Quarterly Performance Report from October 01, 2017 to December 31, 2017

DEFEAT MALARIA

Defeat Malaria Quarterly Performance Report From October 01, 2017 to December 31, 2017

Submission Date: January 31, 2018

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

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

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

Table of Contents List of Tables ------ii List of Figures ------iii ACRONYMS AND ABBREVIATIONS ------iv Executive Summary ------6 Defeat Malaria Goal and Objectives ------7 Summary of Key Achievements (October – December 2017) ------9 Interventions and Achievements on Core Areas of Strategic Focus ------11 1. Achieving and sustaining scale of proven interventions through community and private sector engagement ------11 2. Use of strategic information to adapt to changing epidemiology ------21 3. Improving Myanmar’s capacity to collect and use information ------24 4. Building capacity and health systems strengthening ------26 5. Strengthening capacity of the NMCP and Ethnic Health Organizations (EHOs) ------29 Challenges ------32 Cost Share ------33 Annexes ------34 Annex 1 – Case Finding and Management ------34 Annex 2 – Active case detection by mobile team ------37 Annex 3 – Monthly meeting ------39 Annex 4 – Supervision and monitoring ------40 Annex 5 – Reporting status of VMWs/PPs ------41 Annex 6 – Clinical audit ------42 Annex 7 – Stock out monitoring at the time of monitoring visits ------43 Annex 8 – Capacity building ------46 Annex 9 – BCC ------48 Annex 10 – Advocacy meeting ------51 Annex 11 – Performance Indicators ------52

List of Tables Table 1: Project area coverage as of December 31, 2017 ...... 8 Table 2: Summary of case finding and management by approach (From October to December 2017) .... 12 Table 3: State/Region wise summary of case finding and management (From October 2017 to December 2017) ...... 12 Table 4: Summary of DOT (from October to December 2017) ...... 13 Table 5: LLIN distribution at village-level (October to December 2017) ...... 17 Table 6: LLIN distribution at worksites (from October 2016 to December 2017) ...... 18 Table 7: Monitoring of LLIN coverage and utilization (from July to September 2017) ...... 19 Table 8: Case Detection and Positive status in Letpan Village for past 4 Years period ...... 22 Table 9: Summary of cost share ...... 33 Table 10: Summary of Case Finding and Management by Township (from October 2017 to December 2017) – Mobile Team Approach ...... 34 Table 11: Summary of Case Finding and Management by Township (from October 2017 to December 2017) – VMW Approach ...... 35 Table 12: Summary of Case Finding and Management by Township (from October 2017 to December 2017) – Private Provider Approach ...... 36 Table 13: Summary of active case detection in project villages and work sites (from October 2017 to December 2017) ...... 37 Table 14: Summary of active case detection in non-project villages and work sites (from October 2017 to December 2017) ...... 38 Table 15: Summary of VMW/PP monthly meeting (from October 2017 to December 2017) ...... 39 Table 16: Summary of supervision and monitoring visits to VMWs/PPs (from October 2017 to December 2017) ...... 40 Table 17: Reporting status of VMWs/PPs (from October 2017 to December 2017) ...... 41 Table 18: Summary of clinical audit (from October 2017 to December 2017) ...... 42 Table 19: Summary of stock out monitoring at the time of monitoring visits and on-site data collection (from October 2017 to December 2017) ...... 43 Table 20: Summary of stock out monitoring at monthly meeting (from October 2017 to December 2017) ...... 44 Table 21: Number of VMWs/PPs trained on case management (from October 2017 to December 2017) ...... 46 Table 22: Number of VMWs/PPs trained on diagnosis (from October 2017 to December 2017) ...... 46 Table 23: Number of people reached through Individual Interpersonal communication and Group Health Talks by Mobile Team, VMWs and PPs (from October 2017 to December 2017) ...... 48 Table 24: Number of people reached through individual interpersonal communication (IPC) and Group Health Talks by Private Providers only (from October 2017 to December 2017) ...... 49 Table 25: Advocacy meetings (from October 2016 to December 2017) ...... 51 Table 26: Performance Indicators Tracking Table (from October 2016 to December 2017) ...... 52

List of Figures Figure 1: Map showing coverage of Defeat Malaria ...... 8 Figure 2: Number of people disaggregated by gender, reached through IPC by VMWs/PPs (From October 2017 to December 2017 ...... 16 Figure 3: Facebook page cover (mobile phone) ...... 16 Figure 4: Distribution of forest goers kits at Htee Kaw Htaw village, Myawaddy, Kayin ...... 20 Figure 5: Blood samples were coded and air-dried by Research Assistant at samples collection site, Lower Zin Kaung village ...... 20 Figure 6: Progress of hsRDT study (from October 2017 to December 2017 ...... 21 Figure 7: Map show Let Pan village and two migrant sites (upper left), data collection at household level (lower left), physical checking of status of LLIN (lower middle) and possible mosquito breeding places (all the rest) ...... 23 Figure 8: M & E Surveillance Officer presented about forms and formats to be used at township level ... 24 Figure 9: Effectiveness of training by staff development ...... 24 Figure 10: Data Management Assessment of Kawhoung Township ...... 25 Figure 11: The DQO from Tanintharyi visited Ma Daw village in Palaw Township and interviewed the care taker of a child patient for DOT compliance...... 25 Figure 12: Chief of Party addressed opening speech with special appreciation to the presence of Ethnics Affair Minister of Shan State...... 26 Figure 13: Effectiveness of GIS training by pre and post tests scores ...... 28 Figure 14: Maps showing village wise malaria situations of Kyauktaw Township at FY2017 and Q1 FY2018 ...... 28 Figure 15: Sample of geo-tagged map with ODK ...... 29 Figure 16: Group work activities at master mentor training ...... 30 Figure 17: Demonstration of LLIN hanging ...... 30 Figure 18: Pre- and Post Test Average Score (%) by Area ...... 30 Figure 19: Participants at training of training skill course ...... 30 Figure 20: Average percentage of knowledge in each area ...... 31

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ACRONYMS AND ABBREVIATIONS ABER Annual Blood Examination Rate ACD Active Case Detection ACT Artemisinin-based combination therapy API Annual Parasite Incidence ARC American Refugee Committee BCC Behavior Change Communication BMA Burma Medical Association CBI Community Based Intervention DMR Department of Medical Research DOT Directly observed treatment DQO Data Quality Officers FGD Focus group discussion GMS Greater Mekong Sub-region IEC Information, Education and Communication IPC Interpersonal communication ITN Insecticide treated net KDHW Karen Department of Health and Welfare KNU Karen National Union LLIN Long lasting insecticide net LQAS Lot Quality Assurance System M&E Monitoring and Evaluation MHAA Myanmar Health Assistant Association MIMU Myanmar Information Management Unit MNMA Myanmar Nurse and Midwife Association MOHS Ministry of Health and Sport MOPHS Ministry of Public Health and Sports MRH Maternal and Reproductive Health NGO Non-government organizations NMCP National Malaria Control Program NTG National Malaria Treatment Guidelines ODK Open Data Kit PCD Passive case detection PCR Polymerase Chain Reaction PMI President’s Malaria Initiative PP Private Providers PSI Population Services International QAQC Quality Assurance/Quality Control QAQI Quality Assurance/Quality Improvement RDQA Routine Data Quality Assessment RDT Rapid diagnostic tests RHC Rural Health Centers SOP Standard Operation Procedure TPR Test Positivity Rate USAID United States Agency for International Development

USG United State Government VBDC Vector born Disease Control

VBS Village Based Stratification VMW Village malaria workers WHO World Health Organization

Executive Summary Myanmar’s National Malaria Control Program (NMCP) reported 110,146 malaria cases and 21 malaria deaths in 2016. This marks a decline of 77% in cases and 95% in deaths from 2012 to 2016. However, the malaria burden in Myanmar remains the highest among the six countries of the Greater Mekong Sub-region (GMS), accounting for 62% of the total. Significant challenges interfere with the implementation of a malaria control program, including weak health services in remote areas with high transmission, limited resources and manpower to expand and maintain quality malaria services, internal and cross-border migrations, and evidence of spreading artemisinin resistance along the border areas (especially the Thai-Myanmar border). Under the leadership of the national program, local and international organizations including the U.S. President’s Malaria Initiative (PMI) have collaborated to identify gaps and implement solutions to address these challenges. The Defeat Malaria Activity, funded by PMI, 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. Since October 2016, Defeat Malaria has established collaboration with various stakeholders from the Ministry of Public Health and Sports (MOPHS), the NMCP, local government - respective State/Region Administrations, Township and District Medical Officers (TMO/DMO) and Rural Health Centres (RHCs). In addition, Defeat Malaria is working with international and local non-government organizations (NGOs), including the Regional Artemisinin Initiative (RAI), 3MDG and Global Fund malaria projects. In Kayin and Tanintharyi Regions, Defeat Malaria Activity is working with local administrators and leaders of the target villages . First Quarter of Project Year 2 (October 2017 - December 2017) Key Highlights include:  Geographical coverage with case finding and management covers 32 townships with 882,750 people residing in 1,639 villages.  1,722 long lasting insecticidal nets (LLINs) were distributed to at-risk populations (658 pregnant women, 1,627 migrants and 473 people from newly extended villages)  38,038 people were tested, 878 cases were detected and 99.4% of positive cases were treated according to National Malaria Treatment Guideline. Additionally, during the reporting period, advocacy meetings explaining the scope of Defeat Malaria were conducted in four townships (Kawthoung, Gwa, Thandwe and Mrauk-U).

Refresher trainings on case finding and management were conducted, targeting 497 village malaria workers (VMWs)/Private Providers (PPs). The trained VMWs received rapid diagnostic tests (RDTs), antimalarial drugs, and patient registers. The VMWs and mobile teams provided case detection and management services in targeted areas. In areas where possible, directly observed treatment (DOT) was provided by VMWs to positive cases. DOT monitoring and confirmation was done by checking directly with patients to see if treatment was provided by a VMW or not, according to standard operating procedures (SOPs). Interpersonal communication was provided to those 15 years and above who tested positive for malaria. Group health talks were also provided in communities reaching 5,371 people. To build capacity of project staff and provide updates on the changing malaria epidemiology and utilization of strategic information, an Annual Review Meeting was organized. Project staff at different levels now implement Quality Assurance/Quality Improvement (QA/QI) activities, such as soft and hard folder management and development of guidelines to strengthen Defeat Malaria quality improvement systems for achieving better health care outcomes. The PMI/USAID mission team consisting of the Senior Health Advisor (USAID), Malaria Advisor (PMI) and Chief of Party (Defeat Malaria) visited project townships in Kayin State in November 2017 to observe malaria control activities in PMI supported villages. The team discussed activities with project staff and VMWs and provided suggestions to VMWs to conduct not only malaria interventions, but other activities should the strategy change to an Integrated Community Malaria Volunteer approach in 2018. Defeat Malaria attended the PMI Partners meeting held in Naypyitaw on 20 October 2017 to exchange information on activities implemented in FY2017 and work plans for FY2018, to identify and share lessons learned and solve common problems. Defeat Malaria (URC) presented FY 2017 activities, achievements and challenges. Other partners also provided project presentations and PMI team members provided comments and updates. Defeat Malaria Goal and Objectives The overall goal of the Defeat Malaria Activity is to reduce the malaria burden and control artemisinin-resistant malaria in targeted areas, thereby contributing to the long-term national goal of eliminating malaria in Myanmar. This will be achieved by expanding coverage of community-based prevention and case management services, prioritizing highly endemic and hard-to-reach areas, mobile and migrant populations, and non-state actor areas. Defeat Malaria strengthens the capacity of local partners to effectively lead, manage and implement interventions towards the goal of malaria elimination. The project is also strengthening the malaria surveillance system to better inform and target interventions, and to monitor progress. Defeat Malaria engages communities and promotes the involvement of the private sector. Defeat Malaria works with the NMCP and key partners to achieve the following objectives: Objective 1: Achieve and maintain universal coverage of at-risk populations with proven vector control and case management interventions, while promoting the testing of new tools and approaches.

