CAMBODIA MALARIA ELIMINATION PROJECT (CMEP)

Contract Number: AID-442-C-17-00001

REPORT ON THE RAPID SITUATIONAL ANALYSIS IN SELECTED ODS TARGETED FOR TRANSITIONAL MALARIA ELIMINATION

July 5, 2017

Submitted by:

University Research Co., LLC

Phnom Penh, Cambodia

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Contents

Abbreviations ...... 4 Background ...... 7 Assessment Purpose: ...... 7 Field assessment and data collection ...... 8 Key Findings ...... 9 OD Battambang (BTB) ...... 9 A. Current coverage gaps in malaria prevention and control activities ...... 14 B. Weaknesses in quality of diagnosis and treatment, vector control and surveillance ...... 15 C. Strengths and weaknesses in organizational structures, managerial processes, and provision of priority health activities...... 16 D. Determine health provider capacity, service availability and quality, infrastructure needs, and health care provider skills for delivery of malaria services ...... 18 E. Identify gaps ...... 19 F. Summary ...... 20 OD Thmor Kaul (TMK) ...... 22 A. Current coverage gaps in malaria prevention and control...... 26 B. Weaknesses in quality of diagnosis and treatment, vector control and surveillance ...... 27 C. Strengths and weaknesses in organizational structures, managerial processes, and provision of priority health activities...... 28 D. Determine health provider capacity, service availability and quality, infrastructure needs, and health care provider skills for delivery of malaria services ...... 29 E. Identify gaps ...... 29 F. Summary ...... 30 OD Moung Ressey (MRS) ...... 32 A. Current coverage gaps in malaria prevention and control...... 36 B. Weaknesses in quality of diagnosis and treatment, vector control and surveillance ...... 37 C. Strengths and weaknesses in organizational structures, managerial processes, and provision of priority health activities...... 37

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D. Determine health provider capacity, service availability and quality, infrastructure needs, and health care provider skills for delivery of malaria services ...... 38 E. Identify gaps ...... 39 F. Summary ...... 40 OD Kra Kor (KRK) ...... 42 A. Current coverage gaps in malaria prevention and control...... 46 B. Weaknesses in quality of diagnosis and treatment, vector control and surveillance ...... 47 C. Strengths and weaknesses in organizational structures, managerial processes, and provision of priority health activities ...... 47 D. Determine health provider capacity, service availability and quality, infrastructure needs, and health care provider skills for delivery of malaria services...... 48 E. Identify gaps ...... 50 F. Summary ...... 51 OD Phnom Kravanh (KRV) ...... 53 A. Current coverage gaps in malaria intervention and control: ...... 56 B. Weaknesses in quality of diagnostic and treatment, vector control and surveillance: ...... 58 C. Strengths and weaknesses in organizational structures, managerial processes, and provision of priority health activities ...... 58 D. Determine health provider capacity, service availability and quality, infrastructure needs, and health care provider skills for delivery of malaria services ...... 60 E. Identify gaps ...... 61 F. Summary ...... 62 Discussion ...... 63

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Abbreviations

ACT Artemisinin-based Combination Therapy AFD Agence Francaise De Development AOP Annual Operational Plan BTB Battambang CAP-Malaria Control and Prevention of Malaria CMEP Cambodia Malaria Elimination Project CMS Central Medical Store CNM National Center for Parasitology, Entomology and Malaria Control CRS Catholic Relief Services DFID Department for International Development EDAT Early Diagnosis and Treatment FDH Former District Hospital GF Global Fund HEF Health Equity Fund HC Health Center HF Health Facility HP Health Post HMIS Health Management Information System HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome IPD In-Patient Department IPC Interpersonal Communication KOFIH/KOICA Korea International Cooperation Agency KRK Krakor LLIN / LLIHN Long Lasting Insecticidal Net / Hammock Net

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M&E Monitoring and Evaluation MCH Maternal and Child Health MIS Malaria Information System MMP Mobile and Migrant Population MMW Mobile Malaria Worker MPA Minimum Package of Activity MRS Maung Russey NGO Non-Government Organization NTG National Treatment Guideline OD / ODMS Operational Health District / OD Malaria Supervisor OPD Out Patient Department PHD Provincial Health Department PKV Phnom Kravan Pf Plasmodium falciparum PH Provincial Hospital PMI President’s Malaria Initiative POC Point of Care PP Private Provider PPM Private Public Mix PQ Primaquine PSK Population Services Khmer Pv Plasmodium vivax QC Quality Control QI Quality Improvement RDT Rapid Diagnostic Test RDQA Routine Data Quality Assessment RH Referral Hospital

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RRT Rapid Response Team SOP Standard Operating Procedure SPL Sampov Loun TB Tuberculosis TMK Thmar Kaul TOT Training of Trainer UNICEF United Nations Children’s Fund URC University Research Co. USAID United States Agency for International Development USD United States Dollar VHSG Village Health Support Group VMW Village Malaria Worker WHO World Health Organization

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Background

The USAID | PMI Cambodia Malaria Elimination Project (CMEP) will support the Cambodian National Center for Malaria Control, Parasitology and Entomology (CNM) to reduce malaria morbidity and mortality and eliminate malaria nationwide by 2025. The project will work closely with stakeholders to implement malaria elimination activities in Sampov Loun (SPL) Operational District (OD) and support transition to malaria elimination in 5 ODs including Battambang (BTB), Maung Russey (MRS), Thmar Kaul (TMK), Phnom Kravanh (PKV) and Krakor (KRK) from October 2016, with potential for expansion to 2-3 more ODs in Year 3, through September 2021. CMEP will use an OD-centered approach to build capacity for ongoing transitional malaria elimination activities and malaria elimination. We will actively support the development, implementation, and monitoring of OD annual operational plans (AOP), introducing data visualization to support data use. Joint supervision at all levels to strengthen both the quality of care and routine reporting will be scaled up. To increase reach to at-risk-populations, we will strengthen community networks for Early Diagnosis and Treatment (EDAT), passive and active surveillance, distribution of long-lasting insecticidal nets (LLIN), and Interpersonal Communication (IPC). To reach this goal, the project has set up strategic objectives to: 1. Develop a scalable, evidence-based elimination model in SPL OD and support its dissemination and 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 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.

Assessment Purpose:

The CMEP project supports high quality malaria control and prevention interventions in transitional malaria elimination ODs in Battambang and Pursat provinces where gaps in coverage or quality may exist. These five OD are Battambang, Maung Ressey, Thmor Koul, Phnom Kravanh, Krakor. There is a need to complete a rapid situational analysis in the selected ODs before starting project implementation. This assessment will provide the basis for refining intervention strategies and ensuring that CMEP can properly support these ODs in their efforts to plan and implement activating to reach malaria elimination in near future.

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General objective: Assess the coverage levels, quality of key malaria interventions, and the current capacity and systems readiness at the OD level to conduct accelerated malaria control activities in the aforementioned five ODs in the transitional elimination stage. This includes the review of the existing coverage data and quality of key interventions, the organization and management of a health system in terms of its structures, managerial processes, priority malaria/health activities (e.g. accessibility and coverage of those activities), community participation and the availability and management of resources. The assessment will make use of existing data, if available, and will serve as baseline data for Project monitoring of activities. Particular focus has been given to determine the completeness of reporting, particularly from mobile and migrant populations and the private sector. This assessment was conducted in close collaboration with the CNM, OD/PHD staff, and PMI. Specific objectives:

1. Identify the current coverage gaps in malaria prevention and control/elimination activities (i.e. LLINs, diagnosis, treatment) 2. Detect weaknesses in quality of services of diagnosis and treatment, vector control and surveillance 3. Identify the strengths and weaknesses in organizational structures, managerial processes, and provision of priority health activities, community participation and empowerment, and the management of resources in the operational district health system. 4. Determine health provider (health facility and community health worker) capacity, service availability and quality, infrastructure needs, and health care provider skills for delivery of malaria services. Particular focus will be given to determine the completeness of reporting, particularly from mobile and migrant populations and the private sector. This assessment will be conducted in close collaboration with the CNM, OD/PHD staff, and PMI. 5. Identify gaps (e.g. service delivery, health workforce, health information systems, access to essential diagnostics and medicines, financing, and leadership & governance) to inform the design and development of annual operational plans and to guide implementation plans with the goal of enhancing overall performance of district health systems.

Field assessment and data collection The activity had been conducted between April 24-28 using structured questionnaires to 3 specific respondent categories (OD level, HF level and VMW). CNM/PHD was informed of the visit, however all assessments were conducted by CMEP staff. OD/HF were unavailable to join the assessment to lower levels due to competing priorities.

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Table 1: Number of Transitional Operational District Situational Assessment and Evaluations completed by Type

OD Name OD HF VMW/MMW

Battambang 1 5 7

Maung Ressey 1 5 6

Thmor Koul 1 5 0

Phnom Kravanh 1 5 5

Krakor 1 5 5

Total 5 25 23

Key Findings Battambang Operational District (BTB OD) BTB OD covers four administrative districts namely BTB, Samlot, Ratanak Mondul, and Banon districts with a population in 2016 of 379,218. According to all interviewees (OD/HF/VMWs), population movement is high (>10% of population yearly) to Thailand/other provinces inside the country. There are 28 HFs of which 13 are in endemic areas1, but only 8 HFs have VMW/MMWs (See Table 2). All of Samlot and part of Ratanak Mondul and Banon districts have endemic malaria transmission with a population of 92,245 living in 114 villages of which 73 have VMW/MMWs (See Table 3). The number of cases has reduced from 2,977 in 2011 to 427 in 2016, resulting in a decrease in the Annual Parasite Index (API) from 8.17 to 1.15 (See Table 4). The highest risk groups are men 15-45 who travel to the forest. From 2011-2016, CAP-Malaria supported 102 VMWs/10 MMWs in 5 HFs (Boeng Run, Chork Roka, Chamlong Kouy, Kampong Lpov and Tasanh) while CNM/GF supported 52 VMWs / 9MMWs in the other 3 HFs (Plov Meas, Sdao and Treng). There are 273 private providers of which 146 are registered and only 40 have joined PPM in the past (See Table 3). However, all PPM activities stopped since Jul 2015 due to funding issues with GF. There are eight key NGO partners/donors in the health sector (KOFIH/KOICA, DFID, AFD, GF, UNICEF, URC/USAID, CRS, and NOURISH) of which three (URC/USAID, CRS, GF) are involved in malaria.

