Quarterly Progress Report- Year 2, Quarter 3 April - June 2018

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3)

CAMBODIA MALARIA ELIMINATION PROJECT

Cambodia Malaria Elimination Project

Quarterly Progress Report- Year 2, Quarter 3 April - June 2018

Submission Date: July 30, 2018

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

Submitted by: Sharon Thangadurai, Chief of Party University of Research Co., LLC. House #10, Street No. 214, Sangkat Cheychumneas, Khan Duan Penh, Phnom Penh Email: [email protected]

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

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3)

TABLE OF CONTENTS

TABLE OF CONTENTS ...... iii

Acronyms ...... iv

1. Introduction ...... 1

2. Progress Toward achieving CMEP OBJECTIVES ...... 2 2.1 Objective 1: Develop a scalable, evidence-based elimination model in SPL OD and support its dissemination and replication for malaria elimination in Cambodia...... 2 2.2 Objective 2: Support scale-up of high quality malaria control and prevention interventions in five to eight ODs, where gaps in coverage or quality exist...... 8 2.3 Objective 3: Strengthen national malaria surveillance systems and M&E appropriate for malaria elimination and control activities ...... 14 2.4 Objective 4: Build capacity of Ministry of Health (MOH) to manage, intensify, and sustain malaria control and elimination efforts particularly at the OD level ...... 16

3. Project Management ...... 18 Oversight and Coordination ...... 18 Procurement ...... 20 Financial Management ...... 20 Human Resource Management ...... 21

4. Resolving challenges from FY18 Q2 ...... 23

5. Challenges and actions taken or proposed ...... 23

6. Plans for next Quarter and upcoming events ...... 24

i Cambodia Malaria Elimination Project Quarterly Report (FY18Q3)

ACRONYMS

ACT Artemisinin-based Combination Therapies AOP Annual Operational Plan SBCC Social and Behavior Change Communication BKN Bakan BTB Battambang CAP-Malaria Control and Prevention of Malaria CMEP Cambodia Malaria Elimination Project CBO / CSO Community Based Organization / Civil Society Organization CDC Centers for Disease Control and Prevention CNM Cambodia National Malaria Center COP / DCOP Chief of Party /Deputy Chief of Party COR Contracting Officer’s Representative EDAT Early Diagnosis and Treatment GSSHealth Global Scientific Solutions for Health GUC Grants Under Contract HF Health Facility HPA Health Poverty Action IDQA Internal Data Quality Assessment IPC Interpersonal Communication ITN Insecticide-Treated Net KKR Krakor LLIN / LLIHN Long Lasting Insecticidal Net / Hammock Net M&E Monitoring and Evaluation MC Malaria Consortium MEAF Malaria Elimination Action Framework 2016-2020 MMP Mobile and Migrant Populations MMW Mobile Malaria Worker MoH Ministry of Health MOP Malaria Operational Plan MRS Maung Russey NAMRU-2 Naval Medical Research Unit-2 OD / ODMS Operational Health District / OD Malaria Supervisor PERSUAP Pesticide Evaluation Report and Safer Use Action Plan PHD / PMS Provincial Health Department / Provincial Malaria Supervisor PKV Phnom Kravanh PLN Pailin PMI President’s Malaria Initiative PP Private Provider PPM Private Public Mix PMP Performance Management Plan PSK Population Services Khmer RDT Rapid Diagnostic Tests STA Senior Technical Advisor SOP Standard Operating Procedure SPL Sampov Loun TMK Thmar Kaul UNOPS United Nations Office for Project Services URC University Research Co., LLC USAID United States Agency for International Development VMW Village Malaria Worker VHSG Village Health Support Group WHO World Health Organization

i Cambodia Malaria Elimination Project Quarterly Report (FY18Q3)

1. INTRODUCTION The USAID | PMI Cambodia Malaria Elimination Project (CMEP), 2016-2021, was launched on October 26, 2016 to support the Cambodian National Center for Malaria Control, Parasitology and Entomology (CNM) to reduce malaria morbidity and mortality and contribute towards malaria elimination goals nationwide by 2025. To reach this goal, the project has set up four strategic objectives to: 1. Develop a scalable, evidence-based elimination model in Sampov Loun OD and support its dissemination & replication for malaria elimination in Cambodia. 2. Support scale-up of high quality malaria control and prevention interventions in five to eight ODs, where gaps in coverage or quality exist. 3. Strengthen national malaria surveillance systems and monitoring and evaluation (M&E) appropriate for malaria elimination and control activities. 4. Build capacity of malaria program to manage, intensify, and sustain malaria control and elimination efforts particularly at the OD level. Until Year 2 Quarter 2, CMEP implemented activities in four ODs in Battambang Province (Sampov Loun (SPL), Battambang (BTB), Maung Russey (MRS), Thmar Kaul (TMK)) and two ODs in Pursat Province (Phnom Kravanh (PKV) and Krakor (KKR)). During FY18 Quarter 3 (April to June 2018), CMEP expanded to three additional ODs (two ODs in Pursat Province: Bakan and Sampov Meas, and 1 OD in Pailin Province: Pailin OD). Three transitional ODs graduated to elimination ODs (BTB, MRS and TMK), and Pailin initially started as an elimination OD. See Figure 1. CMEP’s work in all 9 ODs started on 1 May 2018. As the transition did not commence until 1 May 2018, the report also provides activity progress for April for the initial 6 target ODs. There are some limitations with data collected in the new ODs due to human resource issues, tool training/orientation and readiness of government counterparts In all 9 ODs, CMEP conducted the following activities in Q3: . Provided support to a network of health facilities (HFs), village/mobile malaria workers (V/MMWs) and private providers (PPs) in case management and malaria surveillance through regular meetings and supervision visits. . 18393 of suspected cases tested with 5122 positive cases confirmed and all cases received appropriate treatment according to National Treatment Guidelines. . Overall, in 4 elimination ODs in Battambang province, 57% of cases were notified in 1 day (SPL=100%), 35% investigated within 3 days (SPL=100%), and 25% responded to within 7 days (SPL=100%). . CMEP responses to Pursat ODs situation in Q3 including cross checking data, updating the cases daily and weekly, intensifying services at all points of care, the setting up of touchpoint and peer educator volunteers (for Phnom Kravanh and Krakor ODs) . Due to the changes in PRAKAS (Ministerial order) for PP testing and treating restrictions, CMEP along with counterparts enforced the PRAKAS in bi-monthly meetings, and more emphasis was given on reference and BCC activities. . Continued LLIN and LLIHN mass distribution to villages with an annual parasite incidence (API) >5 per 1,000 population covering 295 villages with 62,563 nets distributed in 9 ODs, 44,952 LLINs and 17,611 LLIHNs. . Conducted systematic administration of single low dose primaquine for confirmed P. falciparum (Pf)/mixed cases treating 297/420 (70.7%) of cases in 6 target ODs.

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3)

. Provided a five-day entomology training for 10 HF staff and 20 VMWs as entomology field technicians . Supported CNM technical unit to conduct 27 planned supervision visits to 9 ODs

PITTfinalQ3.xlsx Progress against each performance indicator is presented in the file attached. Figure 1. CMEP Summary of Activity Progress (April-June 2018)

2. PROGRESS TOWARD ACHIEVING CMEP OBJECTIVES 2.1 Objective 1: Develop a scalable, evidence-based elimination model in SPL OD and support its dissemination and replication for malaria elimination in Cambodia. *Note on Objective 1 reporting: Progress is reported for the 5 elimination ODs where possible (although very few activities have started in Pailin OD). For some activities, SPL OD is reported separately, especially where there is insufficient data for the new elimination ODs. Task 1. Pre-implementation situational analysis of current malaria elimination operations in SPL:

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3)