Objective 2: Strengthen the malaria surveillance system to comprehensively monitor progress and inform the deployment and targeting of appropriate responses and strategies. Objective 3: Enhance technical and operational capacity of the NMCP and other health service providers at all levels of service provision. Objective 4: Promote the involvement of communities, private healthcare providers, private companies and state-owned enterprises in malaria control and elimination initiatives. Defeat Malaria currently covers two States (Rakhine in the west and Kayin in the south- east) and one Region (Tanintharyi in the south- east) of Myanmar. Rakhine State has the highest malaria burden in Myanmar (NSP, 2017-2020) and has deep forested mountain ranges. Dawna Mountain Range in Kayin State extends southward, merging with the northern part of Figure 1: Map showing coverage of Defeat Malaria Tanintharyi Hill. 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 as of December 2017. Table 1: Project area coverage as of December 31, 2017 Total Total Total % of Total Target State & Region Covered Covered Covered Population Population Townships Villages Population Covered Tanintharyi 10 433 908,000 233,874 25.76% Northern Rakhine 10 555 334,939 916,000 56.56% Southern Rakhine 6 450 183,180 Kayin 6 201 275,000 130,757 47.55% Total 32 1,639 2,099,000 882,750 42.06%

As shown in Table 1, as of FY18 Q1, Defeat Malaria covers around 900,000 people from 1,639 villages with malaria services, reaching beneficiaries through a network of 1,409 VMWs/PPs and mobile teams. Many people living in Northern Rakhine State have been affected by conflict since August 2017 and activities are still being implemented in two townships (Buthidaung, and Maungdaw). ARC’s Defeat Malaria Project Manager had a meeting with the Backpack Health Worker Team (BPHWT) Director at their office in Maesot on October 26, 2017 and with the Burma Medical Association (BMA) and KNU brigade-5 in December 2017. Both meetings included discussion on collaboration of malaria control activities for hard-to-reach ethnic populations. In December 2017, the Karen Department of Health and Welfare (KDHW)’s sub-grant process with URC was cancelled. KDHW informed us that they will be funded through a different donor to implement health activities in Kyarinseikgyi Township. Thus, ARC still has limitations in expansion of coverage in Kayin State, which has poor health service coverage in areas controlled by non-state actors. As a result, Defeat Malaria activities in Hpa-pun and Kyainseikgyi Townships will not continue starting in January 2018. ARC will take over activities from programs that are ending in 70 villages from Kawkareik, Bokpyin and Tanintharyi townships. Additionally, ARC discussed expansion to additional villages based on identified coverage gaps in Tanintharyi region with Tanintharyi’s NMCP Regional Team Leader. They also discussed ARC taking over 10 villages in the KDHW area of Tanintharyi region as Community Partners International (CPI) has discontinued activities. The NMCP Team Leader will discuss this with Dr. Merdin Myat Kyaw (Marta) – Senior Consultant (Karen Ethnic Health Organization), KDHW’s. Summary of Key Achievements (October – December 2017)  Training activities- In targeted townships, refresher trainings were conducted for 497 VMWs and PPs on malaria case diagnostics and management.  38,038 people were tested for malaria through VMWs, private providers and mobile outreach teams.  878 cases were detected and, among them, 9 cases were referred to hospitals. 864 out of 869 treated cases (99.4%) were in line with National Treatment Guidelines.  Under the DOT strategy, enrollment of positive cases increased to 72.3% (635 positive cases) and all (100%) enrolled cases completed the treatment course.  Interpersonal communication – Defeat Malaria reached 36,437 people (17,187 males, 19,250 females) through interpersonal communication (IPC) including 4,906 migrants. 341 group health talks were conducted reaching 5,371 people (2,524 males and 2,847 females) including 1,774 migrants in targeted areas;  A total of 1,722 LLINs were distributed in 3 villages and 10 worksites, through 30 sub- centers for pregnant women attending ante-natal clinics and to positive patients.  Defeat Malaria’s Central Monitoring and Evaluation (M&E) Team conducted Data Management and M&E Technique trainings to staff in every state/region (Tanintharyi, Northern/Southern Rakhine and Kayin) to build local capacity and ensure provision of quality malaria services and malaria information.

Interventions and Achievements on Core Areas of Strategic Focus This section covers the following topics: 1. Achieving and sustaining scale of proven interventions through community and private sector engagement 2. Adapting to changing epidemiology based on strategic information 3. Improving Myanmar’s capacity to collect and use information 4. Building capacity and strengthening health systems 5. Strengthening capacity of the National Malaria Control Program and Ethnic Health Organizations (EHOs) 1. Achieving and sustaining scale of proven interventions through community and private sector engagement 1.1 Advocacy meetings to promote Defeat Malaria and private sector engagement At the start of FY2018, advocacy meetings (details in Annex 10) were conducted in 4 townships (Kawthoung, Gwa, Thandwe and Mrauk-U) with various stakeholders including local administrative bodies, township health officials, private companies and work site representatives, and village chiefs with the objectives to:  Provide a project orientation to local and health authorities and communities;  Promote community and private sector involvement in malaria prevention and elimination activities; and,  Establish a village malaria worker network by recruiting VMWs and private providers. A total of 429 participants attended the advocacy meetings. 1.2 Capacity building of VMWs/PPs in malaria diagnosis and case management To provide quality malaria health care services to targeted communities, VMWs and PPs started receiving refresher trainings in October 2017. A total of 451 VMWs and 46 PPs received refresher training on malaria diagnosis and case management, how to conduct IPC, stock management, and data collection and reporting from October to December 2017. Each training was 4 days (details in Annex 8). 1.3 Distribution of commodities to all project townships and villages During FY18 Q1, 35,925 RDTs and 180 ACTs were distributed from the central warehouse (in Yangon) to commodity storage sites to facilitate continuous uninterrupted treatment services for targeted communities. From those township level storage sites, commodities (36,613 RDTs and 1,667 ACTs) were delivered to respective sub-stocks for service delivery points i.e., VMWs/PPs during VMW monthly meetings and monitoring and supervision visits, as necessary. 1.4 Ensure early diagnosis and appropriate treatment through different approaches Different approaches such as community-based malaria diagnosis and treatment through VMWs, mobile teams by Defeat Malaria staff, and private sector engagement were used to

11 rapidly expand coverage of malaria case finding and management among at-risk populations including migrants and mobile populations (MMPs) and pregnant women (see Tables 2 and 3). 38,038 people were tested and 878 cases were positive (504 P. falciparum, 353 P. vivax and 21 mixed). The Test Positivity Rate (TPR) was 2.3%. Eight hundred sixty-nine (869) positive cases (99%) were treated. The remaining 1% of cases were not treated as the incorrect dosage of chloroquine and primaquine was provided by VMW. Please see Annex 1 for more details. Table 2: Summary of case finding and management by approach (From October to December 2017) Total Approach Tested Pf Pv Mix TPR% Positive Mobile Teams 4,671 43 30 13 0 0.9% VMWs 29,392 717 399 302 16 2.4% PPs 3,975 118 75 38 5 3.0% Total 38,038 878 504 353 21 2.3%

Table 3: State/Region wise summary of case finding and management (From October 2017 to December 2017) Total State / Region Tested Pf Pv Mix TPR% Positive Tanintharyi Region 11,103 141 32 107 2 1.3% S. Rakhine State 10,745 194 166 27 1 1.8% N. Rakhine State 11,750 414 277 125 12 3.5% Kayin 4,440 129 29 94 6 2.9%

Total 38,038 878 504 353 21 2.3%

1.5 Active Case Detection (ACD) Defeat Malaria teams conducted special mobile activities through active case detection (ACD) in 74 project villages and 37 non-project villages in 19 townships. These were done 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 in certain hard-to-reach areas,  Malaria reduction is needed in identified high burden areas,  ACD (pro-active case detection) is conducted surrounding the positive index case during case investigation,  ACD in epidemiological assessments of persistent malaria transmission areas.

In addition, Defeat Malaria field teams conducted mobile case finding and management activities through ACD in non-project areas to learn the malaria situation (high, moderate, low, or no transmission) as requested by the NMCP.

In FY2017, mobile teams tested 4,671 in project and non-project villages and only found 43 positive cases (30 Pf, 13 Pv, and 0 mixed). In non-project villages, 23 positive cases (18 Pf, 5 Pv, and 0 mixed) were found among 517 tested, while 20 (12 Pf, 8 Pv, and 0 mixed) were found among 4,154 tested in project villages. The TPR in non-project villages was 4.45% while only 0.48% in project villages. For more detail, please see Annex 2. During FY2017, to obtain needed information, increasing the Annual Blood Examination Rate (ABER) was encouraged by practicing ACD. However, as no cases were found during ACD, routine passive case detection (PCD) is now encouraged to improve ABER and to detect more positive cases. 1.6 Directly Observed Treatment (DOT) In FY17, the percentage of P. falciparum in Defeat Malaria areas in Southern Rakhine State was 91% and 65% in Northern Rakhine State. Buthidaung in Northern Rakhine State is one of the World Health Organization’s (WHO) sentinel sites for Therapeutic Efficacy Studies (TESs) and Myanmar’s western border with Bangladesh is under continuous surveillance for artemisinin resistance. Due to a high prevalence of P. falciparum, it is important to reduce the case load as quickly as possible prior to the development of artemisinin resistant parasites. During this reporting period, 504 P. falciparum cases were detected, 405 (85%) were enrolled in DOT and all 405 (100%) cases completed DOT. Twenty-one (21) mixed infection cases were detected, 13 (61.9%) were enrolled in DOT and all 13 (100%) cases completed DOT. On the move to malaria elimination, it will be important to ensure patients are taking the full course of Primaquine to prevent relapse of P. vivax infection stopping onward transmission. In this reporting period, 353 P. vivax cases were detected, 217 (61.5%) of them enrolled in DOT and all 217 (100%) cases completed DOT. Overall, 72.3% of the 878 total positive cases were enrolled in DOT and completed the full course of ACTs under VMW observation from October to December 2017.

Table 4: Summary of DOT (from October to December 2017)

Pf Pv Mixed Total

Total Positive Cases 504 353 21 878 Total positive enrollment in DOT (%) 405 (80.4%) 217 (61.5%) 13 (61.9%) 635 (72.3%) Completed DOT 405 217 13 635 % completed DOT among total positive cases 80.4% 61.5% 61.9% 72.3% % completed DOT among enrolment 100% 100% 100% 100%

1.7 VMW monthly meetings To monitor reporting performance (timeliness and completeness), data collection and verification of data, replenish materials and drugs and polish capacity of VMWs towards NTGs,

Defeat Malaria Township Teams conducted VMW/PP monthly meetings with 93.8% of VMWs/PPs participating from October to December 2017. Please see details in Annex 3. 1.8 Supervision and monitoring Monthly performance and achievements of VMWs/PPs at village level were continuously monitored by respective township staff ensuring on time complete and correct reporting, case detection activities, correct prescription of identified malaria cases, ensuring adequacy of stock supplies, treatment adherence through appropriate practice of DOT, and preventive practices. Based on the monitoring results, supervision visits were scheduled based on prioritized needs to provide support, on-the-job training, and motivation of VMWs/PPs. In this reporting period, 679 supervision visits (234 visits in Tanintharyi Region, 242 visits in Southern Rakhine State, 116 visits in Northern Rakhine State, and 87 visits in Kayin State) were conducted by township health staff following supervision protocols using standardized checklists at VMW/PPs’ villages. 1.9 Reporting status: improve data management capacity VMW/PP activities are partially monitored through attendance at monthly meetings. If a VMW/PP missed two consecutive meetings, the field team would visit them in their village to discuss why they missed the meeting and if they were interested to continue case management activities. If they did not wish to continue, replacements were recruited. Performance of VMWs/PPs is closely monitored through blood examination rate, clinical audits, DOT completeness, data completeness and accuracy, and prevention activities performed. These were monitored through regular review of their activity reports. Reporting proficiency of VMWs/PPs was over 95% despite challenges for reporting from conflict affected areas in Northern Rakhine State. Timely submission of reports steadily increased throughout the quarter with 98.9% (1,246/1,260) submitted on time in October, 99.6% (1,280/1,285) in November, and 100% (1,285/1,285) in December. Please see Annex 5 for details. 1.10 Clinical audit on treatment of positive cases according to National Malaria Treatment Guidelines (NTGs) Quality of health service provision by VMWs/PPs was ensured through initial and refresher trainings emphasizing treatment of malaria cases in line with NTGs. Safety of patients and quality of malaria health care services were continuously monitored through clinical audits at monthly meetings and regularly supervised by township Defeat Malaria staff. In this reporting period, 864 out of 869 treated cases (99.4%) were treated according to NTGs (see Annex 6). VMWs not following NTGs received supervision, were encouraged to use job aids at the time of treatment provision, and received additional messaging stressing the importance of following the NTGs. These VMWs were also encouraged to call field teams to consult on treatment protocols if a patient was detected.