1 CMEP follows the OD classification of endemic and non-endemic villages. This classification is based on the OD’s classification and does not currently rely on updated epidemiologic, entomologic, or other data.

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Figure 1. Map of administrative division and Health infrastructure in BTB OD 2016

Table 2: Number of HFs and Villages in BTB OD

Health Facility (HF) # HF # Staff Village #

PH* (CPA-3) 1 299* Endemic villages 114

FDH in endemic 3 59 # of families 20,362

FDH in non-endemic 0 0 Non-endemic villages 151

HC/HP in endemic 6/4 71 # of families 58,229

HC non-endemic 14 150 Total Villages 241

Total HFs 28 221 Total Families 78,591 *PH: The provincial hospital of Battambang is located in BTB town but it is not under the administrative control of BTB OD. Table 3: Number of Community Health Workers and Private Sector Participants in BTB OD Community Volunteers # Private Sector # VMWs 154 PPs in PPM 40 MMWs 19 PPs registered 146

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Total VMW+MMW 173 PPs not registered 127 Villages with VMW/MMW 73 Total PPs 273 Total VHSG 350 Farms/Companies Participants 4 Villages with VHSG 175 Military Health Staff as PPs 5 VMW supported by CAP- 121 Malaria VMW supported by GF 51 VMW needed to be retrained 51 VMW in Endemic villages 163

Table 4: Number of Cases and API in BTB OD 2011 2012 2013 2014 2015 2016 No. of confirmed cases 2,977 2,625 1,637 1,225 1,052 427 API 8.17 7.41 4.53 3.23 2.72 1.15

In 2016, there were 430 malaria cases reported (273 from VMWs and 157 from HFs). The OD/HF staff/VMWs all said majority of the cases were imported (>50%) from Pursat and Preah Vihear provinces. VMW/MMWs play a leading role in malaria case detection and treatment in the OD detecting more cases than HF staff in 75% (6 of 8) HFs which have VMW/MMWs (See Figure 2). Additionally, this would likely have been higher had the VMWs in those two health facilities not lost GF support since mid-2015. Figure 3 shows there are three main HFs without VMWs contributing to the malaria burden. Other five HFs contribute a small number of malaria cases during the reporting period.

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Figure 2: Malaria Cases in Health Facilites with VMWs by Facility in OD Battambang, 2014-2016 450 400 350 300 250

Cases 200 150 100 50 0 HC VMW HC VMW HC VMW HC VMW HC VMW HC VMW HC VMW HC VMW Kampong Chamlang Ta Sanh Boeung Run Chhak Roka Phlov Meas Sdao Treng Lpov Kuoy 2014 70 427 33 147 35 85 28 87 20 42 32 61 40 35 6 21 2015 78 239 33 173 23 147 14 63 31 33 20 26 28 11 14 7 2016 63 89 11 81 4 83 7 7 15 13 5 0 7 0 19 0 Health Facility (Source: MIS)

2014 2015 2016

Figure 3: Malaria Cases in Health Facilities Without VMWs in OD Battambang by Facility, 2014-2016 40 35 30 25 20

Cases 15 10 5 0 Phnom Battambang Chamkar Cheng Kantueu II Snoeng Ta Kream Svay Por Sampov Prov Hosp Samrong Meanchey 2014 21 10 17 3 5 0 0 0 2015 36 33 28 6 4 4 1 0 2016 11 7 4 1 0 1 1 1

Health Facility (Source: MIS) 2014 2015 2016

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Figure 4 shows the seasonality of the cases, with the largest number of overall cases from March-September over the past three years. The remaining 8 HCs not shown in the figures below had no cases in the last 3 years.2 The percentage of Pf malaria has increased since 2015 and contributed nearly 50% in 2016 (See Figure 5). This trend could reflect the fact that a large amount of infections were acquired in Pursat (where Pf cases are abundant) as reported by all interviewees.

Figure 4: Total Malaria Cases in OD Battambang by Month, 2014- 2016 180 160 140 120 100 80 Cases 60 40 20 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2014 71 48 40 108 135 138 163 94 91 108 103 126 2015 89 57 71 80 88 146 146 85 72 77 58 83 2016 75 52 35 30 25 92 29 26 4 19 20 23

Month (Source: MIS) 2014 2015 2016

2 This data comes from the Malaria Information System run by CNM. All of the VMWs in the area supported by GF were not submitting data from mid-2015 until CMEP activities started in 2017. Therefore the number of cases may have been underreported during that period.

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Figure 5. Malaria species in OD Battambang, 2014-2016 100% 90% 80% 202 595 (47%) 70% 879 (57%) 60% (72%) 50% 36 40% 74 Percentage 30% 192 383 20% 172 (45%) (36%) 10% 174(14%) 0% 2014 2015 2016

Year (Source: MIS)

Pf Mix Pv

A. Current coverage gaps in malaria prevention and control activities ✓ Current coverage: o In BTB OD, there are 9 HCs with Minimum Package of Activity (MPA) services which cover the appropriate target population (8,000-12,000), 5 HCs with <18,000, and 6 HCs which exceed the 18,000 target population. All those exceeding the population target are near BTB town, and therefore have the extra responsibility countered with close distances to populations and good road conditions. In the malaria endemic areas there are an additional 4 health posts (which don’t include MPA services) to improve access to basic health services including malaria in remote areas. Both HF with MPA and non MPA offer out-patient consultation services which include malaria diagnosis and treatment for uncomplicated malaria o In addition, VMW and MMWs are playing very crucial roles in providing malaria services to target populations including health education, LLIN distribution, early diagnosis, treatment for uncomplicated cases and referral of complicated cases o Among 73 VMW villages, 51 villages have continuous LLIN/LLIHNs distribution ongoing and an additional 22 villages will start soon. According to those interviewed, last LLIN/LLIHNs distribution campaign was in 2015 and will be conducted again in 2018. This assessment did not cover household level LLIN coverage (no households were visited). Based on LLIN monitoring by VMWs, 95% (13,337/14,033) households have enough LLINs for their family members and 94% (2,909/3,110) of farms have enough LLINs for migrant workers. All visited VMWs showed their motivation to provide health education and distribute LLINs/LLHINs to target populations. They all are confident they can manage malaria services in their communities

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o There are 273 private providers, of them 146 are registered PPs and only 40 PPs took part in the PPM program until Jul 2015 o From those interviewees and CMEP staff observation there seem to be sufficient service delivery points for malaria services in this OD, and this will only increase with an additional 146 registered private providers to be targeted for inclusion in the PPM scheme ✓ Coverage Gaps: The gaps in malaria prevention and control activities are mostly identified in areas previously supported by GF and non-endemic areas such as: o The interruption of VMW/MMW activities in 22 villages in 3 HFs o Dysfunction of PPM program and low coverage of PPM among PPs (40/273) o Limited health education session/coverage in non-endemic HFs ✓ Recommendations: o Revitalize VMW/MMWs activities in 22 villages previously supported by GF (all these villages are considered malaria endemic) and strengthening existing VMW/MMWs o Revitalize PPM program and expansion to cover relevant PPs

B. Weaknesses in quality of diagnosis and treatment, vector control and surveillance ✓ Weaknesses: o 61VMW/MMWs previously supported by GF need urgent training to revitalize them. This include providing supplies of VMW Kits (RDT/ACT/Monthly registration, scales, bag, thermometer, non-sterilize gloves and safety book), and training them on case management o 40 PPs in PPM also need refresher training as well as another 40 new registered PPs need orientation on PPM and malaria cases management training. Based on MMP assessment only 80 of 146 registered PPs will engage in PPM o Applying the new PPM strategic approach, PPs will get direct supplies of RDT/ACT from the public system (HC). Setting up the new supply system has taken time, however CMEP will continue to support OD/PHD to make it happen quickly o Current RDT supplies include only one vial of buffer for 25 RDTs which makes it difficult to split among PPs as before, likely causing the expiration of many tests in the future. CMEP will monitor closely the use of these kits among PPs.3 o HF staff need orientation sessions on case management and PQ use (should this be included in NTGs) for new HF staff in endemic HFs and 2 HF staff from each non- endemic HFs (40 staff)

3 All RDTs are procured by Global Fund, but CMEP will discuss this issue at the CNM and D&T TWG level for any possible solution.

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o A rapid assessment by field teams and HF staff is needed to ensure proper information is available before expanded continuous LLINs distribution to some areas (especially those previously supported by GF) o Monitoring of malaria case data in HFs is limited, especially in the non-endemic HFs and those previously supported by GF. Records in OPD and malaria monthly report forms were not always organized correctly, and Phnom Sampov HC had a discrepancy between the monthly registration from and the HC1 form. Additionally, 2 VMWs (formerly supported by GF) did not have the new monthly malaria case registration book yet. ✓ Recommendations o Provide case management training to 61 VMWs/MMWs previously supported by GF and replacement of VMW/MMWs covered by CAP-Malaria that are no longer available o Ensure all HFs/VMWs/PPs have needed diagnosis and treatment materials as well as up to date registration books o Support OD to enrol all registered providers in the PPM program, and provide training and supplies for all PPM participants o Work with CNM to ensure supply of RDTs/ACTs reaches OD for distribution to PPs o Ensure all needed LLINs and LLIHNs are available to VMWs/MMWs for continuous distribution o To counteract limited monitoring of malaria case data CMEP will improve the surveillance system and support capacity building to counterparts at OD/HF level including M&E training and malaria surveillance training C. Strengths and weaknesses in organizational structures, managerial processes, and provision of priority health activities. ✓ Strengths: o Four OD management committee members engage in malaria activities: OD director, Pharmacy/drug store, ODMS and HIS staff o OD management committee met on a monthly basis with all health centre chiefs. They understood the objectives and used the meeting to handle technical and managerial aspects as well as update staff on new guidelines, strategies and policy of national programs o AOP 2017 included both the overall OD AOP and malaria OD AOP. OD conducted progress review meetings to evaluate its achievements o OD team conducted quarterly supervision to HFs for malaria and other health programs using standardized check lists. However, they acknowledged they conducted supervision for malaria only to endemic areas and only met their goal (supervision at least twice per year in endemic HFs) in approximately 50% of HFs o ODMS received TOT training on malaria case management in 2015 which included important resources to train HF staff and VMWs on updated 2014 NTGs

