ARM3 7TH QUARTERLY REPORT APRIL 1 – JUNE 30, 2013 ______

FISCAL YEAR 2013, QUARTER 3 PROGRAM YEAR 2

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July 30, 2013

This report was produced for the United States Agency for International Development (USAID) by Medical Care Development International (MCDI).

ARM3 Accelerating the Reduction of Malaria Morbidity and Mortality Program

7th Quarterly Report: April 1, 2013 to June 31, 2012 Fiscal Year 2013 Program Year 2

Submitted to: Dr. Emile Bongo, Agreement Officer Representative (AOR), USAID/ Dr. Milton Amayun, Family Health Team Leader, USAID/Benin

Cover photo: World Malaria Day in

ARM3, Accelerating the Reduction of Malaria Morbidity and Mortality Program (ARM3), is funded by the United States Agency for International Development (USAID), under Cooperative Agreement

AID - 680- A -11-00001. ARM3 is managed by Medical Care Development International (MCDI) as the prime, in collaboration with sub-grantees Africare, Johns Hopkins University – Center for Communications Program (JHU-CCP) and Management Sciences for Health (MSH). The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or of the United States Government.

Table of Contents Table of Contents ...... 1 List of Acronyms ...... 2 Acknowledgements ...... 5 Executive Summary ...... 6 Introduction...... 10 Result 1: Implementation of malaria prevention interventions in support of the National Malaria Strategy improved...... 10 Sub-Result 1.1: Implementation of malaria prevention programs in support of the National Malaria Strategy improved...... 10 Sub-result 1.1a: IPTp uptake increased ...... 11 Achievements ...... 11 Sub-result 1.1.b: Upgrade skills of health workers (public and private sectors) through pre-service and in-service training ...... 12 Results ...... 13 Sub-Result 1.2: Supply and Use of LLINs Increased ...... 13 Achievements ...... 14 Results ...... 15 Result 2: Malaria diagnosis and treatment activities in support of the National Malaria Strategy improved 16 Sub-Result 2.1: Diagnostic Capacity and Use of Testing Improved ...... 16 Achievements ...... 16 Results ...... 18 Sub-Result 2.2: Case Management of Uncomplicated and Severe Malaria Improved ...... 18 Sub-result 2.2.a: Upgrade skills of health workers on clinical management ...... 19 Achievements ...... 19 Sub-result 2.2.b: Implementation of the Performance Improvement Approach (PI) in participating health zones and hospitals ... 20 Achievements ...... 20 Sub-result 2.2.c: Enhance integrated supervision on IPTp, malaria diagnostics and clinical case management of malaria ...... 22 Achievements ...... 22 Results ...... 22 Sub-Result 2.3: Integrated Community Case Management (iCCM) improved ...... 25 Achievements ...... 25 Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened ...... 25 Sub-result 3.1: The National Malaria Control Program’s technical capacity to plan, design, manage, and coordinate a comprehensive malaria control program enhanced ...... 26 Achievements ...... 26 Results ...... 27

Sub-Result 3.2: Capacity to Collect, Manage and Use Malaria Health Information for M&E and Surveillance Improved ...... 27 Achievements ...... 28 Results ...... 32 Sub-Result 3.3: Capacity in Commodities and Supply Chain Management Improved ...... 32 Achievements ...... 33 Results ...... 40 Cross Sectional Activities ...... 40 Results ...... 46 Program Management ...... 47 Field Office ...... 47 Home Office Backstopping and Reporting...... 47 Achievements ...... 47 Major Activities Planned for next quarter (July – September): ...... 50 Financial Summary ...... 53 Annex 1: Quarterly Financial Report ...... 54 Annex 2: Cumulative Financial Report ...... 55 Annex 3: SF 424 ...... 56 Annex 4: OTSS Round 12...... 57

List of Acronyms

AAA/3A Akpro Misserte – – ABC Analysis of stock value, turnover, and volume ABD – - ABFC Association Béninoise de Femmes Chanteuses ACPB Association des Cliniques Privées du Bénin ACT Artemisinin Combination Therapy AIRS Abt’s Indoor Residual Spraying Program AL Artemether + Lumefantrin AMCES Association des Œuvres Médicales Privées Confessionnelles et Sociales ANC Antenatal Clinic AOR Agreement Officer Representative ARM3 Accelerating the Reduction of Malaria Morbidity and Mortality Program (ARM3) AS-AQ Artesunate-Amodiaquine BASICS Basic Support for Institutionalizing Child Survival BCC Behavioral Change Communication BDHS Benin Demographic and Health Survey CAFE Stock Management Software Company CAME Centrale d’Achat des Médicaments Essentiels (Central Medical Stores) CAR Charge de l’Administration et des Ressources CCIB Chambre de Commerce et d’ Industrie de Benin CCM Clinical Case Management CDC Centers for Disease Control and Prevention CEBAC-STP Coalition des Entreprises Béninoises et Associations Privées Contre le SIDA, la Tuberculose, et le Paludisme CHD Centre Hospitalier Départemental CHW Community Health Workers CIP Communication Interpersonnel CNHU Centre National Hospitalier Universitaire CoGeS Comité de Gestion COP Chief of Party DDMS Disease Data Management System DDS Direction Départmentale de la Santé DHS Demographic Health Survey DIEM Direction de l’Infrastructure, de l’Equipement et de la Maintenance DPMED Direction de la Pharmacie, des Médicaments et de l’Exploration Diagnostique DPP Direction de la Programmation et de la Prospective DRZ Dépôt Répartiteurs de zone DSME Direction de la Santé de la Mère et de l’Enfant EEZS Equipe d’encadrement de zone sanitaire EOP Emergency Order Point ETAT Emergency Triage, Assessment and Treatment EUVS End Use Verification Survey FO Field Office FSS-UAC Faculté des Sciences de la Santé--Université d’ Calavi GFATM Global Fund to Fight AIDS, Tuberculosis, and Malaria GHI Global Health Initiative GOB Government of Benin HMIS Health Management Information System HO Home Office HOMEL Hôpital de la Mère et de l’Enfant de 2 | P a g e

HW Health Workers ICCM Integrated Community Case Management ILP Information Logistic Paludisme IMaD Improving Malaria Diagnostics INMES Institut National Médico-Social INSAE Institut National de la Statistique et de l’Analyse Economique IPTp Intermittent Preventive Treatment for Pregnant Women IRS Indoor Residual Spraying IRSP Institut Régional de Santé Publique IVCC Innovative Vector Control Consortium JHU-CCP Johns Hopkins University – Center for Communication Programs KPI Key Performance Indicator LDP Leadership Development Program LIAT Logistic Indicator Assessment Tool LLIN Long Lasting Insecticide-Treated Nets LMIS Logistical Management Information System LOP Length of Project MCDI Medical Care Development International MCM Malaria Case Management MCZS Médicin Coordinateur de Zone Sanitaire M&E Monitoring & Evaluation MEDISTOCK Commodities Management Program MIP Malaria in Pregnancy MIS Malaria Indicator Survey MMAC Malaria Microscopy Accreditation Course MMRT Malaria Microscopy Refresher Training MNCH Maternal, Neonatal and Child Health MOH Ministry of Health MOU Memorandum of Understanding MOP Malaria Operational Plan MSH Management Sciences for Health NGO Non-Government Organization NMCP National Malaria Control Program ORTB Office de Radio et Telévision Béninoise OTSS Outreach Training Support and Supervision PADNET Project to Advance the Durability of Long-lasting Insecticide-treated Nets PAK Pobe – Adja Ouere - Ketou PAS Porto Novo – Aguegues – Seme-Kpodji Pharmeg Registered trademark of a pharmaceutical management software program developed by the French NGO, Pharmacien Sans Frontière 37 (PSF37) PHIC Pediatric Hospital Improvement Collaborative PI Performance Improvement PISAF Project Intégré de Santé Familiale PITA Plan Intégrée de Travail Annuel PMEP Performance Monitoring and Evaluation Plan PMI President’s Malaria Initiative PNLP Programme National de Lutte contre le Paludisme PY Program Year QA/QC Quality Assurance/Quality Control RBM Roll Back Malaria RDT Rapid Diagnostic Test RFA Request for Applications RMIS Routine Malaria Information System ROBS Réseau des ONG Béninoises de Santé

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SAGE Stock Management Software SAKIF Sakete/Ifagni SAM Senior Alignment Meeting SCM Supply Chain Management SGSI Service de gestion du Système d’Information SIRP Systeme d’Information de Routine du Paludisme SNIGS Système National d’Information et de Gestion Sanitaire SOP Standard Operating Procedures SP Sulfadoxine-pyrimethamine STTA Short Term Technical Assistance SWOT Strengths, Weaknesses, Opportunities and Threats TWG Technical Working Group UAC University of Abomey – Calavi UAM United Against Malaria UNICEF United Nations Children’s Fund USAID United Stated Agency for International Development WHO World Health Organization WOM Warehouse Operation Management WG Working Group

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Acknowledgements

ARM3 wishes to thank everyone who helped create this document as well as various technical and financial partners for providing constant support to Benin in the fight against malaria, including the National Malaria Control Program as well as our private sector partners: Coalition des Entreprises Béninoises et Associations Privées Contre le SIDA, la Tuberculose, et le Paludisme (CEBAC-STP); Association des Œuvres Médicales Privées Confessionnelles et Sociales (AMCES); Réseau des ONG Beninoises de Santé (ROBS); and Association des Cliniques Privées du Bénin (ACPB). In addition, we would like to acknowledge the USAID Benin Mission for their constant guidance and financial support in the implementation of the ARM3 Project.

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Executive Summary

ARM 3 Results Sub-Results Key Achievements

1. Implementation of  Conducted the IPTp Barriers Assessment in the south of Benin and malaria prevention drafted the preliminary report programs in support  ARM3 is promoting: of the National o The incorporation of IPTp indicators in the list of indicators to be analyzed by the MOH/Department of Perspective and Malaria Strategy Planning and improved o The use of systems for tracking pregnant women to ensure IPTp coverage 1.1 IPTp uptake  Supervision of IEC/BCC activities in support of IPTp at ANCs was increased conducted in 17 HF  Signed an MOU with IMNES; ARM3 is providing support in incorporating malaria content in INMES’ training curricula  Provided training funds to 75% of the HZs at the national level (25/34). Sixteen HZs (16/25) conducted refresher trainings on IPTp, training 609 health care providers during the quarter, and up to 643 during the year  Organized a workshop with midwives and NGOs on the IPTp tracking strategy for pregnant women  Continued the distribution of LLINs  Carried out supervision and supportive actions which led to the distribution of 82% of LLINs and the receipt of 70% of LLIN payments by June 30, 2013 1.2 Supply and use  Resources for the “Revolving Fund" to support malaria prevention of LLINs increased activities in the private sector have been made available  The request for the support of a Peace Corps Volunteer has been approved. The volunteer will join ARM3 on July 4th to support the LLIN distribution and activities at the community level 2. Malaria diagnosis  Fourteen Standard Operating Procedures (SOP) and the Guidelines and treatment for Laboratory Procedures were successfully validated; they will be activities in support 2.1 Diagnostic distributed next quarter of the National capacity and use of  The training and retraining of microscopists were conducted in Malaria Strategy diagnostic testing Atlantique –Littoral improved improved  Conducted Round 12 of OTSS supervision; a total of 46 health facilities were visited including 43 public and 5 private  12 new and former supervisors were trained in malaria microscopy  The NMCP’s National Malaria Policy on MIP has been reviewed and validated  Carried out training program activities towards extending coverage to all HZs at the national level; 25 HZs with signed MOUs received funding and 19 case management re-trainings were held for 729 health providers, for a total of 757 health providers trained in FY 2013 2.2 Case  ETAT training plan is being implemented. Four additional hospitals management of where added this quarter, totalizing 12 hospitals from the public and uncomplicated and private sectors. ETAT training was provided for 149 health workers, severe malaria including 10 heads of hospitals improved  Twenty five (25/34) HZs and 4 DDS have signed MOUs with the NMCP and ARM3. 24 HZs and 3 DDS received funding to conduct training activities  3 out of 4 DDS have accomplished over 80% of activities outlined in their MOUs (and 1 has achieved 100%)  Integrated supervision of IPTp, malaria diagnostics and clinical

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management of malaria was conducted in 400 health facilities in 20/25 HZs  Continued the operational phase of the performance improvement approach (PIA), trained 646 health workers in collaborative improvement. Quality improvement teams were formed; collaborative process and data collection of indicators is ongoing  In collaboration with the DSME, 62 health workers received training in clinical audits of maternal mortality  Continued coordination with the Direction de la Santé de la Mére et de l´Enfant (DSME), including in iCCM roll-out  NGOs’ terms of reference for iCCM submitted to USAID for approval 2.3. Integrated  Selected 5 NGOs to conduct iCCM activities in the 5 former BASICS community case HZs management  Began review of iCCM SOW for Africare and MSH improved  Census carried out of CHWs trained in the use of RDT which indicates that 94% (87/92) of the CHW are still active  Conducted census and inventory of phones still in CHWs’ possession; 41/48 cell phones are still operational 3. National health 3.1 NMCP’s  Provided technical and financial support to the 2013 Plan Intégré de system’s capacity to technical capacity to Travail Annuel (PITA) deliver and manage plan, design,  Provided institutional support to the NMCP totaling $80,000 so far quality malaria manage, and this year treatment and coordinate a  Facilitated technical working group (TWG) meetings: monitoring & control interventions comprehensive evaluation (M&E), behavior change communication (BCC) and supply strengthened malaria control chain management (SCM) met this quarter program enhanced  Started the coordination and preparation of the Health Facility Survey 2013  Trained 44 statisticians on LOGISNIGS1 and ACCESS  Updated NMCP´s central data platform  Conducted Routine Data Quality Assessment in 24 health facilities  Implemented RMIS validation workshop with data of 34 HZs  Carried out RMIS (SIRP) data collection and supervision of 5 HZs in 3.2 MOH capacity to Atacora-Donga collect, manage and  Facilitated the preparation and publication of two RMIS Newsletters use malaria health  Organized 3 regional meetings for the validation of RMIS data information for collected from January – March 2013 monitoring,  Organized a 5-day formal training on LOGISNIGS for 34 health zone evaluation and statisticians and 10 departmental statisticians surveillance  Provided technical support to the Institut Régional de Santé Publique improved (IRSP) database manager on the use of LOGISNIGS  Trained EUVS surveyors and supervisors in data entry; performed EUVS data analysis and supported the development of the report  Provided technical assistance in data analysis and writing of the IPTp report in 7 HZs in Borgou Alibori  Prepared Benin health facilities database for HFS sampling and contributed to the finalization of health facilities survey protocol  Coordinated with CDC, MOH and MCDI HO to plan the HFS

1 SNIGS has a special software called "LOGISNIGS" which enables data entry, export and import from/ to different levels of the system.