1.11 Monitoring stock out of RDTs and first line antimalarials (ACT) To ensure continuous quality malaria services to communities, Defeat Malaria regularly monitors stock outs of commodities, including RDTs and first line antimalarials (ACTs), at service delivery points. This is done by checking commodity balances of VMWs/PPs at monthly meetings and during monitoring visits. A stock out is defined as a service delivery point experiencing a shortage of stock or availability of expired commodities for a week or longer during last 3 months. To prevent stock outs, regular replenishment of RDTs and ACTs is provided during monthly meetings and monitoring visits. From October to December 2017, VMWs/PPs received monitoring 4,263 times (3,928 times for VMWs and 335 times for PPs) whether during monthly meetings or monitoring visits. Among them, 99.9% of VMWs/PPs reported no RDT or ACT stock outs due to close regular supervision, proper guidance and training (see in Annex 7). 1.12 Strengthen Behavior Change Communication (BCC) Defeat Malaria utilized several communication channels to achieve good coverage of most vulnerable communities. This included interpersonal communication (as the main mechanism for malaria BCC among key affected communities), printed and digital media, project Facebook page, and printed materials (e.g., posters and information leaflets). IPC From October to December 2017, IPC training was conducted at Rathedaung township and a total of 47 participants (male – 20 and female – 27) attended. VMWs and PPs conduct IPC activities during case finding and management activities to share malaria preventive messages with at-risk populations and promote LLIN use and care. In FY18 Q1, 36,437 people (52.8% female), including 4,906 migrants, were reached by IPC in villages and worksites including 3,684 people (47.8% females) reached by private providers. Figure 2 and Annex 9 show the total number of people, disaggregated by sex, reached through IPC with malaria preventive messages. Additionally, group health talks were conducted to share malaria preventive messages and increase utilization of LLINs while mobile teams performed case finding and management and before LLIN distribution. In this reporting period, 341 group health talks were held in Defeat Malaria villages and work sites, reaching 5,371 people (53% females), 1,774 of whom were migrants. Health education sessions were organized at worksites to share malaria preventive knowledge with MMPs. From October to December 2017, 118 health education sessions were conducted at 71 worksites and 1,620 migrants (1,031 males and 589 females) received malaria preventive messages.

Ann 907 867 Bokpyin 834 721 Buthidaung 384 150 Dawei 520 393 Gwa 814 862 Hlaingbwe 530 1116 Hpa-an 812 1308 Kawkareik 255 372 Kawthoung 842 755 Male Female Kyainseikgyi 226 264 Kyaukpyu 567 715 Kyauktaw 968 840 Kyunsu 691 742 Launglon 159 350 Minbya 299 280 Mrauk-U 5368 Myawaddy 813 865 Myebon 833 846 Myeik 465 692 Palaw 428 548 Pauktaw 487 476 Ponnagyun 455 482 Ramree 851 926 Rathedaung 519 607 Sittwe 296 367 Tanintharyi 660 692 Thandwe 1557 1859 Thayetchaung 247 393 Toungup 647 547 Yebyu 68147 0 500 1000 1500 2000 2500 3000 3500

Figure 2: Number of people disaggregated by gender, reached through IPC by VMWs/PPs (From October 2017 to December 2017

Distribution of printed materials Defeat Malaria distributed information, education and communication (IEC) materials such as pamphlets to share core malaria preventive messages to targeted populations during LLIN distribution and ACD. From October to December 2017, 30,680 pamphlets were distributed in covered areas. Printed digital media Bi-weekly reports were developed and distributed to state/regional level Defeat Malaria staff, Defeat Malaria and PMI IPs and the NMCP starting in July 2017 to highlight achievements made possible with project support, as told through the experience of a beneficiary, taking on a human-

Figure 3: Facebook page cover (mobile phone)

interest angle and written in a compelling fashion to engage a general audience. Defeat Malaria is on Facebook (“Defeat Malaria Myanmar”) to test the ability to strengthen online communication and disseminate project achievements, reach local people and groups, and advocate for donor and stakeholder interest and investment in malaria elimination. The compelling Facebook content includes storytelling pictures, short video clips and short articles/stories. The content of the Facebook page is updated weekly by project staff. 1.13 Optimize coverage and promote use of proven vector control interventions Mass Distribution of LLINs From October to December 2017, 253 LLINs were distributed in a village in Kawthoung and two villages in Bokpyin based on the standard “2 persons per 1 LLIN”, thus providing protection for 473 people from 153 households. Both household and population coverage was 100%. Average population per LLIN is 1.87. Table 5 shows mass LLIN distribution/top-up at the village level by state/region. Table 5: LLIN distribution at village‐level (October to December 2017)

Mass distribution Top-up Total Indicator Kawthoung Bokpyin # of Villages 1 2 3 # of Households (HHs) present 39 114 153 # of HHs covered 39 114 153 # of Population present 118 355 473 # of Population covered 118 355 473 Total LLINs Distributed 74 179 253 % of HHs covered 100% 100% 100% % of Population covered 100% 100% 100%

Net Ownership (Pop per LLIN) 1.59 1.92 1.87

LLIN distribution to migrants and mobile populations in collaboration with employers Defeat Malaria seeks to prevent migrants from getting malaria through a focus on worksites by distributing and topping up LLINs. Seven worksites were covered during this reporting period and 805 LLINs were distributed to 1,627 MMPs (Table 6). All worksite households and populations were 100% covered with an average population per LLIN of 2.02.

Table 6: LLIN distribution at worksites (from October 2016 to December 2017) Mass distribution Top up Grand Indicator Bokpyin Kawthoung Tanintharyi Tanintharyi Total # of Worksites 2 3 1 1 7 # of Households (HHs) present 109 166 22 210 507 # of HHs covered 109 166 22 210 507 # of Population present 324 524 47 732 1,627 # of Population covered 324 524 47 732 1,627 Total LLINs Distributed 169 309 33 294 805 % of HHs covered 100% 100% 100% 100% 100% % of Population covered 100% 100% 100% 100% 100% Net Ownership (Pop per LLIN) 1.92 1.70 1.42 2.49 2.02

LLIN distribution to pregnant women during Antenatal Care (ANC) in high transmission areas As pregnant women are at high-risk for malaria, Defeat Malaria is promoting and increasing utilization of LLINs among pregnant women through distribution during antenatal care (ANC) services. Defeat Malaria distributes LLINs to pregnant women in high transmission villages from the four townships of Ann, Gwa, Thandwe and Toungup, each of whom sought their first ANC at HFs. Recording and reporting forms and indicators required by the LLIN distribution to pregnant women SOP were developed and approved by USAID in July 2017. From October to December 2017, LLINs were distributed to 658 pregnant women at their first ANC visit at 30 sub-centres and 5 RHCs in Ann and Toungup townships and activity will be continued at other two townships starting from next quarter. Monitoring LLIN coverage and utilization From October to December 2017, LLIN monitoring was conducted in 138 Defeat Malaria villages. The CAP-Malaria and Defeat Malaria projects have been distributing LLINs in these villages since 2015. According to the LLIN Monitoring SOP, eligible respondents from 21 households in each village were interviewed by VMWs/PPs with an LLIN monitoring data collection form to assess LLIN coverage and utilization in these villages. Monitoring data from VMWs/PPs was forwarded to Defeat Malaria township teams for analysis together with VMWs during monthly meetings. Coverage analysis According to the Lot Quality Assurance System (LQAS) method, if ≥ 15 households of 21 interviewed own an adequate number of LLINs (i.e. at least 1 LLIN for 2.5 persons despite 2 persons per 1 LLIN in the SOP) as teams don’t always distribute LLINs for children under 5 years as they sleep with their parents. For example, if a family consisting of two parents and one

18 child under 5 years receives 1 LLIN, this is considered acceptable for ownership and access. Below this cut-off-point, it is not acceptable. Utilization analysis LLIN use is estimated by the proportion of household members, among the 21 interviewed households, who slept under a LLIN the previous night. If the proportion falls below 70%, this is insufficient. If ≥ 15 households out of 21 interviewed are below 70%, this village is not at an acceptable level. Table 7 includes LLIN monitoring results. Table 7: Monitoring of LLIN coverage and utilization (from July to September 2017)

LLIN ownership LLIN utilization

No. of No. of Total no. of No. of No. of villages villages not # Townships villages villages at an villages at an not at an at an assessed acceptable acceptable acceptable acceptable level level level level

1 Bokpyin 13 8 5 7 6 2 Dawei 14 9 5 7 7 3 Kawthoung 3 3 0 3 0 4 Kyunsu 8 8 0 7 1 5 Launglon 10 9 1 3 7 6 Myeik 6 5 1 5 1 7 Palaw 17 10 7 11 6 8 Tanintharyi 10 10 0 9 1 9 Thayetchaung 13 8 5 9 4 10 Yebyu 8 6 2 7 1 Tanintharyi Total 102 76 26 68 34 11 Hlaingbwe 18 17 1 11 7 12 Hpa-an 8 8 0 4 4 13 Kawkareik 4 4 0 3 1 14 Myawaddy 6 5 1 5 1 Kayin Total 36 34 2 23 13 Grand Total 138 110 28 91 47

According to findings, one-fifth (20.3%) of total assessed villages were not at an acceptable level of LLIN coverage and one third (34.1%) of villages were not at an acceptable level of utilization.

Villages at an unacceptable level of coverage will be included in LLIN top-up distribution in FY18 Q2. BCC campaigns (individual and group health talks) with a focus on the importance and use of LLINs will follow to increase utilization among the community. 1.14 Development and Distribution of Forest Goers’ Package (Activity: 1.2.7) In September 2017, 514 forest goer kits were distributed in three villages located near forested areas in Dawei, Tanintharyi where malaria transmission is relatively high. The community expressed how useful the items in forest goer kits were and in FY18 Q1 an additional 168 kits were distributed to 3 villages in Palaw and 49 to a village in Kyunsu in Tanintharyi Region, and 232 kits to two villages in Myawaddy in Kayin State. Overall, Defeat Malaria distributed 963 Figure 4: Distribution of forest goers kits at Htee Kaw Htaw village, kits for marginalized forest goers in Myawaddy, Kayin three townships in Tanintharyi and one township in Kayin State. Six months after distribution (FY18 Q3), acceptability and utilization of kits will be evaluated using quantitative and qualitative methods through a review of activity data (such as kit distribution, malaria tests and results), beneficiary interviews with a structured questionnaire, and focus group discussions (FGDs). 1.15 Operational research to pilot new tools and approaches to reduce malaria transmission (Activity: 1.5.1) Defeat Malaria is conducting a pilot study on highly sensitive RDTs (hsRDT) versus conventional RDTs (cRDT) in Ann Township, Rakhine State to evaluate the performance of hsRDTs (SD Bioline) versus cRDT in reactive case detection in low malaria transmission settings. Field survey activities started on October 2, 2017, when ethics approval from the Ethics Review Committee of Department of

Figure 5: Blood samples were coded and air‐dried by Research Assistant Medical Research (ERC-DMR) was at samples collection site, Lower Zin Kaung village received. During a field visit in November, the Principal Investigator and partners decided to extend the study to an additional 15 villages, for a total of 50 target villages. Approval from ERC-DMR for the expansion was received on December 15, 2017.