Rapid Situational Analysis and Needs Assessment Report1: Situational Analysis was undertaken for Pailin OD and submitted in Q3 which is currently under review. STTA, Edward Broughton, arrived on 23 April 2018 for the elimination costing analysis. The final draft of the elimination costing analysis report was submitted to USAID/PMI in Q3. The report will be disseminated to CNM and partners upon finalization/approval by USAID/PMI. Task 2. Sustain universal long-lasting insecticidal net (LLIN) coverage: Mass distribution: In support of the CNM/Global Fund/UNOPS initiative for a nationwide ITN mass distribution campaign, in FY18 Q3, CMEP continued supporting the distribution of ITNs to target populations in 92 villages (API >5) in the 5 elimination ODs. Table 1 shows the breakdown of mass distribution in the 5 elimination ODs in Q3. Distribution is based on the CNM established national ratio (1 net per 1.8 persons for residents, 1 net per 1 worker for MMPs). The 5 elimination ODs received 102,950 ITNs (74,650 LLINs, and 28,300 LLIHNs) from CNM for mass distribution in 2018 for both residents and MMPs. By the end of Q3, all ITNs (102,950) were distributed. Table 1: Breakdown of ITN mass distribution in 5 elimination ODs, April – June 2018 (all ITNs were distributed in April 2018) OD LLINS Distributed LLIHNS Distributed Total ITNs Distributed SPL 850 54 904 BTB 1,100 450 1,550 MRS 14,100 5,280 19,380 TMK 0 0 0 PLN 0 0 0

Ensure continuous distribution of LLINs: In line with the updated list of villages for ITN distribution, CMEP’s target for continuous LLIN distribution was 262 villages in the 5 elimination ODs [Act 1.2.3]. In the 5 elimination ODs, CMEP deployed 27,000 ITNs as buffer stock to VMWs in Q3 (target is 20550). CMEP will further deploy ITN’s in Q4, using USG- purchased ITNs. CMEP distributed 7,207 ITN’s (vs. 10938 planned) to target populations during outreach and response activities [Act 1.2.5]. Net top up and malaria education to households: In the 5 elimination ODs, VMWs conducted 2,553 (70% of Q3 target; 3,642 visits) visits to households for net use monitoring, net top-ups and health education [Act 1.2.6]. As a result, 37,564 household members received health education for malaria prevention and LLIN use. 4 supportive supervision visits were conducted by the CNM ITN Unit to the 5 elimination ODs (2 trips to 4 BTB ODs except Pailin). Task 3. Ensure Early Diagnosis and Treatment (EDAT) and follow up: In SPL OD, CMEP activities covered 244 points of care in Q3 [Act. 1.3.1]. In SPL, all 3,436 (100%) suspected malaria cases received a parasitological test. Just over half (58%) of individuals were tested by VMWs, 13% by HFs and the remaining 29% by PPs. Out of all individuals tested, 29 cases (100%) were confirmed positive. All 29 cases notified in SPL were imported cases (see Figure 2 for the case distribution map). 16 cases (55%) were imported from Pursat, 3 (10%) from Thailand and the rest from other provinces in Cambodia. 6 Pv cases were linked to previous cases that were classified as imported during the previous malaria episode. Out of

1 Activity 1,1.1. was completed in Year 1 and is not applicable to the FY18 Q3 reporting period

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3)

29 positive cases, 8 (28%) were Figure 2. Map of reported malaria cases by origin in SPL OD, Pf/mixed and 21 (72%) were Pv Apr-Jun 2018 (Figure 3). Most cases (90%) were among males (26 male, 3 female). The highest number of cases were notified in Kamrieng district (14) compared to Phnom Prek (8) and Sampov Loun (7) districts. Figure 3. Number of confirmed malaria cases in SPL, BTB, MRS and TMK OD’s per species from Oct-2016-Jun 2018 (source MIS/PMIS)

In SPL, 29 out of 29 positive cases (100% versus 86% for the whole of FY17 Year 1) received three DOT (Figure 4). For BTB it was 48/96, (50%), for TMK it was 8/17, (47%), for MRS it was 82/106, (77%). The reasons why BTB, TMK and MRS were less than 100% was due to patient movement (the patients not being physically available for day 3 follow up) and for those cases detected and treated mainly at HF’s were often staff were not available to conduct the 3 day follow up. OD teams are making HF staff more aware of the need to conduct 3-day follow up in the elimination setting should help improve the number of day-3 follow-ups at HFs in the ODs. [Act 1.3.2]. In SPL, DOT treatment in line with NTGs was 100% at HFs and 100% by VMWs. Of the total 29 cases, 8 were Pf/mixed. All 8 Pf/mixed cases were reached through reminder messages via the mHealth application and were automatically transferred to a response team to conduct 28-day follow up. 5 patients out of 8 (63%) received 28-day follow- up (2 of the cases missed the follow up, and 1 other will be followed up in July). For BTB it was 9 out of 19 Pf/Mix. For TMK, it was 1 out of 1 Pf/Mix. For MRS, it was 2 out of 24 Pf/Mix. The reasons why BTB and MRS ODs were lower, were a) patient movement, b) this activity

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3) newly starting in the OD in Q3, and there being relatively low commitment from government counterparts during this period c) slowdown on this activity in the ODs in June due to delays in getting the required approval from RGC for CMEP (however, this issue was eventually overcome at the end of Q3). [Act. 1.3.3]. For VMW visits to patient’s homes for SLDPQ side effects monitoring on day 7 it was 275/297 (92.6%) for 6 target ODs (out of 9 ODs as SPM, BKN and PLN as this activity had not been started in these ODs – this will happen in Q4 FY18). [Act 1.3.4] Figure 4. Implementation of DOT in SPL OD per species (*data fully available Pv, partially Pf)

100% 80% 60% 40% 20% 0% Jan Jan Jun Jun Oct Oct Apr Apr Feb Sep Feb July Dec Dec Nov Nov Mar Mar May May August 2016 2017 2018

Pf/Mix Pv

In Q3, no patients were hospitalized for 2nd line treatment in the 5 elimination ODs [Act 1.3.6]. CMEP provided orientation training to government staff in the 5 ODs (27 HF staff in May at Pailin) and emphasized the use of single low dose primaquine (SLD-PQ) in VMW meetings and for HF staff. All 8 Pf/mixed cases diagnosed in SPL received SLD-PQ treatment (100%), and 8 cases received 7-day follow up. No significant SLD-PQ adverse events were notified. In the four new elimination ODs, out of 50 Pf/mixed cases diagnosed in Q3, 32 Pf/mixed cases received SLD-PQ treatment and 11 cases received 7-day follow up (other cases were not available for the 7-day follow up). No significant SLD-PQ adverse events were notified. There were no case management trainings conducted for heath facility staff in the 5 elimination ODs as they were trained in previous quarters. Regarding the 16 planned trainings for Pailin, due to Global Fund still being active in Pailin, CMEP project in Q3 was not operational as yet. Further discussion with CNM has directed CMEP to implement from mid-July thus the case management training will happen in Q4 for Pailin. CNM pharmacy, lab and diagnosis and treatment units completed 4 supervision visits (versus 5 visits planned) for Q3. [Act. 1.3.10] Task 4. Malaria case reporting, investigation, and response For SPL OD, in Q3, 29 out of 29 cases (100%) were notified within 1 day via the SMS Day-0 mHealth system, investigated within 3 days and response provided within 7 days [Act.1.4.1- 1.4.3]. All HFs and VMWs followed the established 1-3-7 surveillance practice. Table 2 below provides a summary of the elimination OD progress for key activities for Task 3 and Task 4.