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 Continued support to CAME information system improvement  Conducted LMIS national supervision and data collection in 34 HZs and continued with the LMIS and supervision feedback workshop in 3.3 MOH capacity in commodities and  Trained MEDISTOCK users in Oueme-Plateau and conducted post- supply chain training supervision management  Planned next steps in the development of the MEDISTOCK and improved PharMeg software with in-country counterparts  Conducted the EUV survey in Oueme/-Plateau and developed the final report Behavioral Change  Supported the organization of the BCC TWG meeting Communication  Presented communication materials (for radio and TV) to the BCC (BCC) TWG for validation, and contracted local radios to broadcast malaria Cross Sectional messages Activities  Broadcast five reality shows in Kossarou, Boko, Sonnou and Gah- Guru  Conducted community events, including the World Malaria Day celebration in and Parakou, and community events in So- Ava, with more than 12,000 participants and 100,000 radio listeners Non-Governmental  Up to 12 NGOs are working in Atlantique, Oueme and Plateau Organizations departments  ARM3 partners (Africare and JHU-CCP) conducted supervision and distributed equipment and materials to the local NGOs and CHWs  Contracted four additional local NGOs in Littoral.  Selected 6 local NGOs in Zou-Collines and held orientation sessions for directors and accountants  Provided equipment to NGOs and CHWs Field Office  Participated in meetings with the 2014 MOP Team  Held weekly coordination meetings with staff  Interfaced with the MOH (NMCP, DSME and other structures)  Provided technical and logistical support for the implementation of activities described in this report  Supported the activities of short-term technical consultants Home Office  MCDI: backstopping and o Conducted coordination meetings and conferences with the reporting Donor and Partners o Worked with USAID and FO in addressing requests and updating the Work Plan and Budget towards the Program modification of the Cooperative Agreement Management o Continued preparations for the iCCM start-up Activities o Reviewed implementation strategies with field for new activities included under ARM3 work plan following MOP recommendations o Initiated planning and coordination activities for the 2013 Health Facility Survey (HFS) o Held discussions with United States Pharmacopeia (USP) and CDC for the implementation of a drug efficacy study o Provided comments to IPTp Barriers Study submitted by JHU-CCP o Reviewed the Leadership in Strategic Health Communication course proposal submitted by JHU-CCP o Followed up on the training plan for the 34 HZs

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 Africare: o Field visit conducted by Africare’s Office of Health and HIV/Aids Director to the ARM3 project o Supported the selection of the 5 NGOs for iCCM  JHU-CCP: o Led the IPTp Barriers Study o Supported the development of the Leadership in Communications Course  MSH: o Provided TA for the implementation of the End-Use Verification Survey o Conducted discussions with the Prime regarding iCCM o Supported the selection of the iCCM Technical Advisor to be based at the Parakou Office and a Case Management Consultant to support the implementation of the Collaborative Improvement approach Human resources  Reorganized ARM3 Staff at MCDI HO: Dr. Pablo Aguilar has assumed the role of Program Manager and Kaj Gass has joined the team as International Health Program Associate  Completed the recruitment process of two Accountants in and Parakou

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Introduction

Accelerating the Reduction of Malaria Morbidity and Mortality Program (ARM3) in Benin is funded by the United States Agency for International Development (USAID). The ARM3 consortium, led by Medical Care Development International (MCDI) as the prime recipient, includes sub-grantees Africare, Johns Hopkins University – Center for Communication Programs (JHU-CCP), and Management Sciences for Health (MSH). The ARM3 consortium works in partnership with the Benin Ministry of Health’s National Malaria Control Program (NMCP), to implement the five year (October 1, 2011 to September 30, 2016) ARM3 malaria control program. In collaboration with USAID/Benin’s President’s Malaria Initiative (PMI), ARM3 seeks to assist the Government of Benin (GOB) in improving malaria health outcomes in accordance with the NMCP’s guidelines and standards. The primary objective of ARM3 is to help the Government of Benin achieve the PMI target of reducing malaria-associated mortality by 70%, compared to pre-initiative levels in Benin. In support of this PMI objective, the ARM3 program’s specific goal is to increase coverage and use of key life- saving malaria interventions in support of Benin’s NMCP Strategy. ARM3 will also complement and expand the efforts of other donors (for example the Global Fund to Fight AIDS, TB, and Malaria (GFATM), and private sector organizations) to reach the NMCP’s goal of eliminating malaria as a public health problem in Benin by 2030. ARM3’s major results are as follows: Result 1: Implementation of malaria prevention interventions in support of the National Malaria Strategy improved. Result 2: Malaria diagnosis and treatment activities in support of the National Malaria Strategy improved. Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened. The project was launched on October 1, 2011, and currently is in its second year. This ARM3 7th Quarterly Report (April 1, 2013 to June 31, 2013) details the program activities completed and key indicators corresponding to the results and sub-results described in the ARM3 Annual Work Plan and Monitoring and Evaluation Plan. Activities under each sub-result have been aligned to the revised version of the Y2 work plan (WP) in order to reflect the progress made by the project. It also presents the key activities planned for the quarter April – June 2013.

Result 1: Implementation of malaria prevention interventions in support of the National Malaria Strategy improved

ARM3 has been scaling-up prevention efforts through the expansion of IPTp and improved coverage of LLINs through the social marketing of LLINs in the private sector (supported by IEC/BCC activities). The two sub-results are: Sub-Result 1 (IPTp increased) and Sub-Result 2 (supply and use of LLINs increased). Sub-Result 1.1: Implementation of malaria prevention programs in support of the National Malaria Strategy improved

Results from the 2012 Demographic and Health Survey (DHS) show that only 22.8% of pregnant women had received two doses of sulfadoxine – pyrimethamine (SP) in 2011. In support of PMI’s Malaria in Pregnancy (MIP) objectives, ARM3 will improve IPT uptake. To achieve this result, ARM3 is pursuing interventions that include upgrading the skills of government and private health sector workers both through

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pre-service curricula modifications at the major training institutions, INMES and the medical faculty, and in- service training. Additionally, ARM3 is working to provide improved supervision and support to health workers to follow case management and prevention guidelines (including IPTp, in the context of focused- antenatal care (ANC), severe malaria, and clinical IMCI. Finally, ARM3 is continuing the review/implementation of Behavior Change Communication (BCC) campaigns to promote IPTp, LLIN use and early care seeking behavior in addition to improving skills of government health providers on patient counseling.

Sub-result 1.1a: IPTp uptake increased Achievements IPTp barriers assessment The study to assess IPTp barriers in the Health Zones of Cotonou I-Cotonou IV, --Zè and -Kpomassè-Tori-Bossito was finalized. Main barriers identified are: i) social and cultural, as lack of funds for transportation and medical appointments; ignorance of the benefits of prenatal care; ii) timeliness of the first prenatal care appointment; iii) noncompliance to taking SP at home; not attending private sector clinics; and rumors about SP. The health system barriers are: cost of SP at the ANCs; poor treatment of pregnant women (are harshly spoken to); a lack of information on SP; failure to remind pregnant women about the next prenatal care appointment; SP side effects; lack of competence among health providers to stimulate behavior change; high fees for health center visits; tardiness of health workers; and pregnant women’s serology status. In order to address to these barriers ARM3 will implement key interventions that include the following strategies: (1) message design; (2) use of a variety of media to reach various audiences; (3) strengthen interactive programs such as reality radio shows to reach more women; (4) train health providers in interpersonal communication and update their skills on national IPTp policy. Design/create IPTp report from quarterly supervisions In order to institutionalize and scale up the implementation of the "integrated supervision tools" validated during quarter 6, ARM3 will conduct advocacy with the MOH/ Department of Perspective and Planning (DPP) the insertion of the IPTp indicators in the list of indicators to be analyzed by Health Zones during the performance review workshops, in the next quarter. Workshop with midwives and NGOs on tracking IPTp A workshop to present the approach to track IPTp adherence by pregnant women to key stakeholders was held from June 13 to 14, 2013 in Cotonou. Representatives from ARM3, Africare, Global Fund, NMCP, MOH, DSME, health facilities and local NGOs working under ARM3 attended the workshop. The tracking strategy consists of a list of pregnant women followed by midwives who did not meet their ANC appointment, and are assigned to CHWs for tracking. At the end of this two-day session, the approach presented by Africare was validated and next steps for implementation agreed. Supervision of IEC/BCC activities to support IPTp at ANC A supervision of the IEC and BCC activities in seventeen health facilities was conducted in April in conjunction with DDS Zou-Collines.The team assessed and trained in communication techniques and the

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use educational materials, used for pregnant women attending antenatal care (ANC) and mothers of children receiving vaccinations. Only 3/17 HF had printed training materials available. Twenty six HFs were supervised by two teams that distributed 34,529 flyers on LLINs, SP and ACTs. An average of 240-300 flyers were distributed per HF, while major Health Centers (Banikanni, Madina, Zongo and Kpébié andN'Dali) received between 1450 - 2400 flyers. Banners were provided to Kandi HZ and Kassakou (Kandi) health facility.

Success Story from the field The ARM3 Parakou field team developed a chart from the monthly HMIS reports which tracks IPTp2 coverage in health facilities and follows their progress quarterly. It is utilized for post-training assessment and analysis of facilities’ effectiveness. With this chart, ARM3 is able to assess the causes of low IPTp coverage in health centers and to identify CHWs’ best practices. This tool will allow health officials to receive immediate feedback based on the HIMS data and to take steps to improve the coverage and availability of SP. The Abomey ARM3 team is already using this chart to track the status of IPTp2 training coverage in each HZ. During a recent supervision, the IPTp2 tracking tool was introduced in the HZs of Borgou- Alibori. Design IPTp report from quarterly supervisions As part of the Ministry of Health’s regular monitoring and evaluation activities, each HZ must submit a quarterly report to the ministry, Department of Perspective and Planning (DPP). While this report monitors the use and distribution of SP and bed nets, it contains no information on IPTp2. The Parakou office suggests that ARM3 advocate with the DPP for the inclusion of this indicator in the standard reports. Curriculum on interpersonal communication The curriculum on interpersonal communication is still in development; the revised version will be submitted to MCDI in August 2013. Sub-result 1.1.b: Upgrade skills of health workers (public and private sectors) through pre-service and in-service training Faculté des Sciences de la Santé (FSS) and INMES - malaria in pre-service curricula A Memorandum of Understanding (MOU) between INMES, the NMCP and ARM3 was signed on June 25, 2013. Following the signature of the MOU, a malaria working group will be set up under the leadership of the director of INMES, composed of teachers and students. This group, in collaboration with the NMCP and ARM3, will monitor activities, prepare progress reports and identify topics for classes. INMES is also taking part in the review of the National Malaria Guidelines and is incorporating them into its curriculum.

MOU Signing between ARM3 and INMES by the Director of INMES and the ARM3 COP

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Collaboration with health schools in Parakou (EFMS, ENATSE and Faculté de Médecine) In preparation for expanding ARM3 relationships with training institutions in year 3, the scope and approach was discussed with ENATSE and Faculty of Medicine to support the access of to digital libraries.

In-service malaria in pregnancy and patient counseling - training activities for health professionals IPTp Training A total of 643 nurses and midwifes have been trained in IPTp since the beginning of Year 2, in the departments of Atlantique-Litoral, Ouémé-Plateau, Zou-Collines and Borgou-Alibori. In the 7th Quarter, ARM3 provided training funds for IPTp to 25 HZs that have signed MOUs; 16 conducted IPTp trainings. The HZs trained 609 additional health providers (partially disaggregated data: 35 males and 574 females; 7 medical doctors, 249 nurses; 239 midwives, and 114 others). The project has largely surpassed the FY13 Target indicator of 476 health professionals from 12 HZs (re)trained in IPTp using USG funds, and will continue this activity in order to reach 34 HZs as requested by the MOP and Mission.

Results Indicator Baseline LOP Target PY2/Q3 Results Source/Comments Result 1: Implementation of malaria prevention programs in support of the National Strategy improved Sub-result 1.1: IPTp uptake increased 1) Percentage of women who Women who receive two 3.0% 22.8% (total) have completed a pregnancy in or more doses of SP the last two years who received during their last pregnancy DHS report , May 2012 Source 24% (Urban) two or more doses of IPTp within the last two years DHS, 2006 21.9% (Rural) during that pregnancy will reach 85% Proportion of women 28.1% 1.a) Proportion of women attending antenatal clinics RMIS results are from attending antenatal clinics who who receive IPTp2 under 39.3% Source PY2/Q2 receive IPTp2 under direct direct observation by a RMIS (Jan-Mar 2013) observation of a health worker health worker will reach 2011 85% 609 (35 male; 574 Cumulative results year 2 0 FY13 Target: 476 health female) health 643* health professionals 21) Number of health workers professionals from 12 professionals from (re)trained in ITPp trained in IPTp using USG Source health zones (re)trained in 16 health zones funds ARM3 IPTp using USG funds (re)trained in IPTp Health zone training Records using reports * Indicator 21.Number of health workers trained in IPTp using USG funds: The cumulative result in year 2, under the column of comments includes the 609 health professionals trained in quarter 7 plus 34 trained during previous quarter. This number (34) replaces the 73 health workers (double counting) mentioned in the 6th Quarter Report.

Sub-Result 1.2: Supply and Use of LLINs Increased

In support of this sub-result, ARM3’s innovative approaches to scaling-up interventions for impact are the support of in-country private and non-governmental partners to support specific interventions. The consortium believes that efforts to scale up malaria control in the public sector are certainly critical and necessary, but probably insufficient to achieve the ambitious goals sought by the NMCP and USAID without increasing access to quality services through the private sector, non-governmental organizations (NGOs), and participation of community organizations. ARM3 is using a target subsidy approach that will permit employees of CEBAC-STP member companies to purchase LLINs at a subsidized price and to do so through an installment payment mechanism that may include having the installment payments deducted from their paychecks over time. The social marketing of

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100,000 LLINs will permit CEBAC-STP members to utilize the proceeds generated through the sale to support complementary activities to include malaria prevention and health promoting behaviors. Achievements Institutional support to CEBAC-STP ARM3 supported the LLIN social marketing to CEBAC-STP member companies which will be conducted in two phases. The first phase took place throughout this quarter and will be brought to a close by the end of July. Prior to delivery of the LLINs to each company, ARM3 trained designated focal points of CEBAC-STP member companies for this activity, providing BCC training and communication materials, and supporting supervision and reporting. CEBAC-STP conducted phone supervisions and visits to assess the level of distribution, review registers, collect detailed data on the distribution and achievements. By the end of June 2013 by CEBAC-STP visited all participating companies and compiled comprehensive data while ARM3 and NMCP staff visited a sub-sample of all the companies in order to assess the distribution and data collection by process, through MCDI HO program officer who traveled to Benin to support the supervision process. Implementation of the LLIN mass media BBC campaign With the support of the NMCP, trainings were held prior to the LLIN distribution which emphasized communication techniques for behavior change. Focal points of each company learned how to manage the distribution, fill out the appropriate forms and conduct education sessions. More than 10,000 flyers and t- shirts were distributed to participating companies and their employees in order to promote their participation and support. Results of the Phase 1 Benin Private Sector LLIN Distribution Campaign As of June 30, 2013, 82% of the LLINs were distributed and 70% of the payments have been collected. By the end of the quarter, 71% (20/28) of all companies have distributed more than 75% of the LLINs, 18% (5/28) distributed between 50 to 75% and only 10% (3/28) distributed less than 50%. During supervision 1,000 nets were collected from small companies with agencies in remote regions of the country as these were not able to cover distribution costs. ARM3 will address the issue of additional transportation costs for certain partners before Phase 2 distribution, by holding a workshop to discuss experiences and lessons learned. The possibility of allowing small companies to sell mosquito nets at a higher margin in order to cover transportation, supervision and promotion costs will be reviewed. Regarding funds recovered, by the end of the quarter 46% (13/28) of all the companies have recovered more than 75% of the funds, 14% (4/28) distributed between 50 to 75% and 38% (11/28) recovered less than 25%. Charts 1 and 2 below summarize these findings. Graph 1: LLIN Distribution among 28 CEBAC-STP enterprise members

LLIN distribution among 28 CEBAC-STP enterprise members Benin, June 2013

30 20 10 0

75-100% 50-75% <50% Number of Enterprises of Number % LLIN Distributed

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Graph 2: Collection of LLIN funds

Collection of funds among 28 CEBAC-STP enterprise members in Benin, June 2013 14

12 10 8 6 4 Number of Enterprises of Number 2 0 75-100% 50-75% <50% % Payment from sales

By the end of July 2013, unsold LLINs will be returned to the warehouse and will be included in the LLINs to be distributed in the next distribution phase. In order to prepare for Phase 2 of distribution, ARM3 will conduct a review of lessons learned and success stories with CEBAC-STP and its members and will advocate with business leaders to receive their support.

Environmental compliance In order to ensure compliance with USAID environmental regulations according to the Initial Environmental Examination (IEE), MCDI has procured the LLINs from a WHO approved brand, Vesstegarrd-Frandsen. ARM3 requested that the vendor provide a biodegradable packaging; LLINs are delivered to final beneficiaries without the outer packaging, which is being retained by CEBA-STP members during distribution. The packaging will be collected by ARM3 at the end of the distribution and will be disposed following international regulations, including the stipulations of the USAID Africa Bureau, Programmatic Environmental Assessment for Insecticide-Treated Materials in USAID Activities in Sub-Saharan Africa. MCDI has started the assessment of existing local facilities for final disposal. Partnership with Peace Corps/Benin ARM3 requested the support of a Peace Corps Volunteer (PCV) which has been approved. The PCV for the Cotonou office arrived in Benin on June 30, 2013. The PCV will join the ARM3 team and support the overall implementation of LLIN distribution activities with the private sector in Phase 2 and will later support malaria community activities.