Progress of index case notification and blood sample collection is monitored weekly and monthly. From October to December 2017, 20 index cases (40% of sample size i.e., 50 index cases) were notified and 762 blood samples were collected from index case contacts. The test positivity rate of contacts by cRDT was 1.2% and 4.2% by hsRDT. Activities will continue until the target sample size of 50 index cases and 1,980 blood samples of index case contacts are reached. Collected blood samples were sent to the Department of Medical Research’s (DMR) Parasitolological Laboratory for quality assessment and further Polymerase Chain Reaction (PCR) confirmatory diagnosis. For efficient resource utilization during the low malaria transmission period (February to mid-June), the survey team will be reorganized into one team composed of four Research Assistants led by a Research Coordinator vs the previous two teams comprised of eight Research Assistants, two Research Supervisors and Figure 6: Progress of hsRDT study (from October 2017 to December 2017 one Research Coordinator.

2. Use of strategic information to adapt to changing epidemiology 2.1 USAID mission trip to Dawei Township, Tanintharyi Region The USAID mission, along with the Defeat Malaria Team, visited Dawei Township from October 16-18, 2017 to field test the applicability of the new SOP for foci investigation and meet with officials from Tanintharyi Regional Public Health Department. The team was composed of:  Karen Cavanaugh, Director, Office of Public Health, USAID-Myanmar  Feliciano Monti, Malaria Advisor, President’s Malaria Initiative (PMI) Myanmar  William Hawley, Chief, Entomology Branch, CDC-Atlanta, USA  Jimee Hwang, Medical Epidemiologist, CDC-Atlanta, USA  David Sintasath, Regional Malaria Advisor, PMI, RDMA-Bangkok  Chief of Party, Defeat Malaria and others

The team met with the Tanintharyi Regional Public Health Director, NMCP Team Leader, and WHO Field Coordinator to discuss regional health issues and Defeat Malaria support for the Tanintharyi Region NMCP. On October 17, 2017, the team went to Wartaw Village, Dawei Township, 15 miles away from the Thai border, to assess the field context suitability for the recently approved foci

investigation SOPs and identify possible improvements. The team met with VMWs and the local community to gather information on the malaria context and where people usually contract malaria. The team also visited an active focus, looked for possible breeding sites, and suggested habitat manipulation or modification opportunities. On October 18, 2017, the team met with the NMCP Team leader to discuss the foci investigation SOP, field trip findings, and the malaria context in Tanintharyi Region. Meeting outcomes included recommendations to update the village-based stratification framework and geo-mapping of transmission reduction/elimination areas based on the current malaria epidemiological context in Tanintarhyi Region/Dawei Township. 2.2 Assessment of continuous malaria positive cases in Letpan Village, Toungup Township, Rakhine Letpan village’s VMW continues to regularly detect malaria positive cases. Over the last four years, the ABER was adequate with a minimum of near 10% (Table 8) and a high of 83%. Letpan’s geography makes it favourable for malaria. It is located near a mountainous area with the highest elevation at 250 feet and the Ma Ei stream flowing just beside the village. Letpan and its surroundings are not very favourable for mosquito breeding. The total population is about 790 with 85% comprised of the Rakhine Ethnic Group while the remaining 15% are Chin Ethnic Group. Table 8: Case Detection and Positive status in Letpan Village for past 4 Years period

Year Pop Tested Positive Pf Pv Mixed ABER TPR API

Oct 13- Sept 14 712 70 13 12 0 1 9.8% 18.6% 18.26 Oct 14- Sept 15 712 83 11 9 2 0 11.7% 13.3% 15.45 Oct 15- Sept 16 795 306 24 21 3 0 38.5% 7.8% 30.19 Oct 16- Sept 17 792 657 32 27 5 0 83.0% 4.9% 40.40 The TPR is steadily declining with a TPR of 18.6% in FY14 and 4.9% in FY17 (73.7% reduction). However, API increased over the last three years and P. falciparum is dominant. Key Informant Interviews (KIIs) with the VMW and Village Leader indicate an increase in malaria cases compared to three years ago, which aligns with Defeat Malaria’s surveillance data. Due to the increase in cases, Defeat Malaria conducted an assessment on the presence of malaria in Letpan Village. Summary of findings and strategy for Letpan Village Receptivity of Letpan village seems low, however, forest goer groups (timber extraction and hill side farmers) remain vulnerable. API is increasing with the increase in ABER (18.26/1,000 API in FY14 to 40.40/1,000 in FY17). Three Key Informant Interviewees stated malaria transmission is not local but rather, is contracted outside the village. Local malaria transmission is unlikely. Even though malaria positive cases were seen among children under 5, they had stayed with family in the forest for two weeks to one month. While travel history and length of stay were provided, no strong epidemiological evidence (based on interval between date of travel and

onset of fever) was available. Field teams received guidance on how to properly conduct case investigations with regard to recent travel. Thanks to the VMW, quality case detection and treatment services are available and accepted by most of the village. While LLIN coverage is good, only 42% of the village is fully protected by a LLIN.

Figure 7: Map show Let Pan village and two migrant sites (upper left), data collection at household level (lower left), physical checking of status of LLIN (lower middle) and possible mosquito breeding places (all the rest)

Based on the findings, Letpan Village is most likely a “Residual Non-active Foci” and active local transmission is present at the worksite, not at the village. The following interventions are planned for FY18: 1. Training of VMW and Defeat Malaria staff on collection of specific data (i.e., date of onset of fever and dates of travel, names of places travelled) to differentiate between imported and locally contracted malaria cases. 2. Case investigation for all positive cases. 3. Testing of all fever cases (without obvious cause) within 24 hours from the onset of fever. 4. Analysis of surveillance data by positivity rate among farmers, forest goers and timber extraction workers. Total number of these population groups should be collected or estimated. 5. Distribution of LLINs to all immigrants from other townships to Letpan village and BCC to encourage use at timber extraction sites.

6. BCC on care, longevity and effective use of LLINs. Encourage use of LLINs by all populations, especially fever cases, timber extraction workers and forest goers. 7. Explore the possibility of establishment of malaria services (VMWs) among forest goers where active transmission is present (worksite). 3. Improving Myanmar’s capacity to collect and use information 3.1 Data Management and M&E technique training Defeat Malaria is updating activities, work plans and the M&E plan annually in accordance with the changing epidemiological situation, results-based malaria health needs of communities, malaria operational plan, and lessons learned from the previous year. Defeat Malaria M&E guidelines are followed by all partners, and forms and formats are used consistently across all implementing areas. The Central M&E team, in close collaboration with State/Region level staff, facilitated capacity development activities for Township Team

Leaders/Coordinators, Health Facilitators, Team Figure 8: M & E Surveillance Officer presented about Assistants and Data Assistants in data quality forms and formats to be used at township level assurance, data utilization and dissemination. Learning objectives were to understand and apply standardized and updated forms, formats and data verification techniques for promoting data quality, to understand and describe Defeat Malaria goals, objectives, outputs and key performance indicators, and to understand and apply

Figure 9: Effectiveness of training by staff development the data utilization template for regular monitoring.

In FY18 Q1, trainings were conducted in 5 townships (Sittwe, Toungup, Thandwe, Hpa-An and Dawei) for 134 Defeat Malaria staff from URC, ARC, MHAA and MNMA. The mean pre-test score of 58.1% increased to 80% post-training, revealing a statistically significant (P-value 0.000 by paired t test) increase in scores.

3.2 Management of Data Quality Provision of Routine Data Quality Assessments (Activity 2.1.5) The objectives of the Routine Data Quality Assessments (RDQAs) are to strengthen the monitoring and evaluation system, promote data quality for surveillance and improve service quality for patients’ safety. According to results and recommendations of mock RDQA from FY2017, all relevant township level staff, including partners, supported appropriate M&E trainings. In FY18 Q1, Data Quality Officers facilitated M&E trainings for staff in their respective areas and conducted RDQA visits to 10 out of 31 targeted townships. A RDQA visit to Kawthoung prior to the M&E training revealed the status of the data management system (Figure 14). Weaknesses found during the RDQA were emphasized in the M&E training via scenarios and exercises for data collection and reporting forms, thorough explanations through in-depth discussions about key performance indicators and measures per M&E guidelines were covered.

Figure 10: Data Management Assessment of Kawhoung Township

During RDQA visits, Data Quality Officers (DQOs) supported VMWs/PPs to correctly fill individual stock cards to be compatible with monthly drug consumption, refills and balance. DQOs also ensured the township office filing system is in line with the guidelines. The Central M&E team encouraged DQOs and M&E Officers to enhance on-site data verification at the village level, including interviewing beneficiaries to ensure DOT compliance, and providing RDQA Figure 11: The DQO from Tanintharyi visited Ma Daw village in Palaw Township and interviewed the care taker of a child patient to all townships next quarter. for DOT compliance.

4. Building capacity and health systems strengthening 4.1 Quarterly assessment and use of strategic information Defeat Malaria’s annual review meeting was held from December 14-17, 2017 in Yangon and Taunggyi with 119 staff. The objectives were to evaluate the performance of Defeat Malaria activities in FY17, orient staff on the Year 2 work plan, realize the concepts and operationalization of malaria elimination, and update staff

on M&E, Finance, Figure 12: Chief of Party addressed opening speech with special appreciation to the Administrative and Logistics presence of Ethnics Affair Minister of Shan State procedures. Supportive supervision was covered to ensure quality improvement of VMWs’ health service provision. Defeat Malaria staff stressed the importance of effective supervision through following supervision protocols, appropriate utilization of the checklist, and meeting with beneficiaries to ensure compliance. Topics also covered how to prepare prior to supervision, activities during the visit, and what is needed for follow-up after supervision. Staff discussed challenges and shared best practices and experiences from different regions. Topics varied including: female involvement in VMW recruitment, effectiveness of the DOT strategy, safety measures in following the NTGs, effectiveness of prevention coverage, adequacy of stock supply, reaching vulnerable MMPs, pregnant women, and children under-five. Lessons learned from previous years were shared and participants made suggestions for improvements in FY18. Lessons learned from townships not achieving targets included: hard- to-reach areas (water ferry only available once a week, etc.), NTGs weren’t followed due to communication barriers with ethnic VMWs with low education, low DOT adherence was due to VMWs’ competing needs/interest to go to the field to make money vs the need to supervise the 14-day treatment course, and external restrictions on movement in conflict areas hindered supervision and led to missed RDQA. Additionally, staff participated in an indicators’ exercise related to impact, outcomes, outputs and activities of Defeat Malaria in a logical sequence and data verification game. The Regional Technical Director highlighted use of malaria elimination as a quality improvement measure to be undertaken in FY18 through efficient utilization of resources through village- based stratification and appropriate interventions relevant to the changing malaria epidemiology.

He encouraged field staff to closely monitor receptivity, vulnerability and quality health care services in their areas. Staff also discussed advocacy for community involvement, the importance of DOT and prevention of drug resistance, effective utilization of key messages for BCC, and USAID / PMI photography guidelines. 4.2 Quality Assurance/Quality Improvement (QA/QI) On September 26, 2017, a QA/QI training was conducted at the Central Level with 64 participants (46 males, 18 females) by Dr. Neeraj Kak (Senior Vice President - URC Home Office) with the following objectives: - To strengthen Defeat Malaria quality improvement systems for achieving better health care outcomes - To increase patients’ quality of life and satisfaction with malaria interventions After the training, Defeat Malaria staff: - Developed QA/QI guidelines and manuals and distributed them to the state/region and township levels. - Teams at different levels now apply QA/QI methods including recording keeping of all activities and documentation of: . National Guidelines; . Project Documents; . Reports; and, . Project Strategies. - A posting for a QA/QI Director was posted at the Myanmar Information Management Unit (MIMU) and on social media related to I/NGO jobs/vacancies and the recruitment process is ongoing. 4.3 Training towards capacity building of central and township level staff on GIS GIS training on data digitizing, spatial analysis, map projection and mapping (second training) was conducted for 23 Defeat Malaria staff from November 29 to December 3, 2017 in Yangon. The trainees were Defeat Malaria staff from the central office and newly recruited Township Team Leaders/Coordinators from URC and ARC. The first training was held for 29 participants including Township Team Leaders and State/Region level staff from URC, MHAA, and MNMA in October 2017.