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o OD has good coverage of point of care malaria services in endemic areas (13 HFs and 173 VMW/MMWs in 73 villages of 114 endemic villages). The 41 endemic villages without VMWs are located nearby HF (less than 5 km) or along good road which make it easy to access. There are also 146 registered private providers in the OD, but only 40 used to be part of PPM which stopped since Jul 2015 o Rapid response team (RRT) for OD is available and this team could be trained and equipped with necessary equipment/materials for response to malaria outbreaks ✓ Weaknesses: o Supervision had been conducted to HFs and recorded in the golden book, but only two of the five HCs visited had regular supervision, one had 50% of planned supervision, and two had no supervision at all o PPM and VMWs supported by GF stopped working since July 2015 due to funding issues o None of the team received program management training in the past year, and did not recall ever having received this training o Team could not solve the discrepancy between HMIS and MIS reported malaria cases. They did not conduct analysis of malaria cases besides monthly aggregate case reports o ODMS only spends 50% of their time on malaria program activities because they have to cover other health programs which are not officially their responsibility o The OD team did not have a clear direction on how to include PPs into the PPM program, and feel there are too many PPs in the OD making it difficult to manage if all are included o OD will receive an additional 11 microscopes to equip all HFs. ODMS acknowledged the challenges to ensure the functioning and quality of microscopy reading/accuracy o All OD/HFs staff interview didn’t see malaria as their priority and no clear dedicated staff for malaria as required in MEAF 2016-2020, expect ODMS ✓ Recommendations: o Revitalize 61 VMW/MMWs and 146 PPs in PPM programs in the OD (both implementation and appropriate trainings) o Provide M&E training and program management training to OD team, especially ODMS and HMIS staff (36 staff from 28HFs, 2 from each endemic HF and 1 from non-endemic HF) o Support the inclusion of all needed malaria activities in the overall OD AOP 2018 o Strengthening supportive supervision from OD to HFs and cover all the HFs in the OD. The full supervision team (ODMS, HIS, Drug store) will have to conduct quarterly visits to all 8 HFs in endemic areas after which one could the same with 4 HPs and 13 HFs in non- endemic areas (less work load so only one staff will be needed)

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o Coordinate and engage OD/PHD/CNM/CMEP to strengthen malaria interventions in BTB OD via regular supportive visits from CNM/PHD to ODs and from OD to HFs/VMWs/PPs using structural questionnaires/checklists o Train existing RRT for response activities to malaria case increases and/or outbreaks using existing investigation and response forms/tools for malaria elimination until the SOP for malaria outbreaks become available. CMEP will support CNM to develop and finalize malaria outbreak response SOP by the end of Y1 o CMEP needs to coordinate with CNM and OD to make a clear strategy of testing at HFs with newly equipped microscopes

D. Determine health provider capacity, service availability and quality, infrastructure needs, and health care provider skills for delivery of malaria services ✓ Strengths: o The OD has 28 HFs (13 endemic) and 173 VMW/MMWs (19 MMWs) o 112 VMW/MMWs received training on malaria case management in 2015 as part of the CAP-Malaria project o At least 2 people in each HFs surveyed were engaging in malaria activities o At least 2 people in each HFs surveyed received malaria case management training in 2015 o All five HF chiefs attend regular monthly meetings at OD offices and also conducted regular monthly meetings with all HF staff. They understood well the objectives of the meeting and used it to handle technical and managerial aspects as well as training on updated guidelines, strategies and policies of the national programs o Three of the five HFs visited conducted supervision to VMW/MMWs for malaria using standardized check lists o Health facility staff has access to monthly malaria reports o All the 5 VMWs in Tasanh catchment area had attended regular monthly meetings at the HF. They understood well the objectives of the meeting, submitted monthly reports, and received replenishment of RDTs/ACTs and receive updated guidance from OD/HF o All 5 VMWs in Tasanh area had received supervision o All VMWs provided malaria services in their villages including diagnosis, treatment and health education and completed outreach activities. They have job-aids and tools such as treatment charts, diagnosis charts and health education flip charts ✓ Weaknesses: o No VMW activities in one GF supported HF since July 2015 due to lack of funding

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o All of the visited HFs spent less than 30% of their time on malaria related activities and most less than 5% of their time (most staff held more than one role) o Verification of reports were not always conducted or done appropriately o In all visited HFs there was not much engagement with the private sector as PPs are managed by higher level government staff o All staff in HC could do OPD consultation and treatment, although not all of them have been trained on the new NTGs o Limited use of malaria case reports and capacity to analyse information o At least 5 of the 7 VMWs had difficulty with phone communication (no service) ✓ Recommendations: o Provide orientation on updated NTGs during HC monthly meetings with follow up during quarterly supportive supervision o Revitalize the functioning of VMWs in areas previously supported by GF with refresher trainings on malaria case management and reporting o Replace supplies of RDTs, ACTs, scales, thermometers, gloves and recording books where needed

E. Identify gaps ✓ Gaps: o In areas previously supported by GF funding and related activities have been pending since mid-2015 o One HF had a shortage of funds in 2016 for malaria activities (Sdao FDH which is GF supported) o No supply of RDTs/ACTs for PPs o There has been little improvement in increasing the number of malaria tests being done at all levels (HF/VMW/PP). Following the testing criteria in NTG 2014 everyone with fever should be tested, however testing if often only given to those deemed at high risk (having been in the forest). Even in CAP supported areas the skills of providers who rarely meet suspected malaria cases (many have less than once case per year) have gone down ✓ Recommendations: o Reorganize VMW meetings and encourage OD/HF to select new VMWs in areas where they might have moved out or can no longer do their job o Map all PPs and work with the PHD/OD to encourage them to register and attend monthly PPM meetings

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o This has created an urgent need to reactivate village level volunteers and PPM program, retrain previous health staff, and train new health staff for the first time. This reactivation of the program will require both ensuring proper stocks of materials are available at all points of care and ensuring the staff is trained on how to complete their prevention, diagnosis, and treatment activities o Work with OD to ensure supervision to all HFs/VMWs/PPs occurs to maintain their skills and adequate supplies of RDT/ACT. CMEP has asked CNM to request Central Medical Store (CMS) to send the needed supplies to the OD, and will continue to work with CNM to ensure the best strategy and make sure we get supplies in the hands of PPs o CMEP will work with CNM/ODMS to suggest having the PP meeting venue and supply point at each administrative district to facilitate the participation from PPs o CMEP and CNM should consider developing new simple tools that can be used to improve the number of malaria tests done by health providers, as some have said the flow chart in the NTG 2014 is not user friendly

F. Summary ✓ Conclusion BTB OD has basic infrastructure and human resources with good coverage of points of care (HFs, VMWs, PPs) that can support the transition to malaria elimination. There are also opportunities to strengthen and scale up quality malaria services to 15 HFs in non-endemic areas, as well as all 146 registered PPs. However there is no need for placing VMWs here as the HF can manage the work through outreach. 4. In terms of program management, CMEP plans to support capacity building and follow up through supportive supervision to make the improvement realistic. ✓ Key Findings o Good coverage of point of care malaria services in endemic areas o Interruption of PPM program and VMW/MMWs supported by GF o Malaria cases dropped in all areas of the OD in 2016 o Supplies of malaria commodities for PPs in PPM are still a challenge o Good management and leadership of ODMS, clear flow of information and OD has a functioning rapid response team (RRT)

4 VMWs are placed by CNM, when the criteria has been satisfied. Currently the government criteria is (1) the village is more than 5 km from the HC, and (2) village reaches an API threshold determined by the government. The latest global fund thresholds for 2018 include those above 5/1,000 and a predicted API (modelled by CHAI) above 5/1,000.

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o Need capacity building on program management for OD team o Needs malaria case management training for OPD staff, VMW/MMWs and PPs o Needs M&E training of HMIS staff (HF chief & HF malaria staff as well as ODMS & OD HMIS) o Needs new tools/flow chart to boost malaria test uptake by HF/VMW/PP o Needs effective QI system in place at all points of care to improve quality care and reporting o Lack of IEC materials for malaria education in previously GF supported VMW/MMWs o No information on ITN coverage in some parts of the OD ✓ Actions to Address or Findings to Incorporate for Programmatic Purposes 1. Revitalize 61 VMW/MMWs and 80 PPs in PPM programs with appropriate trainings, equipment and supplies. Based on the MMP mapping only 80 of 146 registered PPs will engage in the PPM program 2. The PPM strategy is to distribute free RDTs/ACTs to PPs. This can improve accessibility to quality malaria services and motivate the participation from PPs 3. Support capacity building on program management for OD team (4 persons) 4. Support malaria case management training to 36 OPD staff, 164 VMW/MMWs and 80 PPs (Refer to Table 4) 5. Support M&E training of HMIS staff, HF chief and HF malaria staff as well as ODMS and OD HMIS (36 staff from 28 HFs, 2 from each endemic HF and 1 from non- endemic HF) 6. Develop new tools/flow chart together with CNM/partners to boost malaria test uptake by HF/VMW/PP 7. Set up/strengthen effective QI system in place at all point of care to improve quality care and reporting via regular and structural supportive supervision, meetings and workshops 8. Supply contextual based IEC materials for malaria education to all Points of Care (POCs) 9. Support the inclusion of all needed malaria activities in the overall OD AOP 2018 10. Train existing RRT for response activities to malaria case increases and/or outbreaks

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Thmor Kaul Operational District (TMK OD)

TMK OD covers two administrative districts (TMK and Bavel) with a population in 2016 of 231,169. According to all interviewees (OD and HF staff), population movement is high (>10% of population yearly) to Thailand/other provinces inside the country. There are 19 HFs of which 3 HFs are in endemic areas and none of them have any VMW/MMWs (See Table 4). All the 3 endemic HFs located in Bavel district bordering with SPL OD have a population of 21,210 living in 25 villages (See Table 5). TMK and Sangke OD are the 2 ODs in BTB province that were not in the CAP-Malaria supported target area. There are 95 private providers, all are registered and only 40 have joined PPM in the past (See Table 5). However, all PPM activities stopped since July 2015 due funding issues with GF. There are eight key NGO partners/donors in the health sector (KOFIH/KOICA, DFID, AFD, GF, UNICEF, URC/USAID, CRS, and NOURISH) of which three (URC/USAID, CRS, GF) are involved in Malaria.