Results Indicator Baseline LOP Target PY2/Q3 Results Source/Comments Result 1: Implementation of malaria prevention programs in support of the National Strategy improved Sub-result 1.2: Supply and use of ITNs increased Proportion of pregnant 75.5% (total) 2) Percent of pregnant women 20% women who slept under an who slept under an ITN the ITN the previous night in DHS report, May 2012 73.9% (Urban) previous night Source intervention areas will 76.5% (Rural) DHS, 2006 reach 85% 3) Percent of children under five 20% Proportion of children 71% (total) DHS report, May 2012 who slept under an ITN the under five who slept under

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Indicator Baseline LOP Target PY2/Q3 Results Source/Comments previous night Source an ITN the previous night 70.5% (Urban) DHS, 2006 in the intervention areas 71.3% (Rural) will reach 85% Proportion of households 4) Percent of households with a 25% 79.8% (total) with a pregnant woman pregnant woman and/or children and/or children under five DHS report, May 2012 under five that own at least one Source 78.2% (Urban) that own at least one ITN ITN DHS, 2006 81% (Rural) will reach more than 90% 36,022 delivered to employees out of 4.a) Number of LLINs Distribute 100,000 LLINs 45,000 delivered to CEBAC-STP reports / distributed through social through social marketing 27 enterprises ARM3 program reports marketing among employees among employees and 25,111,000 CFA and dependents of CEBAC-STP dependents of CEBAC- collected out of member organizations STP member organizations 44,000,000 CFA expected

Please note: ARM3 is not responsible for mass distribution of LLINs. Result 2: Malaria diagnosis and treatment activities in support of the National Malaria Strategy improved ARM3 supports improved case management of both severe and uncomplicated malaria and improved diagnosis of malaria through use of microscopy and RDTs. Result 2 consists of two sub-results: Sub-Result 2.1 (diagnostics capacity and use of testing improved) and Sub-Result 2.2 (case management of uncomplicated and severe malaria improved). Sub-Result 2.1: Diagnostic Capacity and Use of Testing Improved ARM3 assists the NMCP in enhancing capability and utilization of quality malaria diagnostic services via the implementation of enhanced supportive supervision at government health facilities. Prior to ARM3, MCDI implemented a supportive supervision program throughout the country through the IMaD program. Achievements Validation of Standard Operating Procedures Manual for Laboratory Diagnosis of Malaria As planned, the final validation workshop of the Standard Operating Procedures (SOP) for malaria laboratory diagnosis took place on May 6 and 7, 2013, in Lokossa. Thirty (30) participants from various organizations (MOH, NMCP, public and private hospitals and religious NGOS) attended, with a 11 female participants. All the 14 Standardized Operating Procedures (SOP) for laboratory diagnosis of malaria and 8 related procedures were validated and are ready for dissemination. The SOP's include: collecting capillary and venous blood; making thick [GE] and thin blood smears [FS]; preparing the buffer solution; preparation of Giemsa; staining slides GE/FS with Giemsa; reading and quantification of malaria parasites; identification of Plasmodium species; cleaning and storage of slides, use and maintenance of microscopes; use and conservation of Rapid Diagnostic Tests (RDTs); Internal and External Quality Assurance; disposal of biohazardous materials and reagents) and eight related to the following procedures: hand washing, use of gowns, gloving, decontamination workstation, accidental exposure to blood, what to do in case of electrocution, fire management in laboratory and weighing in the laboratory. Training of new supervisors and to provide refresher training for former supervisors ARM3 held a workshop to train and retrain 24 microscopists, including 12 new trainees from public and private health facilities in the Atlantique-Littoral, Ouémé-Plateau and Zou-Colline departments, from April 8- 13, 2013 in Lokossa, with 6 female participants. This training was aligned with the new malaria guidelines which state that suspected cases of malaria must be confirmed by microscopy or RDTs before treatment.

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The evaluation of the results for the new supervisors showed a significant improvement in the practical parameters. Sensitivity (ability to identify true positive slides) increased from 81% to 94%, species identification increased from 63% to 85% and parasite density counts increased from 31% to 47%. Specificity (ability to find true negative slides) did not change, remaining at 93%. Among the senior supervisors, sensitivity increased from 80% to 100% while post-test specificity showed marginal improvement at an already extremely high level over pre-test levels, rising from 98% to 100%. Species identification increased from 67% to 96% and parasite density showed significant improvement, rising from 43% at pre-test to 79% at post-test.

Senior supervisors workshop in Lokossa – April 8-13, 2013 Mr. Saliou giving instructions to senior supervisors during the practice pre-

test, Lokossa, April 8-13, 2013

Validation supervision of trained/retrained laboratory technicians From June 17 to July 2, 2013 the 12 biotechnologists trained in the Atlantique-Litoral department received supervisory visits focused on malaria diagnosis (including microscopy and RDTs). Each technician was assessed in all the stages of the diagnostics, from sampling techniques to the reading of malaria slides (6) and RDTs (10). Preliminary results of the readings of standard slides showed a sensitivity of 100%, a specificity of 100%, species identification of 95.83%, and a mean parasite density of 75%, indicating a high level of competence. A final report on the findings will be presented once the supervision of Ouémé- Plateau and Zou-Collines is completed. Outreach Training Support and Supervision (OTSS) Round 12 OTSS Round 12 was successfully carried out with the support of 5 supervisory teams, composed of 36 laboratory technicians and clinical supervisors and the ARM3 Parakou team. A total of 48 health facilities were visited, including 43 public and 5 AMCES private facilities, in Borgou-Alibori, Atacora-Donga, Kandi, , Kobli and Parakou. All the supervision teams used the standard OTSS criteria for supervision. The data has been introduced into the database and the analysis was conducted. A more detailed supervision can be found in Annex 4.

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Results Indicator Baseline LOP Target PY2/Q3 Results Comments Result 2: Malaria diagnosis and treatment activities in support of the national malaria strategy improved Sub-result 2.1: Diagnostic capacity and use of diagnostic testing improved Results shown are for OTSS Round 12 (PY2 5) Percent of targeted health Q3) Proportion of health 97.7% centers that have the following: 95.8% centers with the ability to 1) personnel trained in malaria Indicator describes OTSS perform biological diagnostics, 2) no stocks-outs 1 HF did not meet facilities only Source diagnostics for malaria affecting malaria diagnostics for the indicator criteria OTSS (either microscopy or rapid due to lack of 7 or more days, 3) a functional Only 43 of the 48 HFs Round 7 diagnostic testing) will be microscope (non-RDT facilities trained malaria 85% diagnostic staff had enough recorded only) information to be analyzed for this indicator

12 new OTSS supervisors trained, 12 former OTSS On average, at least 1 provided refresher Results shown are for health worker from each training OTSS Round 12 (PY2 22) Number of health workers PY1: staff type (lab/clinic) per 117 trainings Q7) trained in malaria diagnostics Average facility per supervisory 41 lab trainings (including microscopy/RDTs) trainings visit trained in malaria 76 clinical trainings Target only includes and case management with USG Lab: 1.4 diagnostics (including facilities with labs funds Clinic: 1.3 microscopy/RDTs) and Lab: 0.85

case management with Clinical: 1.58

USG funds 48 facilities reporting for PY2/Q7

Sub-Result 2.2: Case Management of Uncomplicated and Severe Malaria Improved Upgrading the skills of health workers is critical to proper case management of severe and uncomplicated malaria. ARM3’s vision is to assure quality enhancement through developing/updating clinical case management guidelines and related tools, supporting the training of private and government health staff, and implementing the Performance Improvement Approach (PIA) in HZs and hospitals. An integral part of quality assurance requires an enhanced and integrated supervision approach which includes IPTp, malaria diagnostics, and clinical case management. In year 1, Malaria guidelines and training curricula were updated (Malaria in pregnant women, Integrated supervision tool, Malaria diagnostics in para-clinical settings, case management of uncomplicated malaria at the community level and the use of RDTs, and IMCI training materials); 48 health care providers from 6 HZs were trained in IMCI, the ETAT training needs assessment was completed in nine hospitals, mannequins for ETAT training were procured, 14 supervisors and facilitators and 13 participants were trained in ETAT. Ten LDP trainers were trained, LDP Senior Alignment Meeting and an initial Leadership Development Program workshop were held, accommodating 40 participants.

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Sub-result 2.2.a: Upgrade skills of health workers on clinical management Achievements Validation of the training manuals and other key documents, such as the National Malaria Policy, linked to the validation of the training manuals under Sub-result 1.1a) The NMCP’s National Malaria Policy on MIP has been reviewed/validated this quarter. An editing committee is incorporating the final recommendations for its publication and distribution in Quarter 8. Case Management Training of uncomplicated malaria2 ARM3 supported the HZs’ training teams by providing training funds to the 25 HZs (3 HZs in Atlantique, 4 Littoral, 2 Oueme, 3 Plateau, 3 Zou, 3 Collines, 4 Borgou, 3 Alibori) with which it has signed MOUs. Nineteen of these 25 HZs implemented case management refresher trainings this quarter, retraining 729 health providers in the new protocol for case management during the quarter, and up to 757 health providers trained in year 2. The HZs are requesting additional funds in order to train the "non-qualified" health workers and to extend training to the private sector health facilities. These concerns will be discussed during the preparation of the year 3 Work Plan. Participants in a training session for the ETAT practice The retrainings were conducted by personnel in the same health zones, avoiding unnecessary use of resources, including theoretical and practical exercises on ANC/IPTp and MCM protocol. Trainees’ score increased between pre-tests and post-tests. IMCI and ETAT Training/Post-ETAT training follow-up The project has engaged 8 hospitals to participate in the strategy of "Emergency Triage, Assessment and Treatment (ETAT) in the first year and 4 additional hospitals in Year 2, reaching a total of 12 hospitals where ETAT is now being implemented. Efforts focused on ETAT indicators and on incorporating this methodology at the selected hospitals. Refresher training was conducted for the personnel of the above-mentioned 8 hospitals (totaling 41 health professionals). Four new hospitals were selected, following the selection criteria of the DSME and WHO, raising the number of hospitals where ETAT is being implemented to 12. Sixty eight new health professionals were trained in ETAT in these 4 hospitals. Advocacy actions to promote and support ETAT were conducted with key personnel, including 40 heads of hospitals, accountants, lab technicians and statisticians, in all 12 hospitals. By the end of Quarter 7, 109 health professionals received training in ETAT.

2 The number of HZs and health professionals retrained in IPTp is mentioned under Sub Result 1.1.b, IPTp training, above.

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Table 1: ETAT activities in Quarter 7 (April-June 2013) Type of activity Male Female Total Profession details Affiliation to Public or private sector

10 heads of hospital 16 public Briefing of 12 hospitals’ key 10 accountants 29 11 40 24 private personnel on ETAT 10 lab technicians

10 statisticians 6 medical doctors Refresher training for 8 17 public 13 28 41 34 nurses hospitals’ health workers 24 private 1 statistician Initial training of 12 18 medical doctors 26 private hospitals’ health workers on 30 38 68 40 nurses 43 public ETAT 10 heads of hospitals 10 accountants 10 lab technicians 59 public TOTAL 72 77 149 11 statisticians 91 private 74 nurses 24 medical doctors

Sub-result 2.2.b: Implementation of the Performance Improvement Approach (PI) in participating health zones and hospitals Achievements DDS and Health Zone Strategic Operational Plans/Implementation of MOUs with HZs During Quarter 7, ARM3 and the NMCP signed MOUs with the Zou-Collines DDS (1), the Borgou-Alibori DDS (1), and seven (7) HZs, bringing the total number of HZs to 25 (out of 34). In addition to the DDS mentioned above, the Oueme-Plateau DDS, Atlantique-Littoral DDS and existing HZs of Atlantique-Littoral, Ouèmé-Plateau and Zou-Collines were enrolled in Quarter 6. The initial 12 HZs in Atlantique-Littoral and Ouèmé-Plateau will continue implementing the 4 main activities3 as planned, while the remaining 13 HZs will implement 3 of the 4 main activities (1,2, and 3), in order to ensure a rapid increase in coverage towards the target of 34 HZs. The inclusion of "malaria collaborative performance improvement approach” will be discussed during the elaboration of the Y3 WP. Twenty four of twenty five HZs and three of four DDS have received an advance of funds. The two remaining unfunded did not submit their requests in time. Sixteen HZs conducted trainings of health personnel in IPTp and nineteen conducted trainings in case management. Sixteen HZs have presented financial reports. Follow up actions to ensure the submission of financial reports from DDS and remaining HZs will be carried out during the next quarter. Evaluation of MOUs The quarterly evaluation of HZ MOUs shows a high implementation rate for almost all HZs and DDS. The assessment included: a review of the financial resources allocated by activity, capacity to address difficulties encountered, and corrective actions taken to improve the HZ and DDS performance. ARM3 will conduct an assessment in Bourgou Alibori to identify causes of underperformance and support the improvement of these indicators.

3 (1) integrated supervision of malaria services; (2) training on IPTp and ANC; (3) and training on malaria case management, 4): malaria collaborative performance improvement approach.

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Table 2: ARM3 Summary of the results of the MOUs Evaluation (April-June 2013), percentage of implementation of planned activities in 25 HZs countrywide Regions Number of Number of Implementation activities carried activities rate out planned Atlantique Littoral 22 22 100% (7 health zones) Ouémé Plateau 16 20 80% (5 health zones) Zou /Collines 16 18 88.9% (6 health zones) Borgou Alibori 10 21 47% (6 health zones) NATIONAL 64 81 79% (25 health zones)

Quality Assurance/Quality improvement Collaborative Improvement Collaborative Improvement is a learning model that enables teams to achieve improvements in quality through a process of structured, shared learning among many teams working on the same problem area and promoting the rapid dissemination of successful practices. During quarter 7, ARM3 continued implementing the Collaborative Improvement in Ouémé-Plateau and Atlantique-Littoral as part of the HZ activities implemented under the MOUs. By the end of the quarter, 330 people were trained in the Collaborative Improvement, both in Atlantique- Littoral and Ouèmé-Plateau, for a total of 683 health professionals trained in collaborative improvement in Year 2. Table 3: HWs trained in Collaborative Improvement in the 12 targeted HZs in Atlantique-Littoral and Ouèmé-Plateau January -March 2013 April-June 2013 Total trained in Number of persons trained Number of persons trained collaborative Atlantique Littoral Cot 1-4 (A-L) 24 20 Cot 2-3(A-L) 9 32 Cot 5(A-L) 20 14 Cot 6(A-L) 25 21 AS(A-L) 27 54 OKT(A-L) 42 37 AZT(A-L) 25 27 Ouèmé Plateau PAK (O-P) 27 15 SAKIF (O-P) 18 0 ABD (O-P) 20 19 PAS (O-P) 77 70 3A (O-P) 39 21 Total (AL+OP) 353 330 683

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Leadership development program (LDP) The Leadership Development Program (LDP) coaches provided feedback to the participating teams to improve their leadership projects. The challenges included improving the ability to confirm diagnosis and better manage health information. LDP facilitators conducted follow-up visits and provided guidance to participating teams in order to monitor project progress. Projects will be presented to senior management early next quarter. Sub-result 2.2.c: Enhance integrated supervision on IPTp, malaria diagnostics and clinical case management of malaria Achievements Integrated Supervision Integrated supervision of case management was conducted this quarter. Qualified health professionals in an estimated 400 public health facilities from 20 HZs, where MOUs have been signed with ARM3, were assessed. Data is being processed and will be included in the 8th Quarterly Report. Preliminary findings from regarding the malaria case management and ANC/IPTp guidelines show that all staff is aware of the new malaria guidelines, know how to use the ACT treatment scheme and are aware of the requirement to test the patient before treatment. Areas needing improvement include: poor record keeping, especially related to the management of inputs, lack of documentation of procedures and services, lack of systematic use of RDTs, stock outs of SP and poor reporting of the IPTp indicator in the registers. The ARM3 team is developing recommendations to address these issues. Clinical audit of maternal mortality training In collaboration with the DSME, 62 health workers (71% female) received training in clinical audits of maternal mortality (62% of the targeted audience). This training provides the knowledge and skills necessary to identify causes of death recorded in clinical registers. This activity will continue next quarter.

Results Indicator Baseline LOP Target PY2/Q3 Results Source/Comments Result 2: Malaria diagnosis and treatment activities in support of the national malaria strategy improved Sub-result 2.2: Case management of uncomplicated and severe malaria improved 36.7% (all ages) 62.28% (all ages) 17.5% < 5 6) Percent of suspected malaria 90% of suspected malaria RMIS results are from 52.6% ≥ 5 cases submitted to laboratory cases will be tested via 79.29% < 5 PY2/Q2 testing microscopy/RDTs (Jan-Mar 2013) Source 53.39% ≥ 5 RMIS FY11/Q4 ≥ 95% of patients (all 82.4% (all ages) ages) who tested positive for malaria (via 70.2% < 5 7) Percent of patients (all ages) EUVS report, Jun microscopy or RDT) will 91.4% ≥ 5 who tested positive for malaria 2013 (Oueme-Plateau) -- receive an effective anti- (via microscopy or RDT) who (based on a sample of malarial (ACT) Micro – all ages received an anti-malarial 15- health facilities) 47%% Micro only ≥ 85% RDT – all ages RDT only ≥ 95% 79.3% < 35% of patients (all 57.6% (all ages) EUVS report, April ages) who tested negative 67.2% < 5 2012 8) Percent of patients (all ages) for malaria (via 48.6% ≥ 5 who tested negative for malaria -- microscopy or RDT) will Micro – all ages EUVS (June 2013) (via microscopy or RDT) who receive an effective anti- 40.1% results for this received an anti-malarial malarial (ACT) RDT – all ages indicator are being 59.5% revised. Further

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Micro only < 35% information to be RDT only < 45% provided in Quarterly Report 8th. OTSS Round 9 PY1/Q3 (June) OTSS Round 11 PY2/Q1 (December) OTSS Round 12 OTSS Round 12 100% (N=48) PY2/1Q3 (April) Supervisory visits will be 9) Percent of targeted health OTSS Round 11 conducted at 100% of facilities that received -- 100% (N=47) For OTSS Round 12, targeted health facilities at supervision OTSS Round 9 ARM3 was least once every 6 months 100% (N=46) responsible for the 48 HFs that have not yet been included under the HZ MOU decentralization scheme. Percent of children under- <1% 10) Percent of children under- five with suspected malaria five with suspected malaria (fever) in the last two Source (fever) in the last two weeks weeks who received 12.3% DHS report, May 2012 DHS, 2006 who received treatment with treatment with ACTs in

ACTs targeted areas will increase

to 85% ≥ 90% of mothers / 11) Percent of mothers / caretakers who sought caretakers who sought treatment <1% treatment with the use of with the use of ACTs for their ACTs for their under-five under-five children with 6.7% DHS report, May 2012 Source children with suspected suspected malaria (fever) within DHS, 2006 malaria (fever) within 24 24 hours of onset of their hours of onset of their symptoms symptoms Develop, review, update and implement with the 12) Number of schools of MOH the guidelines and nursing and educational training curricula on MOU signed with institutions that have updated 0 malaria diagnosis and 1 INMES their malaria guidelines and treatment at a total of 4 curriculum schools of nursing and educational institutions (2 in PY2; 2 in PY3) Support training in clinical IMCI for 72 newly hired 13) Number of newly hired ARM3 training reports health workers in the health workers trained in -- No new trainees private sector to contribute clinical IMCI Total to date: 48 to national scale-up of clinical IMCI

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ARM3 training reports LOP running total:

Cumulative 33 hospitals received training at the national level.

