow up are done according to the SOP. CMEP staff turnover – the M&E Manager and M&E Officer resigned in Q1 to take up new positions in other organsiations (however, recruitment proceeded, 2 candidates were selected and they should start working for CMEP during FY20 Q2). The operational dynamics on CSO and CNM engagement and flow of funds in the new 5 expanded ODs (which are funded by GF), may challenge CMEP TA support to the 5 ODs. Regular visits, interaction and joint coordination with GF CSO’s, PHD and OD is the best way forward to resolve internal administration and management challenges within UNOPS and GF processes. CMEP anticipates the ongoing concerns from PHD and ODs will still remain and CMEP shall still continue to provide quality TA support through CMEP focal persons and regular field visits. 6. PLANS FOR NEXT QUARTER AND UPCOMING EVENTS CMEP as part of the Year 4 Q2 work plan will implement the following :  Follow up meetings in the new expanded ODs with PHDs and OD staff.  IP2 referesher and cascading training to MMWs.  Introductory work required in the 5 ‘new’ elimination ODs.  Sub grantee quarterly meeting and report submission.  Interprovincial working group meeting to be held in Kp Channang.  MEAF 2 meeting and finalization of the M&E plan.  Participation in Malaria Annual Conference in Feb 2020.

 Organise and participate in CNM National Research working group meeting.  ODTL progress and technical review meeting.  Central Level program review meeting in March 2020.

ANNEX 1 CSO FY20 Q1 RESULTS TABLES

Table 1. AHEAD Results FY20 Q1 (BTB, PLN, SPL, TMK Elimination ODs) Indicators Target Actual Target explanation

1. # of health education campaigns Reached over target due to organized in high transmission 60 75 more new MMPs settlement villages identifies 2. # of mobile/migrant and new 1,500 2,411 Reached over target due to settlers reached with BCC more new MMPs who came messages through IPC for working for corn harvesting and collecting of cassava and participated in the education campaign. Screened 774 suspected patients (male: 380 and Female: 394) during the campaigns. 3. # of ITNs distributed to 150 1,328 Reached over target due to mobile/migrant population new MMPs coming to work for seasonal corn and cassava collection. 4. # of mobile/migrant settlements 60 80 Reached over target due to mapped new MMPs coming to work for seasonal corn and cassava collection. 5. # of suspected malaria patients 130 183 Over target due to increase referred to VMWs/HFs in MMPs 122 183 Over target due to increase 6. # or % of suspected referrals in MMPs reaching VMW/MMW or HFs 7. # of reports of any increased 2 0 No case increase or malaria cases or outbreaks outbreaks 8. # of meeting organized with 3 4 Reached over target. Four ODs, HCs and/or PHD by CSOs ODs and 2 PHDs attended meetings organized by

AHEAD.

9. # of government meetings 4 6 Attended Pro-TWGH in Pailin attended by CSOs (Pro-TWGH 2 times, 2 times in BTB and 2 meeting) times OD monthly meeting in Sampov Loun and Thmar

Koul

Table 2. OEC Results FY20 Q1 (MRS Elimination OD)

Indicators Target Actual Target explanation

1. # of health education campaigns NA 15 organized in high transmission villages 2. # of mobile/migrant and new settlers Had to suspend the activities reached with BCC messages through 448 326 temporarily in November IPC 2019 3. # of LLINs distributed to NA 264 mobile/migrant population 4. # of mobile/migrant settlements NA 14 mapped OEC always encouraged Contact Points to mobilize 5. # of suspected malaria patients MMPs to access blood testing 915 149 referred to VMWs/HFs service from VMWs/HFs. Mainly due to this, OEC could not reach its target 6. # of patients seeking treatment at 915 149 As above VMWs/HFs Malaria cases or outbreask 7. # of reports of any increased malaria 12 0 did not occur in targeted cases or outbreaks areas 8. # of meeting organized with ODs, HCs and/or PHD by CSOs NA 3

9. # of government meeting attended NA 3 by CSOs (Pro-TWGH meeting)

Table 3. PFDA Results FY20 Q1 (BKN and SPM Elimination ODs)

Indicators Target Actual Target explanation

1. # of health education campaigns Below target because organized in high transmission required more discussion villages 23 16 with OD counterparts and CMEP OD teams regarding the new target areas. 2. # of mobile/migrant and new 320 510 Over target due to more settlers reached with BCC MMPs coming to work in the messages through IPC target areas. 3. # of ITNs distributed to 42 441 Achieved over target mobile/migrant population because ITNs not only distributed through health education campaigns, but also through net use monitoring conducted by PFDA’s contact points 4. # of mobile/migrant settlements 7 4 Under target because mapped required more discussion with OD counterparts and CMEP OD teams to explore new migrant settlements, forest workers/goers sites in the select areas 5. # of suspected malaria patients 43 149 Over target due to contact referred to VMWs/HFs points active in seeking suspected malaria patients. 41 149 Over target due to contact 6. # of suspected refer reach to points active in seeking service VMW/MMW or HFs suspected malaria patients. 7.# of report any increased malaria 0 0 Malaria cases or outbreask cases or outbreaks did not occur in targeted areas

8. # of meeting organized with 2 1 Under target due to ODs, HCs and/or PHD by CSOs availability issues with OD counterpart.