Figure 6. Map of administrative division and Health infrastructure in TMK OD 2016

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Table 5: Number of HFs and Villages in TMK OD

Health Facility (HF) # HF # Staff (MD) Administrative structures #

OD office 1 24 (5) District (Commune) 2 (17)

RH (CPA-1) 1 46 (10) Endemic villages 25

FDH in endemic 1 19 (3) # of families 4,544

FDH in non-endemic 0 0 Non-endemic villages 136

HC in endemic 3 24 # of families 45,550

HC non-endemic 14 106 (1) Total Villages 161

Total HFs 19 209 (19) Total Families 50,094

There were no VMW/MMWs in the ODs and the 322 Village Health Support Group (VHSGs) didn’t provide any malaria services (Table 5).

Table 6: Number of Community Health Workers and Private Sector Participants in TMK OD Community Volunteers # Private Sector # VMWs 0 PPs in PPM5 40 MMWs 0 PPs registered 95 Total VMW+MMW 0 PPs not registered 0 Villages with VHSG 161 Total PPs 95 Total VHSG 322 Farms/Companies Participants 0 VMW supported by CAP- 0 Military Health Staff as PPs 5 Malaria VMW supported by GF 0 VMW needed to be retrained 0 VMW in Endemic villages 0

5 The PPM program through CNM has criteria for enrolment. This includes being registered, licensed, and providing malaria services. All providers which meet the criteria will be enrolled.

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In 2016, there were 41 malaria cases (Pf: 17, Mix: 3, Pv: 22) reported from all HFs in TMK OD (Figure 7). The OD and HF staff interviewed said all of the cases were imported (100%) from other ODs, especially from Pursat and Preah Vihear province (>50%). Overall, there were not many malaria cases per HF, even in “endemic” villages as categorized by CNM it was below 20 cases/year/HF or an average of < 2 cases/HF/month. The number of cases has reduced from 209 in 2011 to 41 in 2016, resulting in a decrease in the API from 1.03 to 0.18 (See Table 7). The highest risk groups are men 15-45 who travel to the forest.

Table 7: Number of Cases and API in TMK OD 2011 2012 2013 2014 2015 2016 No. of confirmed cases 209 197 80 84 80 41 API 1.03 0.91 0.36 0.37 0.34 0.18

Figure 7. Malaria cases in HFs (with 2016 cases) in TMK OD, 2014-2016 20 18 16 14 12 10 8 6 4 2 0 Ampil Bavel I Thmar Khleang Boeng Kdol Ta Khnach Boeng O Ta Ki Pram Lvea Ta Poung (FDH) Koul (RH) Meas* Pring Hen* Romeas Pram Daem* 2014 11 1 17 8 3 8 4 3 4 0 2 2015 11 10 19 7 12 5 1 4 1 1 0 2016 15 7 5 4 2 2 2 1 1 1 1

Health Facility (Source: MIS) 2014 2015 2016

*HFs in endemic area Figure 8 below shown 8 HFs where there were no malaria case detection during the whole year 2016. Even in 2014 and 2015 there were very few cases detected and two of them didn’t have any malaria cases from 2014-2016.

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Figure 8. Malaria cases in HFs (with 2016 cases) in TMK OD, 2014-2016 12 10 8 6 4 2 0 Bansay Chrouy Kok Anlong Run Ta Meun Rung Chrey Prey Khpos Bavel II Traeng Sdau** Khmum** 2014 10 5 2 0 1 1 0 0 2015 2 3 2 1 0 0 0 0 2016 0 0 0 0 0 0 0 0

Health Facility (Source: MIS)

2014 2015 2016

** Chrouy Sdau and Kok Khmum didn’t have any malaria cases from 2014-2016 Interestingly, in 2014 the majority of cases occurring during the normal transmission season (May-Oct), however in 2015 there was no clear seasonal pattern, and in 2016 the majority of cases happened early in the year from Jan to March (See Figure 9). This suggests that we need to be vigilant and ensure malaria activities occur year round as you never know when the cases may come.

Figure 9. Total malaria cases in TMK OD by month, 2014-2016 18 16 14 12 10 8 6 4 2 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2014 6 5 5 6 7 5 3 12 8 7 5 13 2015 16 1 6 8 2 7 9 4 2 12 3 9 2016 5 11 6 1 3 2 2 4 2 2 1 2

Month (Source: MIS)

2014 2015 2016

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Figure 10 shows malaria species in TMK OD did not change much. Pv or mixed infections account for almost 45% throughout the reporting period. Although it seems more mixed infections are becoming Pf infections, it is plausible that this effect is due to changes in the RDTs that were used (Pan Antigen before April 2015 and Pv specific Antigen from April 2015).

Figure 10. Malaria species in TMK OD, 2014-2016 100% 90% 80% 40 33 19 (42%) 70% (49%) (46%) 60% 50% 17 4 40% 23 30% 18 20% 29 19 (37%) (44%) 10% (23%) 0% 2014 2015 2016

Health Facility (Source: MIS)

Pf Mix Pv

A. Current coverage gaps in malaria prevention and control in TMK OD ✓ Current coverage: o In TMK OD, there are 12 HCs with MPA services which cover the appropriate target population (8,000-12,000) and 6 HCs with the population between 13,000 - 15,000. This suggests MPA coverage is reasonably designed for the target population. MPA services offer out-patient consultation services which include malaria diagnosis and treatment for uncomplicated malaria o There are 25 villages which participated in the 2015 LLIN distribution campaign o There are 95 PPs, all of them are registered PPs and only 40 PPs took part in the PPM program until July 20156 ✓ Coverage Gaps: The gap of malaria prevention and control activities are mostly identified in areas previously supported by GF and in non-endemic areas, and include the following: o No VMW/MMWs in the OD

6 During the PPM Mapping exercise we visited all private providers that were on the OD list. If we found other PPs along the way we also interviewed them.

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o Dysfunction of PPM program and low coverage of PPM among PPs in the past (40/95) o Limited health education session coverage in non-endemic HFs o This assessment did not cover household level LLIN coverage (no households were visited). Last LLIN campaign only covered 25 villages in 3 HFs in the OD (eligible people are 21,210 or < 10% of OD population) o From those interviewees and CMEP staff observation there seem to not be sufficient service delivery points and activities for malaria services in this OD during the assessment ✓ Recommendations: o Utilize VHSG in the 25 endemic villages to support malaria prevention activities o Revitalize PPM program and expansion to cover PPs which meet the enrolment criteria

B. Weaknesses in quality of diagnosis and treatment, vector control and surveillance ✓ Weaknesses: o No VMW/MMWs in the OD to support diagnosis and treatment, vector control (LLIN distribution) and surveillance o HF staff did not receive training on the 2014 NTGs or malaria case management for years o Recording of malaria cases in HFs is limited in all HFs visited possibly due to low case numbers. For example, during the visit to Bavel FDH there was only one malaria case and it wasn’t recorded properly in the OPD book o No PPM activities (see PPM mapping report for more detailed information) o No continuous LLIN/LLIHNs distribution for MMPs ✓ Recommendations o Provide case management training to HFs, 2 from each facility (40 staff) o Ensure all HFs/PPs have needed diagnosis and treatment materials o Support OD to enrol all registered providers which meet the criteria (established by CNM/PPM unit) in the PPM program, and provide training and initial supplies for all PPM participants. Applying the new PPM strategic approach, PPs will get direct supplies of RDT/ACT from public system o Field teams and HF staff need to gather relevant data to better target households before expanded continuous LLINs distribution to some areas in the 25 villages previously covered by LLINs distribution campaign in 2015 o Ensure all needed LLINs and LLIHNs are available to MMPs (going out or coming in) o To counteract limited monitoring of malaria case data CMEP will improve the surveillance system and support capacity building to counterparts at OD/HF level including M&E training and malaria surveillance training

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C. Strengths and weaknesses in organizational structures, managerial processes, and provision of priority health activities ✓ Strengths: o Four OD management committee members engage in malaria activities: OD director, Pharmacy/drug store, ODMS and HIS staff o AOP 2017 included both the overall OD AOP and malaria OD AOP o ODMS received TOT training on malaria case management in 2015 which included important resources to train HF staff and PPs on updated 2014 NTGs o Rapid response team (RRT) for OD is available and this team could be trained and equipped with necessary equipment/materials for response to malaria outbreaks ✓ Weakness: o No supervision for malaria from OD to HFs o PPM supported by GF stopped working since July 2015 due to funding issues o Only one of the team received program management training in the past year as part of Masters of Public Health course but other 3 did not recall ever having received this training o They did not conduct analysis of malaria cases besides monthly aggregate case reports o ODMS only spend 20% of his time on malaria program because he has to cover other health programs as he is also deputy OD director ✓ Recommendations: o Provide program management to all 4 members of OD team o Revitalize 40 PPs and add 55 new PPs in PPM programs in the OD o Support the inclusion of all needed malaria activities in the overall OD AOP 2018 o Strengthen supportive supervision from OD to HFs and cover all the HFs in the OD. The full supervision team (ODMS, HIS, Drug store) will have to conduct quarterly visits to all 3 HFs in endemic areas after which one could the same with 15 HFs in non-endemic areas (less work load so only one staff will be needed) o Coordinate and engage OD/PHD/CNM/CMEP to strengthen malaria interventions in TMK OD via regular supportive visits from CNM/PHD to ODs and from OD to HFs/PPs using structural questionnaires/checklists o Train existing RRT for response activities to malaria case increases and/or outbreaks using existing investigation and response forms/tools for malaria elimination until the SOP for malaria outbreaks become available