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3)

For the four new elimination OD, 113 out of 219 cases (52%) were notified within 1 day via

Task 3. Ensure EDAT and follow-up

Activity SPL BTB TMK MRS PLN 4 Activity No. OD OD OD OD OD ODs (%) Support VMWs visits to patient’s homes 29/29 48/96 8/17 82/106 N/A 68.5% 1.3.2 for completing 3 days DOT for all treated (100%) (50%) (47%) (77%) cases Support VMWs trips to patients on day 0 5/8 9/19 1/1 2/24 N/A 54.6% 1.3.3 day 7 and day 28 for treatment follow up (62.5%) (47.4%) (100%) (8.3%) for of Pf/Mix cases Task 4. Implement malaria case reporting, investigation, and response Activity SPL BTB TMK MRS PLN 4 ODs (%) Activity No. 100% 57% 100% 39% N/A 74% Notification within 1 day of all malaria 1.4.1 cases by HF staff & VMWs (SMS Day-0 Alert System/Geotagging related cost)

Investigation within 3 days of all malaria 100% 36% 71% 11% N/A 54.5% 1.4.2 cases by response team (OD, HF, VMW & village chief) Response within 7 days to all malaria 100% 27% 29% 3% N/A 39.8% 1.4.3 cases by response team the SMS Day-0 mHealth system, 60 out of 219 cases (27%) were investigated within 3 days and 34 out of 219 cases (16%) response provided within 7 days [Act.1.4.1-1.4.3]. In quarter 4, during VMW and OD/HF meetings, CMEP will emphasize the practices of 1-3-7 surveillance. Overall, for the 4 elimination ODs in Battambang province, 57% of cases were notified in 1 day (SPL=100%, BTB=57%, MRS=39%, TMK=100%), 35% investigated within 3 days (SPL=100%, BTB=36%, MRS=11%, TMK=71%), and 25% responded within 7 days (SPL=100%, BTB=27%, MRS=3%, TMK=29% ). The reasons why BTB, MRS and TMK OD’s had lower notification, investigation and response percentages than SPL were a) the starting of these new activities in Q3 (and staff not being fully familiar with the 1-3-7 strategy), and b) the SMS system still not functioning well in the elimination ODs including delays of up to 24 hours for the mobile supplier to send the required messages for the apps. These activities can be improved with further familiarization of OD staff with 1-3-7 surveillance and by OD staff following up/checking on cases via phone calls (like for SPL OD). Task 5. Strengthen case management, reporting, and response to all malaria cases in the private sector The CMEP PP/public-private mix (PPM) status has changed since the introduction of the MOH PRAKAS (this is a MOH legal regulation) for PPs in Q3. PPs can no longer test or treat any patients in the ODs. The CMEP team updated the list of PPs in the 5 elimination ODs with 234 PPs enrolled in the PPM [Act.1.5.1]. PP bi-monthly meetings and bi-monthly supervision will continue in CMEP target ODs. Bi-monthly meetings were conducted in May 2018 as planned with the participation of 98% of PPs (229/234) [Act 1.5.3]. HF/OD staff provided two bi- monthly supervision visits to 52 PPs in SPL in April, and 172 PPs in all 5 elimination ODs in May and June 2018. PPs visited were either absent from bi-monthly meetings or are having performance issues. The purpose of the supervision visits was to provide technical feedback on referrals and improve BCC initiatives. 92 (94%) visits were accomplished (versus 98 planned) for all 234 private providers [Act 1.5.4]. The number of visits was below the target because

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3) visits to PPs in PLN OD were not conducted as planned. 1 supervision visit from CNM’s PPM unit was conducted in Q3 to SPL & MRS (although no supervision visits were planned for Q3). Task 6: Build capacity and strengthen systems to manage elimination activities2 Supporting VMW monthly meetings: Monthly meetings continued in Q3 to support capacity building of VMWs and HF staff. Meetings were held during the fourth week of April, May, and June. In April 2018, 147 VMWs from SPL attended the monthly meeting (from a total of 168 VMWs in SPL). In Q3, for 4 ODs, 771 VMWs attended meetings versus 1,321 planned in Q3 (58% target achieved for 3 ODS except Pailin , because there was no activity for Q3 in Pailin which was supported by Global Fund . [ Act 1.6.1]. CMEP OD teams visited 88 VMWs (for 4 BTB ODs) at their homes to review progress and provide on-site mentoring (versus 66 planned) [Act 1.6.2]. Integrated supervision from ODs to HFs: Supervision visits were conducted to 70 HFs in the 4 BTB elimination ODs using the CNM supervision checklist (versus 72 target) [Act 1.6.3]. No artemisinin-based combination therapy (ACT) or rapid diagnostic test (RDT) stock outs or potential stock outs were detected at the time of supervision. Data verification on total tests, total confirmed cases and total treated cases was also performed. Stock monitoring: CMEP continues to provide weekly RDT and ACT (ASMQ & Pyramax) stock status reports to CNM and partners including UNOPS and updates from all HFs in the 9 target ODs. CMEP facilitated reallocation of ACTs (ASMQ) from SPL OD/HFs to ODs experiencing a shortage, particularly in Pursat province. In Q3 there was an additional supply of ASMQ from CNM – 1,300 blisters to Pursat for KRK/PKV ODs, 3,080 adult blisters of Pyramax to Pursat and PLN and 220 Pyramax to BTB. CNM also sent 2,000 RDTs to PLN. Refresher training on 1-3-7- approach: The 1-3-7 training target for Q3 was met in Q2 due to the request from CNM on surveillance training (except for Pailin OD) [Act 1.6.5]. District Special Working Group for Malaria Elimination: 5 meetings were conducted in Q3 (planned was 7, 2 meetings did not take place because BTB/MRS OD groups are still not ratified). In the 4 elimination ODs the meetings facilitated updates of the malaria situation for participants and the discussion of common challenges [Act 1.6.7]. Provincial Special Working Group for Malaria Elimination: 2 meetings were conducted in BTB and PLN province. Task 7. Social and Behavior Change Communication (SBCC) for malaria elimination In the 5 elimination ODs, 6,784 individuals were tested for malaria who received IPC for malaria education (target is 4717) [Act 1.7.1]. In addition to malaria patients, IPC was provided to 295 people (31 sessions carried out at the 5 ODs) from high-risk groups during case response activities [Act 1.7.2]. At the farms, VMWs organized small group education sessions to deliver key malaria messages by using their IPC skills and job aids developed by CMEP. As a result, 37,564 MMPs were reached at farms with malaria outreach educational activities in FY18 Q3. CNM Health Education unit visited PKV and KRK ODs in June 2018 [Act 1.7.3]. Task 8. Support civil society organizations (CSOs/CBOs) to complement malaria elimination activities In Q3, Action for Health Development, (AHEAD) worked collaboratively with CMEP counterparts at OD, HF and community level. In this period, AHEAD organized 15 village health education sessions in remote areas (100% achieved against target), reaching a total of 668 high risk persons (including 143 MMPs). 38 MMP settlements were also mapped; 87

2 No targets were set for activities 1.6.6. and 1.6.8. Therefore, these are not included in FY18 Q3 report.

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3) suspected malaria patients were referred to both public health facilities and VMWs; 100% of referred cases were followed up and could reach service delivery points (among the referred cases, no cases were found positive for malaria). AHEAD distributed 85 ITNs (130% achieved against target) [Act 1.8.1]. Table 3 provides the AHEAD results for Q3. Table 3: AHEAD results from April-June 2018 in SPL OD Indicators SPL OD Target Actual # of health education campaigns organized in target villages 15 15 # of people reach by campaigns 0 668 # of LLINs distributed through Campaign 65 85 # of mobile/migrant settlements mapped 50 38 # of suspected malaria patients referred to VMWs/HFs 90 87 # of patients reached VMWs/HCs 65 87 # of Response activity events organized assisted by AHEAD 1 0

Task 9. Conduct operational research in the context of malaria elimination The CMEP team continued consultations with PMI/USAID on planning research activities to evaluate the use of highly sensitive RDTs in the context of re-active case detection in elimination areas. The study protocol was submitted to the Cambodian National Ethics Committee for Health Research (NECHR) in June 2018 and was approved by the NECHR during its meeting on June 29, 2018. [Act 1.9.1]. Task 10. Refine existing malaria elimination tools, SOPs, and guidelines The Case Investigation Form was first revised in September 2017. Since then, CMEP continued its operations in line with the revised malaria elimination tools. There were no updates to these documents in Q3. Due to some limitations in capturing information with the revised tool, CMEP internally developed a complementary form to capture additional information on 28- day follow up for Pf/Mixed cases, the travel history of patients (not captured in the case investigation form) and information on people receiving screening during response activity. 2.2 Objective 2: Support scale-up of high quality malaria control and prevention interventions in five to eight ODs, where gaps in coverage or quality exist Task 1. Rapid Situational Analysis and Needs Assessment Report Two new transitional ODs were added to CMEP target ODs: Bakan (BKN) and Sampov Meas (SPM) ODs in Pursat province. OD situational analyses were undertaken during FY18 Q3 and preliminary results were used in the updated CMEP work plan and M&E plan in Q2. The OD situational analysis reports were submitted to USAID for review on May 31, 2018 in Q3. Task 2. Ensure universal coverage with LLINs Mass distribution: As described in Objective 1 Task 1, CMEP, in collaboration with UNOPS, provided support to CNM for ITN mass distribution. CMEP supported the distribution of ITNs to target populations in 253 villages (API > 5) in 4 ODs [PKV=135 LLIHNs, KRK=8,772 ITNs (6,080 LLINs, 2,692 LLIHNs), SPM=18,422 ITNs (13,022 LLINs, 5,400 LLIHNs), BKN= 13,400 ITNs (9,800 LLINs, 3,600 LLIHNs)]. The distribution is based on the CNM established