9. # of government meeting 2 8 8 government meetings attended by CSOs (Pro-TWGH were attended by PFDA staff meeting) in this reporting period.

Table 4. PFDA Results FY20 Q1 (KRK and PKV Transitional ODs)

Indicators Target Actual Target explanation

1. # of health education campaigns Under target because organized in high transmission required more discussion villages 77 47 with OD counterparts and CMEP OD teams on the new target areas. 2. # of mobile/migrant and new 680 1,443 Over target due to more settlers reached with BCC MMP coming to work in the messages through IPC target areas. 3. # of ITNs distributed to 208 2,335 Achieved over target mobile/migrant population because ITNs not only distributed through health education campaign, but also through net use monitoring conducted by PFDA’s contact points 4. # of mobile/migrant settlements 5 5 On target. mapped 5. # of suspected malaria patients 100 444 Over target because contact referred to VMWs/HFs points have been so active in seeking out suspected malaria patients 6. # or % of suspected refer reach 95 444 Over target because contact to service VMW/MMW or HFs points have been so active in seeking suspected malaria patients. 7.# of reports of any increased 0 0 No increased malaria malaria cases or outbreaks situation to report. 8. # of meeting organized with 0 0 Was not planned. ODs, HCs and/or PHD by CSOs

9. # of government meeting 2 4 4 of government meetings attended by CSOs (Pro-TWGH were attended by PfDA staff meeting) in this reporting period.

ANNEX 2 LAB QA/MICROSCOPY TRAINING TABLES

Table 1: Slides crosscheck for Lab QA October- December 2019 in BTB and PLN Provinces

HC Lab HC Lab QA Lab QA Lab OD Name of HC result result result result Negative Positive Negative Positive

RDTs malaria & RDTs G6PD PLN Ou Chrar - Transportation and storage - Performance

RDTs malaria & RDTs G6PD Krachab - Transportation and storage - Performance BR 10 00 10 00 Tasanh 13 PV 2 13 PV 2 Sdao 10 00 10 00 BTB BTB RH 13 PV 2 13 PV 2 RDTs malaria & RDTs G6PD Treng - Transportation and storage - Performance SPL RH SPL 09 05 09 05 Trang 0 0 0 0 Pichenda 0 0 0 0 TMK TMK RH 09 PV 1 09 PV 1 BV 04 00 04 00 RDTs malaria & RDTs G6PD Klang Meas - Transportation and storage - Performance MRS MRS RH 17 PV 1 17 PV 1 RDTs malaria & RDTs G6PD Prey Trolach - Transportation and storage - Performance

RDTs malaria & RDTs G6PD Preak Chik - Transportation and storage - Performance TOTAL 85 06 85 06 ACCUR 100% 100% ACY

ANNEX 3 CMEP PV RADICAL CURE IMPLEMENTATION Q1

Table 1: Implementation of Pv Radical Cure in BTB and PLN Provinces (November – December 2019)

No. Test Treat OD No. PV Test G6PD results Treat Completed Completed Completed Remarks G6PD PQ 14 name Patient ASMQ D3 FU D7 FU D14 FU used Normal Deficiency days

1 female treated BTB 8 12 7 0 8 7 7 6 4 only ASMQ

1 patient under SPL 8 6 6 0 8 6 5 4 2 20Kg & 1 female

1 female, 1 case is low weight (<20 MRS 21 19 18 0 21 18 18 17 14 kg)& 3 cases not FU/complete yet

2 moblie people TMK 3 1 1 0 3 1 1 1 1 refuse for 14 day treatment FU

PL 2 2 2 0 2 2 2 2 2 No comment

Total 42 40 34 0 42 34 33 30 23

 This quarterly report (Oct to December 2019) considered the cases only until 31st Dec 2019 which completed D3, D7 & D14 Foloow up fully. Below have mention D3,D& , D14 follow up. In January 2020 which is not part of this reporting period all cases tested in this reporting period was 100% followed up and none of the case was missed.  CMEP approach for “follow up” is direct meeting/physical visit between health staff and patient. Phone call from health staff to patient (for follow up/reminder to take drug) has been also recommended if the HFS staff are not able to meet the patiet face to face. In BTB – out of total 7 PQ treated cases ; 4 completed all 14 days follow up in December 2020 and the rest 3 completed in January 2020. 100 % 14 days FU completion. In SPL – out of 6 PQ treated cases ; 2 completed all 14 days follow up in December 2020, and the rest 4 completed 14 days in January 2020. 100% 14 days FU completion In MRS – out of 18 PQ treated cases ; 14 completed all 14 days follow up in December 2020, and the rest 4 cases completed in January 2020. 100 % 14 days FU completion.