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D. Determine health provider capacity, service availability and quality, infrastructure needs, and health care provider skills for delivery of malaria services ✓ Strengths: o The OD has 19 HFs (3 endemic) and 95 PPs o At least 2 people in each HFs surveyed were engaging in malaria activities o All five HF chiefs attend regular monthly meetings at OD offices and also conducted regular monthly meetings with all HF staff o All the 5 visited HFs (including 3 endemic HFs) have the 2017 AOP for overall HF activities that has quarterly targets o No stock outs of malaria commodities (RDT and ACT) in the past year in all the HFs visited ✓ Weaknesses: o No VMW and PPM activities in the OD o All of the visited HFs spent less than 10% of their time on malaria related activities and most less than 5% of their time (most staff held more than one role) o Verification of reports were not always conducted or done appropriately o In all 5 visited HFs known about PPM in the past, 3 of them also work as PP out of office hour and was joint PPM in the past, but not yet informed of the new PPM strategies/policies o No staff in HC have been trained on the new NTGs since 2015 o Limited use of malaria case reports and capacity to analyse information ✓ Recommendations: o 40 PPs in PPM stopped in July 2015 an need refresher training as well as another 55 new registered PPs need orientation on PPM and malaria cases management training o HF staff didn’t receive malaria case management training for long time (before Jul 2015), they need training and PQ use, should this be included in NTGs (40 staff) o Provide orientation on updated NTGs to all HF staff ( 40 staff??) during HC monthly meetings with follow up during quarterly supportive supervision

E. Identify gaps ✓ Gaps: o Ensuring supply of RDTs/ACTs for PPs in the PPM program is difficult. The supply mechanism is still difficult to set up at field level as some of the meeting locations where

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they receive supplies are long distances from their home. Additionally, the OD has not yet secured the supplies needed to distribute to PPs from the CMS o There has been little improvement in increasing the number of malaria tests being done at HFs o All 5 HFs visited did not properly use the monthly registration of malaria cases in HFs (no supplies of registration book from OD/CNM to HF) ✓ Recommendations: o Facilitate the distribution of updated malaria monthly registration to all HFs in year 2 of CMEP project o Provide M&E training and program management training to OD team, especially ODMS and HMIS staff (40 staff) o Map all PPs and work with the PHD/OD to encourage them to register and attend monthly PPM meetings o CMEP and CNM should consider developing new simple tools that can be used to improve the number of malaria tests done by health providers, as some have said the flow chart in the NTG 2014 is not user friendly o CMEP will work with CNM/ODMS to suggest having the PP meeting venue and supply point at each administrative district to facilitate the participation from PPs

F. Summary ✓ Conclusion TMK OD has limited infrastructure (POC) and human resources to cover appropriate activities transitioning to malaria elimination. To effectively do this we need to strengthen and scale up quality malaria services to 15 HFs in non-endemic areas as well as among all 95 registered PPs for EADT and use VHSGs for prevention activities. CMEP plans to support capacity building and follow-up through trainings and supportive supervision to all relevant public and private providers. Key Findings o Good coverage of HFs with MPA services, but point of care services are limited o Interruption of PPM program as previously supported by GF o Malaria cases dropped in all areas of the OD in 2016 o Still difficult to supplies proper amount of malaria commodities for PPs in the PPM program o OD has functioning Rapid Response Team (RRT) o Need capacity building on program management for OD team

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o Need malaria case management training for OPD staff, VMW/MMWs and PPs o Need M&E training of HMIS staff, HF chief and HF malaria staff as well as ODMS and OD HMIS o Needs new tools/flow chart to boost malaria test uptake by HF/PP o Needs effective QI system in place at all point of care to improve quality care and reporting o No information on ITN coverage in the OD ✓ Actions to Address or Findings to Incorporate for Programmatic Purposes 1. Revitalize and scale up 40 PPs in PPM programs with appropriate trainings, equipment and supplies. Set up supplies system for PPM and organize bi-monthly meetings 2. Support capacity building on program management for OD team (4 persons) 3. Provide malaria case management training for 38 OPD staff and 40 PPs 4. Provide M&E training of HMIS staff, HF chief and HF malaria staff as well as ODMS and OD HMIS (24 staff from 19 HFs, 2 from each endemic HF and 1 from non- endemic HF) 5. Develop new tools/flow chart together with CNM/partners to boost malaria test uptake by HF/PP 6. Set up /strengthen effective QI system in place at all point of care to improve quality care and reporting via regular and structural supportive supervision, meetings and workshops. The full supervision team (ODMS, HIS, Drug store) will have to conduct quarterly visits to all 3 HFs in endemic areas after which one could do the same with 14 HFs in non-endemic areas (less work load so only one staff will be needed) 7. Support the inclusion of all needed malaria activities in the overall OD AOP 2018 8. CMEP needs to coordinate with CNM and OD to make a clear strategy of testing at HFs with newly equipped microscopes.

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Moung Ressey Operational District (MRS OD) Background characteristics: MRS OD covers three administrative districts with a population of 206,481 in 2016 and among these 30,848 live in endemic areas. The population movement is not stable, as some move to work in Thailand and some go to the forest when they finish the rice cultivation (especially adult males). It is estimated about 10 % of the population are considered as migrants. There are 15 HFs, (1 RH, 13 HCs and 1 HP), of which four are in endemic areas. Three of the endemic HFs (Kos Kralor, Prey Tralach and Prek Chik) have at total of 38 VMWs. The VMW/MMWs have not been active since end of 2015 (i.e. no monthly meetings). There are many NGOs in MRS OD, but only 4 key NGO partners for health (KOFIH/KOICA, RACHA, WHO and URC). Figure 11. Map of administrative division and Health infrastructure in MRS OD 2016

Table 8: Number of HFs and Villages in MRS OD

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Health Facility (HF) # HF # Staff (MD) Administrative structures #

OD office 1 17 (4) District (Commune) 3 (20)

RH (CPA-2) 1 81 (24) Endemic villages (families) 38 (6,557)

FDH in endemic 0 0 # people in endemic area 30,848 137 FDH in non-endemic 0 0 Non-endemic villages (families) (36,760) HC in endemic 4 50 (1) # people in non-endemic area 175,633 175 HC non-endemic 9 84 (1) Total Villages (families) (43,317) Total HFs +OD office 15 232 (30) Total population 206,481

Table 9: Number of Community Health Workers and Private Sector Participants in OD MRS Community Volunteers # Private Sector # VMWs 4 PPs in PPM 49 MMWs 8 PPs registered 65 Total VMW+MMW 50 PPs not registered 80 Villages with VMW/MMW 38 Total PPs 145 Total VHSG 348 Farms/Companies Participants 0 Villages with VHSG 175 Military Health Staff as PPs 0 VMW supported by CAP- 0 Malaria VMW supported by GF 51 VMW needed to be retrained 51 VMW in Endemic villages 51

Figure 12 below shows a big drop of malaria cases in 2016 (compared to 2014 and 2015) among the 3 HFs with VMWs, while the others stayed relatively the same. Based on the 6 VMWs interviewed among 3 HCs in malaria endemic areas said “more than 90% of malaria cases in 2016 in their place occurred among mobile and migrant population. All the cases occurred among forest goers who travel outside the district to Pursat province”. The ODMS said: “the environment, especially forest areas, has completely changed since the last three years”. Malaria has dropped down from year by year as VMWs perceived. Some VMW‘s villages have very few malaria cases for the whole year and no malaria endemic areas at all. Figure 13 shows a similar

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trends among non-endemic HCs with cases and had one village with no cases in the last three years.

Figure 12. Malaria Cases in Endemic HFs in OD MRS, 2014- 2016 250 200 150 100 50 0 HF VMW RH HF VMW HF VMW HF Maung Robas Prey Tralach Prek Chik Keas Kralor Rrussei_RH Mongkol 2014 109 94 37 21 35 9 66 24 2015 195 75 47 57 20 22 7 21 2016 69 10 34 24 0 8 1 19

Health Facility (Source: MIS) 2014 2015 2016

Figure 13. Malaria Cases in Non-Endemic HFs in MRS OD, 2014-2016 40 35 30 25 20 15 10 5 0 Russey Thipdei Prey Svay Kear Maung Kakoh Prey Tauch Ta Loas Chrey Kraing 2014 24 36 16 3 4 0 1 0 0 2015 13 12 15 9 4 2 5 1 0 2016 15 6 4 2 2 1 0 0 0

Health Facility (Source: MIS) 2014 2015 2016

*HFs in endemic area

During 2014-2015 a majority of cases occurred from June-October (as expected), however cases remained low for all of 2016 (See Figure 14). Malaria species in MRS OD had a noticeable increase in the proportion of Pf cases since 2014 (See Figure 15). In 2016, there were only 195

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malaria cases, with a majority of Pf or mixed cases imported by forest goers and mobile and migrant people who went to Veal Veng district in Pursat. The number of cases has reduced from 1,461 in 2011 to 196 in 2016, resulting in a decrease in the API from 7.57 to 0.97 (See Table 10). The highest risk groups are men 15-45 who travel to the forest.