22 Public 19 Private

12 hospitals trained by ARM3 (8 in Quarter 6 and 4 in Quarter 7), and the 21 hospitals/health centers that have been trained in ETAT by Support refresher training and supervision to ensure PISAF appropriate management 21/50 4 new hospitals 14) Number of hospitals that and referral practices for This quarter all of the hospitals (33) received a refresher training for severe malaria to the health workers from provided severe malaria case remaining 29 hospitals the 12 hospitals were training by management nationwide PISAF either trained or 29 (total) received refresher 17 public training so as to start 12 private the group on implementation at the same time.

Note: the original LOP target was 55 hospitals. This value has been revised down to 29 as PISAF has already provided training for severe malaria case management to 21 hospitals. There are 5 hospitals of the proposed 55 that cannot be identified

Cumulative totals year 729 health care 2 : 757 health 23) Number of health workers FY13 Target: 476 health professionals from professionals (re) trained in case management care professionals from 12 19 health zones trained in case with artemisinin-based health zones (re)trained in (re)trained in case management combination therapy (ACTs) case management with management with with USG funds ACTs using USG funds ACTs using USG fund Health zone training reports

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Sub-Result 2.3: Integrated Community Case Management (iCCM) improved Since 2009, the PMI team, in conjunction with the Maternal and Child Health Program, has funded community case management (CCM) via a grant to MSH to cover 5 HZs in the north of Benin. CCM activities in Benin currently involve a wide range of partners including USAID/PMI, Africare, UNICEF, CRS, other international and local NGOs, and a number of community and faith-based organizations. USAID/Benin supported BASICS in implementing iCCM in 5 HZs in the north of Benin: Kandi, Banikoara, Tchaourou, , that came to an end in 2012. Contingent upon approval from USAID, the ARM3 project will resume implementation in the 5 original BASICS HZs; the pilot SMS component will also be included. This is a new activity which was added to the ARM3 Work Plan in this current year. Achievements Identify and sign contracts with NGOs On-site visits of the 10 shortlisted NGOs were conducted from April 16 to 19, 2013 by a team made up of Africare, MCDI, DSME and DNSP. Selection criteria for each NGO included assessment and verification of legal status, office space, personnel and staffing, cash and banking, accounting system, audits, procurement, equipment, and inventory. At the end of the assessment, 5 local NGOs, one per HZ, were selected. On-site visit to CBBE in Banikoara: Table 4: Local NGOs selected for iCCM component in the 5 Africare, MCDI and DSME staff former Basic Zones

Department Health Zones Selected NGOs Notes DONGA BASICS former NGO BASSILA GRADE Not a BASICS former NGO DJOUGOU --OUAKE SIANSON ALIBORI BASICS former NGO BANIKOARA CBBE BASICS former NGO KANDI--SEGBANA HANDICAP PLUS BORGOU BASICS former NGO TCHAOUROU DEDRAS

Census conducted on CHWs trained in RDT use To estimate the need for RDTs, ARM3 organized a census of CHWs trained in the use of RDTs by the BASICS Project. In total, 92 CHWs were trained in the use of RDTs, 17 CHWs were female (18.5%). The report shows that 94.6% of the CHWs are still active and that the average number of children treated with ACTs during the last quarter is 1,415. Implementation of SMS / GSM Concurrently with the RDT census, ARM3 assessed the availability, functionality and indemnity of cell phones distributed by BASICS in 2012, to conduct the pilot SMS / GSM program, applying a standard format to 48 CHWs. Of these CHWs, 41 had phones that were still operational. The CHWs without working phones stated that they were no longer functional due to loss or damage.

Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened

Result 3 consists of three sub-results: Sub-Result 3.1: MOH/NMCP capacity to deliver and manage quality malaria treatment and control interventions improved; Sub-Result 3.2: Capacity to collect, manage and use

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malaria health information for M&E and surveillance improved; and Sub-Result 3.3: Capacity in commodities and supply chain management improved. This result is oriented towards the improvement of the coordination, decentralization, and transparency in the financial management and managerial capabilities of the NMCP. In year 1, the TWG began conducting key activities such as: planning the project supported M&E workshops, drafting publications of the RMIS bulletin, RBM meetings, creating an inventory of IT capacities and implementing an IT equipment plan.

Sub-result 3.1: The National Malaria Control Program’s technical capacity to plan, design, manage, and coordinate a comprehensive malaria control program enhanced ARM3 is undertaking activities to reinforce the capacity of the NMCP to manage malaria interventions. One of the primary methods includes the support and promotion of NMCP Technical Working Groups (M&E, Supply Chain Management, Communications, and Case Management) to meet regularly and to assist in coordinating with other malaria implementing partners. Additionally, ARM3 will seek out other Malaria Control Partners operating in Benin to work to improve collaboration. Achievements Technical and financial support of the 2013 Plan Intégré de Travail Annuel (PITA) The NMCP rescheduled implementation of the PITA review for July 2013, during Quarter 8. NMCP Institutional support ARM3 continued to support the financial management of the NMCP. By June 30, 2013 (Year 2) ARM3 has funded approximately $80,000 in expenses for the NMCP. The funds have been used to cover costs of services (communications including corporate telephone subscription and internet), equipment (5 laptops, one desktop computer and 4 printers, photocopier repair, etc.), and activities including TWG meetings and malaria partners meetings.

Continued support to Malaria Technical Working Group (TWG) meetings Monitoring and Evaluation TWG The M&E TWG meeting was held on June 1, 2013 at the NMCP offices. Twelve participants from the MOH (NMCP), CRS and ARM3 attended. Main points in the agenda were:  Brainstorming to review current malaria control monitoring and evaluation protocols;  Discussion of issues identified during the late quarterly validation of RMIS data;  Examination of the level of compliance of RMIS forms with the HMIS M&E forms;  Validation of the RDQA (Routine Data Quality Assessment) methodology and tool; and  Discussion of potential solutions for improving the reporting of community-based malaria data.

In order to reduce the time lag in the transmission of data from the community level, CRS and Africare agreed to adhere to the HMIS timeline, sending information on the 5th of each month rather than the 10th. The dissemination of the PNLP1 Form approved by the M&E TWG is delayed, due to additional requests of the NMCP Coordination Group that requires the review of definitions including: severe malaria with positive test result, uncomplicated malaria with negative test result, uncomplicated malaria tested by RDT and uncomplicated malaria tested by thick smear (GE). Once there is an agreement on the above-mentioned definitions, a chart providing operational definitions will be added to the back of the PNLP1 Form. BCC TWG Meeting As recommended during the BCC TWG in March, ARM3 submitted the French version of the BCC Strategy document to the NMCP. It presents the malaria situation in Benin and describes key behaviors, barriers,

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audiences, messages and strategies from the PMI BCC guidelines. ARM3 will follow up with the NMCP for approval. ARM3 facilitated the quarterly BCC TWG meeting held on June 26, 2013. Main points in the agenda were:  Presentation of the NMCP music video on malaria prevention and management;  Approval request to air the LLIN video spot developed by ARM3;  Presentation of flyers reproduced by ARM3 partners;  Establishment of a committee to validate tools produced;  Coordinate communication activities with local press linked to communication policy plans from the Ministry of Health; and  Mobilization of funds for the telefilm initiated by “Son Pour Son Multiproduction”. ARM3 is currently preparing the Leadership in Strategic Health Communication course to be held in Ouidah from July 22 to August 2nd 2013. The SOW has been shared with PNLP, and PNLP has provided a list of 25 participants. The workshop is designed for managers involved in behavior change communication. Two facilitators from JHU-CCP will support this activity. SCM TWG meeting ARM3 facilitated the SCM TWG on May 8th, 2013. Main points in the agenda were:  The procurement of a buffer stock for the NMCP from the PMI emergency fund in order to avoid stock outs;  The review of a legal framework establishing the management of a common grouping;  Presentation of the results of supply chain supervision and the level of consumption for each HZ;  Update of the malaria commodities Supply Plan;  Scheduled supply chain managers’ coordination meetings to address emergency situations concerning the availability of malaria medicines (it was agreed to meet once a week, every Friday).

Results Indicator Baseline LOP Target PY2/Q3 Results Source/Comments Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened Sub-result 3.1: NMCP’s technical capacity to plan, design, manage and coordinate a comprehensive malaria control program enhanced The 4 NMCP technical ARM3 program reports 15) The number of meetings working groups Accumulated TWG held by the NMCP technical (monitoring and M&E -1 meetings in Y2: working groups (monitoring and evaluation, supply chain, SCM –3 -- M&E -3 evaluation, supply chain, communications, and case BCC – 1 SCM –5 communications, and case management) are meeting CM-0 BCC – 2 management) regularly as planned (twice CM-0 per year)

Sub-Result 3.2: Capacity to Collect, Manage and Use Malaria Health Information for M&E and Surveillance Improved Successful program management requires timely and accurate data to make rational and informed decisions on policy and interventions. ARM3 plans on evaluating and strengthening each of the major information systems including the HMIS/RMIS (LogiSnigs & LogiHops), LMIS (Medistock), IRSP sentinel surveillance, OTSS, EUVS and other malaria-related systems. The objective is to ensure that each system is providing high quality and timely data for decision making and to address barriers in information collection, management, and utilization.

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Achievements Health Facility Survey By request of the FY 2013 MOP, in collaboration with CDC, PMI, the Mission and the NMCP, ARM3 has begun preparations for the Health Facility Survey (HFS) 2013. As a PMI implementing partner, ARM3 is committed to ensuring technical and logistical support to the survey. During the quarter, ARM3 participated in coordinating conference calls with the above-mentioned partners, allocated personnel to support the HFS, both at the FO and HO, participated in planning discussions, reviewed and commented on the protocol and the survey instruments, translated the protocol into French, promoted the discussion of the survey instruments with the field team, developed a budget and coordinated with the MOH to assess the availability of local supplies, assessing at the same time the possibility of international procurement based on the availability of local equipment/supplies. The ARM3 team also updated the list of Benin health facilities used as the sampling framework and conducted the sampling based on CDC recommendations. In the last weeks, the HO IT staff started programming the questionnaires into tablets with the ODK software. During the next quarter, ARM3 will continue with the planning and will proceed with the operational part of the survey. Capacity Building Training of 44 statisticians (34 from the 34 HZs and 10 from the 6 Departmental Directorates) on LOGISNIGS4 and ACCESS software ARM3, DDS and NMCP staff conducted two five day trainings on LOGISNIGS (first 3 days) and ACCESS (last 2 days), for 44 staff from all 34 HZs and 6 health departmental directorates. The first was held at Bohicon for staff coming from departments in the South and the second in Parakou for the remaining Northern departments. This training will certainly reduce Routine Malaria Information System (RMIS) report submission delays and will strengthen the quality of data collected monthly. Trained statisticians will be able to better detect coherence errors and perform improved data analyses, which will provide the HZ coordinators with more accurate information to conduct facility-based situation analyses. Following recommendations from the TWG, refresher trainings will be conducted each semester to strengthen statisticians’ knowledge of these software programs. The DDS also recommended incorporating hospital statisticians to the LOGISNIGS and ACCESS trainings in the future. Update NMCP central data platform ARM3 provided technical support to update NMCP´s databases: RMIS, MEDISTOCK, LMIS, HMIS, Community Health (Palu Alafia-GFATM), as well as the EUV surveys. Data from different regions of the country were merged and analyzed to detect outliers and errors within databases.

Routine Data Quality Assessment (RDQA) and Verification Process In collaboration with the NMCP M&E team, the ARM3 M&E team conducted a RDQA with the participation of 3 health department statisticians and 8 HZ statisticians. The sampling framework was designed using 3 stages of random selection. Half of the country [six out of twelve departments were selected, from each department a sub sample of half of the HZs was selected (8 out of 18)], and 3 Health Facilities were selected per HZ. The assessment was then conducted within 24 health facilities. The objectives of the RDQA were to: i) assess reporting capacities of facilities and management of malaria data, ii) evaluate the quality of collected data, iii) identify difficulties encountered by all RMIS users, and iv) propose solutions.

4 "LOGISNIGS" is a software that is part of the SNIGS which enables data to be exported and imported to different levels of the system.

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Chart 3 below summarizes the results of the data management systems assessment. The link with the NHIS is the main strength highlighted while improvement is required in the structure, functions and attitudes of the personnel, data management process, availability of tools and structure, and definition of indicators and communication directives. Chart 4 below summarizes the results of the assessment at the national level, showing the need for improving the links of the M&E Unit with the National Reporting System and data management process as major priorities. Graph 3: Summary Assessment of the data Graph 4: Data management Assessment at the management system, June 2013 national level, June 2013

The findings of the HF and HZ assessment indicate the capacity level of staff, equipment available and people trained. However, the quality of malaria related data is still low as 60 % of health workers do not perform data quality control before sending their monthly report, and those reporting the data have difficulties understanding malaria diagnosis, malaria treatment or the use of the software. Recommendations for HZs are to: i) routinely perform random on-site data verification, ii) backup data on a monthly basis, iii) properly organize the PNLP1 data form hard copies, and iv) provide a refresher briefing to RMIS users in HF on the filling of PNLP1. Recommendations for health facilities include: i) perform a data review before submission; and ii) work as a team during data compilation. A report with detailed findings will be included in Quarterly Report 8.

34 HZs Routine Malaria Information System (RMIS) validation workshops During Quarter 7, ARM3 in collaboration with the NMCP, organized 3 regional meetings for the validation of data collected from January to March, 2013, within all HZs, in Nattitingou (May 6 to 7), Porto Novo (April 25 to 26) and Bohicon (May 10 to 11). Eighty participants (6 statisticians from DDS, 34 HZ statisticians, 34 MCZS - 2 from NMCP, and 4 from ARM3) assessed more than 2,200 reports from 901 health facilities. The findings from this quarter show a reduction of the error rate in the departments of Borgou Alibori, Atacora Donga, Zou Collines and Mono Couffo.

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The HMIS reports the number of malaria cases, deaths, and fatality rates at the facility level. Concerns have been raised about accuracy, timeliness and coverage (MOP 2013). Since the beginning of ARM3, one of its focus areas has been to promote RMIS reporting. From Quarter 1 to Quarter 6, RMIS completeness has been consistently increasing.

Graph 5: RMIS completeness since ARM3 involvement RMIS Completeness 100 90 90.4 80 84.9 before ARM3 70 66.4 61.7 Q1 60 62.2 Q2 50 35.2 Q3 40 37.8

30 Q4 Completeness% in 20 Q5 10 Q6 0 before Q1 Q2 Q3 Q4 Q5 Q6 ARM3

According to its mandate, ARM3 has been promoting the incorporation of the RMIS in the private sector. Graph 6 below shows how the RMIS completeness has improved in the private sector from Quarter 3 to Quarter 6 in comparison to the public sector, while demonstrating a rise in both sectors.

Graph 6: RMIS completeness by type of health facility (public or private) Public versus private RMIS completeness

100 92.2 90.4 90 76.7 76.9 80 73.6 70 62.2 60 public 50 39.6 40 34.7 private 30 20 10 0 Q3 Q4 Q5 Q6

It is important to assess the quality of the data being reported and the level of error in order to ensure improvement. The table below shows an important error reduction in Mono-Couffo and Zou-Collines, a slight increase of error in Atlantique Littoral and Ouémé-Plateau, and an error reduction of 2.8% in Atacora- Donga.

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However, a Quarterly RMIS supervision conducted in 5 HZs in Atacora-Donga has identified certain aspects that need to be addressed in order to ensure consistency (see Quarterly RMIS supportive supervision in Atacora and Donga, below).

Table 5: Error rate per region calculated during data validation meetings DEPARTMENTS ERROR RATE ERROR RATE ERROR During quarter 6 During quarter 7 BEHAVIOR MONO COUFFO 40.9% 11.9% -28.1 ZOU COLLINES 41.7% 19.3% -22.4 BORGOU ALIBORI 6.4% 4.1% -2.3 ATACORA DONGA 6.9% 4.1% - 2.8 ATLANTIQUE LITTORAL 15.1% 19.2% +4.1 OUEME PLATEAU 22.2% 26.8% +4.6

Quarterly RMIS (SIRP) supportive supervision of data collection sites (in 5 HZs in Atacora and Donga) Held from June 24 to 29, 2013, the RMIS supervision of HMIS personnel focused on the five HZs within Atacora and Donga. Eighteen out of 19 heads of health centers were monitored during the quarter, 33.3%, were female. The main results obtained are:  The consistency of data on the PNLP1 forms and primary sources (books, notebooks and nursery cards) is 38%,  Almost 50% of the health providers supervised do not perform quality control when filling out the PNLP1,  50% of the health providers supervised were previously trained on the RMIS (also known as Systeme d’Information de Routine du Paludisme, SIRP), and  22% of health facilities visited have the RMIS user manual.