The training built capacity of Defeat Malaria staff to develop GIS maps to display distribution and clusters of malaria cases and village-based malaria stratification promoting data utilization and further geotagging of malaria cases in target elimination areas. The former Associate Professor of the Geography Department, Loikaw University facilitated the training.

Figure 13: Effectiveness of GIS training by pre and post tests scores Training effectiveness was assessed by pre- and post-training test scores. The applicability of GIS mapping was followed-up by Township Team Leaders asking staff to develop township-level maps with detected malaria cases and village-based malaria contexts. Figure 18 shows maps developed by the Kyauktaw Township Team Leader, a township in Northern Rakhine State, for visualizing the village-based malaria context in Kyauktaw and

Figure 14: Maps showing village wise malaria situations of Kyauktaw Township at FY2017 and Q1 FY2018 monthly observation of malaria cases. 4.4 Improved surveillance through mHealth Defeat Malaria piloted the use of a mobile application for strengthened surveillance using OpenDataKit (ODK). This was used in the hsRDT study to visualize locations of index cases and contact participants.

Figure 15: Sample of geo‐tagged map with ODK Defeat Malaria also piloted ODK for performance tracking of field works by measuring time from notification to reactive case investigation. Staff can record their location (GPS) during interviews at participants’ households as well as the time of case investigation. Visualization of the geotags was supported through Tableau software (Figure 19). Defeat Malaria used the CSPro data entry and management system in the hsRDT study to minimize data errors through close supervision of field data collection activities and data validation with minimal lag time for data entry processes. The output of the CSPro application is an SPSS syntax file and data are currently shared through google drive. 5. Strengthening capacity of the NMCP and Ethnic Health Organizations (EHOs) 5.1 Conducted master mentor training on Community-based Interventions for NMCP staff to improve access to Essential Health Services In collaboration with the NMCP Department of Public Health, Jhpiego and URC conducted a five-day master mentor workshop on Community-based Interventions (CBI) from November 13 to 17, 2017. Out of 16 participants, 14 were from the NMCP and two from Defeat Malaria/ Jhpiego field staff. The training equipped participants to be able to perform cascade trainings, particularly for VMWs, on a range of topics including:  Community participation and community ownership through identification of community structures and community resource persons in controlling infectious diseases, including malaria;  Integrated community malaria volunteers and their roles;  Updates on accurate diagnostic skills;  Prescription of drugs and management of illness; and,  How to ensure proper recording and reporting of community data and how to properly store drugs and commodities at the community level.

Figure 16: Group work activities at master mentor training Figure 17: Demonstration of LLIN hanging

A pre- and post-training assessment was administered to ensure participants retained the necessary knowledge and skills. Action plans for subsequent general trainer trainings and training for volunteers were developed on the last day of workshop.

Pre Test Post Test

91% 90% 88% 100% 72% 63%

33% 50%

0% A. History Taking and B.Rapid Diagnostic C.Treatment of Malaria Physical Examination Testing (RDT) for malaria

Figure 18: Pre‐ and Post Test Average Score (%) by Area

Figure 22 shows the increase in pre- and post-test scores for history taking and physical examination (33% to 91%), RDTs (72% to90 %) and treatment of malaria (63% to 88%). Overall, the average score increased from 72% to 94% between the pre- and post-test. Six out of sixteen participants attained a passing score (80%) on the pre-test and all participants passed the post-test. 5.2 Conduct training skill course for NMCP staff In collaboration with the NMCP, Jhpiego conducted a training skills course for Vector Born Disease Control (VBDC) staff from December 11 to 15, 2017. Eighteen participants attended, including the 15 participants from the NMCP who completed the master mentor training on CBI. Participants were trained on different training methodologies and skills including how to

Figure 19: Participants at training of training skill course 30

ensure effective facilitation, demonstration and coaching, and how to assess clinical skills. Pre-and post-knowledge and skills tests were administered to understand participants’ acquisition of knowledge and skills. An increase in the overall average score from 67% on the pre-test to 100% on the post-test suggests a strong uptake of knowledge. The results for each knowledge category can be seen in Figure 24.

Approach to Clinical Training112% Pre‐test 120% 100% Post‐test 80% Coaching in Clinical 108%Creating a Positive Training Training 87% 60% 40% 20% 0%

Conducting an Effective 80% Interactive Training Techniques Clinical Demonstration 103%

102% Presentation Skills Figure 20: Average percentage of knowledge in each area 5.3 On-site trainings In collaboration with URC, Jhpiego co-facilitated VMW trainings conducted in Ponnagyun Township, Rakhine state and Dawei Township, Tanintharyi region in November and December 2017. A total of 116 VMWs received technical updates on clinical diagnosis and management of malaria, how to fill the forms, conduct different BCC topics and perform RDT testing using different teaching aids including case studies and group exercises. 5.4 Conduct joint support supervision with project staff/BHS During this reporting period, Jhpiego participated in joint supervision visits led by ARC’s monitoring and evaluation team and field operation team to Hlaing Bwe Township, Kayin state to assess data and stocks, and to assist in performing RDQAs. Meanwhile, Jhpiego also participated in monthly VMW meetings conducted in Sittwe and Dawei Townships, and supported report collection from VMWs and stock management. During the meetings, volunteers received quick technical updates on the importance of RDT testing and health education for community health. Volunteers also received feedback on data entry in DOT forms and patient registers during the meeting. 5.5 Explore opportunities to leverage the existing support of the Ministry of Health and Sports (MOHS) in updating the pre-service and in-service curriculum In FY18 Q1, Jhpiego’s Field Capacity Development Director continued contributing technical support in reaching a final consensus on prevention, diagnosis, and case management of

uncomplicated and severe malaria in pregnancy including pre-referral treatment at the Health Centre and Hospital levels that included national ANC guidelines. This effort has ensured technical standardization on management of malaria in pregnancy among the NMCP and Maternal and Reproductive Health (MRH) division of the Department of Public Health and paved the way for updating the management of malaria in pregnancy components of the pre- service curriculum as well as in-service training to be in line with this new national ANC guideline. 5.6 Capacity building for malaria epidemiology and basic entomology of VBDC staff. Defeat Malaria served as resource on the following trainings as requested by NMCP/ WHO:

 Training of NMCP medical officers, Malaria Assistants, Malaria Inspectors (Total 125 participants – Male 116, Female 9) from elimination states/regions on Malaria Elimination conducted by WHO in Yangon.  Training of entomological staff on vector control measures linked to elimination in Kyokone, Yangon 5.7 Strengthen malaria surveillance system, improve data management capacity at all levels To strengthen township-level data management, Defeat Malaria donated 19 laptops to Rakhine State NMCP to ensure timely and complete reporting. 5.8 Capacity building of EHO ARC’s Defeat Malaria Project Manager had a meeting with Dr. Ed Marta at the KDHW office, Hpa-An on October 24, 2017 and discussed project activity implementation in Kyarinseikgyi Township. However, as stated earlier, the process was cancelled as KDHW will work with other funding sources. Challenges  Temporary suspension of activities in Maungdaw and Buthidaung villages due to conflicts - During the early weeks of October 2016 and last weeks of August 2017, unstable security conditions due to conflict occurred in Northern Rakhine State causing interruption of Defeat Malaria field activities. Defeat Malaria faced difficulties providing malaria services to villagers from conflicted villages who moved to other areas until December 2017. Defeat Malaria targeted villages in Buthiduang and Maungdaw Townships were severely affected by the conflicts.  Difficulty in finding malaria cases – Due to aggressive and universal coverage of prevention and case management by all implementing partners, malaria prevalence has reduced in most geographical areas. This led to low detection of positive malaria cases. Most of the new expansion villages have a low malaria caseload. Through negotiation and collaboration with State/Regional Health Departments and VBDC, Defeat Malaria will work beyond target areas and continue to practice a village-based strategy and introduce intensified case finding activities. In areas where malaria prevalence is low or zero, it is

necessary to adapt to the changing epidemiology and utilize appropriate approaches. In these areas, sustaining no malaria status and reducing low malaria transmission to zero malaria transmission can be recorded as impact of the project. Thus, the surveillance system needs to be strengthened to maintain the objectives even it is costlier.  Delay in Procuring ACTs – under the USAID DELIVER Project, ACT procurement took six months for delivery. Under USAID GHSP-PSM, Defeat Malaria was notified that ACT procurement will take a minimum of 10 months, indicating ACTs will not be provided to Defeat Malaria until at least February 2018. To ensure no stock outs of ACTs, Defeat Malaria is working with the NMCP and working closely with townships to stock/redirect commodities as needed.  ARC’s Defeat Malaria Project Manager met with Burma Medical Association (BMA) in Maesot on October 26, 2017 and the Karen National Union (KNU) brigade-5 in December 2017 to discuss coordinating Defeat Malaria project activities in Hpa-Pun Township. Given the change in direction for funding sources, the KNU focal point of Hpa-Pun Township confirmed that they won’t conduct Defeat Malaria activities. Thus, ARC still has limitations in expansion of coverage in Kayin State which has poor health service coverage in areas controlled by non-state actors.

Cost Share As of FY18 Q1, Defeat Malaria has contributed $172,494.36 in cost share, 5.36% of the aggregate requirement of $3,218,500.00.

Table 9: Summary of cost share

Cost Share Summary Total Cost Share Requirement $3,218,500.00 Total Cost Share Reported (including this period) $172,494.36 Remaining cost share $3,046,005.64

Annexes Annex 1 – Case Finding and Management

Table 10: Summary of Case Finding and Management by Township (from October 2017 to December 2017) – Mobile Team Approach

# Township Tested Total Positive Pf Pv Mixed TPR% 1 Bokpyin (ARC) 77 5 0 5 0 6.49% 2 Dawei (URC) 652 1 0 1 0 0.2% 3 Kawthoung (ARC) 0 0 0 0 0 - 4 Kyunsu (URC) 724 4 1 3 0 0.6% 5 Launglon (URC) 93 0 0 0 0 0.0% 6 Myeik (URC) 322 0 0 0 0 0.0% 7 Palaw (URC) 348 1 1 0 0 0.3% 8 Tanintharyi (ARC) 108 0 0 0 0 0.0% 9 Thayetchaung (URC) 383 0 0 0 0 0.0% 10 Yebyu (URC) 104 0 0 0 0 0.0% Tanintharyi Total 2,811 11 2 9 0 0.4% 11 Ann (URC) 78 4 4 0 0 5.1% 12 Gwa (MNMA) 347 0 0 0 0 0.0% 13 Kyuakpyu (URC) 0 0 0 0 0 - 14 Ramree (URC) 0 0 0 0 0 - 15 Thandwe (MNMA) 291 0 0 0 0 0.0% 16 Toungup (URC) 127 3 2 1 0 2.4% Southern Rakhine Total 843 7 6 1 0 0.8% 17 Buthidaung (MHAA) 0 0 0 0 0 - 18 Kyauktaw (URC) 0 0 0 0 0 - 19 Maungdaw (MHAA) 0 0 0 0 0 - 20 Minbya (URC) 294 22 21 1 0 7.5% 21 Mrauk-U (URC) 0 0 0 0 0 - 22 Myebon (URC) 0 0 0 0 0 - 23 Pauktaw (URC) 191 1 1 0 0 0.5% 24 Ponnagyun (URC) 0 0 0 0 0 - 25 Rathedaung (MHAA) 124 0 0 0 0 0.0% 26 Sittwe (URC) 0 0 0 0 0 - Northern Rakhine Total 609 23 22 1 0 3.8% 27 Hlaingbwe (ARC) 175 0 0 0 0 0.0% 28 Hpa-an (ARC) 0 0 0 0 0 - 29 Kawkareik (ARC) 90 0 0 0 0 0.0% 30 Kyarinseikgyi (ARC) 0 0 0 0 0 - 31 Myawaddy (ARC) 143 2 0 2 0 1.4% Kayin Total 408 2 0 2 0 0.5% Defeat Malaria Total (Mobile) 4,671 43 30 13 0 0.9%