Table 10: Number of Cases and API in MRS OD 2011 2012 2013 2014 2015 2016 No. of confirmed cases 1,461 833 307 479 509 196 API 7.57 4.21 1.52 2.36 2.46 0.97

Figure 14. Malaria cases in MRS OD, 2014-2016 100 90 80 70 60 50 40 30 20 10 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2014 22 16 31 13 14 31 90 54 68 70 57 49 2015 37 14 26 28 40 95 63 63 57 42 26 26 2016 25 24 14 13 20 19 21 13 17 8 13 14

Month (Source: MIS)

2014 2015 2016

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Figure 15. Malaria Species in OD TMK, 2014-2016 100% 90% 157 80 80% 231 (31%) (39%) 70% (48%) 60% 74 10 50% 40% 119 30% 274 105 (54%) (54%) 20% 129 10% (27%) 0% 2014 2015 2016

Year (Source: MIS)

Pf Mix Pv

A. Current coverage gaps in malaria prevention and control ✓ Current coverage: o In MRS OD, there are 3 HCs with MPA services which cover the appropriate target population (8,000-12,000) and 5 HCs with the population between 13,000-15,000 populations and 5 HCs cover >15,000 population. This means in OD MRS, the MPA services cover have higher target populations than they should and may be overcrowded o In the 4 HFs in malaria endemic areas, each covers > 15, 000 population. Thus the role of VMWs and PPs are very important to improve accessibility to patients o Malaria prevention and control activities included: (1) EDAT by HF, VMW, and (2) providing health education at point of care by VMW and HF staff. There are some gaps such as outreach activities to improve accessibility to vulnerable groups o In non-endemic areas, there are only routine services at HFs where the same package of malaria services are available o There are private providers who offer diagnosis and treatment services for malaria patients but no clear information about how many PPs are in these categories o Last LLIN distribution was in 2015 to the villages in 4 endemic HFs o World Health Organization (WHO) is implementing DHIS2 in all 13 HFs, 38 VMWs and 2 PPs for malaria cases investigation and classification since Jun 2016 ✓ Coverage gaps: o There are some gap such as outreach activities to improve accessibility of vulnerable groups as the southern part of the OD is connected to Cardamom mountain chain

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o PPs are no longer part of PPMs since July 2015 o No continuous LLIN distribution to MMPs ✓ Recommendation: o Set up outreach activities by VMWs to improve accessibility of vulnerable groups o Revitalize PPM program o Select villages at high risk for continuous LLIN distribution activities to MMPs

B. Weaknesses in quality of diagnosis and treatment, vector control and surveillance ✓ Weaknesses: o 49 PPs in the OD are no longer part of PPM since Jul 2015 o 50 VMW/MMWs have taken part in DHIS2 trainings & meetings, but didn’t perform basic malaria prevention activities o No malaria case management training since 2015 o No information on LLIN coverage ✓ Recommendations o Provide case management training to HFs, 2 from each (28 staff) o Ensure all HFs/PPs have all need diagnosis and treatment materials o Support OD to enrol all registered providers in the PPM program, and provide training and initial supplies for all PPM participants o Work with CNM to ensure supply of RDTs/ACTs reach OD for distribution to PPs o Ensure all needed LLINs and LLHINs are available to MMPs (going out or coming in)

C. Strengths and weaknesses in organizational structures, managerial processes, and provision of priority health activities. ✓ Strengths: o Four OD management committee members engage in malaria activities: OD director, Pharmacy/drug store, ODMS and HIS staff o There are regular meetings among OD health technical teams and OD management teams on a monthly basis with reports for each meeting o OD have both the overall OD AOP and malaria OD AOP 2017 o Malaria AOP 2017 support by CMEP in place and implementation has started

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o ODMS received TOT training on malaria case management in 2015 which included important resources to train HF staff and PPs on updated 2014 NTGs o OD has RRT for general health related issues and all HFs have malaria staff and RRT teams o Health Equity Fund (HEF) is available everywhere o All HFs in endemic areas have VMWs/MMWs in place o Reporting system is good, have internet access at all levels of HFs, and access to electronic database ✓ Weakness: o General AOP in place, but not clear budget to support for malaria activities o No supervision for malaria from OD to HFs o None of the OD team received program management training in the past year o ODMS spend more time on his duty as deputy OD director than his time on malaria program because he has to cover other health programs o No M&E training in last 2 years ✓ Recommendations: o Provide program management to all 4 member of OD team o Strengthen supportive supervision from OD to HFs and cover all the HFs in the OD o Train existing RRTs for response activities to malaria case increases and/or outbreaks

D. Determine health provider capacity, service availability and quality, infrastructure needs, and health care provider skills for delivery of malaria services ✓ Strengths: o The OD has 14 HFs (4 endemic), 50 VMW/MMWs and 65 registered PPs o At least 2 people in each HFs surveyed were engaging in malaria activities o All five HF chiefs attend regular monthly meetings at OD offices and also conducted regular monthly meetings with all HF staff o All HFs have health equity fund services o The OD implementing DHIS2 piloting for malaria elimination o No stock out of malaria commodities (ACT/RDT) o

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✓ Weaknesses: o No PPM activities in the OD, except 2 PPs who take part in DHIS2 o All of the visited HFs spent less than 10% of their time on malaria related activities and most less than 5% of their time (most staff held more than one role) o No staff in HCs have been trained on the new NTGs since 2015 o VMW/MMWs only conducting case management and reporting based on DHIS2 system but do little activities related to malaria prevention (HE, LLINs distribution) ✓ Recommendations: o 49 PPs in the PPM program stopped in July 2015 and need refresher trainings as well as another 16 new registered PPs need orientation on PPM and malaria cases management training o 30 HF staff need malaria case management training o Replace supplies of RDTs, ACTs, scales, thermometers, gloves and recording books

E. Identify gaps ✓ Gaps: o Supply of RDTs/ACTs for PPs in the PPM program is not happening on a regular basis as the mechanism to distribute directly from OD to PPs (rather than HCs) has not been finalized by CNM, and there is a shortage as CMS is only estimating the number needed by HCs and not PPs. o There has been little improvement in increasing the number of malaria tests being done at all levels (HF/VMW) o All 5 HFs visited did not properly use the monthly registration of malaria cases standard forms (no supplies of registration book from OD/CNM to HF/VMWs) o ODMS didn’t enter data in the MIS or HMIS as all cases were reported via DHIS2 o No specific malaria related plan for supervision or outreach to commune/at-risk villages o No follow up/feedback from OD after HFs submitting data o Microscopes not functioning well and some don’t work at all ✓ Recommendations: o Facilitate the distribution of updated malaria monthly registration to all HFs o Map all PPs and work with the PHD/OD to encourage them to register and attend monthly PPM meetings

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o Support development of malaria micro-plans7 o Support development and implementation of supervision checklists and tools o Support specific malaria related plans for supervision/outreach o Support M&E training to help HFs give appropriate feedback to VMWs o Support for microscopy lab activities as on the job training and QA

F. Summary ✓ Conclusion MRS OD has infrastructure and human resources to cover appropriate activities transitioning to malaria elimination. However, in order to ensure success CMEP will strengthen and scale up quality malaria services to 9 HFs in non-endemic areas as well as among all 49 registered PPs for EADT and prevention activities, and strengthen the surveillance system from all POCs. CMEP plans to do this by supporting capacity building and follow up through supportive supervision and training. CMEP will consider supporting microscopy capacity building in HFs that provide severe malaria case management. ✓ Key Findings o Interruption of PPM program supported by GF since July 2015 o Malaria cases dropped in all areas of the OD in 2016 o Still challenging to provide proper supplies of malaria commodities to those in the PPM program o OD has functioning rapid response team (RRT) o Need capacity building on program management for OD team o Need malaria case management training for OPD staff, VMW/MMWs and PPs o Need M&E training of HMIS staff, HF chief and HF malaria staff as well as ODMS and OD HMIS o Need new tools/flow chart to boost malaria test uptake by HF/PP o Need effective QI system in place at all points of care to improve quality of care and reportingNo information in OD MIS data base due to ongoing DHIS2 piloting in the OD supported by WHO/PHD. As requested by CNM, CMEP will continue to facilitate piloting of DHIS2 in the OD. CMEP will also support the OD staff to report simultaneously through the MIS (including paper registers which are uploaded to the online MIS at the OD level). The DHIS2 system does distinguish between imported and local cases.

7 The AOP development process in CMEP is similar to what Global Fund calls malaria micro-planning. In this instance micro-planning refers mostly to micro-plans for net distribution. AOP is more comprehensive and covers microplanning and other aspects of malaria services/activities.

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✓ Actions to Address or Findings to Incorporate for Programmatic Purposes 1. Revitalize and scale up 49 PPs in PPM programs with appropriate trainings, equipment and supplies. Set up supplies system for PPM and organize bi-monthly meetings 2. Supply monthly reporting book to VMWs 3. Support capacity building on program management for OD team (4 persons) 4. Support malaria case management training for 28 OPD staff and 49 PPs and 50 VMW/MMWs 5. Support M&E training of HMIS staff, HF chief and HF malaria staff as well as ODMS and OD HMIS (20 staff from 14 HFs, 2 from each endemic HF and 1 from non- endemic HF) 6. Develop new tools/flow chart together with CNM/partners to boost malaria test uptake by HF/PP 7. Set up/strengthen effective QI system in place at all point of care to improve quality care and reporting via regular and structural supportive supervision, meetings and workshops

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Kra Kor Operational District (KRK OD)

KRK OD covers one administrative district with a population of 91,564 in 2016. The OD estimates 20% of the population are mobile people, moving depending on seasonal work. There are 10 HFs (1 RH and 9 HCs), and 6 of 9 HCs are in malaria endemic areas (with a total of 96 VMWs). The VMW/MMWs have not been supported since the end of 2015 (i.e. no monthly meeting), except in areas of CAP-Malaria support. There are two NGOs that support the OD on malaria (CMEP, and PFD). KRK OD just upgraded from HC Krakor (former district hospital) to become the OD and started functioning since last year.

Figure 16. Map of administrative division and Health infrastructure in KRK OD 2016

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Table 11: Number of HFs and Villages in KRK OD Health Facility (HF) # HF # Staff (MD) Administrative structures # OD office 1 11 (1) District (Commune) 1 (9) RH (CPA-1) 1 23 (3) Endemic villages 46 FDH in endemic 0 0 # people in endemic area 67,115 FDH in non-endemic 0 0 Non-endemic villages 59 HC in endemic 6 64 (0) # people in non-endemic area 24,449 HC non-endemic 3 21 (0) Total Villages (families) 105 Total HFs +OD office 11 119 (4) Total population 91,564

Table 12: Number of Community Health Workers and Private Sector Participants in KRK OD Community Volunteers # Private Sector # VMWs 92 PPs in PPM 47 MMWs 6 PPs registered 47 Total VMW+MMW 98 PPs not registered 8 Villages with VMW/MMW 52 Total PPs 55 Total VHSG 210 Farms/Companies Participants 4 Villages with VHSG 105 Military Health Staff as PPs 0 VMW supported by CAP- 37 Malaria VMW supported by GF 61 VMW needed to be retrained 61 VMW in Endemic villages 98

Figure 17 below shows a big drop in the number of malaria cases in 2016 among most of the 5 HFs with VMWs. Figure 18 shows similar trends among HFs without VMWs of reducing caseload and one HC with no malaria cases from 2014-2016. Krakor RH had an increase in the number of malaria cases in 2016, which may be due to the improvement of capacity of newly promoted RH which is less dependent on the Pursat Provincial Hospital.