ARM3 will prioritize the consistency of the data in these 5 HZs during the next quarters to improve the quality of the information and to ensure its reliability.

Follow up of sentinel site activities Sentinel site visits and database updates by IRSP staff have been scheduled. The ARM3 statistician provided technical support to the IRSP person in charge of their database in order to improve the quality of database management. At the same time, ARM3 trained the IRSP database manager on LOGISNIGS. With knowledge acquired during this training, the database manager will be able to compare data from routine data collection with data collected from sentinel sites.

Quarterly supervision of data collection sites The quarterly supervision of data collection sites was conducted in late June of 2013. This activity was carried out by teams comprised of individuals from the NMCP (national and regional offices), HZ statisticians and ARM3 staff. The objectives were to: i) assess and improve the HWs’ knowledge of the PNLP1, ii) check coherence among collected data, iii) evaluate the concordance between data on the PNLP1 and primary data sources, i.e. patient registers; and iv) formulate recommendations to resolve problems that hinder data quality. A total of 4 regions, 11 HZs, and 40 HFs were visited. Forty HF personnel (35% female, 65% male) were supervised. The methodology included assessment through questionnaires, verification of physical documents (registers, stock paper, ACT copy books) and providing feedback to HWs on data collection and

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quality assurance of data. The results of the supervision are summarized in the quarterly supervision indicators table below.

Publish quarterly newsletters and annual RMIS annual bulletin The quarterly Routine Malaria Information System (RMIS) newsletter #9 (January – March 2013) Palu-Info was developed and distributed to stakeholders in order to keep them abreast of the malaria epidemiological situation and ongoing activities. The NMCP also decided to begin the Annual RMIS Bulletin for 2012, which will summarize key activities that took place over the last year. This publication will include information in malaria epidemiological indicators (i.e. morbidity, mortality), and trends.

PALU INFO editorial committee at Bohicon during the design of annual bulletin

Results Indicator Baseline LOP Target PY2/Q3 Results Source/Comments Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened Sub-result 3.2: MoH capacity to collect, manage and use malaria health information for monitoring, evaluation and surveillance improved ≥ 95% of targeted facilities reporting PY2/Q2Results RMIS results are from 16) Percent of targeted facilities through the RMIS 83,6% PY2/Q2 reporting through the Routine 37.8% and sentinel RMIS: (753 public and (Jan-Mar 2013) Malaria Information System and surveillance sites are private health facilities, IRSP has started data sentinel surveillance sites are Source providing complete out of 901 facilities) collection and received providing complete information RMIS information on a IRSP Sentinel training to improve the on a regular and timely basis for (FY11/Q4) regular and timely Surveillance: 100% quality of data base decision making basis for decision (5of 5) management. making

Sub-Result 3.3: Capacity in Commodities and Supply Chain Management Improved

The continuous availability of high quality malaria commodities is crucial to reduce malaria related morbidity and mortality in Benin. The main objective of ARM3’s supply chain management (SCM)

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component is to strengthen Benin’s SCM activities, including building the capacity and improving the performance of Benin Central Medical Store (CAME). ARM3 intends to work with CAME to improve governance practices, warehousing of drugs and financial information systems to improve their performance. ARM3 is supporting the NMCP and CAME in designing and implementing a well-designed Malaria Logistic Management Information System (LMIS) in order to reduce stock outs and overstock. The LMIS end goal is to track malaria commodities and make sure that the right product is available in the right quantity, in the right condition, at the right time, in the right place, and at the right cost. Achievements Upgrade staff’s capacity to exploit SAGE 100 software/Continued support to CAME’s information system CAME’s new operating system, SAGE 100, is installed and functional at the central level, but CAME is not able to fully exploit the software. CAME staff face stock management issues and difficulties managing the location of the stock. In addition, CAME's IT team does not have the capacity to fully run SAGE 100 in all of its warehouses due to problems in the original set-up and the software provider’s absence, whose contract has ended. ESTERAID will provide technical assistance to CAME by hiring a consultant (funded through ESTHERAID via ACAME - Association of Central Purchasing of Essential Drugs) who will be responsible for the reconfiguration of SAGE100 and training of all staff. This will take place in two sessions in August and September 2013. This activity will be funded through ESTHERAID via ACAME. LMIS national supervision and data collection From April 7 – April 13 2013, the NMCP, supported by ARM3, organized a national supervision in 34 HZs to assess the implementation of LMIS management parameters for health workers, the timeliness and completeness of data in the transmission of ILP and storage conditions. A total of 34 distribution depots, 26 area hospitals, 5 departmental hospitals and 68 peripheral health centers were visited and received coaching on LMIS parameters and use of MEDISTOCK software. Assessment of Health Facility Reporting Supervision revealed the number of health centers which submitted reports and orders as prescribed by the LMIS for the first quarter of 2013. Graph 7 shows the average reporting rate by department. Graph 7: Health Facility Reporting by Department

Level of reporting of health facilities by department

%% FS HF ayant having rapporté reported % %FS HF n'ayant having pasnot reportedrapporté

71% 76% 61% 59% 59% 57% 39% 41% 41% 43% 29% 24%

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Drug storage conditions Supervision teams assessed the storage conditions in the HZs’ DRZ on the basis of an evaluation grid. To meet the conditions of “good storage" at least 14 of 17 criteria must be met5. Graph 8 illustrates the performance of all DRZ and HZ departments. Graph 8: Storage Conditions at the DRZ by Department

Storage Conditions at the DRZ by Department

80%

60%

40%

20%

0% DRZ AL DRZ AD DRZ MC DRZ BA DRZ OP DRZ ZC

Good Conditions for Stock Poor Conditions for Stock Bonnes conditions de stockage Mauvaises conditions de stockage

LMIS and supervision feedback Workshop in Lokossa Following the national supervision of inventory stock levels, a workshop was conducted on April 29 and 30, 2013 in Lokossa. There were 50 participants who reviewed data collected in Quarter 1 to evaluate tools used and proposed recommendations for improving the performance of the LMIS-Information Logistic Paludisme (ILP).

Success Story from the field: Pharmacy Manager’s experience in Ouidah Hospital As a result of the training received by a pharmacy manager in Ouidah Hospital on topics such as LMIS MEDISTOCK, 5S Method, etc., he was able to give a workshop presentation to his fellow managers explaining proper drug management. With the minimal investment of time and dedication, he achieved a high performance level of storage conditions in his shop and was confident enough to share what he learned with his peers.

5 Good storage conditions include: temperature control measures in place, adequate ventilation, protection from direct sunlight and moisture, proper security measures, and avoidance of storing materials on the ground.

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Store and pharmacy in the Ouidah Zonal Hospital; Photo Credit: Ghislaine Djidjoho Extended the use of MEDISTOCK to all 34 DRZs - Engagement of a MEDISTOCK programmer Updated MEDISTOCK Software to Version 4+ Training of MEDISTOCK Users In May 2013, a training was held for Medistock users in the Ouémé and Plateau departments. The session was attended by 25 participants (2 MCZS, 5 RAC/ ZS, 5 G/DRZ, 3 SASAC/HZ, 3 G / STOCK/HZ / CHD, 1 PF-PNLP/DDS-OP, 1 Statistician DDS and 5 others).

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Participants were informed on the theoretical concepts on the LIMS-ILP as well as on the use of the updated MEDISTOCK v4 + program. This allowed them to update MEDISTOCK / LMIS -ILP databases by recording movements of stock during the period of January through April 2013. At the end of this training, the 5 depot managers received an Internet USB key. This allows DRZ managers to connect to the platform MEDISTOCKWEB (www.medistockweb.org) from their posts by Internet. The Ouémé/Plateau session, held under the supervision of the NMCP-OP focal point and ARM3 Supply Chain Coordinator, took place in Abomey with a participation rate of 96%. This was the last in a series of 6 sessions for the 6 DDS, 34 DRZ and 27 hospitals. The table below presents the participants, including the HZs, Health directions, stock experts, statistics and others. A total of 193 health professionals were trained out of 205 identified with a sustained participation rate above 94%. Table 1: Health workers Trained on the updated MEDSTOCK Version 4+ software

ATLANTIQUE MONO/ BORGOU/ ATACORA ZOU/ OUEME/ All 6 Agents /LITTORAL COUFFO ALOBORI /DONGA COLLINES PLATEAU DEPT. Medic coordinator HZ (MCZS) 6 3 5 0 4 2 20 Charge de l'administration et 6 4 7 4 6 5 32 des ressources G/DRZ 7 4 7 5 6 5 34 C/SAAE/HZ+CHD 3 4 3 4 5 3 22 G/STOCK/HZ+CHD 2 5 7 6 5 3 28 PHARMACIEN/HZ+CHD 0 1 1 1 1 0 4 MA ou PF/PNLP/DDS 1 1 1 1 1 1 6 G/STOCK/CAME 0 0 0 1 0 0 1 STATISTICIEN/DDS 0 1 0 0 0 1 2 AUTRES 12 2 13 12 2 3 44 Number of Agents Trained 37 25 44 34 30 23 193 Number of Agents Identifies 41 26 46 32 36 24 205 Rate of Participation/DEPT. 90% 96% 96% 106% 83% 96% 94%

Graph 9: Participation of LMIS-ILP managers training on MEDISTOCK v4 +

100 90

80 70 60 50 40 30 Percentage (%) 20 10 0 ATLANTIQUE/ MONO/ BORGOU/ ATACORA/ ZOU/ OUEME/ ENS. 6 DPTS. LITTORAL COUFFO ALOBORI DONGA COLLINES PLATEAU

HommeMale Female

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Post training follow-up of MEDISTOCK users Following the training of managers involved in the management of LMIS-ILP on the in-depth utilization of the updated MEDISTOCK v4 +, a post-training follow-up was held to ensure the effective use of the software. Monitoring was conducted in 11 HZs within 2 departments, Atlantique / Littoral and Mono/Couffo. The monitoring team was composed of ARM3 project technicians and the departmental NMCP. This joint team visited 21 facilities (11 hospitals and 10 DRZ) and met with 33 managers. This monitoring focused on the following points: i) availability of the MEDISTOCK software v4 + ii) functionality of the MEDISTOCK software v4 + iii) control of MEDISTOCK software v4 + iv) updating the MEDISTOCK_ILP data base, v) export of MEDISTOCK_ILP data to the NMCP (DDS MS), vi) export of logistics data to www.medistockweb.org platform, and vii) completeness of monthly reports to the DRZ. Monitoring revealed the following findings: Table 2: Assessment of access to MEDSTOCK V4 + by DRZ and Hospitals Structures Availablity Functionality of Mastering of Update of Export of the data base of MEDISTOCK the software database MEDISTOCK_ILP vers MEDISTOC v4+ MEDISTOC MEDISTOCK le PNLP (DDS et/ou K v4+ K v4+ _ILP MS) ATLANTIQUE/LITTORAL DRZ Cotonou 1-4 Yes Yes Yes Yes No DRZ Cotonou 2-3 Yes Yes Yes No No DRZ Cotonou 5 Yes Yes Yes No No DRZ Cotonou 6 Yes Yes No No No DRZ AS Yes Yes No No No DRZ AZT Yes Yes Yes Yes No DRZ OKT Yes Yes Yes Yes No Perf. DRZ 100% 100% 71% 43% 0% Homel Yes Yes Yes Yes No HZ Suru-Lere Yes Yes No No No HZ Menontin No No No No No HZ Ab. Calavi Yes Yes Yes Yes No HZ Yesdah No No No No No Perf. HOPITAUX 60% 60% 40% 40% 0% Perf. 83% 83% 58% 42% 0% Atlantique/Littoral Mono/Couffo DRZ Ktl Yes Yes Yes Yes No DRZ Add Yes Yes Yes Yes No DRZ La Yes Yes Yes Yes No DRZ Come Yes Yes Yes Yes No Perf. DRZ 100% 100% 100% 100% 0% HZ Klouekanme Yes Yes Yes Yes No HZ Aplahoue No No No No No HZ Lokossa Yes Yes No No No HZ Come Yes Yes Yes Yes No CHD Mono No No No No No Perf. HOPITAUX 60% 60% 40% 40% 0% Perf. Mono/Couffo 77% 77% 67% 67% 0%

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These results show that with the ownership of MEDISTOCK v4 + by DRZ and Hospitals it is possible to improve the management of LMIS-ILP (42% AL and 67% MC). Nevertheless, it is necessary to update MEDISTOCK ILP and strengthen the transmission of databases to the NMCP. We expect an improvement in the level of ownership of MEDISTOCK v4 + in the coming quarters. Post-training follow-up continues in the next quarter in the four remaining departments. Table 3: Assessment of the level of use of MEDSTOCKWEB by DRZ over the last six months

Monthly export of the ILP database of the platform: www.medistockweb.org Storage Dispatchers Jan Feb Mar April May June COT 1-4 No No Yes No Yes Yes COT 2-3 No No Yes No No Yes COT 5 No No Yes No No Yes COT 6 No No No No No No AS No No No Yes Yes Yes AZT Yes No No No No Yes OKT No No No No Yes Yes Atlantique/Littoral 14% 0% 43% 14% 43% 86% ADD No No No No No Yes KTL No No Yes No No Yes Comé Yes Yes Yes No No Yes Lokossa No No Yes No No Yes Mono/Couffo 25% 14% 75% 0% 0% 100% We note in this table that during the first half of 2013, the DRZ gradually and slowly began sharing logistics data through MEDISTOCK web platform (www.medistockweb.org). A change in the proportion of DRZs who use MEDISTOCKWEB to exchange data between logistics management actors using LMIS-ILP can be observed in Graph 2 below. Graph 2: Proportion of DRZs exporting MEDISTOCK-LMIS (ILP) per month to the platform: www.medistockweb.org

100% 90% Atlqntiaue/Littoral 80% Atlantique/Littoral 70% Mono/Couffo 60% 50% 40%

Percentage 30% 20% 10% 0% Jan Févr Mars Avril Mai Juin Month

In June 2013, 86% of DRZs in the department of Atlantique-Littoral and 100% in the department of Mono- Couffo could export MEDISTOCK ILP database to the MEDISTOCKWEB platform.

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Identification of new participants for training in the use of MEDISTOCK v4 + During the feedback workshop for LMIS participants held in April 2013 in Lokossa, it became clear that not all those involved in the management of ILP were included in the previous training sessions. As a result, HZ Coordinators provided a list of new participants. The following table summarizes the number of new participants identified to participate in the MEDISTOCK v4 + training by department. Agreement between DPMED, PSF and ARM3 to develop a combined version of MEDISTOCK and Pharmeg In order to have a single common drug management software for Benin, DPMED has chosen the software MEDISTOCK to undergo an update so that it can be integrated with the PharMeg software. To this end, a preliminary version incorporating the two software programs, MEDISTOCK and PharMeg, has been developed by ARM3 and Pharmacists Without Borders 37. During this quarter, the discussions with PSF 37 on MEDISTOCK and PharMeg resulted in the: i) agreement on a timeline for the development of common software; ii) decision to operate the software to be developed, and iii) identification of specifications for the common software. This preparatory work is essential. The other problem faced is a rapid response in the acquisition of development tools (these are now defined). EUV survey in Oueme/Plateau ARM3 conducted the End Use Verification Survey, developed by PMI, to assess the availability and proper use of malaria commodities and to provide information by quarter that can be used for programmatic purposes. In order for the health system to benefit from the EUV, it was conducted with the NMCP and HZ Training teams (specifically those involved in the management of ILP, the management of malaria cases). It was financed and technically supported by ARM3. This survey was conducted from June 3 to 7, 2013 in the Ouémé-. The sample consisted of 20 structures as follows: 5 DRZ 3HZ and 12 health centers (2 or 3 CS by HZ). Key observations/recommendations of the EUVS and next steps:  80% malaria commodity managers and 93% of staff working in CCM were trained on stock management and new CCM guidelines, and 90% of visited facilities submitted their malaria commodities LMIS report on time.  5% of facilities have not presented AL the day of the visit. The high rate of health facilities with stocks-out of AL6, 12 and 18 on the day of the visit, can be explained by a specific request made during this quarter: use of overstocked quantities of AL24 for the treatment of malaria for all groups. This measure was taken to prevent the expiration of AL24. ARM3 strongly recommends that the NMCP base its estimates on the consumption data transmitted by the health facilities, through the LMIS monthly report for the next national quantification of malaria commodities. The LMIS currently has a high completeness rate (90%). ARM3 will monitor the next quantification exercise.  The national levels of RDT and SP are very low at the central level and at visited facilities. Therefore, we strongly recommended that all stakeholders involved in supplying RDTs and SP immediately deliver their projected quantities in order to maintain best practices (testing before treating, IPTp) observed during the study. Measures are being taken by USAID to correct this situation for SP (local emergency order).  54.6% malaria cases in patients under age 5 were not treated with ACTs. This is either due to the stock out of AL 1x6, leading to the prescription of AL6 which is available outside the health facility or the lack of funds and supervision for CM. In order to avoid future stock outs, the MOH is considering conducting procurement of a buffer stock for the NMCP from the PMI emergency fund.