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3) national ratio (1 net per 1.8 persons for residents, 1 net per 1 worker for MMPs). A total of 192,800 ITNs (133,000 LLINs and 59,800 LLIHNs) from CNM were planned for mass distribution in 2018 for both residents and MMPs (in Q2 there were 5 transitional ODs, out of which 3 moved to elimination (BTB, TMK and MRS) and in Q3 2 additional ODs (BKN and SPM) were included as transitional ODs all being in Pursat province making it a total of 4 transitional ODs., . By the end of Q3, 40,729 ITNs (28,902 LLINs and 11,827 LLIHNs) were distributed. Only PKV OD completed distribution to all villages by March 2018, while the rest will continue distribution in Q4 (Jul-Sep) [Act 2.2.2]. This was due to delays in ITN transportation from central to OD level. In PKV OD, 135 LLIHNs were distributed to MMPs through touch points due to increasing malaria cases. Continuous LLIN distribution and top up monitoring: Initially, there was no plan to deploy ITNs to VMWs/MMWs in Q3 given the ongoing mass distribution campaign. However, since CNM revised targets for ITN mass distribution to only villages with an API ≥5, CMEP deployed ITNs to villages that are not covered by the mass campaign. Therefore, 5,325 ITNs were deployed as buffer stock at the VMW level (vs 16,300 planned). During this reporting period, CMEP distributed 387 ITNs (vs 9,540 planned) to target populations during outreach and response activities in May/June. The actual result was less than planned due to mass distribution overlaps [Act 2.2.5]. VMWs distributed 229 ITNs at big farms in Q3 (versus 540 target) [Act 2.2.6]. VMWs/MMWs conducted outreach visits to households and farms to top up ITNs using remaining nets from the previous deployment, along with SBCC activity and EDAT services, when required. 2,023 (99%) visits were accomplished (versus 2,037 planned) by VMWs to households for use monitoring and health education [Act 2.2.7]. 15,341 individuals received malaria education through IPC (versus 14,259 planned) [Act 2.2.8]. Task 3. Ensure EDAT and follow up Provide ongoing support in malaria diagnosis and treatment: CMEP activities covered 795 point of care units in April (for 5 transitional ODs) in the targeted sites and moved to 474 points of care units in May and June (for 4 transitional ODs) [Act 2.3.1]. In the 4 transitional ODs, 11,609 individuals were tested, 4,858 were confirmed with malaria and 4,875 cases were treated in Q3 (see Figure 5). Among confirmed cases, 31% (1,528) were Pf/mixed and 3,330 cases (69%) were Pv. Three-day DOT was provided to 325 Pf/mixed cases by VMWs (87% of total 374 Pf/Mix cases). [Act. 2.3.2]. 266 Pf/mix case received SLD-PQ treatment. [Act 2.3.3]. There were two severe malaria cases, however there was no treatment failure requiring hospitalization in Q3. [Act. 2.3.4]

Figure 5. Confirmed malaria cases in 4 ODs

1600 1400 1200

1000 800 600 400 ConfirmedMalaria Cases 200 0 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2016 2017 2018 9 Bakan 8 9 6 8 7 13 17 22 31 24 40 24 20 29 14 7 14 22 29 36 27

Sampov Meas 6 11 7 14 7 9 9 31 48 43 33 60 43 34 26 22 20 19 51 30 74 kravanh 112 108 92 76 86 74 83 290 469 465 422 500 796 862 644 565 580 722 92312411394 Cambodia Malaria Elimination Project Quarterly Report (FY18Q3)

Table 4 provides a breakdown of confirmed malaria cases by species in the 4 ODs. Overall, there was a significant increase in Pf and Pv cases from May 2017 onwards (especially in Phnom Kravanh and Krakor ODs – see figure 6). The likely reasons for this include: (i) VMWs were fully functioning by May 17, contributing to more cases detected and reported; (ii) after the plantation season finished more people went to forested areas and were exposed to high risk areas (especially males); (iii) CMEP/PHD/OD/HCs started to investigate villages with high reported cases, however response activities were not fast enough to prevent transmission in the forested areas. This situation still holds into Q3 which is at a transmission peak – even though CMEP and counterparts have spent intensive effort in responding to the situation in Q3. Figure 6. Monthly malaria cases in Kravanh and Krakor ODs

Table 4. Breakdown of confirmed malaria cases by species in 4 ODs OD Name Species Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Pf 71 71 54 40 40 34 45 166 261 247 222 260 434 345 238 198 179 208 321 347 418 Kravanh Pv 38 37 34 36 46 37 36 117 201 202 190 222 336 478 377 343 382 465 574 861 945 Mix 3 0 4 0 0 3 2 7 7 16 10 18 26 39 29 24 19 49 28 33 31 Pf 62 59 52 8 45 16 43 90 196 173 152 111 145 119 57 56 67 47 72 82 115 Krakor Pv 35 32 27 6 23 30 32 75 152 97 130 121 139 165 159 167 138 167 215 196 317 Mix 4 4 2 0 1 0 2 9 2320 9 18 21 10 6 6 3 10 5 2 12 Pf 7 4 4 6 5 9 11 17 1517 27 17 13 8 6 3 6 13 11 3 3 Bakan Pv 1 3 2 0 0 2 4 410 5 13 7 616 6 4 8 916 3024 Mix 020222216200152000230 Pf 4 7 5 2 6 4 7 20 24 25 16 27 21 15 7 7 11 0 14 7 17 Sampov Meas Pv 2 4 2 12 1 5 2 11 23 18 15 32 19 19 18 15 9 19 37 23 55 Mix 000000001021301000002 Outreach activities: Seventy-four (74%) percent of all confirmed malaria cases were in Phnom Kravanh (PKV) and 21% in Krakor (KRK) ODs, with the remaining 5% in the other ODs. Maps showing village incidence in Kravanh and Krakor ODs are below in Figure 7. Although there were some changes in the number of cases identified in individual villages, the general areas of concern remain the same with most representing areas near the forest.