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Figure 17. Malaria Cases in HFs with VMWs in OD KRK, 2014- 2016 700 600 500 400 300 200 100 0 HF VMW HF VMW HF VMW HF VMW HF VMW Chheu Tom Svay Sor Chhouk Meas Sna Ansar Krakor 2014 75 94 31 57 31 0 25 0 8 0 2015 283 593 38 253 146 166 77 24 0 128 2016 200 416 16 106 98 12 89 0 0 0

Health Facility (Source: MIS)

2014 2015 2016

Figure 18. Malaria Cases in HFs without VMWs in OD KRK, 2014-2016 90 80 70 60 50 40 30 20 10 0 Boeng Kantuot Krakor RH Ansa Chambak* Kampong Po Kampong Luong 2014 14 0 7 8 0 2015 81 14 20 3 0 2016 37 25 5 4 0

Health Facility (Source: MIS)

2014 2015 2016

*HFs in endemic area Figure 19 shows there does seem to be a normal distribution of cases around the rainy season (May-Oct) in all three years. In 2015 there was much higher number of cases increasing from May-Dec and really into Feb 2016. Malaria species in KRK OD show a noticeable increase in

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the proportion of Pf cases after 2014, although the percentage of Pf and mixed cases stays high (over 65%) from 2014-16 (See Figure 20). This also matches with the reports that most of the cases are imported from forest workers. The number of cases has varied, but is roughly the same in 2011 (1,035) as in 2016 (1,036), with a slight decrease in the API from 12.23 to 11.56 (See Table 13). The highest risk groups are men 15-45 who travel to the forest.

Table 13: Number of Cases and API in KRK OD 2011 2012 2013 2014 2015 2016 No. of confirmed cases 1,035 429 254 350 1,851 1,036 API 12.23 5.03 2.94 4.01 20.93 11.56

Figure 19. Malaria cases in KRK OD, 2014-2016 350 300 250 200 150 100 50 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2014 14 12 11 11 10 11 38 37 37 56 53 60 2015 52 29 46 58 72 251 316 211 144 227 224 223 2016 134 118 84 48 39 90 109 94 43 101 94 81

Month (Source: MIS)

2014 2015 2016

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Figure 20. Malaria species in KRK OD, 2014-2016 100% 384 90% 297 120 (21%) 80% (34%) (29% 134 70% 48 60% 50% 113 40% 1335 690 30% (72%) (67%) 20% 117 10% (33%) 0% 2014 2015 2016

Year (Source: MIS)

Pf Mix Pv

A. Current coverage gaps in malaria prevention and control ✓ Current coverage: o In KRK OD, there are 1 RH and 9 HCs, all of 9 HFs have MPA and only 1 HC has cover >12, 000 population. This means in KRK OD had good coverage of MPA services for its target population o OD have 47 PPs in PPMs before September 2015, of the total 55 PPs (8 PPs are not registered) o In all 6 HFs in malaria endemic areas have VMW/MMWs (92/6) o Malaria prevention and control activities included: (1) EDAT by HF, VMW, and (2) providing health education at point of care by VMW and HF staff. There are some gaps such as outreach activities to improve accessibilities of vulnerable groups o In 3 HFs in non-endemic areas, there are only routine services at HFs where the same package of malaria services are available: (1) EDAT by HF, (2) provide health education at point of care by HF staff o Last LLINs distribution held in 2015 to the villages in 6 endemic HFs ✓ Coverage gaps: o There are some gap such as outreach activities to improve accessibilities of vulnerable group as the southern part of the OD is connected to Cardamom mountain chain o PPs are not active in PPM since September 2015

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o No continuous LLINs distribution to MMPs in at-risk villages ✓ Recommendation: o Set up outreach activities by VMWs to improve accessibilities of vulnerable group o Revitalize PPM program o Select villages at high risk for continuous LLINs distribution activities to MMPs

B. Weaknesses in quality of diagnosis and treatment, vector control and surveillance ✓ Weaknesses: o 66 VMW/MMW previously supported by GF did not functioning since Jul 2015 o Last malaria case management training for HFs were in 2015 o No information on LLINs coverage o No entomology information o No specific malaria related plan for supervision or outreach to commune/at-risk villages o No follow up/feedback from OD after HFs submitting data o Most of malaria patients are mobile people that are difficult to follow up ✓ Recommendations o Provide case management training to HFs, 2 from each (20 staff) o Ensure all HFs/PPs have all needed diagnosis and treatment materials o Support OD to enrol all registered providers in the PPM program, and provide training and initial supplies for all PPM participants o Work with CNM to ensure supply of RDTs/ACTs reach OD for distribution to PPs o Ensure all needed LLINs and LLIHNs are available to MMPs (going out or coming in) o Support development and implementation of supervision checklists and tools

C. Strengths and weaknesses in organizational structures, managerial processes, and provision of priority health activities ✓ Strengths: o There are regular meetings among OD health technical teams and OD management teams on a monthly basis with reports for each meeting o HEF is available everywhere

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o General AOP in place, but no budget to support malaria activities. However, the Malaria AOP 2017 development was supported by CMEP, is in place, and implementation has started o ODMS received TOT training on malaria case management in 2015 o All HFs in endemic areas have VMWs/MMWs in place o All HFs have malaria staff and RRT teams ✓ Weakness: o No supervision for malaria from OD to HFs and VMWs for the past two years o ODMS is newly appointed, and still needs support from more experienced ODMS staff (such as the Sam Povs Meas ODMS) o No HFs have malaria micro-plans o No standardized supervision tool o No collaboration with PPM on malaria activities o No entomology information o Many staff have more than one responsibility, many of the staff also work for the Krakor referral hospital o Poor infrastructure including no map of OD/white board for health coverage o Never received any training for program management especially for malaria ✓ Recommendations: o Provide program management training to all 4 members of the OD team o Strengthen supportive supervision from OD to HFs and cover all the HFs in the OD o Train existing RRTs for response activities to malaria case increases and/or outbreaks o Support development of malaria micro-plans o Support specific malaria related plans for supervision/outreach o Support M&E training to help HFs give appropriate feedback to VMWs

D. Determine health provider capacity, service availability and quality, infrastructure needs, and health care provider skills for delivery of malaria services. ✓ Strengths: o The OD has 10 HFs (6 endemic), 98 VMW/MMWs and 55 PPs o At least 2 people in each HFs surveyed were engaging in malaria activities

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o All five HF chiefs attend regular monthly meetings at OD offices and also conducted regular monthly meetings with all HF staff o All HFs have 2017 AOP and malaria activities are strongly supported by CMEP o Malaria drugs are available at all public HFs and VMWs in malaria endemic areas observed during the interviewing. o All HFs have NTG 2014 in place o Receiving integrated supervision from OD o All HFs have HCMC and health staff meeting regularly in place as well as meetings with OD o Malaria service is free of charge for patients with ID poor through HEFs o During interviews with VMWs they showed good skills in providing malaria services including diagnosis, treatment, health education, prevention, and commitment to contribute towards malaria elimination ✓ Weaknesses: o No PPM activities in the OD o No staff in HC have been trained on the new NTGs since 2015 o No VMW meetings, trainings, or activities since mid-year 2015 o Not enough health education materials o Difficulty in following up patients during the rainy season o Difficulty to meet people for health education (as they are busy working) o Not often testing suspected patients with RDTs if they don’t have all malaria signs/symptoms ✓ Recommendations: o Provide training/refresher training of 47 registered PPs on PPM strategies and malaria cases management o Provide malaria case management training to 22 HF staff o Replace supplies of RDTs, ACTs, scales, thermometers, gloves and recording books o Revitalize VMW program and provide new kits to all VMWs as many of the old kits were damaged, lost, or broken o Ensure adequate amount of health education materials are available and replace the new sign boards of VMWs which are installed in front of their house o Review the village risk stratification and better analyse VMW data

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o Encourage VMWs/MMWs to do more testing of suspected cases according to the decision tree chart in the national guideline

E. Identify gaps ✓ Gaps: o Supply of RDTs/ACTs for PPs in the PPM program is difficult as OD does not have supplies from CNM o There has been little improvement in increasing the number of malaria tests being done at all levels (HF/VMW/PP) o HFs do not properly use the standard form for monthly registration of malaria cases in all 5 HFs visited (no supplies of registration book from OD/CNM to HF) o Lack of human resource as malaria officials often have many other responsibilities. Additional staff have been requested by the OD, but have not yet been assigned o No budget from government for malaria activities o Materials (white board, etc.) are not available o No OD map for health coverage o No storage room for LLINs at OD o No computers in HFs o No training on M&E and HMIS has ever taken place in this OD ✓ Recommendations: o Facilitate the distribution of updated malaria monthly registration for HF to all HFs o Provide M&E training and program management training to OD team, especially ODMS and HMIS staff (20 staff) o Map all PPs and work with the PHD/OD to encourage them to register and attend monthly PPM meetings o Support transportation costs for outreach/supervision. This is in our work plan already o Provide training on program management o Update list of at-risk villages and start continuous LLIN distribution for mobile and migrant populations o Find way to reach at-risk individuals (especially forest goers) in all villages (not only those with VMWs) o Ensure all HFs have needed materials/funds for malaria activities and adequate storage facilities where needed

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o Support the development of the health coverage map for OD/HFs o Coordinate and engage OD/PHD/CNM/CMEP to strengthen malaria interventions o Revitalize the VMW program o Provide all training on M&E and HIMIS to HIS Staff (including collection of data on all malaria cases including new report formats, data analysis and producing basic figures)

F. Summary ✓ Conclusion KRK OD needs improvements in infrastructure (POCs) and human resources to reduce malaria cases to the levels needed to be considered for elimination activities. This includes working with all 6 HFs in endemic areas along with strengthening and scaling up quality malaria services to 3 HFs in non-endemic areas as well as among all 47 registered PPs for EADT and prevention activities. CMEP plans do this through training, capacity building and follow up through supportive supervision which will include regular visits from central level (CNM) and PHD teams. ✓ Key Findings o Interruption of VMW and PPM program supported by GF since September 2015 o Malaria cases dropped in all areas of the OD in 2016 o OD has functioning rapid response team (RRT) o Needs capacity building on program management for OD team o Needs to revitalize VMW/PPM program including malaria case management training for OPD staff, VMW/MMWs and PPs o Needs M&E training of HMIS staff, HF chief and HF malaria staff as well as ODMS and OD HMIS o Supply of RDTs/ACTs for PPs in the PPM program is difficult as OD does not have supplies from CNM o HFs do not properly use the standard form for monthly registration of malaria cases in all 5 HFs visited (no supplies of registration book from OD/CNM to HF) o No budget from government for malaria activities o Materials (white board, etc.) are not available o No OD map for health coverage o No adequate storage for LLINs o No computers in HFs