Table 11: Summary of Case Finding and Management by Township (from October 2017 to December 2017) – VMW Approach

# Township Tested Total Positive Pf Pv Mixed TPR% 1 Bokpyin (ARC) 845 20 2 17 1 2.37% 2 Dawei (URC) 623 24 0 23 1 3.9% 3 Kawthoung (ARC) 1,101 5 4 1 0 0.5% 4 Kyunsu (URC) 1,008 19 3 16 0 1.9% 5 Launglon (URC) 478 0 0 0 0 0.0% 6 Myeik (URC) 581 2 1 1 0 0.3% 7 Palaw (URC) 646 17 6 11 0 2.6% 8 Tanintharyi (ARC) 1,067 22 8 14 0 2.1% 9 Thayetchaung (URC) 188 0 0 0 0 0.0% 10 Yebyu (URC) 154 0 0 0 0 0.0% Tanintharyi Total 6,691 109 24 83 2 1.6% 11 Ann (URC) 1,848 91 76 14 1 4.9% 12 Gwa (MNMA) 952 7 6 1 0 0.7% 13 Kyuakpyu (URC) 886 0 0 0 0 0.0% 14 Ramree (URC) 1,909 1 0 1 0 0.1% 15 Thandwe (MNMA) 1,776 4 4 0 0 0.2% 16 Toungup (URC) 1,384 26 22 4 0 1.9% Southern Rakhine Total 8,755 129 108 20 1 1.5% 17 Buthidaung (MHAA) 696 62 18 37 7 8.9% 18 Kyauktaw (URC) 2,839 168 117 49 2 5.9% 19 Maungdaw (MHAA) 0 0 0 0 0 - 20 Minbya (URC) 627 59 40 18 1 9.4% 21 Mrauk-U (URC) 109 18 16 2 0 16.5% 22 Myebon (URC) 1,731 41 36 5 0 2.4% 23 Pauktaw (URC) 1,080 2 2 0 0 0.2% 24 Ponnagyun (URC) 992 10 5 4 1 1.0% 25 Rathedaung (MHAA) 1,057 6 4 2 0 0.6% 26 Sittwe (URC) 943 6 1 5 0 0.6% Northern Rakhine Total 10,074 372 239 122 11 3.7% 27 Hlaingbwe (ARC) 542 6 4 2 0 1.1% 28 Hpa-an (ARC) 1,196 8 1 6 1 0.7% 29 Kawkareik (ARC) 649 0 0 0 0 0.0% 30 Kyarinseikgyi (ARC) 611 28 19 8 1 4.6% 31 Myawaddy (ARC) 874 65 4 61 0 7.4% Kayin Total 3,872 107 28 77 2 2.8% Defeat Malaria Total (VMW) 29,392 717 399 302 16 2.4%

Table 12: Summary of Case Finding and Management by Township (from October 2017 to December 2017) – Private Provider Approach

# Township Tested Total Positive Pf Pv Mixed TPR% 1 Bokpyin (ARC) 182 10 1 9 0 5.49% 2 Dawei (URC) 30 0 0 0 0 0.0% 3 Kawthoung (ARC) 440 6 2 4 0 1.4% 4 Kyunsu (URC) 328 3 3 0 0 0.9% 5 Launglon (URC) 0 0 0 0 0 - 6 Myeik (URC) 244 0 0 0 0 0.0% 7 Palaw (URC) 230 1 0 1 0 0.4% 8 Tanintharyi (ARC) 0 0 0 0 0 - 9 Thayetchaung (URC) 147 1 0 1 0 0.7% 10 Yebyu (URC) 0 0 0 0 0 - Tanintharyi Total 1,601 21 6 15 0 1.3% 11 Ann (URC) 468 41 37 4 0 8.8% 12 Gwa (MNMA) 0 0 0 0 0 - 13 Kyuakpyu (URC) 204 0 0 0 0 0.0% 14 Ramree (URC) 267 0 0 0 0 0.0% 15 Thandwe (MNMA) 0 0 0 0 0 - 16 Toungup (URC) 208 17 15 2 0 8.2% Southern Rakhine Total 1,147 58 52 6 0 5.1% 17 Buthidaung (MHAA) 0 0 0 0 0 - 18 Kyauktaw (URC) 95 1 1 0 0 1.1% 19 Maungdaw (MHAA) 0 0 0 0 0 - 20 Minbya (URC) 0 0 0 0 0 - 21 Mrauk-U (URC) 20 3 1 1 1 15.0% 22 Myebon (URC) 212 9 8 1 0 4.2% 23 Pauktaw (URC) 446 3 3 0 0 0.7% 24 Ponnagyun (URC) 294 3 3 0 0 1.0% 25 Rathedaung (MHAA) 0 0 0 0 0 - 26 Sittwe (URC) 0 0 0 0 0 - Northern Rakhine Total 1,067 19 16 2 1 1.8% 27 Hlaingbwe (ARC) 0 0 0 0 0 - 28 Hpa-an (ARC) 60 0 0 0 0 0.0% 29 Kawkareik (ARC) 0 0 0 0 0 - 30 Kyarinseikgyi (ARC) 0 0 0 0 0 - 31 Myawaddy (ARC) 100 20 1 15 4 20.0% Kayin Total 160 20 1 15 4 12.5% Defeat Malaria Total (Private 3,975 118 75 38 5 3.0% Provider)

Annex 2 – Active case detection by mobile team

Table 13: Summary of active case detection in project villages and work sites (from October 2017 to December 2017)

# Total Total Test Villages/ Coverag P Mixe Tota # Township populatio Teste Pf Positivit worksit e v d l n d y Rate es 1 Bokpyin 5 1,415 24 1.70% 0 2 0 2 8.33% 2 Dawei 8 3,241 652 20.12% 0 1 0 1 0.15% 3 Kyunsu 6 3,225 724 22.45% 1 3 0 4 0.55% 4 Launglon 3 1,676 93 5.55% 0 0 0 0 0.00% 5 Myeik 4 1,545 322 20.84% 0 0 0 0 0.00% 6 Palaw 7 1,737 348 20.03% 1 0 0 1 0.29% 7 Tanintharyi 3 2,719 59 2.17% 0 0 0 0 0.00% 8 Thayetchaung 6 2,779 383 13.78% 0 0 0 0 0.00% 9 Yebyu 3 499 104 20.84% 0 0 0 0 0.00% Tanintharyi Total 45 18,836 2,709 14.38% 2 6 0 8 0.30% 10 Ann 1 179 69 38.55% 4 0 0 4 5.80% 11 Gwa 9 1,344 332 24.70% 0 0 0 0 0.00% 12 Thandwe 4 920 279 30.33% 0 0 0 0 0.00% 13 Toungup 1 132 62 46.97% 0 0 0 0 0.00% Rakhine (South) 15 2,575 742 28.82% 4 0 0 4 0.54% Total 14 Minbya 1 259 65 25.10% 5 0 0 5 7.69% 15 Pauktaw 2 1,103 191 17.32% 1 0 0 1 0.52% 16 Rathedaung 2 582 124 21.31% 0 0 0 0 0.00% Rakhine (North) 5 1,944 380 19.55% 6 0 0 6 1.58% Total 17 Hlaingbwe 4 1,934 113 5.84% 0 0 0 0 0.00% 18 Kawkareik 1 1,693 90 5.32% 0 0 0 0 0.00% 19 Myawaddy 4 3,816 120 3.14% 0 2 0 2 1.67% Kayin Total 9 7,443 323 4.34% 0 2 0 2 0.62% 1 Grand Total 74 30,798 4,154 13.49% 8 0 20 0.48% 2

Table 14: Summary of active case detection in non‐project villages and work sites (from October 2017 to December 2017)

# Village Total Total Test Cover Mixe # Township s/ populati Teste Pf Pv Total Positivity age d worksit on d Rate es 1 Bokpyin 6 7277 53 0.73% 0 3 0 3 5.66% 2 Tanintharyi 1 732 49 6.69% 0 0 0 0 0.00% Tanintharyi 7 8009 102 1.27% 0 3 0 3 2.94% Total 3 Ann 7 6071 9 0.15% 0 0 0 0 0.00% 4 GWA 3 0 15 - 0 0 0 0 0.00% 5 Thandwe 1 0 12 - 0 0 0 0 0.00% 6 Toungup 4 27376 65 0.24% 2 1 0 3 4.62% Rakhine (South) 15 33447 101 0.30% 2 1 0 3 2.97% Total 7 Minbya 5 382 229 59.95% 16 1 0 17 7.42% Rakhine (North) 5 382 229 59.95% 16 1 0 17 7.42% Total 8 Hlaingbwe 5 394 62 15.74% 0 0 0 0 0.00% 9 Myawaddy 5 6459 23 0.36% 0 0 0 0 0.00% Kayin Total 10 6853 85 1.24% 0 0 0 0 0.00% Grand Total 37 48691 517 1.06% 18 5 0 23 4.45%

Annex 3 – Monthly meeting

Table 15: Summary of VMW/PP monthly meeting (from October 2017 to December 2017)

% of VMWs/PPs VMW / PP Posts have # Township Male Female Total attended the to attend the meeting meeting 1 Bokpyin 126 14 90 104 82.5% 2 Dawei 63 12 43 55 87.3% 3 Kawthoung 135 66 45 111 82.2% 4 Kyunsu 120 27 85 112 93.3% 5 Launglon 78 12 57 69 88.5% 6 Myeik 90 9 80 89 98.9% 7 Palaw 117 29 75 104 88.9% 8 Tanintharyi 133 32 99 131 98.5% 9 Thayetchaung 51 8 42 50 98.0% 10 Yebyu 39 12 17 29 74.4% Tanintharyi Total 952 221 633 854 89.7% 11 Ann 183 113 53 166 90.7% 12 Gwa 195 84 111 195 100.0% 13 Kyaukpyu 150 112 35 147 98.0% 14 Ramree 264 158 65 223 84.5% 15 Thandwe 354 115 239 354 100.0% 16 Toungup 222 90 119 209 94.1% Southern Rakhine 1,368 672 622 1,294 94.6% Total 17 Buthidaung 50 28 4 32 64.0% 18 Kyauktaw 150 69 78 147 98.0% 19 Maungdaw 0 0 0 0 - 20 Minbya 66 44 14 58 87.9% 21 Mrauk-U 26 17 9 26 100.0% 22 Myebon 165 84 80 164 99.4% 23 Pauktaw 126 69 52 121 96.0% 24 Ponnagyun 120 67 51 118 98.3% 25 Rathedaung 150 56 83 139 92.7% 26 Sittwe 96 18 73 91 94.8% Northern Rakhine 949 452 444 896 94.4% Total 27 Hlaingbwe 96 17 78 95 99.0% 28 Hpa-an 207 48 159 207 100.0% 29 Kawkareik 51 17 34 51 100.0% 30 Kyainseikgyi 83 30 49 79 95.2% 31 Myawaddy 63 22 39 61 96.8% Kayin Total 500 134 359 493 98.6% Grand Total 3,769 1,479 2,058 3,537 93.8%

Annex 4 – Supervision and monitoring

Table 16: Summary of supervision and monitoring visits to VMWs/PPs (from October 2017 to December 2017)

# of visits to Total # of VMWs and PPs # Township # of visits to PPs VMWs supervised 1 Bokpyin 28 3 31 2 Dawei 15 0 15 3 Kawthoung 21 4 25 4 Kyunsu 18 8 26 5 Launglon 12 0 12 6 Myeik 18 6 24 7 Palaw 20 10 30 8 Tanintharyi 54 0 54 9 Thayetchaung 6 4 10 10 Yebyu 7 0 7 Tanintharyi Total 199 35 234 11 Ann 35 8 43 12 Gwa 37 0 37 13 Kyaukpyu 50 9 59 14 Ramree 28 1 29 15 Thandwe 42 0 42 16 Toungup 31 1 32 Southern Rakhine Total 223 19 242 17 Kyauktaw 35 1 36 18 Minbya 7 0 7 19 Myebon 16 2 18 20 Pauktaw 8 2 10 21 Ponnagyun 13 2 15 22 Rathedaung 15 0 15 23 Sittwe 15 0 15 Northern Rakhine Total 109 7 116 24 Hlaingbwe 32 0 32 25 Hpa-an 16 0 16 26 Kawkareik 29 0 29 27 Myawaddy 8 2 10 Kayin Total 85 2 87 Grand Total 616 63 679