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3)

Figure 7. Map of villages with high number of malaria cases in PKV and KRK

Forest interventions: In response to case increases in Pursat province, from April to June 2018, CMEP continued supporting forest interventions to increase malaria services coverage for forest workers, particularly in PKV and KRK ODs where population movement into forest areas is still very dynamic. The interventions were managed through 9 selected touch point volunteers (3 in KK and 6 in PKV by increasing from 3 in Q2 to 6 in Q3) and 15 peer educators (5 in KK and 10 in PKV by increasing from 5 in Q2 to 10 in Q3). As a result, in Q3 12 bi- weekly meetings were organized in PKV and KK ODs. Based on the information collected during the meetings, 24 touch point and peer volunteers conducted site visits to meet with forest workers, tested 1247 suspected malaria patients, 401 patients (229 Pv + 172 Pf/Mx), or 32%, were found positive which is relatively high due to the high number of cases in these ‘hotspot’ areas), distributed 367 ITNs, conducted 1419 health education sessions which reached 1862 forest workers. Joint efforts were made regarding forest interventions between Pursat province and 2 neighboring provinces (Kampong Speu and Kampong Chhnang). A meeting of the provincial special working group for malaria elimination (PSWGME) in Pursat was held on 28 May 2018. The meeting included the Pursat PSWGME and sub-working groups of 3 provinces (Pursat, Kg. Speu and Kg. Chhnang) held under the chairmanship of the Pursat Provincial Vice Governor and CNM Director. The meeting had 61 participants, including all 3 PHD directors, 4 other CNM staff, members of Pursat PSWGME, Kg Speu PHD team, Kg. Chhnang PHD team and several NGO partners (including CMEP, PSI, PSM, CHAI, CHADA). The highlights of the meeting were to plan and design activities to better track MMP’s in 3 adjacent provinces, improve better coordination and joint planning and intervention. Capacity building: In Q3, CMEP conducted case management training in Pursat for 47 HF staff [2.3.8a]. (from SPM and BKN ODs) OD. 22 VMWs also received training [2.3.8b]. This training included SLD-PQ training [2.3.7]. CNM supervision: Supervision visits were made by CNM technical team in Q3 to 2 ODs . [Act 2.3.10]. The details of the supervision visits are in table 3 below. Task 4. Strengthen case management and reporting in the private sector: Private Provider Mapping: CMEP worked with 237 PPs through the end of April (5 ODs) and then transitioned to 133 PPs in May and June (4 ODs) under Objective 2. The mapping was updated in Q3 [Act 2.4.1]. However, the role of PPs under CMEP has now changed since the PRAKAS in Q2 – PPs will no longer provide RDT or give ACTs to presenting patients. PPs must now refer suspected malaria patients to nearby health facilities and provide BCC. Also, data for surveillance purposes will not be collected from PPs. CMEP did not provide any refresher trainings to PPs in Q3 as they were all trained in Year 1 [Act 2.4.2]. Ten bi-monthly

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3) meetings (versus 4 planned) were held in the 4 ODs (all 10 meetings in May) [Act 2.4.3]. 418 PPs attended (some PPs were met twice in Q3, and those that were not met in bi-monthly meetings were met during subsequent data collection visits). In addition, HF/OD teams visited PPs to review malaria case recording and reporting, and to collect necessary data and provide feedback. 57 visits (vs 56 planned) were accomplished during the reporting period (each HF/OD visited approximately 5 PPs per visit) [Act. 2.4.4]. Supervision visits: During this reporting period, there were no supervision visits planned from CNM to CMEP target ODs. However, 1 supervision visit was conducted for PPs by CNM to PKV and KRK ODs, [Act. 2.4.5]. The main purpose was to make sure PPs follow the new PRAKAS and to advise PPs to no longer test and treat clients for malaria. Task 5. Build capacity and strengthen systems to manage malaria control activities: CMEP Support to VMWs/MMWs: 69 (18-KRK;18-PKV;9-MRS;24-BTB) monthly meetings for VMWs/MMWs were held in all 4 ODs during April to June 2018 (no VMW network exists in TMK OD) [Act 2.5.1]. During these meetings, VMWs reported information on malaria cases, received RDTs/ACTs from health center staff, received on the job training for case management including SBCC, case registration/reporting, ITN monitoring and top-up reports. VMWs also shared challenges (including difficulties with DOT completion among MMP and forest-related workers; poor road conditions and long distances to travel and unnecessary demands of topping up ITNs among the residents). In April 2018, 327 VMW from 5 transitional ODs attended the meeting while in May and June, on average, 202 VMWs from 4 transitional ODs attended the monthly meeting. In total, 730 VMWs attended meetings versus 726 planned (100.5%). This figure was a bit higher than planned. This can be explained by VMWs from annexed villages also attending the meeting. In total, 103 VMWs were absent during monthly meetings but were visited by the HF staff. This was higher than anticipated. During Q3, CMEP teams at OD level will work with VMWs to encourage them to attend meetings to share experiences and build knowledge. Integrated supervision from OD to HFs: 71 supervisory visits were accomplished during Q3 (versus 40 planned) [Act 2.5.3]. Build capacity and strengthen systems to manage malaria commodities: CMEP provided support in stock monitoring and management to the nine target ODs (SPL, TMK, BTB, MRS, PKV, and KRK, PLN, SPM, BKN ODs, (the elimination ODs are also included here for this malaria commodity report). CMEP used the mHealth application (via laptops) [Act 2.5.4-2.5.5] which automatically geotags facilities and locations to allow close monitoring of places visited. In this Quarter, 466 visits were conducted to health facilities. Weekly stock monitoring revealed RDT ‘potential stock outs’ were reported only once from a HF in SPL OD and no ‘stock out’ was detected. For ACTs, no stock out or potential stock outs were reported. ACT distribution: Due to an increase in cases in Pursat in Q3, reallocation of drugs within the ODs and the neighboring provinces was facilitated by CMEP. In total, CMEP supported 23 trips for drug reallocation from other ODs to PKV and KRK ODs and within PKV and KRK. In addition, CMEP supported ODs and PHDs to collect ACTs from CMS and CNM 6 times. To summarize, CMEP actively facilitated reallocation of ASMQ from CNM and from neighboring provinces to Pursat: . On May 21, CNM supplied 400 doses of ASMQ to Pursat to further allocate to service providers . On May 24, CNM transferred 1,000 doses of ASMQ from Battambang to Pursat . On June 13, CMEP supported transport of 800 doses of ASMQ from CNM to Pursat . 20,000 tablets of Quinine and Tetracycline were delivered from CMS to Pursat in early May 2018

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3)

. 23-24 June 2018, CMEP facilitated and supported transportation of 500 doses of ASMQ and 3,054 Pyramax from CNM to Pursat province . 23-24 June 2018, 26 doses of Pyramax were transported from CNM to Pailin OD (under emergency distribution of malaria drugs to operational levels) Visits to selected VMWs from CNM VMW Unit: CNM’s VMW Unit carried out their planned 2 visits in Q3 in KRK and PKV ODs [Act. 2.5.6]. Provincial special working group for malaria elimination [Act 2.5.7]: On 28th May the PSWGME meeting was held in Pursat province. Task 6. Strengthen BCC interventions for intensified malaria control IPC to tested malaria cases and high-risk groups: For BTB, TML and MRS ODs during April 2018, 1,407 suspected malaria patients were tested and received IPC. From April to June 2018, 10,202 suspected malaria patients were tested and received IPC (in PKV, KRK, SPM and BKN ODs) in Q3 [Act 2.6.1]. In KRK and PKV ODs, the peer educators and touch points provided 1,419 health education sessions to 1,862 MMPs [Act 2.6.2]. Public Service announcement broadcasting: Due to a significant increase of malaria cases in Pursat during Q3, the Pursat PHD Director requested support from CMEP to develop public service announcements (PSAs) to broadcast via local radio. In June, the PSAs were broadcasted every day 4 times a day. The purpose of the PSA was to alert the population to the malaria situation, prevention and service provision. Malaria education campaigns at schools: During Q1 and Q2, malaria education lessons were taught to students (5 lessons in the curriculum). In Q3, CMEP staff continued working with provincial/district education staff, school directors and teachers to reinforce malaria messages. CMEP prepared a tool to assess basic malaria knowledge of students and basic malaria knowledge and practices among student’s families and people in their communities. The assessment will be carried out in Q4. One supervision visit (1 visit for 2 ODs) from the CNM health education unit was conducted to Phnom Kravanh and Krakor ODs, Pursat Province. Task 7. Support civil society and community-based organizations (CBOs) to implement interventions to transition toward malaria elimination: Provide support to selected CSO partners & Implement sub-grant activities [Act 2.7.2]: AHEAD (TMK & SPL): In Thmar Kaul OD, AHEAD conducted 15 health education campaigns (out of 15 planned) reaching 202 people including MMPs. Also, AHEAD distributed 115 ITNs (target: 30 ITNs) to vulnerable people, mapped 18 MMP settlements (out of 15 planned), and referred 54 (target: 50) suspected malaria patients to VMWs and HFs. All referred cases reached the service delivery points. The targets and actual results accomplished by AHEAD in 2 ODs are in Table 5a (AHEAD elimination activities are described in Objective 1). Table 5a: Summary of AHEAD Results (April to June 2018)