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Results Indicator Baseline LOP Target PY2/Q3 Results Source/Comments Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened Sub-result 3.3: MoH capacity in commodities and supply chain management improved Available LMIS reports The national malaria All 34 DRZ report but not commodity supply chain Quarterly reports: all DRZ reports cover all is functioning with an 17) Number of quarterly and 34 of the health facilities LMIS that regularly annual reports generated by the -- under their supervision. provides quarterly and LMIS per year Annual Expected quarterly annual reports (4 reports: 0 reports for PY2: 4 quarterly and 1 annual Expected annual reports reports) PY2: 1 ≥85% of government health facilities have 80.3% ACTs available for 18) Percent of government health EUVS June, 2013 treatment of facilities with ACTs available for 87.6% Source uncomplicated malaria treatment of uncomplicated Sample size is limited to RMIS for patients of any age at malaria 15 HFs in Oueme-Plateau (FY11/Q4) any point in time covered by project-supported EUV surveys 77.3% ≥85% of health facilities RMIS results are from 18.a) Percent of health facilities Source report no stock-outs of 87.6% PY2/Q2 reporting no stock-outs of ACTs RMIS ACTs (Jan-Mar 2013) (FY11/Q4) ARM3 program reports Complete (100%) NB: Indicator implementation of reformulated to reflect reforms initiated in 19) Percent of facilities in reforms implemented 0% CAME so as to improved 0% compliance with CAME reforms within CAME in lieu of governance and CAME reforms transparency of its implemented by other operations facilities. Results from the EUVS are analyzed and used to 20) Percent of facilities that submit Results ARM3 program reports identify management and an action plan in response to the pending 0% Restitution to the health operational issues in the End-Use Verification Survey EUVS report zones has yet to occur commodity supply chain system Cross Sectional Activities The ARM3 BCC component supported the spread of information on the following focus areas during the quarter: (1) proper use of LLINs, (2) SP intake, (3) prompt care seeking, and (4) adherence to treatment and use of antimalarials. Key messages were disseminated regarding: the use of insecticide-treated nets; the importance of women attending antenatal care visits and the benefit of SP intake; the importance of diagnostics before taking medication; and promoting the use of ACTs. In order to increase knowledge, change attitudes and stimulate behavior change, ARM3 relied on several channels to reach and mobilize its audiences: Mass Media Broadcasting of Radio Programs: ARM3 radio programs have been expanded to reach more zones in the project catchment areas. As of today, ARM3 has developed a partnership with 8 local radio stations

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airing malaria programs in various formats including magazines, reality programs, and TV spots. The programs are facilitated by knowledgeable health providers recommended by the HZ Coordinators. The programs promote messages on LLIN use, the importance of ANC and benefits of SP use among pregnant women, proper diagnostics and treatment of severe malaria, and promotion of ACT use. Educational activities are the most used intervention under the ARM3 BCC strategy. Community awareness events and reality radio programs attract many beneficiaries who are able to learn about malaria while having fun at the same time. Community interventions are more effective when integrated into people’s local culture and practices.

Table 4: Local Radio Stations Radio stations Covered health zones Content/Format delivered Number of aired radio programs

Radio La Voix de Lama Allada, Ze, So Ava, Toffo, Tori, -Diagnostics 6 in French and 6 in Calavi, Mono, Zou and Oueme -Severe cases of malaria among Fon. Spot was (part) children broadcast 270 times. -ITN importance -Managing and maintaining ITN Radio Immaculee Allada, Ze, So Ava, Toffo, Tori, -Malaria 3 in French and 3 in Conception Calavi, Cotonou, Atlantique, -Prevention among pregnant Fon. Spot was Zou, Mono, Oueme, Plateau women broadcast 12 times. Couffo, Borgou. Partially -Simple malaria cases among Alibori, Atacora and Donga children Radio Collines FM de Dassa-Glazoue, Aklahonkpa, -Diagnostics 8 in Mahi and 7 in Glazoue Glazoue -Severe cases of malaria among Idaasha. Spot was children broadcast 30 times. -ITN importance -Managing and maintaining ITN

Radio Royale Pobe-Adja, Ouere, Ketou; -Diagnostics 6 in French and 5 in d’Abomey -Abomey- -Severe cases of malaria among Fon. Spot was children broadcast 44 times. -ITN importance -Managing and maintaining ITN Radio Kpasse Ouidah, Tori, Kpomassse, -Home care of malaria in children 6 in French and 6 in Allada, Calavi, Come, Grand -Importance of ITN use in fighting Fon. Popo malaria -Managing and maintaining ITNs Radio Deema Parakou, N’Dali, Perere, Nikki -What is malaria? ---Simple 15 in Bariba and 15 in (part), Tchaourou( part) malaria among children Peul. Radio spot -Prevention of malaria among broadcast 30 times. pregnant women -Severe case of malaria -Diagnostic. Radio de Banikoara Banikoara, Kerou (part), Kandi -What is malaria? 6 in Bariba and 10 in (part) -Simple malaria Peul. Radio spot -Prevention of malaria in broadcast 20 times. pregnancy -Severe malaria -Diagnostics Radio Kandi Kandi, Gogounou (part), -What is malaria? 12 in Dendi and 12 in Segbana (part), Banikoara (part), -Simple malaria Bariba. Radio spot (part) -Prevention of malaria in broadcast 30 times. pregnancy -Severe malaria -Diagnostics

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Reality shows held in Kandi, N’Dali and Baniokara Five reality shows widely attended by community members as well as local government and religious leaders were conducted in Kossarou (Kandi), Boko (N'Dali), Sonnou and Gah-Gur (Banikoara), with a total of 2,093 participants, 823 men and 1,270 women (73 men and 20 women politicians). Sixteen female volunteers were chosen to respond to questions posed by the radio host on the theme of “malaria prevention in children under five years of age and pregnant women (LLIN use and uptake of SP).'' All women received awards for their Demonstration of the benefits of sleeping under LLINs in Kassakou, Kandi participation.

Testimonies from the reality shows Mrs. Josiane Gagbehou, from Agbangnizoun Commune: “I did not care about using a LLIN with my child until one day he got sick with a high fever. I waited too long and my child got sicker. My husband and I spent a lot of money to save his life. After learning about malaria prevention, I began sleeping under an ITN with my child; he has not gotten sick since”. Dr Edith Djenomtin, Glazoue Medical Chief: “When ARM3 informed me about the community education event to be held in Sowignadji, I was very skeptical. I thought that ARM3 would simply give long talks to the community. I was pleasantly surprised by the interactive nature of the event that successful held the attention of the audience. I was very impressed by ARM3’s innovative way of educating the community on proper health care management”.

BCC Material ARM3 offices in Cotonou, Abomey and Parakou supported BCC cross sectional activities through the distribution of printed materials to health centers, partners and at community events. Table 5 summarizes the type of materials, quantities and recipients. Table 5: Distribution of BCC Material Material Partner Quantity Flyers CRS 9,000 DDS Borgou/Alibory, 10,000 A/L

Zou/Colline 34,529

Pamphlet (green color) DDS Borgou/Alibori 2,000 Banner PNLP 4 Kossarou health 1 center Kandi health zone 1 office T-shirts PNLP 100 DDS A/L 200 DDS B/A 200

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Material Partner Quantity Kakemonos ARM3 5 Pamphlet (pink color) DDS A/L 2,000

Flyers highlight the importance of using LLINs, IPTp, SP and ACTs. Pamphlets contained key information on malaria vectors, prevention and management while t-shirts promoted the International Malaria Day slogan, “Invest in the future: Defeat Malaria”. The Kakemonos aimed to inform the public about the partners within the ARM3 Consortium. Community Events As part of the ARM3 temporary BCC strategy to mobilize communities and increase the visibility of malaria prevention as recommended by the BCC working group, ARM3 supports partners in the organization of community education events. During this quarter, ARM3 supported three community events: 1. World Malaria Day in Cotonou on April 25, 2013. ARM3 supported the PNLP in organizing a conference by providing materials, and participating in a parade to promote healthy habits and malaria prevention. This parade started at the Ministry of Traditional and religious leaders attending the event in Parakou Health and ended at the soccer stadium. 2. Launch of Malaria International day in Parakou on May 2, 2013. In partnership with the Health Direction Department and the prefecture of Borgou and Alibori, ARM3 facilitated the launch of the event, aiming to: (1) educate the public through a community awareness event about malaria prevention and management; (2) obtain support from leaders for malaria control and prevention activities; (3) mobilize local media to disseminate information to the population. The community awareness event was conducted in the most populous and visited areas of Parakou and reached local traditional and religious landmarks.

An estimated 12,000 people were reached by this event. Different communication channels, including local radios as Radio Urban FM, radio ORTB, Radio Arzeke, radio Maranatha, and radio Deema reached an estimated 100,000 people. A short video of this activity was recorded and aired on the four Beninese TV channels.

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3. So Ava Boat Community event (May 29, 2013). ARM3 partner JHU-CCP conducted a boat awareness event in So-Ava with participation from authorities, health providers, NMCP officers, women’s association groups, boat owner associations and ARM3 representatives. This activity was oriented to educate people about malaria and to mobilize community leaders to support people’s effort, reaching an estimate of 2,000 people. Mobilization activities included visits to Ahomey, Houedo Gdabi, Vekky and Ganvie; where MOH representatives shared the importance of using the free diagnosis and treatment services offered at the public health facilities as part of the national policy. As part of the event, 1,000 pamphlets, 5,000 flyers and 200 T-shirts were distributed.

Testimonies from the World Malaria Day in Parakou Alassane Assanatou, retailer, 18: “This event marks a big day. I joined this parade out of curiosity. I learned a lot. Before today, my friends, parents, and I used to think malaria was caused by the sun or exposure to the rain. But today, I was delighted to learn that only mosquitoes cause malaria. I do not recall having heard similar messages in recent months. I do not have a radio nor do I have time to listen to it. I always wake up early in the morning and return home late each day. It was through this event that I learned that one needs to do a diagnostic to confirm malaria before taking medication. I will share this information with my peers and parents. My suggestion is to extend the sensitization to my parents living in Kobe, Yebouberi, and the surroundings on malaria vector”. Kora Azi, artist-painter, 40: “This event brings me joy because many youth do not believe in malaria before they become victims of the disease. They never take precaution and it is only when they are affected that they realize their mistake. Messages on malaria vectors were interesting, especially the fact that only mosquitoes transmit malaria. What I have also retained is to go immediately to the clinic or hospital for diagnostic and treatment anytime I have a fever. I believe that the caravan is a great idea. I have followed it and perceived its impact on people exposed to messages. I urge the team to continue to sensitize and go further in villages. Be aware that the majority of people in Parakou use roots and other powder to treat malaria, which is not appropriate. It means that community education is of paramount importance here”.

Women’s Group Association joined ARM3 to spread malaria prevention information to Community education led by health providers those who are constantly exposed to during the So-Ava community awareness event mosquito bites in So-Ava

Lessons learned:  Identifying and building upon local cultural and social events is very effective in disseminating malaria messages, facilitating outreach to marginalized communities .  A variety of methods such as the So Ava boat awareness campaign should be used for hard to reach communities and illiterate populations for more effective outreach.

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 Community mobilization is a successful approach, particularly in rural or hard to reach areas where there are no other forms of public awareness campaigns.  The involvement of departmental units (EEZ) leads to better operationalization of activities.

Testimonies from the BCC interventions in the So Ava Community Honfo Lamane, male, traditional Healer, 75, So Ava center: “Your presence reinforces our work to treat and cure diseases. The song by our local artist brought a new word to illustrate malaria. Rather than saying the “disease of sun”, the song says the “disease of mosquitoes”, this is very new to me. I really enjoyed that sketch on malaria prevention. What I will tell people back home is to protect their children and ensure that pregnant women take SP”. Agbenoukpon Justine, female, retailer, 27, So Ava Center: “This event shows that there are people who care about us. I was attracted by the music. I did not know that the mosquitoes live by taking out our blood. I have never used a LLIN before but starting today I have decided to buy one. I enjoyed the song and the sketch. I would recommend bringing us LLIN and SP”.

Assisting local NGOs in implementing community engagement activities Contracting with local NGOs in Littoral (Cotonou) Contracts were signed between 4 Littoral NGOs and ARM3 through Africare in April 2013. The first disbursement has been made available upon signature of the agreement. Through these partnerships, ARM3 expands its community engagement component with 354 additional Community Health Workers, totaling 234 communities with 594 community health workers in which ARM3 is active. The strategy of the NGOs in the department of Littoral includes: (i) social mobilization campaigns on malaria prevention (LLIN, IPTp) and treatment, (ii) a card tracking system to improve IPTp uptake, (iii) strengthening NGO capacity in supervision and follow-up of CHWs’ activities, (iv) strengthening the capacity of the CHWs through lessons learned sharing meetings, and (v) record keeping and information management. Selection of local NGOs in Zou-Collines The recruitment of NGOs in Zou and Collines was launched on May 13, 2013. Twenty three applications were received and analyzed by a review committee composed of ARM3, Africare, DSME and the Beninese NGOs implementing Health activities Network (ROBS) representatives. Twelve NGOs were shortlisted for the on-site visit and pre-award evaluation at the end of June 2013. Following the pre-award evaluation an assessment of the legal status, office space, personnel and staffing, cash and banking, accounting system audits, procurement procedures, equipment and inventory, was conducted. Six local NGOs (one per HZ) were selected as presented in the table below. Table 6: Local NGOs selected for the implementation of BCC activities in Zou-Collines

Department Health zones Selected NGOs

Zou Abomey Grafed

Bohicon La vie nouvelle

Cove Aldipe

Collines Dassa Odma Fndh Save Capid

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Orientation Workshop for Local NGOs The above mentioned six NGOs’ directors/program managers and their accountants participated in a two-day orientation workshop in Bohicon from June 27 to 28, 2013. The agenda included the review of the NGOs’ scopes of work and responsibilities, performance framework, work plan, budget, and proposed agreement to be signed with Africare. Local NGO Supervision and Supplying the NGOs and Participants at Zou-Collines local CHWs with Equipment NGOs orientation workshop A joint supervision of activities implemented by NGOs was conducted by ARM3 partners Africare and JHU-CCP from May 8 - 10, 2013 in Atlantique, Oueme and Plateau. During this visit, computers and accessories, cameras, cell phones, registers, communication materials and t-shirts were distributed to the NGOs and CHWs.

Delivery of equipment from ARM3 Partner, Africare to NGO Directors: Autre Vie NGO at Porto-Novo (left) and CERPADEC NGO at Ouidah (right)

Results Indicator PY2/Q3Target PY2/Q3 Source/Comments Results Cross sectional – BCC 12 signed agreements available; Selected 5 NGOs for ICCM activities in the five former Number of NGOs/CBOs BASICS health zones and 6 additional NGOs implementing community-based 18 12 oriented on their SOW in Zou/Collines in the BCC activities reporting period. Sub agreements are being finalized for signature. 674 (30x14 Atlantique, Number of CHWs implementing Ouémé- Plateau & 594 Reports from 12 active NGOs only community-based BCC activities Zou-Collines departments; 3x118 in Littoral) 420 (30x14 in Number of CHWs trained in Atlantique, Ouémé- 240 Reports from 12 active NGOs only malaria and BCC Plateau & Zou- Collines

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departments) Number of pregnant women referred to the health facilities for 1 302 722 Reports from 7 out of the 12 active NGOs IPT Number of LLINs in the 9 480 7 957 Reports from 7 out of the 12 active NGOs households Number of LLINs used in the 9 480 5 802 Reports from 7 out of the 12 active NGOs households Number of people who know ACT as the appropriate treatment for 14 160 5 872 Reports from 7 out of the 12 active NGOs malaria Number of children under the age of five referred to health facilities 594 288 Reports from 7 out of the 12 active NGOs for severe cases of malaria Number of home visits done by 9 480 5 487 Reports from 7 out of the 12 active NGOs CHWs Number of mothers or caretakers who have children under the age of 3 780 10 959 Reports from 7 out of the 12 active NGOs five and pregnant women educated through home visits Total number of people educated 18 960 21 063 Reports from 7 out of the 12 active NGOs through home visits Number of education session 594 440 Reports from 7 out of the 12 active NGOs performed by CHWs Number of mothers or caretakers who have children under the age of 2 010 6 760 Reports from 7 out of the 12 active NGOs five and pregnant women educated through groups sessions Total number of people educated Reports from 12 active NGOs 5 940 13 047 through group sessions

Program Management Field Office Under the direction of the Chief of Party and Technical Coordinator, the ARM3 FO technical and administrative team participated in meetings with the 2014 MOP Team, held 12 weekly ARM3 coordination meetings, participated in 3 monthly RBM meetings, interfaced with the MOH (NMCP, DSME and other offices), supported the activities of short term technical consultants, provided technical and logistical support for the implementation of activities described in this report, and prepared the ARM3 Quarter 7 report. Home Office Backstopping and Reporting Achievements MCDI HO: Technical/financial support and coordination HO support to Cooperative Agreement Modification: HO continued the review of the ARM3 Y2 WP and Budget as per the Mission´s request; addressed the MOP team’s request for clarification regarding additional activities included in the revised version of the WP (health facility survey, impact evaluation, drug efficacy testing, free drug policy assessment, training and accreditation of private sector drug sellers, printing IMCI registers, integration of EPI, Malaria, PMTCT and ANC registers); and developed a new Branding and Marketing Strategy to align with PMI requirements. iCCM Preparation: HO conducted the following activities in preparation for the inclusion of iCCM in ARM3’s WP: i) review and updated of the original proposal; ii) started the review of the Africare Sub-Award amendment and SOW related to iCCM, iii) began developing the MSH SOW and Amendment, iv) follow up with Medic Mobile and the ARM3 team regarding SMS reporting in the 5 HZs designated for iCCM.