Annex 5 – Reporting status of VMWs/PPs

Table 17: Reporting status of VMWs/PPs (from October 2017 to December 2017)

Total Number Of Number of % of On-time cumulative # % of VMWs/PPs On-time Report of Of VMWs/PPs Reporti # Township Reported (On Report VMWs/PPs have to ng time report + submitted by among submit the Status Late report) VMWs/PPs reported report 1 Bokpyin 129 128 123 99.2% 96.1% 2 Dawei 99 98 96 99.0% 98.0% 3 Kawthoung 135 131 131 97.0% 100.0% 4 Kyunsu 120 114 113 95.0% 99.1% 5 Launglon 78 75 73 96.2% 97.3% 6 Myeik 90 90 90 100.0% 100.0% 7 Palaw 117 109 108 93.2% 99.1% 8 Tanintharyi 135 133 132 98.5% 99.2% 9 Thayetchaung 51 50 50 98.0% 100.0% 10 Yebyu 39 37 37 94.9% 100.0% Tanintharyi Total 993 965 953 97.2% 98.8% 11 Ann 183 177 177 96.7% 100.0% 12 Gwa 195 195 195 100.0% 100.0% 13 Kyaukpyu 150 150 150 100.0% 100.0% 14 Ramree 264 253 253 95.8% 100.0% 15 Thandwe 354 354 354 100.0% 100.0% 16 Toungup 222 221 218 99.5% 98.6% Southern Rakhine Total 1,368 1,350 1,347 98.7% 99.8% 17 Buthidaung 50 32 32 64.0% 100.0% 18 Kyauktaw 207 205 205 99.0% 100.0% 19 Maungdaw 0 0 0 - - 20 Minbya 66 61 61 92.4% 100.0% 21 Mrauk-U 26 26 26 100.0% 100.0% 22 Myebon 165 165 165 100.0% 100.0% 23 Pauktaw 126 124 124 98.4% 100.0% 24 Ponnagyun 120 120 120 100.0% 100.0% 25 Rathedaung 150 143 139 95.3% 97.2% 26 Sittwe 96 94 94 97.9% 100.0% Northern Rakhine Total 1,006 970 966 96.4% 99.6% 27 Hlaingbwe 96 96 96 100.0% 100.0% 28 Hpa-an 219 219 219 100.0% 100.0% 29 Kawkareik 51 51 51 100.0% 100.0% 30 Kyainseikgyi 126 118 118 93.7% 100.0% 31 Myawaddy 63 61 61 96.8% 100.0% Kayin Total 555 545 545 98.2% 100.0% Grand Total 3,922 3,830 3,811 97.7% 99.5%

Annex 6 – Clinical audit

Table 18: Summary of clinical audit (from October 2017 to December 2017)

Total % of Pf and Total Total positive % of Mixed patients Positive Total Positive cases treated who was cases referred cases treated cases treated # Township treated cases in found in according among according to in reporting reporting to NTG in positive National reporting month month reporting cases Treatment month month Guideline 1 Bokpyin 35 35 35 0 100.0% 100.0% 2 Dawei 25 25 24 0 100.0% 96.0% 3 Kawthoung 11 10 10 1 90.9% 100.0% 4 Kyunsu 26 26 26 0 100.0% 100.0% 5 Launglon 0 0 0 0 - - 6 Myeik 2 2 2 0 100.0% 100.0% 7 Palaw 19 19 18 0 100.0% 94.7% 8 Tanintharyi 22 22 22 0 100.0% 100.0% 9 Thayetchaung 1 1 1 0 100.0% 100.0% 10 Yebyu 0 0 0 0 - - Tanintharyi Total 141 140 138 1 99.3% 98.6% 11 Ann 136 136 136 0 100.0% 100.0% 12 Gwa 7 7 7 0 100.0% 100.0% 13 Kyaukpyu 0 0 0 0 - - 14 Ramree 1 1 1 0 100.0% 100.0% 15 Thandwe 4 4 4 0 100.0% 100.0% 16 Toungup 46 46 43 0 100.0% 93.5% Southern Rakhine Total 194 194 191 0 100.0% 98.5% 17 Buthidaung 62 62 62 0 100.0% 100.0% 18 Kyauktaw 169 167 167 2 98.8% 100.0% 19 Maungdaw 0 0 0 0 - - 20 Minbya 81 80 80 1 98.8% 100.0% 21 Mrauk-U 21 20 20 1 95.2% 100.0% 22 Myebon 50 50 50 0 100.0% 100.0% 23 Pauktaw 6 6 6 0 100.0% 100.0% 24 Ponnagyun 13 12 12 1 92.3% 100.0% 25 Rathedaung 6 6 6 0 100.0% 100.0% 26 Sittwe 6 5 5 1 83.3% 100.0% Northern Rakhine 414 408 408 6 98.6% 100.0% Total 27 Hlaingbwe 6 6 6 0 100.0% 100.0% 28 Hpa-an 8 8 8 0 100.0% 100.0% 29 Kawkareik 0 0 0 0 - - 30 Kyainseikgyi 28 27 27 1 96.4% 100.0% 31 Myawaddy 87 86 86 1 98.9% 100.0% Kayin Total 129 127 127 2 98.4% 100.0% Grand Total 878 869 864 9 99.0% 99.4%

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

Table 19: Summary of stock out monitoring at the time of monitoring visits and on‐site data collection (from October 2017 to December 2017)

Total # % of sites % of sites % of sites % of sites Total # of Total # Total # of Total # of Total # of of VMW which which which which VMW with of PP with PP with # Township visited with NO experienced experienced experienced experienced NO ACT visited NO RDT NO ACT VMW RDT NO RDT NO ACT NO RDT NO ACT stock out PP stock out stock out stock out stock out stock out stock out stock out 1 Bokpyin 28 28 100% 28 100% 3 3 100% 3 100% 2 Dawei 15 15 100% 15 100% - - - - - 3 Kawthoung 21 21 100% 21 100% 4 4 100% 4 100% 4 Kyunsu 18 18 100% 18 100% 8 8 100% 8 100% 5 Launglon 12 12 100% 12 100% - - - - - 6 Myeik 18 18 100% 18 100% 6 6 100% 6 100% 7 Palaw 20 20 100% 20 100% 10 10 100% 10 100% 8 Tanintharyi 54 54 100% 54 100% - - - - - 9 Thayetchaung 6 6 100% 6 100% 4 4 100% 4 100% 10 Yebyu 7 7 100% 7 100% - - - - - Tanintharyi Total 199 199 100% 199 100% 35 35 100% 35 100% 11 Ann 35 35 100% 35 100% 8 8 100% 8 100% 12 Gwa 37 37 100% 37 100% - - - - - 13 Kyaukpyu 53 53 100% 53 100% 9 9 100% 9 100% 14 Ramree 28 28 100% 28 100% 1 1 100% 1 100% 15 Thandwe 42 42 100% 42 100% - - - - - 16 Toungup 31 31 100% 31 100% 1 1 100% 1 100% Rakhine (South) Total 226 226 100% 226 100% 19 19 100% 19 100% 17 Kyauktaw 92 92 100% 92 100% 1 1 100% 1 100% 18 Minbya 7 7 100% 7 100% - - - - - 19 Mrauk-U 4 4 100.0% 4 100.0% 1 1 100.0% 1 100.0% 20 Myebon 16 16 100% 16 100% 2 2 100% 2 100% 21 Pauktaw 11 11 100% 11 100% 2 2 100% 2 100% 22 Ponnagyun 14 14 100% 14 100% 2 2 100% 2 100% 23 Rathedaung 15 15 100% 15 100% - - - - - 24 Sittwe 16 16 100% 16 100% - - - - - Rakhine (North) Total 175 175 100.0% 175 100.0% 8 8 100.0% 8 100.0% 25 Hlaingbwe 32 32 100% 32 100% - - - - - 26 Hpa-an 16 16 100% 16 100% - - - - - 27 Kawkareik 29 29 100% 29 100% - - - - - 28 Kyarinseikgyi 39 39 100% 39 100% - - - - -

Table 20: Summary of stock out monitoring at monthly meeting (from October 2017 to December 2017)

Total # % of sites % of sites % of sites % of sites Total # of Total # Total # of Total # of Total # of of VMW which which which which VMW with of PP with PP with # Township visited with NO experienced experienced experienced experienced NO ACT visited NO RDT NO ACT VMW RDT NO RDT NO ACT NO RDT NO ACT stock out PP stock out stock out stock out stock out stock out stock out stock out 1 Bokpyin 93 93 100% 93 100% 11 11 100% 11 100% 2 Dawei 50 50 100% 50 100% 5 5 100% 5 100% 3 Kawthoung 98 98 100% 98 100% 13 13 100% 13 100% 4 Kyunsu 84 84 100% 84 100% 28 28 100% 27 96.4% 5 Launglon 69 69 100% 69 100% 0 0 - 0 - 6 Myeik 72 72 100% 72 100% 17 17 100% 17 100% 7 Palaw 65 65 100% 65 100% 22 22 100% 22 100% 8 Tanintharyi 131 131 100% 130 99.2% 0 0 - 0 - 9 Thayetchaung 32 32 100% 32 100% 18 18 100% 18 100% 10 Yebyu 29 29 100% 29 100% 0 0 - 0 - Tanintharyi Total 723 723 100% 722 99.9% 114 114 100% 113 99.1% 11 Ann 140 140 100% 140 100% 26 26 100% 26 100% 12 Gwa 195 195 100% 195 100% 0 0 - 0 - 13 Kyaukpyu 131 131 100% 131 100% 16 16 100% 16 100% 14 Ramree 211 211 100% 211 100% 12 12 100% 12 100% 15 Thandwe 354 354 100% 354 100% 0 0 - 0 - 16 Toungup 185 185 100% 185 100% 24 24 100% 24 100% Rakhine (South) Total 1,216 1,216 100% 1,216 100% 78 78 100% 78 100% 17 Buthidaung 32 32 100% 32 100% 0 0 - 0 - 18 Kyauktaw 130 130 100% 130 100% 6 6 100% 6 100% 19 Minbya 57 57 100% 57 100% 0 0 - 0 - 20 Mrauk-U 22 22 100.0% 22 100.0% 4 4 100.0% 4 100.0%

Annex 8 – Capacity building

Table 21: Number of VMWs/PPs trained on case management (from October 2017 to December 2017)

Village Malaria Private Providers Workers # Township Grand Total Sub- Sub- M F M F total total 1 Dawei 8 17 25 - 1 1 26 2 Launglon 4 20 24 - - - 24 3 Thayetchaung 2 8 10 - 4 4 14 4 Yebyu 5 7 12 - - - 12 Tanintharyi Total 19 52 71 - 5 5 76 5 Ann 32 16 48 7 1 8 56 6 Kyaukpyu 29 12 41 6 - 6 47 7 Ramree 50 28 78 2 1 3 81 8 Toungup 22 41 63 8 - 8 71 Southern Rakhine Total 133 97 230 23 2 25 255 9 Minbya 15 5 20 - - - 20 10 Mrauk-U 13 9 22 4 - 4 26 11 Myebon 23 23 46 4 2 6 52 12 Ponnagyun 17 16 33 6 - 6 39 13 Sittwe 4 25 29 - - - 29 Northern Rakhine Total 72 78 150 14 2 16 166 Grand Total 224 227 451 37 9 46 497

Table 22: Number of VMWs/PPs trained on diagnosis (from October 2017 to December 2017)

Grand Total 224 227 451 37 9 46 497

Annex 9 – BCC

Table 23: Number of people reached through Individual Interpersonal communication and Group Health Talks by Mobile Team, VMWs and PPs (from October 2017 to December 2017)