THK OD Indicators Target Actual Organize village HE campaign 5 5 Number of people reached by malaria messages through the campaign 0 202 Number of LLINs distributed through Campaign 30 115 Work with local authorities to map MMP 15 18

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3)

Refer malaria suspect patients to HF/VMW 50 54 Patients reached through VMWs/HCs 40 54 Report any malaria cases or outbreaks 1 1

PFDA (PKV, KK, BTB, MRS) In Q3, Partner for Development in Action (PFDA) organized 114 health education sessions (out of 42 planned) reaching 1,614 people (target: 826). PFDA mapped 30 MMP settlements (target: 15) in remote areas (mostly in annex villages) and distributed 728 ITNs (out of 913 planned) to mapped MMPs. In addition, PFDA referred 248 suspected malaria patients (target: 143) to the VMWs/HFs (99% reached the VMWs/HFs); 99/248 were cases found positive for malaria. See table 5b below. Table 5b: Summary of PFDA Results PKV OD KK OD BTB OD MRS OD TOTAL Indicators Target Actual Target Actual Target Actual Target Actual Target Actual # of health education campaigns organized villages 15 39 8 55 9 8 10 12 42 114 # of people reached by campaigns 300 455 150 918 188 102 188 166 826 1641 # of LLINs distributed (by USG funds) 300 378 175 350 219 0 219 0 913 728 # of mobile/migrant settlements mapped 5 14 3 5 4 3 3 8 15 30 # of suspected malaria patients referred to VMWs/HFs 43 146 28 72 36 5 36 25 143 248 99% % of referred patients reached VMWs/HFs 146 97% 72 100% 5 100% 25 100% 248 (avera ge) Sub-grant oversight and management: The CMEP team Compliance and Sub-Grants Coordinator continued work with AHEAD/PFDA on financial issues/documentation and further instructed sub-grantee staff on budget monitoring, cost effectiveness and ensuring compliance. The Senior BCC Advisor supported report writing, verification of data and provided BCC materials for implementation. In Q3, both AHEAD and PFDA showed significant improvement in their report writing. However, AHEAD mentioned several challenges including difficulty organizing health education campaigns during farm workers work hours and movement of MMPs during public holiday. PFDA faced challenging geographic target areas and limited knowledge of contact points. CMEP and both sub-grantees discussed these challenges and developed action plans. On 26 April, CMEP organized a quarterly progress review meeting with AHEAD/PFDA in Battambang Province. As part of the meeting, capacity development activities were provided on financial management, using smartphones to map MMPs, M&E, branding, gender, communication skills and basic malaria knowledge. In addition, CMEP is in the process of selecting sub-grantees for Year 3. Task 8. Operational research A study on highly sensitive RDTs (hsRDTs) will be conducted in BTB and Pailin elimination ODs in FY18 and FY19 from July 2018 - June 2019. During Q3, the CMEP team continued consultations with PMI/USAID and CNM on research aimed at evaluating the performance of hsRDTs in the context of re-active case detection in elimination areas. The study protocol was submitted to the Cambodian National Ethics Committee for Health Research (NECHR) in June 2018 and was approved by the NECHR during its meeting on June 29, 2018. 2.3 Objective 3: Strengthen national malaria surveillance systems and M&E appropriate for malaria elimination and control activities

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3)

Task 1. Refine and harmonize M&E reporting forms and support consistent use by public and private healthcare providers Work with CNM/partners to harmonize M&E reporting forms: CMEP worked on revision of the Case Investigation and Re-Active Case Detection forms (with CNM/WHO) [Act 3.1.1]. Support consistent use of the harmonized forms by providers: In Q3, 87% of providers submitted surveillance data on time (Figure 8) consisting of 100% from health facilities, 90% from VMWs and 71% from private providers. As part of ongoing support, CMEP will provide additional training to Pailin OD to institutionalize elimination forms to HFs and VMW’s (this will be undertaken in Q4) [Act 3.1.2]. Figure 8: Percentage of HFs, VMWs/MMWs, and private providers in target transitional ODs submitting surveillance data on time per national guidelines. 100% 100% 99% 98% 98% 97% 97% 96% 95% 95% 95% 94% 94% 94% 92% 90% 89% 87%

100% 87% 86% 86% 86% 83% 80%

80% 71% 60% 40% 20% 0% BATTAMBANG THMAR KOUL MAUNG RUSSEI KRAVANH KRAKOR

FY2017 Q3 FY2017 Q4 FY2018 Q1 FY2018 Q2 FY2018 Q3

Task 2. Provide technical assistance on data management and use Conduct IDQA at OD and selected HFs by ODMS/PMS and CMEP [Act 3.2.2]: The CMEP IDQA report was approved by COR during Q3. IDQA and associated M&E training was provided to CMEP staff from all OD’s in Q3 at Battambang Training Centre (OD TL’s, OD Data Assistants and HF staff from each OD). Further IDQA training will be provided to counterpart staff during an M&E training in Q4. Provide TA to CNM on village-based stratification and facilitate use of stratification tools CNM conducted 1 meeting in Pursat in Q3 to announce a new strategy for the allocation of VMWs, LLIN distribution for Battambang/Pursat provinces based on API criteria [Act 3.2.3]. Referring to API as the criteria, CMEP assisted CNM’s ITN mass distribution campaign in all target ODs (except TMK OD) and planned to remove several VMWs in the coming years from villages where no cases were found over the last 6-12 months. Provide TA to CNM on data visualization and outbreak module development for MIS: The distribution of the CMEP OD Bulletins for Q1/Q2 (and which will be developed for 9 ODs for Q3) has already contributed to the TA to CNM on data visualization. The bulletins provide useful representations of OD cases, species, and is provided in local language [Act 2.3.4]. CNM supervision: Several visits were conducted by CNM technical units to CMEP target areas. The M&E/Data Management unit. Table 6 summarizes these visits [Act 2.3.5]. Table 6: Summary of CNM Technical Unit visits in Q3. CNM Unit Supervision Dates and ODs Visited in Q3 VMW May (PKV)

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3)

Health Education June (PKV & KRK) ITN April (PKV), May (KRK & TMK), June (MRS) Epi-surveillance June (PKV, KRK & BTB) M&E/Data Mgmt. May (BTB & SPL), June (PKV & KRK) Laboratory June (BTB & SPL) PPM April (MRS & SPL). May (PKV) Pharmacy/Logistics May (PKV, KRK, MRS & SPL) Entomology April (PKV), May (PKV) Management Team June (PKV) Task 3. Support further development of electronic data reporting and use platform CMEP continues to monitor and follow up on the use of smartphones designated to VMWs and tablets designated to HF/OD staff that provide notification and reporting of malaria cases and stock status of malaria commodities. Task 4. Entomology Training 3 (Conduct entomology training for OD and PHD staff) In Q3, CMEP supported CNM to provide a 5-day field technician entomology training to HFs and VMWs for PKV OD (30 trainees) [Act 3.4.2]. The training involved sessions on entomology control/elimination, objectives of entomology surveillance, vector identification and field visits for mosquito and larvae collection. This was the first time an event of this kind has been organized in Cambodia. The next 5-day training is planned for BTB in August 2018. 2.4 Objective 4: Build capacity of Ministry of Health (MOH) to manage, intensify, and sustain malaria control and elimination efforts particularly at the OD level Task 1. Develop and implement a plan to strengthen technical and management capacity at National, PHD and OD levels OD AOP development [Act 4.1.4.]: All 9 ODs and 3 PHD representatives were invited to the AOP development workshop. During this workshop, the additional elimination activities were discussed, and targets revised. The counterpart expressed support and cooperation to CMEP activities and the collective agreement was that the revised for AOP for Year 2 was signed off. This exercise not only helped in designing the plan for CMEP, but it also capacitated the PHD and OD members to understand better resource mobilization and better planning and monitoring on malaria activities Laboratory quality assurance [Act 4.1.8]: The CMEP lab supervisor and the PLS conducted a supervised assessment to HFs selected for laboratory QA in May to understand and assess gaps around reagents, lab materials, staff capacity gaps. The schedule was as follows:  7-11 May: BTB OD (Sdav, Tasanh, Boeung Run, Pechenda, RH SPL, RH Pailin, Krachap and OU Chra)  17-18 May: TMK OD (TMK RH, KTH HC, KLM HC, OPD HC)  12-14 June: 2018 MRS OD (MRS RH, Prey Trolach HC)  There was a total of three trips, the general findings were: -