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Coordination of the 2013 Health Facility Survey: MCDI’s HO is supporting the planning of the HFS to be carried out in September 2013 in coordination with the CDC and USAID Benin Mission. MCDI specifically supports: i) review of the protocol and questionnaires, ii) development of a budget with field staff, iii) translation of the protocol, iv) coordination with local experts, and v) development of ODK-based program surveys in tablets as part of ARM3’s strategy of introducing mobile technologies. Meetings and communication with ARM3 Consortium partners: MCDI HO held regular coordination meetings with partners (Africare, JHU-CCP and MSH), including ongoing programmatic aspects and discussing the roles of the partners for the implementation of the iCCM component. OTSS Round 12 Analysis: MCDI HO M&E Officer completed the OTSS Round 12 analysis based on data collected in 46 health facilities. HO and FO reviewed the new version of OTSS in order to ensure precise data outputs for this reporting. A full report in addition to key findings can be found in Annex 4. End User Verification Survey (EUVS): Discussed the approach to be followed in the implementation of the Quarter 7 EUVS with MSH, ARM3 support and agreed on the sample size (20 structures per quarter, up to the total of 80 structures by year), following PMI recommendations. Benin drug efficacy study: MCDI HO held communications with United States Pharmacopeia and CDC in order to asses on their availability to provide technical support for the implementation of a Drug Efficacy Study in Benin. USP is not available however has provided the contact of an organization supported by USP that could be made available in case of need. CDC was contacted by request of the mission and they shared their prior experience in conducting efficacy studies (budget and technical proposal). It was observed that the available funding won’t be sufficient for the implementation of this study and a preliminary agreement was reached in order to postpone it for FY 2014 or early 2015 while further funding is made available. MCDI HO STTA Ed Aldrich, MCDI Senior Program Manager, travelled to Benin from April 28-May 29, 2013 to step in as Acting COP during Lee Yellott’ s annual leave. Mr. Aldrich was responsible for the technical, administrative and financial management of ARM3. Victoria Ryan, International Health Program Associate, travelled to Benin from May 18-June 1, 2013 to support the supervision of the LLIN Social Marketing during the Private Sector Coordinator’s absence. Ms. Ryan, in collaboration with the NMCP, visited CEBAC-STP member companies participating in the LLIN distribution campaign to assess the status of distribution towards bringing Phase I to closure.

HUMAN RESOURCES/ Reorganization of ARM3 Staff at MCDI HO Pablo Aguilar, Senior Public Health-Malaria Program Officer, joined the ARM3 team after working with MCDI’s Bioko Malaria Control Project for 2 years. Dr. Aguilar will support the HO backstopping efforts of ARM3 as Program Manager working jointly with Joseph Carter, Director of MCD’s International Division, Lee Yellott, ARM3 Chief of Party and the rest of the ARM3 team. Kaj Gass, International Health Program Associate joined the MCDI HO team and will contribute to programmatic support of ARM3 as well as other MCDI projects.

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Africare HO Visits to Benin: Africare’s Office of Health and HIV/AIDS Director, Dr. Kechi Achebe conducted a visit to Benin from April 29 to May 3, 2013. One of Dr. Achebe’s objectives was to coordinate with Africare’s field staff and the ARM3 COP in order to strengthen the implementation of activities. JHU-CCP HO IPTp Barriers Study: Lead the field implementation of the study provided feedback and overviewed the development of the 1st report. Leadership in strategic communication course: Developed technical proposal and programmed the activity with prime. MSH HO End User Verification Survey (EUVS): Provided technical assistance for the development of the protocol, coordinated with donor and partners for the implementation and supported the development of the final report. iCCM Preparation: Supported the selection of a: i) iCCM Technical Advisor to support the implementation of iCCM from the Parakou office, and ii) Case Management Consultant to support the implementation of the CIA in the areas assigned to MSH.

49 | P a g e Major Activities Planned for next quarter (July – September):

RESULT 1: Implementation of malaria preventions in support of the National Malaria Strategy improved  Dissemination of the NMCP National Malaria Policy on MIP.  In country dissemination of the IPTp Barrier study and recommendations  Updated IPTp messages and materials based on the results of the IPTp Barriers study  Promote the institutionalization of the IPTp “integrated supervision tools” in to the MOH  Continue community BCC activities to support IPTp  Continue supervision rounds and retraining of midwives and nurses in IPTp  Submission of the interpersonal communication curriculum to prime  Implementation of the interpersonal communication training  Signing of MOU with FSS  TA for the implementation of activities outlined in the MOU by INMES and FSS  To continue the in service training of malaria in pregnancy  Closure and evaluation of the Phase 1 distribution round  Conduct debriefing workshop of Phase 1 and validation of the Phase 2 Plan  Re -start the LLIN BCC support activities, including the BCC campaign  Distribute LLINs to companies in the second phase  Retrain the health committees  Write TOR for a consultation on the cost effectiveness of the management of LLINs by insurance companies  Draft MOU for AMCES, ROBS and ACPB  Validate MOU and send to network partners for amendment and acceptance  Develop a proposal for activities to implement for the three networks  Plan approved activities for the representatives of the networks and NMCP  Assist the case management department by identifying private sector partners to be included in training

RESULT 2: Malaria Diagnosis and Treatment activities in support of the National Malaria Strategy improved  Disseminate SOP and Laboratory guidelines at national level  Conduct follow-up supervision to the training of biotechnologists in the departments of Ouémé-Plateau and Zou-Collines  OTSS Round 13 in the departments of Mono-Couffo, Atacora-Donga and Borgou-Alibori  In the field, supervise the activities outlined in the MOU in the departments Ouémé-Plateau and Zou- Collines.  Continue OTSS training and supervision activities  CM/IPTp Technical Working Group will be held.  Conduct follow-up supervision of activities outlined in the MOUs with the HZs.  Organize the learning group session for the Collaborative Approach in collaboration with the DDS and LDP team members.  Organize field visits to the HZs to monitor the start-up activities of « AC » by the health facilities included in group 2.  Continue implementing the IMCI and ETAT training plan  Follow up to DDS and HZs strategic operational plans

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 Conduct technical and financial supervision of underperforming DDS and HZs  Conduct follow-up supervision of the Collaborative Approach in the group 1sites.  Support the training of coaches on the collaborative approach and the placements of EAQ in the health facilities.  Support the calculation of baseline indicators for the third group and perform data collection and validation for the Collaborative for the first two groups.  Organize the first follow-up visit to LDP teams who attended the third workshop in Atlantique-Littoral and Ouémé-Plateau.  Organize the second follow-up visit to LDP teams who attended the third workshop in the Atlantique- Littoral and Ouémé-Plateau with the support of short term technical assistance.  Organize the fourth LDP workshop and present the LDP team’s results with the help of a consultant.  In coordination with the DSME conduct the clinical audits  Conduct meeting of the Case Management TWG to Promote the discussion of EPI, ANC, PMTCT and malaria registers at the Health Facility Level, and development of an implementation Plan coordination with PNLP, DSME and HIV/AIDS program  Hire a local coordinator for the training and registration of the private sector providers  Engage private sector (ROBS and AMCES) in the ARM3 private sector initiative  Provide funding to private sector partners for conducting trainings and workshops  Work jointly with other USAID in country collaborators at different levels to enhance the implementation of the private sector engagement initiative and assess the feasibility of innovative alternatives.  Continue to scale up the training on malaria diagnostics and treatment in health facilities  Sign contracts with 5 NGOs in the former BASICS HZs.  In country coordination of ARM3 iCCM technical teams and review of field work plans  Roll out of the iCCM component activities  Coordination with MOH, DDS and HZs participating in the project  Disbursement of funds to NGOs  Retraining of existing CHW and started the selection of new CHWs.

RESULT 3: The national health system’s capacity to deliver and manage quality malaria treatment and control  Support the organization of M&E TWGs  Support PITA mid-term implementation review  Quarterly nationwide RDQA at required levels  Provide refresher training of staff (SNIGS, DDS, HZs) on LOGISNIGS  Organize quarterly supervision of data collection sites  Pursue routine maintenance of LOGISNIGS databases  Publish RMIS quarterly newsletters (PALU INFO)  Organize meetings for quarterly validation of RMIS data in 34 HZs  Support the NMCP in its effort to disseminate the new PNLP1 form and train RMIS users  Semi-annual maintenance of LOGISNIGS within 34 HZs  Conduct the Health Facility Survey 2013  Conduct a therapeutic efficacy testing (under discussion with MOP-possible rollover into Y3 or Y4)  Start discussions with the MOH-NMCP for the implementation of a free treatment policy assesment  EUV in 20 health facilities in Borgou Alibori  On the job training for MEDISTOCK v4 users  Training of partners (CRS, and others) in MEDISTOCK v4

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 Assess and update the data collection tools MEDISTOCK  Support DPMED to develop a common software (MEDISTOCK and PharMeg) for drug management  Provide technical support to staff involved in the use of MEDISTOCK RESULT 4: CROSS SECTIONAL- BCC  Hold the leadership in strategic communication course from July 22 through August 2nd, 2013.  Validate the report on IPTp barriers and redesign SP messages.  Reproduce and distribute flyers  Review the interpersonal communication module and training  Develop a video drama for case management mistreatment  Support mass media campaign: supervising radios, revising current message content based on ITP barriers findings  Air TV spots on ITN and finalize the spot on SP before airing  Attend GTTC-BCC working group meeting  Follow up with the PNLP on the ARM3 BCC strategy  Reproduce PNLP music- video on malaria prevention and management  Participate in USAID review and IMCI meetings  Support to Savalou community festival.  Zou-Collines departments o Sign sub agreements with the 6 selected NGOs following MCDI approval of the sub agreements o Conduct the training of NGOs’ members on malaria and BCC approaches o Implement community BCC in selected communities  Select eight local NGOs in Mono-Couffo, Atacora and Borgou-Alibori departments to contract with in Year 3 (advertize the call for proposal, review applications, shortlist 16 NGOs, conduct on site visit and pre award evaluation, and select 8 local NGOs)  Sign sub agreements with the selected NGOs in BASICS former HZs and start iCCM implementation.

52 | P a g e Annex 4: OTSS Round 12 The OTSS Round 12 database includes about 40% of the health facilities added to the OTSS scheme under the ARM3 project. Supervisory responsibilities for the remaining 60% have been decentralized via MOUs to the Health Zones responsible for the health facilities in the Borgou-Alibori and Atacora-Donga Departments. The data presented within this report represent facilities from each of the 4 groups of health facilities added to the OTSS Quality Assurance Program (QAP) since the beginning of the Improving Malaria Diagnostics (IMaD) project and through the current ARM3 project. The last column of the figure just below shows the most up-to-date progression of the OTSS QAP in Benin for which data are available. In essence, this report presents data on the following:

 15 facilities from Group A (or 42% of the total of Group A) that have received 10 supervisory visits since 2009  9 facilities from Group B (or 39% of the total of Group B) that have received 9 supervisory visits since 2010  6 facilities from Group C (or 46% of the total of Group C) that have received 6 supervisory visits since 2011  18 facilities from Group D (or 39% of the total of Group D) that have received 4 supervisory visits since 2012 The analysis is not meant to compare data across these 4 groups (at least not in every case), but rather to show a subset of information from each of the larger groups that should, for the most part, stand alone in interpretation. The analysis of these data follows the prescribed indicators for OTSS in Benin. In some instances, line-by-line, detailed analyses were conducted to examine exact determinants of particular trends; otherwise, aggregate values (i.e. weighted averages and sums) were used when drawing conclusions/recommendations.

IMaD ARM3 Fiscal Year 2009 2010 2010 2010 2011 2011 2011 2012 2012 2012 2012 2013 Quarter 4 2 3 4 3 4 4 2 3 4 4 2 Round 1 2 3 4 5 6 7 8 9 10 11 12 1 36 (A) 24 (B) 13 (C) 46 (D) 2 36 (A) 24 (B) 13 (C) 46 (D) 3 36 (A) 24 (B) 13 (C) 46 (D) 4 36 (A) 23 (B) 13 (C) 18 (D) 5 36 (A) 23 (B) 13 (C) 6 36 (A) 23 (B) 6 (C) 7 36 (A) 23 (B) 8 36 (A) 23 (B) 9 36 (A) 9 (B)

Visits by Health Facility Groups Facility Health by Visits 10 15 (A) Cumulative Sites by 36 60 60 60 72 72 72 72 46 118 46 48 Round *Round 12 data are limited to only those facilities still under the supervisory purview of ARM3; complementary data from the Health Zones has yet to be retrieved.

Health Facility Resources The resources available to a health facility significantly influence the ability of laboratory staff and clinicians to effectively complete their tasks. This section is intended to present a picture of the resources currently available to health facilities. The resources evaluated include those that are most important for malaria diagnostics. Effective and timely diagnosis of malaria is the most important factor leading to positive treatment outcomes. Positive outcomes are significantly hindered by misdiagnoses, delays, stock-outs, and malfunctioning equipment (microscopes or RDTs). Indicators FY13 Targets % of Health Facilities with at least 1 Functional Microscope for Malaria Microscopy 100% of those observed % of Health Facilities Experiencing Stock-outs Interrupting Malaria Microscopy ≤ 5% of those observed % of Health Facilities Missing Recommended SOPs ≤ 50% of those observed 57 | P a g e

% of Health Facilities Missing Recommended Bench Aids 0% of those observed % of Health Facilities using RDTs that report no stock-outs of RDTs 100% of those observed Table 1: Total Microscopes vs. Percent of Functional Microscopes Proportion of Facilities Non- Ratio of Functional Functional Total with at least 1 Functional functional Microscopes (Average of Microscopes Microscopes Microscope for Malaria Microscopes Facility-Specific Ratios) Microscopy Group A Subset | Visit 10 36 4 40 92.6% 100.0% (n=15 | Facilities Reporting) Group B Subset | Visit 9 14 3 17 83.3% 100.0% (n=8 | Facilities Reporting) Group C Subset | Visit 6 10 2 12 75.0% 100.0% (n=6 | Facilities Reporting) Group D Subset | Visit 4 24 17 41 68.4% 100.0% (n=17 | Facilities Reporting)

Findings: Functional microscopes are vital to increasing volume of malaria microscopy completed and to ensure high quality of results. To monitor the level of functional microscopes, OTSS records the number of functional and broken microscopes which can then be used to calculate a ratio of functional microscopes.

 Every facility reported having a functioning microscope for malaria microscopy.  There are 6 facilities included in OTSS Round 12 that report having 1 functional microscope and no back-up microscopes.  Interestingly, the health facilities that have been involved in the OTSS QAP the longest have the highest quantity of functional microscopes.

Interpretation and Recommendations:  OTSS Supervisors may wish to begin recording the number of microscopes that are irreparable in order to better quantify the number of non-functional, but repairable microscopes (may require modifications to the checklist).  OTSS Supervisors may wish to begin noting the particular reasons why otherwise repairable microscopes are non- functional (may require modifications to the checklist).  While facilities with laboratories are a subset of the malaria diagnostic infrastructure in Benin, they play an important role in providing low cost, consistent confirmation of malaria diagnosis as well as allowing for speciation and evaluation of severity of illness. For these reasons, additional support should be given to continue to improve the ratio of functional microscopes and scale of microscopy in Benin. Percent of Health Facilities Experiencing Stock-outs that Interrupted Microscopy

Findings:  No facilities from any of the OTSS Groups reported stock-outs that interrupted their ability to perform malaria microscopy.

Interpretation & Recommendations:  It should still be reiterated to the supervisors conducting the OTSS QAP that stock-outs should only be noted if they cause interruptions to the normal practice of malaria diagnostics. For instance, if a facility reports a stock-out, the supervisor should follow-up to ensure the reported stock-out did indeed cause disruptions/interruptions to malaria microscopy and that the stock-out lasted for 7 or more consecutive days. If it did not then it should not be recorded as a stock-out.