Individual IPC Group Health Talk # Township Migrants Sessions Migrants Male Female Total Male Female Total included # included 1 Bokpyin 834 721 1,555 1,156 78 804 732 1,536 867 2 Dawei 520 393 913 108 0 0 0 0 0 3 Kawthoung 842 755 1,597 1,647 72 333 254 587 587 4 Kyunsu 691 742 1,433 49 0 0 0 0 0 5 Launglon 159 350 509 29 0 0 0 0 0 6 Myeik 465 692 1,157 66 0 0 0 0 0 7 Palaw 428 548 976 108 0 0 0 0 0 8 Tanintharyi 660 692 1,352 200 67 405 377 782 262 9 Thayetchaung 247 393 640 23 0 0 0 0 0 10 Yebyu 68 147 215 29 0 0 0 0 0 Tanintharyi Total 4,914 5,433 10,347 3,415 217 1,542 1,363 2,905 1,716 11 Ann 907 867 1,774 21 0 0 0 0 0 12 Gwa 814 862 1,676 83 8 102 135 237 15 13 Kyaukpyu 567 715 1,282 1 0 0 0 0 0 14 Ramree 851 926 1,777 9 0 0 0 0 0 15 Thandwe 1,557 1,859 3,416 170 4 69 103 172 0 16 Toungup 647 547 1,194 10 0 0 0 0 0 Southern Rakhine Total 5,343 5,776 11,119 294 12 171 238 409 15 17 Buthidaung 384 150 534 0 0 0 0 0 0 18 Kyauktaw 968 840 1,808 158 13 59 82 141 23 19 Maungdaw 0 0 0 0 0 0 0 0 0 20 Minbya 299 280 579 142 3 14 44 58 0 21 Mrauk-U 53 68 121 14 0 0 0 0 0 22 Myebon 833 846 1,679 123 3 18 15 33 0 23 Pauktaw 487 476 963 59 8 85 63 148 0 24 Ponnagyun 455 482 937 140 4 51 51 102 0 25 Rathedaung 519 607 1,126 0 0 0 0 0 0 26 Sittwe 296 367 663 157 6 22 42 64 0

Individual IPC Group Health Talk # Township Migrants Sessions Migrants Male Female Total Male Female Total included # included Northern Rakhine Total 4,294 4,116 8,410 793 37 249 297 546 23 27 Hlaingbwe 530 1,116 1,646 43 5 6 29 35 0 28 Hpa-an 812 1,308 2,120 163 18 121 208 329 18 29 Kawkareik 255 372 627 19 52 435 712 1,147 2 30 Kyainseikgyi 226 264 490 0 0 0 0 0 0 31 Myawaddy 813 865 1,678 179 0 0 0 0 0 Kayin Total 2,636 3,925 6,561 404 75 562 949 1,511 20 Grand Total 17,187 19,250 36,437 4,906 341 2,524 2,847 5,371 1,774

Table 24: Number of people reached through individual interpersonal communication (IPC) and Group Health Talks by Private Providers only (from October 2017 to December 2017)

Individual IPC Group Health Talk # Township Migrants Sessions Migrants Male Female Total Male Female Total included # included 1 Bokpyin 117 116 233 150 9 72 99 171 47 2 Dawei 8 9 17 0 0 0 0 0 0 3 Kawthoung 191 175 366 366 18 143 67 210 210 4 Kyunsu 176 177 353 2 0 0 0 0 0 5 Launglon 0 0 0 0 0 0 0 0 0 6 Myeik 134 185 319 0 0 0 0 0 0 7 Palaw 95 107 202 104 0 0 0 0 0 8 Tanintharyi 0 0 0 0 0 0 0 0 0 9 Thayetchaung 99 101 200 7 0 0 0 0 0 10 Yebyu 0 0 0 0 0 0 0 0 0 Tanintharyi Total 820 870 1,690 629 27 215 166 381 257 11 Ann 199 200 399 7 0 0 0 0 0 12 Gwa 0 0 0 0 0 0 0 0 0 13 Kyaukpyu 120 140 260 1 0 0 0 0 0 14 Ramree 100 109 209 0 0 0 0 0 0 15 Thandwe 0 0 0 0 0 0 0 0 0 16 Toungup 118 44 162 7 0 0 0 0 0

Individual IPC Group Health Talk # Township Migrants Sessions Migrants Male Female Total Male Female Total included # included Southern Rakhine Total 537 493 1,030 15 0 0 0 0 0 17 Buthidaung 0 0 0 0 0 0 0 0 0 18 Kyauktaw 51 49 100 0 0 0 0 0 0 19 Maungdaw 0 0 0 0 0 0 0 0 0 20 Minbya 0 0 0 0 0 0 0 0 0 21 Mrauk-U 10 4 14 4 0 0 0 0 0 22 Myebon 90 63 153 42 0 0 0 0 0 23 Pauktaw 184 137 321 20 0 0 0 0 0 24 Ponnagyun 111 103 214 79 0 0 0 0 0 25 Rathedaung 0 0 0 0 0 0 0 0 0 26 Sittwe 0 0 0 0 0 0 0 0 0 Northern Rakhine Total 446 356 802 145 0 0 0 0 0 27 Hlaingbwe 0 0 0 0 0 0 0 0 0 28 Hpa-an 36 16 52 2 0 0 0 0 0 29 Kawkareik 0 0 0 0 0 0 0 0 0 30 Kyainseikgyi 0 0 0 0 0 0 0 0 0 31 Myawaddy 83 27 110 58 0 0 0 0 0 Kayin Total 119 43 162 60 0 0 0 0 0 Grand Total 1,922 1,762 3,684 849 27 215 166 381 257

Annex 10 – Advocacy meeting

Table 25: Advocacy meetings (from October 2016 to December 2017)

Date of Total # State/Region Township Place of meeting Male Female Advocacy Attendant 30-Sep-17 2 Miles Hospital (Kawthoung) 12 54 66 1 Tanintharyi Kawthoung 30-Nov-17 2miles Hospital 7 53 60 Tanintharyi Total 19 107 126 2 Rakhine (South) Gwa 8-Nov-17 Aung Mingalar Hall 30 47 77 3 Rakhine (South) Thandwe 7-Nov-17 Pyin Nyar Yadanar Hall 38 86 124 Southern Rakhine Total 68 133 201 4 Rakhine (North) Mrauk-U 31-Oct-17 Mrauk-U Township Hostipal 29 73 102 Northern Rakhine Total 29 73 102 Grand Total 116 313 429

Annex 11 – Performance Indicators

Table 26: Performance Indicators Tracking Table (from October 2016 to December 2017)

Actual Annual Target Indicators Frequency Baseline Achievements (FY2018)

IP 1: Annual Parasite Incidence (API) in Defeat Malaria villages Annual 8 (CAP-M FY15 N/A 5.5 progress report)

IP 2: Annual Blood Examination Rate Annual 6% in 2015 (from N/A 7% National M&E Plan) IP 3: Percent of indigenous cases among cases investigated (in Quarterly 9% in 2015 (from N/A 80% elimination areas) National M&E Plan)

IP 4: Percent of active foci among foci investigated (in elimination Quarterly N/A N/A 80% areas) IP 5: Proportion of villages with zero positive cases for at least Annually 18.5% (CAP-M N/A 23% last three consecutive years database) OC 1.1 % of households in targeted areas that own at least one Baseline and end NA NA insecticide treated net (ITN) line OC 1.2 % of households in targeted areas that own at least one 47% (in Rakhine), NA NA ITN for every two persons 60,2% (in Tanintharyi), 65.6% (in Kayin) - from CAP-M End line Household Surveys

OC 1.3 % of individuals in targeted areas who slept under ITN NA NA the previous night. (disaggregate by type of net, pregnant women, children under 5 OC 1.4 % of service delivery points which report no stock outs Quarterly Minimum 85% (from 99.9% ≥ 80% of RDTs lasting more than one week during the past 3 months CAP-M) (disaggregate by type of SDP)

Actual Annual Target Indicators Frequency Baseline Achievements (FY2018)

OC 1.5 % of service delivery points which report no stock outs Quarterly Minimum 85% (from 99.9% ≥ 80% of first line antimalarial medicines (ACT) lasting more than one CAP-M) week during the past 3 months (disaggregate by type of SDP) OC 1.6 % of patients found positive who received antimalarial Quarterly Minimum 95% (from 99.4% ≥ 95% treatment according to National Malaria Treatment Guidelines CAP-M FY15 progress report) OC 1.7 % of Malaria Positive cases with having completed the Quarterly 25% (from CAP-M 72.3% 50% treatment under DOT FY15 progress report) OP 1.1 Number of insecticide treated net purchased in any fiscal Quarterly 92,986 (From CAP-M 1,722 70,900 year with United State Government (USG) funds that were FY16 progress report) distributed in this quarter OP 1.2 Number of artemisinin-based combination therapy (ACT) Quarterly NA 180 32,400 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 with USG Quarterly NA 35,925 465,000 funds that were distributed (PMI required indicator) OP 1.4 Number of individuals reached with malaria behavior Monthly 514,333 (from CAP-M 36,437 100,000 change messages through interpersonal communication (individual 5 year progress talks) report) OP 1.5 Number of health workers trained in case management Month of training 5,155 (from CAP-M 5 497 1,500 VMWs/PPs with ACTs with USG funds (Disaggregated by male, female, and year progress report) profession) (PMI required indicator) OP 1.6 Number of health workers trained in malaria laboratory Month of training 5,443 (from CAP-M 5 497 1,500 VMWs/PPs diagnostics (rapid diagnostic tests (RDTs) or microscopy) with year progress report) USG funds (Disaggregated by male, female, and profession) (PMI required indicator) OP 1.7 % of VMWs/PPs in Defeat Malaria target areas received at Annually N/A N/A ≥ 80% least two supervisory visits per year

Actual Annual Target Indicators Frequency Baseline Achievements (FY2018)

OC 2.1 % of service delivery points in targeted areas report Monthly ≥ 80% (from CAP-M 5 97.7% ≥ 80% monthly data of malaria cases (disaggregate by type of SDP) year progress report)

OC 2.2 % of service delivery points in targeted areas report Monthly N/A 99.5% ≥ 80% monthly data of malaria cases on time (disaggregate by type of SDP) OC 2.3 % of positive cases notified within 24 hours in elimination Monthly N/A N/A 70% targeted townships OC 2.4 Foci investigation rate Monthly N/A N/A 60%

OC 2.5 Active focus response rate Monthly N/A N/A 70%

OP 2.1 Number of townships that have developed and updated Annually N/A N/A 33 Village Based Stratification (VBS) annually OP 2.2 Number entomological surveys conducted in persistent Semiannual N/A 0 3 transmission areas OP 3.1 % of targeted health services with Quality Annually N/A 0% 60% Assurance/Quality Control (QAQC) system received quarterly internal assessments of the QA system in collaboration with NHL/NMCP OP 3.2 Number of trainings on malaria technical skill and training Quarterly by N/A 2 20 facilitation skill supported by Defeat Malaria Jhpiego OP 3.3 Number of trainers developed through Defeat Malaria Quarterly by N/A 16 72 Jhpiego OP 3.4 Number of people trained through on-site training Quarterly by N/A 0 360 supported by USG program (Defeat Malaria) Jhpiego

Actual Annual Target Indicators Frequency Baseline Achievements (FY2018)

OP 3.5 Percentage of trainers supervised during trainings Quarterly by N/A 40% 50% Jhpiego OP 3.6 Percentage of master mentors retaining at least 80% of Quarterly by N/A 0% 80% of master mentors acquired skills and knowledge Jhpiego acquired skills and knowledge OP 3.7 Number of joint supervision visits to VMW for data Quarterly by N/A 1 6 quality assessments Jhpiego OP 4.1 Number of private companies and state-owned Annual N/A 40 60 enterprises involve in malaria activities OP 4.2 Number of health education sessions conducted in the Quarterly N/A 118 300 targeted areas with participation from collaborating companies and enterprises