3 No targets were set for activity 3.4.3 in Q3 FY 2018

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3)

 Some of the HF lab staff do not clearly understand the current laboratory setups and performance  Some of the labs lacked materials and equipment and have been using expired reagents. In addition, some of them have not used microscopes for diagnosis and have poor microscope skills  The lab technicians used different procedures due to them not following the standard specific SOPs  Some of the Lab Technicians require refresher training to improve their microscopy skills  At Krachap HC, Pailin OD, the microscope is broken. At Ou Chra HC there was a stock-out of reagents and lack of materials for malaria microscopy.  A number of HF lab staff participated in Malaria Microscopy Refresher Training organized by CNM, WHO which included new versions of microscopy SOPs and QA development systems

The CMEP lab supervisor participated in a malaria microscopy refresher training in May (organized by WHO/CNM) and the CNM lab unit conducted a supervision visit to BTB/SPL. On the job training and mentoring by CNM units (Regional task forces and entomology) [Act 4.1.9]: The entomology training that was conducted by CNM and CMEP will further support on the job training to the entomological field technicians on an ongoing basis. As part of the next step, these entomological field technicians will be guiding and supporting VMWs on vector surveillance in Pursat and foci investigation in elimination ODs. E-Payment [Act 4.1.10]: The e-payment system is used to pay per diems, transportation and other allowances through mobile payments. During Q3, CMEP set up e-payments for 159 VMWs in 10 Health Centers in SPL OD (Kamrieng HC, Trang HC, Pich Chenda HC, Barang Thlak HC, Takrey HC, Takrey HC, Sereymeanchey HC and Sampov Loun HC). E-payment accounts were also opened for the remaining two HCs in SPL (Bur HC and Trav Chhou HC). Task 2. Support CNM and MOH to develop and maintain a system for on-going technical and management capacity development Provide technical assistance to CNM [Act 4.2.1]: CMEP (Case Management/Lab QA Advisor and the PPM/MMP coordinator) joined a meeting at CNM on 22nd May with all GF sub- recipients to discuss quarterly progress of activities, challenges and ways forward. Participants also discussed stock status of ASMQ in malaria endemic ODs/provinces. CMEP teams from both Phnom Penh and provincial/OD levels assisted CNM, PHD and provincial authorities organize the World Malaria Day commemoration in three target provinces: Battambang on 24th April 2018 in Ratanak Mondul district, Pailin on 25th April in Salakrao district and Pursat on 25th April in Veal Veng district. The event in Veal Veng district, Pursat province was the biggest organized (around 1,500 people joining). Two ministers participated (Minister Health, Minister of Environment) together with Pursat provincial and district governors, CNM Director, deputies and officers, PHD, OD directors, public health staff, volunteers, private sector, villagers, students, military, police and forest rangers. Donor and partner representatives included WHO, USAID/PMI, UNOPS, CMEP, PSM, PSI, Euro Continent. The theme was “READY TO DEFEAT MALARIA”. NTG Dissemination Workshop: A one day session was held for all national hospital and military/police hospitals (25th May) to learn and understand severe case management and implementing national treatment guidelines and also assessing the gap and better plans to supply drugs. CMEP participated as a trainer in this event.

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3)

CMEP progress review [Act 4.2.2.]: The CMEP COP and Technical Advisors, CNM Director and CNM team and 3 PHD Directors of Pursat, Battambang and Pailin held a meeting on 9 May at CNM. The meeting was organized to undertake CMEP central level project review and implementation, to discuss the transition from GF to PMI for Pailin OD, as well as maintaining smooth cooperation among CNM-CMEP, PHDs and other partners. Task 3: Improve malaria policies and guidelines [Act 4.3.1] In Q3, CMEP team participated in a drug policy meeting held on 31st May in Phnom Penh, where there were discussions, presentations and updates on TES results and proposals foir new treatment regimens for Cambodia malaria NTGs. CNM BCC strategy development: [Act 4.3.1] In this reporting period, CMEP supported the design of the CNM BCC ‘strategy book’ in Khmer language. CMEP along with CNM reviewed the strategy book which is ready for printing and dissemination. 3. PROJECT MANAGEMENT Oversight and Coordination CMEP Field Visits: During Q3, several key and non-key staff (including CMEP’s technical, M&E, programmatic and financial teams) and COR visited the target ODs. The visits were necessary to provide quality support and guidance, as well as assess CMEP’s progress throughout Q3. The field visits played an important role for the CMEP team to collaborate and improve OD malaria initiatives and activities. Additional visits from the COP focused on reviewing AOP targets and learning what worked well or needed improvement. CMEP PP-OD Meeting: On 22-23 May, CMEP PP team (COP, STA, Senior BCC Advisor and Admin/Finance Manager) and CMEP OD team (OD Team Leaders (ODTLs) and OD Team Leader Assistants) met in Pursat PHD. The overall objective of the meeting was to build team capacity so that there is a better understanding of project operations and Y2 priorities. The discussions and outcomes of the meeting covered areas that provided OD teams to understand why particular activities were not being implemented and why certain targets are not being reached. Planning monthly activity plans realistically to reduce variances between budget versus actual expenditures - Encourage participation and how to develop and encourage and building capacity of sub-grants - Year 1 Contractor Performance Assessment Report, CPAR and how to improve CPAR results in Y2 - Malaria case increase in Pursat, and as a result a joint action plan was developed - SPL elimination model, achievements, challenges and lessons learned, as well as how effectively CMEP could replicate the model to other ODs. On 29 May 2018, at Pailin - PHD, CMEP team (SPTA, and ODTL, BTB) met with Pailin PHD team (PHD Director, Deputy Director and PMS) under coordination from CNM team (Deputy Director and Chief of Technical Bureau). The meeting focused on malaria activities in Pailin, progress and challenges. The team also discussed the CMEP supported activities as well as how soon GF-supported activities should transition to CMEP. –It was agreed that CMEP will support a few activities so as to gradually step in and build on the existing malaria work. It was agreed that CNM will have a meeting with UNOPS and share CMEP’s plan and also provide guidance to relevant authorities. On 25-26 June, CMEP PP team (COP, STA, Finance and Admin Manager, and Finance Coordinator) and CMEP OD teams (OD TLs and OD TL Assistants) met in BTB PHD. The objective of the meeting was to discuss project progress, successes, and challenges, as well as build staff capacity. The CMEP team went over discussing - pending program activities, achievements, lessons learned, and challenges - Budget and corrections on budget coding in