Figure 1: Percent of Health Facilities Missing Recommended Malaria Reference Materials (SOPs & Bench Aids)

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Percent of Health Facilities Missing Recommended SOPs and Bench Aids 100.0% 90.0% 78.0% 80.0% 69.5% 70.0% 67.0% 65.0%

60.0% 54.0% 49.0% 50.0% 45.0% 40.0% 32.0% 30.0% 20.0% 10.0% 0.0% % of Health Facilities Missing SOPs % of Health Facilities Missing Bench Aids

Group A Subset - Visit 10 | (n=15) Group B Subset - Visit 9 | (n=9) Group C Subset - Visit 6 | (n=6) Group D Subset - Visit 4 | (n=18)

Findings: Malaria laboratory standard operating procedures (SOPs) and Bench Aids are recommended to be present in every lab conducting diagnostic testing. They provide reference tools on a range of laboratory tasks to help support high quality diagnostics. This is particularly important during times of staff turnover or when diagnosticians are required to work across multiple diagnostics tests in addition to malaria microscopy and RDTs.

 Due to the temporal nature of the data presented in Figure 2 (i.e. Group A having received reference materials well before Group D), one may be inclined to note, especially in the case of bench aids, that reference materials may be lost or destroyed over time. A more comprehensive analysis would need to be undertaken in order to determine if this is indeed a trend.  There are still a large number of facilities missing recommended SOPs and Bench Aids.  Currently, and only for Bench Aids do the subsets of health facilities from Groups A, B, and C satisfy the target for this indicator.

Interpretation & Recommendations:  The ARM3 project may consider, upon a more complete analysis, (re)distributing malaria diagnostic reference materials to facilities that have either lost previously distributed SOPs/Bench Aids or to those having never received them in the first place.

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Figure 2: Health Facility RDT Status RDT Status of Health Facilities 100.0% 100.0%

90.0% 83.3% 80.0% 77.8% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 25.0% 16.7% 20.0% 13.3% 10.0% 6.7% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% RDTs Used RDTs Used, but Out-of-Stock RDTs Not Used No Data

Group A Subset - Visit 10 | (n=15) Group B Subset - Visit 9 | (n=9) Group C Subset - Visit 6 | (n=6) Group D Subset - Visit 4 | (n=18)

Findings: Consistent and reliable RDT stocks are critical in the continued improvement of malaria diagnostics and movement to ensure confirmation of suspected malaria cases. Chronic RDT stock-outs lead to multiple problems including unfamiliarity of RDT procedures and mistrust of test results. It is imperative that supply chain and funding mechanisms continue their support to ongoing national malaria objectives.

 At least three-quarters of all facilities included in Round 12 of OTSS use RDTs.  No facilities that otherwise use RDTs reported being out-of-stock of RDTs.  One-quarter of facilities from the Group D subset do not use RDTs.

Interpretation and Recommendations:  OTSS supervisors should pay special attention to the proportion of facilities presented in the figure above that did not provide data. Each of the facilities included in the OTSS QAP should be able to provide a response at least on whether or not they use RDTs.

Training & Staffing Health facility personnel play a key role in implementing programs that are put in place to enhance the effectiveness of a health system. This section is intended to give an understanding of the personnel that are currently working throughout the health system. The information contained in this section can be used to identify facilities where on-the-job training will improve the quality of diagnosis.

Indicator FY13 Target Number of On-Site Trainings Conducted in Malaria Diagnostics 1 per OTSS visit per staff type

Number of Formal and Informal (On-site) Trainings Conducted in Malaria Diagnosis by Staff Type and Sex Information on formal and informal trainings is not yet available.

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Figure 3: Average Number of Laboratory Staff by Type Average Number of Laboratory Staff by Type 6

5.13 5 4.33

4 3.71 3.71 3.33

3

2.06 2 1.67 1.67 1.33 1.33 0.89 1 0.83

0 Average Full-time Staff Average Full-time Malaria Staff Average Full-time Diagnostics Staff

Group A Subset - Visit 10 Group B Subset - Visit 9 Group C Subset - Visit 6 Group D Subset - Visit 4 (n=15 | Facilities Reporting) (n=7 | Facilities Reporting) (n=5 | Facilities Reporting) (n=16 | Facilities Reporting)

Findings:  Full-time staff includes Biomedical Scientists, Laboratory Technicians, Laboratory Assistants, Students/Interns, and Nurses Aids.  The average full-time diagnostics staff recorded for Groups B and C is below 1 clearly indicating that at least a few facilities from each group do not have this type of staff present. In all other instances, at least 1 staff member of each type is present in each facility of each subset.

Quality Assurance Proper equipment, well trained personnel and effective quality assurance systems are essential for a properly functioning health system. The purpose of this section is to present information on the quality of malaria diagnostics and the efficient use of resources. This information can help determine how quality-of-care can be increased through improved diagnoses and identifying ways through which resources can be utilized more effectively. Quality assurance activities are also important for the overall improvement of laboratory and clinical staff. These activities enable staff members to assess how well they are currently doing and to set goals for their future improvement.

Indicator FY13 Target % of Facilities Performing Malaria Microscopy Using Appropriate Guidance 90% % of Facilities Performing RDTs Using Appropriate Guidance 95% % of Facilities Complying with Results of Negative Tests (RDTs & Blood Slides) 80% % of Facilities Performing Internal Quality Assurance Tasks (Overall Average Proportion of all 50% 8 IQA Tasks) % of Health Facilities Correctly Reading Malaria Microscopy Slides 100%

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Figure 4: Percent of Facilities Performing Malaria Microscopy Using Appropriate Guidance

Percent of Facilities Performing Malaria Microscopy Tasks Using Appropriate Guidance

100% 98% 96% 96% 95% 95% 95% 94% 93% 93% 93%

90% 90% 89%

85% 85%

80%

75% Slide Prep Avg Score Slide Reading Avg Score Combined Slide Prep/Reading Avg Scores

Group A Subset - Visit 10 Group B Subset - Visit 9 Group C Subset - Visit 6 Group D Subset - Visit 4 (n=15 | Facilities Reporting) (n=8 | Facilities Reporting) (n=6 | Facilities Reporting) (n=14 | Facilities Reporting)

Figure 5: Percent of Facilities Performing all Blood Smear (Slide) Preparation Steps Correctly (1st Observation Only)

Percent of Facilities Performing all Blood Smear (Slide) Preparation Steps Correctly

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

100% 93.3%

90% 85.7%

83.3% 78.6%

80% 75.0% 66.7%

70% 66.7%

62.5% 60.0%

60% 50.0%

50%

42.9% 42.9%

40.0% 37.5%

40% 35.7%

33.3% 33.3%

28.6%

26.7% 26.7%

30% 25.0%

20% 16.7%

10%

0% Patient/slide preparation Specimen collection Specimen collection Spreading thin films Spreading thick films Labeling Disposal of infectious Slide storage (fingerprick) (venepuncture) material

Group A Subset - Visit 10 Group B Subset - Visit 9 Group C Subset - Visit 6 Group D Subset - Visit 4 (n=15 | Facilities Reporting) (n=8 | Facilities Reporting) (n=6 | Facilities Reporting) (n=14 | Facilities Reporting)

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Figure 6: Percent of Facilities Performing Slide Staining & Reading Procedures Correctly (1st Observation Only)

Percent of Facilities Performing all Slide Staining and Reading Steps Correctly

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

100%

93.3% 93.3%

87.5% 87.5%

90% 85.7%

83.3%

78.6% 78.6% 75.0%

80% 75.0%

73.3% 73.3%

71.4% 66.7% 70% 66.7%

60%

50.0% 50.0% 50%

40% 33.3% 30% 20% 10% 0% Preparation of stain Staining - Giemsa Slide drying Slide examination Slide reading Result reporting Result delivery

Group A Subset - Visit 10 Group B Subset - Visit 9 Group C Subset - Visit 6 Group D Subset - Visit 4 (n=15 | Facilities Reporting) (n=8 | Facilities Reporting) (n=6 | Facilities Reporting) (n=14 | Facilities Reporting)

Findings:  The first observation is a better predictor of normal, day-to-day procedures carried out by the clinicians/laboratory technicians as subsequent observations are guided by the OTSS Supervisors in order to ensure that clinicians/technicians are avoiding mistakes made during previous observations.  The facilities included in the subset of Group D show the lowest level of performance across activities meant to gauge their ability to properly carry out malaria microscopy tasks.  In general, all facilities included in OTSS Round 12 are performing at a high level with respect to their ability to properly carry out malaria microscopy tasks.

Interpretation and Recommendations:  Representations (Figures 5 & 6) holding the facilities to the highest standard (i.e. showing only those facilities where all steps for each task were performed correctly) show that overall that there is still room for improvement across the two procedures.  From the figures above it’s clear where emphasis should be placed. In blood slide preparation, the majority of facilities were unable to perform all steps correctly for patient/slide preparation and specimen collection (venipuncture). In slide staining and reading, with the exception of slide drying, result delivery, and perhaps preparation of stain, technicians could benefit from more intensive supervisory guidance.  If laboratory technicians are systematically underperforming in certain areas of blood smear preparation and slide staining & reading, it may be due to their perception of unnecessary and therefore unperformed steps against which they are otherwise scored. OTSS supervisors should take care to explain the importance of neglected steps for each task presented above.  OTSS supervisors may wish to begin systematically recording the reasons for unperformed steps for each task by way of chronicling national malaria diagnostic trends. This exercise may lead to modifications to training procedures, bench aids & SOPs, or laboratory procurement practices.

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Figure 7: Percent of Facilities Performing RDTs Using Appropriate Guidance Percent of Facilities Performing RDT Tasks Using Appropriate Guidance 100% 92.0% 91.0% 88.0% 89.3% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Group A Subset - Visit 10 Group B Subset - Visit 9 Group C Subset - Visit 6 Group D Subset - Visit 4 (n=9 | Facilities Reporting) (n=8 | Facilities Reporting) (n=5 | Facilities Reporting) (n=11 | Facilities Reporting)

Figure 8: Percent of Facilities Performing all RDT Steps Correctly (1st Observation Only)

Percent of Facilities Performing all RDT Steps Correctly

100.0% 100.0% 100.0% 100.0% 100.0%

100%

88.9% 88.9% 87.5%

90% 87.5%

81.8% 80.0%

80% 77.8%

72.7% 72.7%

70%

62.5% 62.5%

60.0% 60.0% 60.0% 55.6%

60% 55.6%

54.5% 50.0%

50% 44.4%

40% 27.3%

30% 25.0%

20%

10% 9.1% 0.0% 0% RDT preparation Patient preparation Blood collection + dispensing RDT procedure + reading Recording results Disposal of infectious material Result delivery results

Group A - Visit 10 Group B - Visit 9 Group C - Visit 6 Group D - Visit 4 (n=9 | Facilities Reporting) (n=8 | Facilities Reporting) (n=5 | Facilities Reporting) (n=11 | Facilities Reporting)

Findings:  Overall, facilities have shown high levels of performance when administering RDTs.  When being observed for administering an RDT, the first observation is a better predictor of normal, day-to-day procedures carried out by the clinicians/laboratory technicians as subsequent observations are guided by the OTSS Supervisors in order to ensure that clinicians/technicians are avoiding mistakes made during the immediately preceding observations.  Only in result delivery have technicians shown to perform at the highest level across all OTSS Groups.  The lowest performing categories of administering RDTs to patients are RDT preparation, RDT procedure and reading results, and patient preparation.

Interpretation and Recommendations:  The representations (Figures 7) holding facilities to the highest standard (i.e. showing only those facilities where all steps for each task were performed correctly) show that overall that there is still room for improvement in RDT administration.

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 OTSS supervisors may wish to begin systematically recording the reasons for unperformed steps for each task by way of chronicling national malaria diagnostic trends. This exercise may lead to modifications to training procedures or bench aids & SOPs.

Figure 9: Percent of Facilities Complying with Results of Negative Malaria Tests vis-à-vis Prescription Practices Prescriber Adherence to Negative Test Results

100%

92.0% 92.0%

87.0% 87.0%

90% 86.0% 84.0%

80%

74.0% 72.0%

70%

60.1%

60.0% 59.5% 60% 58.8%

50%

40%

30%

20%

10%

0% RDT Adherence Blood Slide Adherence Overall Adherence (n=10 | n=8 | n=6 | n=11 | Facilities Reporting) (n=14 | n=3 | n=5 | n=11 | Facilities Reporting) (RDTs & Blood Slides)

Group A Subset - Visit 10 Group B Subset - Visit 9 Group C Subset - Visit 6 Group D Subset - Visit 4

Table 2: Frequency and Percentage of Treatments Prescribed to Negative Tests Coartem Total % Coartem Fansidar Total % Fansidar Quinine Total % Quinine Group A - Visit 10 (n=15 | Facilities Reporting) 8 57.1% 0 0.0% 6 42.9% Group B - Visit 9 (n=9 | Facilities Reporting) 5 100.0% 0 0.0% 0 0.0% Group C - Visit 6 (n=6 | Facilities Reporting) 0 0.0% 0 0.0% 3 100.0% Group D - Visit 4 (n=18 | Facilities Reporting) 3 9.4% 0 0.0% 29 90.6%

Findings:  Overall, Groups A and C show relatively high levels of adherence to negative RDT and blood slide tests. Group D, the newest group to the OTSS QAP, shows the lowest level of adherence.  Prescription practices for negative tests, while not recommended in the first place, show a high level of variability with respect to national treatment guidelines – a proxy indicator of how positive test cases may be treated.

Interpretation and Recommendations:  OTSS supervisors must continue to stress the importance of adhering to negative malaria test results vis-à-vis the appropriateness of writing scripts for antimalarials and how this outcome figures in to the overall process of differential diagnosis.  Further, supervisors should continue to point out that Quinine prescriptions are not in line with the malaria treatment guidelines for Benin. Prescribers should be equipped with the appropriate information concerning treatment guidelines and given strategies to dissuade clients from requesting an antimalarial medication that is not recommended by the government of Benin.

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Figure 10: Percent of Facilities Performing Internal Quality Assurance Tasks

Percent of Facilities Performing IQA Tasks

100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

100%

93.3%

88.9% 88.9% 88.9%

90% 86.7%

81.3% 77.8%

80% 75.0%

70% 62.5%

60%

50.0% 50.0% 50%

40%

31.3% 26.7%

30% 26.7%

22.2%

20.0% 16.7%

20% 16.7%

13.3%

12.5%

11.1% 11.1%

10% 6.3%

0.0% 0.0% 0.0% 0% Positive Control Slides pH Meter Calibration with Slides Re-checked Slide Results Recorded Slides Stored for Slides Stored in Slide Boxes Species ID Routinely Parasite Counting Available for Testing Known Standards and Documented by in QA Register Re-Reading Performed Routinely Performed new Batches of Stain Laboratory Staff

Group A Subset - Visit 10 | (n=15) Group B Subset - Visit 9 | (n=9) Group C Subset - Visit 6 | (n=6) Group D Subset - Visit 4 | (n=16)

Findings:  Of the 8 IQA tasks presented above, the majority of facilities included in OTSS Round 12 show very low levels of compliance with respect to half of the promulgated tasks which include positive control tests on new batches of stains, calibrating pH meters with known standards, performing internal quality assurance measures on stained slides (rechecking and recording results), and documenting slide results from these IQA measures in a QA register.  Amongst the last 4 tasks presented in the figure above, Group D, the newest Group to enter the OTSS QAP, shows the lowest level of compliance in each. Group C facilities are all in compliance with these IQA tasks.

Interpretation and Recommendations:  There is much work to be done to ensure that more facilities begin implementing their own IQA measures in the interim period between quality assurance visits from the OTSS supervisors.  The OTSS supervisors should continue to encourage and instruct facility/laboratory heads on the importance of starting up IQA measures in their facilities.

Figure 11: Agreement, Sensitivity and Specificity for Blood Slide Cross-Checking Agreement, Sensitivity & Specificity for Blood Slide Cross-Checking

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.0% 99.0% 100% 98.0% 97.0% 96.0% 95.0% 95%

90%

85%

80%

75% % Agreement between Supervisors and Malaria Sensitivity Specificity Microscopists

Group A Subset - Visit 10 Group B Subset - Visit 9 Group C Subset - Visit 6 Group D Subset - Visit 4 (n=15 | Facilities Reporting) (n=8 | Facilities Reporting) (n=6 | Facilities Reporting) (n=12 | Facilities Reporting)

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Findings:  The results of the slide cross-checking component of the QAP are very good and the participating facilities/technicians are maintaining relatively constant levels of high performance for slide agreement, sensitivity and specificity – all are registering in the mid to high 90th percentiles according to the most recent OTSS data and Groups C and D show perfect agreement with OTSS supervisors.

Interpretation and Recommendations:  OTSS supervisors should stress to laboratory heads the importance of storing at least 10 malaria slides for quality assurance purposes. If OTSS supervisors find that some of the stored slides are improperly prepared and are not appropriate for re-checking, they should encourage facilities to store more than 10 slides.  There is still work to be done in encouraging all facilities to participate in each component of the QAP and to the recommended extent.

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