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3) order to improve financial tracking - Internal preparation of Y3 work plan and Y3 OD AOPs to be initiated from next OD progress review with counterparts - As the follow up from ODTL meeting the M&E training was conducted by M&E team to all staff - Startup of LLIN durability monitoring in FY18Q4 in 2ODs. Sub-grant oversight and management: CMEP’s M&E Officer, Compliance and Sub-Grants Coordinator and Senior BCC Advisor conducted orientation for sub grantees (AHEAD and PFDA) on the procurement and financial management (details are provided under activity 2.7.1). CMEP COP and team met PFDA Executive Director and Finance Officer to discuss their performance and ways to improve PFDA implementation in 4 CMEP ODs. Meetings with USAID, CNM, Implementing Partners, and Others: (1) Meetings with the USAID COR Team During Q3, the CMEP team had meetings with the COR team, CO, and others at USAID: - Meeting with COR team on April 6, 2018 to discuss the following items – a) Progress of staff recruitment and plan for its implementation to the new ODs, b) Follow up on any progress/actions by CMEP on DQA findings reported by USAID team, c) CMEP preparation for World Malaria Day, a plan of site visit of COR team on 26-27 April 2018 to Pursat province, d) Overview of workplan by COR team and discussion on entomology activities, and e) Budget allocation and financial discussion on planned versus actuals of Q1 and Q2 FY18. CMEP COP and URC Senior Vice President met with COR team on April 12th to discuss the project progress, DCOP position, cost analysis of SPL elimination, budget and, low burn rate. CMEP and COR team met on 23 April at CMEP PP office discussing potential OR topics, the hsRDT study and costing analysis for SPL elimination model. A number of OR topics were raised and discussed such as a strategy to reach MMPs and useful tools for prevention and treatment, G6PD rapid test as prerequisite of Pv radical cure with Primaquine, Ivermectin administration, integration with strengthened health systems. It was agreed that study areas for the hsRDT be expanded from BTB OD to all elimination ODs in BTB and Pailin provinces to better capture different aspects for the study. CMEP and COR teams met on 27 April 2018 at CMEP office to finalize CMEP Year 2 work plan targeting 6 ODs from Oct 17 to April 18 and targeting 9 ODs from May-Sep 18. The discussion were around, increased malaria cases in Pursat province, particularly in Kravanh OD and possible steps to prevent eventual outbreak in the coming transmission season. Also, concerns on MOH PRAKAS to stop supplying RDT, ACT to PPs and stop allowing PPs to provide malaria treatment but only refer cases to public health facilities were had. CMEP and COR team held a monthly meeting on 7th May at CMEP office to update the project progress, discuss issues, and improve communication between CMEP and COR/USAID. CMEP and COR team met to discuss the finalization of the M&E Plan on May 22nd. Changes were agreed upon and a revised plan was submitted on June 8, 2018. From June 25-29, 2018 COR and USAID M&E staff joined a VMW monthly meeting in Krakor OD, attended and observed the CNM/CMEP entomology training in Pursat and observed the CMEP M&E training in Battambang. (2) Meetings with CNM and Other Partners Meeting with CNM Director and Technical Bureau Chief: The CMEP COP and Technical Advisors, CNM Director and CNM team and 3 PHD Directors of Pursat, Battambang and Pailin held a meeting on 9 May at CNM. The meeting was organized to undertake CMEP central level project review and implementation, to discuss the transition from GF to PMI for Pailin OD, as

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3) well as maintaining smooth cooperation among CNM-CMEP, PHDs and other partners. CMEP Technical Advisors attended a meeting at CNM on 18 May with CNM team and other partners to discuss the malaria case increase in 7 provinces (including Pursat province) and the shortage of anti-malaria drugs in locations that require urgent solutions (including reallocating from provinces with surplus stock, administrating Quinine and Tetracycline, procuring loose tablets of Artesunate and Mefloquine, and introducing new ACT “Pyramax”). CMEP COP, SPTA and STA held meetings on June 20, 2018 at CNM with CNM Director and with Chief of Technical Bureau. During the meetings, the team discussed the malaria case increases in Pursat and CMEP’s response, the hsRDT study, HMIS & MIS, CMEP central review and the CMEP start-up in Pailin OD/province. In addition, CNM and CMEP held meetings during Q3 as below: -Diagnosis and treatment meeting which included lab QA at WHO in April 2018 -Participatory meeting of malaria partners for progress review implementation of RAI2E at CNM in May 2018 -‘Update on responses to malaria increases meeting’ at CNM in May 2018-Drug resistance meeting with WHO and research malaria partners in May 2018 Meeting with Procurement Supply Management (PSM): CMEP COP and technical team met GHSC/PSM on 18 May at CMEP PP office to discuss effective ways for communication and collaboration of the two USAID/PMI funded projects. It was agreed to have regular meetings to improve coordination and work on systems strengthening in supply chain. CMEP PPM Coordinator attended a training session organized by the PMI-GHSC/PSM in Kep province. The training targeted officers from the Ministry of Environment and Provincial Department of Environment’s from all malaria endemic provinces. It provided information, how ITNs are distributed and properly used, how to raise awareness on malaria prevention and the proper seeking of care for forest rangers and forest communities. Meeting with UNOPS: CMEP COP and STA met UNOPS Program Coordinator, M&E and Procurement Officers on 7 May at UNOPS PP office. They discussed the malaria program supported by Global Fund and PMI/USAID and project operations in Pailin, as well as OR under GF support. Discussions were also raised about costs of case investigation and response in the elimination activities and on stock monitoring of malaria commodities. Procurement During Q3, CMEP procured equipment and furniture for the three new ODs (see Table 7 for the list). As vehicles were planned to be procured in Q3, CMEP submitted a purchase order to the supplier, however the two vehicles are expected to arrive in Q4. Table 7 CMEP Procured Items FY18 Q3 No. Item Unit Purchased date 1 MONITOR 3 11-Apr-2018 2 VISA CARD 1 11-Apr-2018 3 ACCESS POINT 1 9-May-2018 4 LOUDSPEAKER 1 9-May-2018 5 LAPTOP DELL 14 24-May-2018 6 MOTOR HONDA 12 28-May-2018 7 DESK 12 24-May-2018 8 CABINET 6 24-May-2018 9 ROTATING CHAIR (CENTURY) 12 24-May-2018 10 SAFE BOX 3 24-May-2018 11 CABINET 1 30-May-2018 Financial Management

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3)

Human Resource Management By the end of Q3, CMEP team comprised 53 staff. See figure 9 for the staffing progress Figure 9: Overall CMEP staffing progress from FY18 Q1 to FY18 Q3 100 100

50 50 46 50 53 0 2 3 3 0 FY18 Q1 FY18 Q2 FY18 Q3 Key Staff Total Number of Staff Required Key Staff Required Total Number of Staff

New staff: 1 Laboratory Supervisor, 2 HF Coordinators, 1 OD Team Leader, 1 OD TL Assistant and 1 OD Data Assistant joined CMEP in Q3. Table 12 lists the new staff details.

4. RESOLVING CHALLENGES FROM FY18 Q2 Overall, Q2 maintained ongoing implementation prior to approval of the modification. In February 2018, the modification was approved providing a clear direction of expansion and elimination OD activity planning. Pailin OD, being under the support of GF, needed a clear plan with direction from CNM and the PHD. The CMEP PP team organized a series of meetings with UNOPS and invited CNM to visit Pailin for transition planning. The Pailin PHD and the PMS were supportive of the transition plan and allowed CMEP to gradually roll out interventions. However, delay in ‘DOAG’ signature posed challenges, but activities continued. 5. CHALLENGES AND ACTIONS TAKEN OR PROPOSED

Cambodia Malaria Elimination Project Quarterly Report (FY18Q3)

The expansion of elimination ODs from 1 to 5 and the addition of two new transitional ODs demanded a series of discussions with the PHDs and ODs. The CMEP team worked closely with the ODs in Battambang, Pailin and Pursat provinces to revise the CMEP work plan and integrate elimination activities in the ongoing year 2 plan. The entire month of April involved a series of consultations and revisions of the work plan. With support from CNM, PHDs and ODs, CMEP finalized the year 2 revised work plan and received approval from USAID/PMI. Recruitment of a new DCOP went through several iterations of candidates. The DCOP was finally selected and the position was envisaged to be filled by June 2018. The process of identifying CSOs for the new ODs was initiated in Q3. Despite limited CSOs in target provinces, CMEP decided to expand the process to nationally and regionally based organizations and invited 10 CSOs to submit proposals. The selection process will start in Q4. 6. PLANS FOR NEXT QUARTER AND UPCOMING EVENTS The major focus for Q4 is completing activities approved in the Y2 revised workplan. Year 3 work planning will be initiated along with the FY18 annual report. Due to the revision in the workplan to include LLIN durability monitoring and entomological training (postponed since Q2), these activities will be a priority. The following are the upcoming events for Q4 FY18: . Selection of CSOs as CMEP sub-grantees . Finalizing costing analysis of the malaria elimination model in SPL and disseminating to CNM and other partners . Finalizing new CMEP OD teams and offices. . Carrying out a central review of CMEP progress . Developing CMEP Year 3 Work Plan and OD AOPs . Startup of hsRDT study . Startup of LLIN Durability Monitoring in BTB and KRK ODs.

Ends,