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✓ Actions to Address or Findings to Incorporate for Programmatic Purposes 1. Revitalize and scale up 47 PPs in PPM programs with appropriate trainings, equipment and supplies. Set up supply system for PPM and organize bi-monthly meetings 2. Revitalize 66 VMW/MMWs with appropriate trainings, equipment and supplies 3. Support capacity building on program management for OD team (4 persons) 4. Support malaria case management training for 22 OPD staff and 47 PPs and 98 VMW/MMW (66 from GF and refresher for 32 from CAP-Malaria) 5. Support M&E training of HMIS staff, HF chief and HF malaria staff as well as ODMS and OD HMIS (20 staff from 10 HFs, 2 from each endemic HF and 1 from non-endemic HF, and 3 OD staff) 6. Set up /strengthen effective QI system in place at all point of care to improve quality care and reporting via regular and structural supportive supervision, meetings and workshops

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Phnom Kravanh Operational District (KRV OD) KRV OD covers two administrative districts namely Phnom Kravanh and Veal Veng with a population in 2016 of 90,105. According to the director of KRV OD, it is estimated that about 10% of the population are considered as migrants. Some of them moved from other districts or provinces to work in the OD and others move to other provinces or to neighbouring countries (mainly Thailand). In total, there are 12 health facilities [one referral hospital, eight health centers, and three health posts] as shown in table 10. All HFs are in malaria endemic areas with a total of 143 VMWs/MMWs. Thirty two private providers have been registered in the PPM scheme. However, there is no clear information about unregistered PP in the OD. There is no supervision, no RDT and ACT supplies from OD to PPM or report from PPM to OD at the time of survey. For migrant populations, some of them are working in farm companies such as MDS, Pheaphimex, and road construction companies and the others do forest-related work such as logging, hunting, etc. Because KRV is a malaria endemic OD, there was entomology research conducted in February 2017 in Promoy and Anlong Reap HCs. For malaria data, it is available only for this last one year as the OD is newly established. Key NGO partners working in the OD include URC, PFD, Anakut Komar, Chivit Thlay Thno, and RACHA. Among those, CMEP and PFD are working on malaria. Figure 21. Map of administrative division and Health infrastructure in Phnom KRV OD 2016

Table 14: Number of HFs and Villages in KRV OD, 2016

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Health Facility (HF) # HF # Staff Village #

PH* 1 21 Endemic villages 61

FDH in endemic 0 0 # of population 79,328

FDH in non-endemic 0 0 Non-endemic villages 19

HC/HP in endemic 8/3 49 # of population 10,777

HC/HP non-endemic 0 0 Total Villages 80

Total HFs 12 70 Total Families 90,105

Table 15: Number of Community Health Workers and Private Sector Participants in OD KRV Community Volunteers # Private Sector # VMWs 122 PPs in PPM 32 MMWs 28 PPs registered 46 Total VMW+MMW 143 PPs not registered N/A Villages with VMW 61 Total PPs N/A Total VHSG 0 Farms/Companies Participants 3 Villages with VHSG 0 Military Health Staff as PPs 0 VMW supported by CAP- 10 Malaria VMW supported by GF 133 VMW needed to be retrained 140 VMW in Endemic villages 143

Based on data from HIS, malaria cases in the OD greatly increased from 1,956 in 2014 to 5,266 in 2015, and then subsequently decreased to 1,633 in 2016. In 2015, malaria cases greatly increased in Promoy HC which was considered an outbreak and interventions were carried out. In 2016, due to lack of funding from GF for VMWs monthly meetings, some HCs such as Bak Chichean, Phnom Kravanh, Samraong and Tasah did not receive malaria cases reported from VMWs.

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CAP-Malaria supported only 10 VMWs (2 in Pramaoy HC, 2 in Hun Sen Thmarda HC and 6 in Anlong Reap HC) and it is noted that the majority of cases in the HC were captured and treated by VMWs/MMWs. Figure 22 shows malaria cases in HCs detected by HC staff and VMWs from 2014 to 2016.

Figure 22: Malaria Cases in Health Facilities in KRV OD, 2014- 2016 1800 1600 1400 1200 1000 800 600 400 200 0 Malaria cases Malaria VM VM VM VM VM VM VM VM VM HF HF HF HF HF RH HF HF HF W W W W W W W W W Phnom Phnom Bak Hun Sen Pramaoy Samraong Anglong Prongil Kravanh Ta Sah HC Kravanh Chichean Thmarda HC HC Reap HC HC HC RH HC HC 2014 246 1119 125 35 82 33 0 0 133 8 0 0 42 9 85 3 15 21 2015 724 1607 317 453 276 389 120 344 182 91 285 0 125 89 114 19 10 121 2016 278 191 211 0 213 0 139 102 221 0 79 0 76 19 75 0 1 28

Health Facility (Source: MIS)

For the trend of malaria cases, they generally increased from June to October, but in 2015 there was an abnormal increase of malaria cases in June and July where an outbreak was confirmed. After interventions were provided the number of cases began to drop again (Figure 23). Figure 24 shows the predominant malaria species in PKV OD was Pf in 2015 and 2016 (>60%). The number of cases has reduced from 4,518 in 2011 to 1,448 in 2016, resulting in a decrease in the API from 61.03 to 17.44 (See Table 16). The highest risk groups are men 15-45 who travel to the forest.

Table 16: Number of Cases and API in KRV OD 2011 2012 2013 2014 2015 2016 No. of confirmed cases 4,518 3,635 1,563 1,956 4,978 1,448 API 61.03 48.77 20.71 25.59 64.33 17.44

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Figure 23: Malaria Cases in KRV OD, 2014-2016 1200 1000 800 600 400 200 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2014 100 58 83 74 89 215 257 176 262 216 175 251 2015 349 226 240 359 417 653 1088 632 407 353 275 267 2016 234 167 157 80 95 158 140 133 170 107 101 91 Month (Source: MIS)

2014 2015 2016

Figure 24. Malaria Species in PKV OD, 2014-2016 100% 1196 90% 530 675 (23%) 80% (35%) (32%) 70% 706 31 60% 50% 872 40% 3364 1072 30% (64%) (66%) 20% 409 10% (21%) 0% 2014 2015 2016

Year (Source: MIS) Pf Mix Pv

A. Current coverage gaps in malaria intervention and control: ✓ Current Coverages: KRV OD has been recently separated from Sampov Meas OD in 2016. There is 1 referral hospital (CPA1), 8 health centers and 3 health posts. Although newly established, the OD has key focal points for malaria including the OD malaria supervisor (ODMS), and the HMIS data

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officer. The malaria AOP in place and is being implemented with regular meetings with technical teams and strong support from senior team from Sampov Meas OD and from NGOs partners, mainly CRS and URC. All 12 HFs are endemic HFs with a total of 122 VMWs in all 61 endemic villages and 28 MMWs. They play a crucial role in malaria case detection, treatment, and outreach activities to provide education as well as ITN monitoring and distribution. ✓ Coverage gaps: o Human resource for OD office is limited. There are only eight OD staff and seven work part time as hospital staff. Although they do have the recommended number of OD staff, they are only able to focus on their duties part time. o As the OD is newly established, they reported limited capacity of OD staff on malaria program management and requested training on general management o There is a rapid response team, but no malaria specific response team in the OD o Only 10 out of 143 VMWs/MMWs in the OD were supported by CAP-Malaria and had functioning malaria case management and prevention. The majority of the remaining 133 VMWs/MMWs supported by GF were not active, although there is no data on the precise number who are still providing case management services o No relationship with private providers in the OD with HF staff or VMWs/MMWs o No capacity building on case management to HF staff and VMWs/MMWs since 2015 o Only one out of five VMWs had a malaria education flip chart, and that VMW had been under CAP-malaria. There is a need to ensure all GF supported VMWs have malaria education materials o No information on LLIN coverage in the OD ✓ Recommendation: o Need more full-time OD staff. Although they do have the required OD staff (ODMS, and data/field assistants), they only work part time and should be converted to full-time to ensure they can meet all their duties. o Need to build OD capacity on program management through training and support from OD CMEP team o Build capacity of healthcare providers and VMWs/MMWs on malaria case management through trainings, monthly meetings, and supportive supervision o Re-activate all VMWs/MMWs in all target villages o Train PPM providers on case management and ensure proper stocks of RDT/ACTs o Provide enough IEC materials on malaria for all health care providers and VMWs in the OD o Ensure full coverage of ITNs in all endemic villages

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B. Weaknesses in quality of diagnostic and treatment, vector control and surveillance: ✓ Weaknesses: o 32 PPs have not been functioning since September 2015 o No capacity building on management, malaria case management, M&E supervision, RDQA, and logistic and drug management since 2015 o No bednet distribution SOP at OD level o No data collection from VMWs on malaria cases at the time of survey because there are no funds for monthly meetings o No funds for malaria activities from GF or government budget from mid-2015 (malaria education at community, supervision to VMW/MMW, or transportation to pick malaria commodities) o Among 5 VMWs visited only 1 had flipchart and other materials at the time of interview (the one who had the flipchart was previously supported by CAP malaria) o One of 5 VMWs reported difficulty in following up patients due to high population movement and long distances/difficult terrain between VMW and patients home o One of 5 VMWs reported that some people have a lack of trust in VMWs and go to private providers ✓ Recommendations: o Help facilitate collaboration with PPM on malaria activities o Provide training on case management and M&E supervision, RDQA and logistic and drug management to OD and HF staff o Provide case management training to VMW/MMWs, especially those previously supported by GF o Ensure all relevant SOPs are available at all HFs o Ensure the availability of malaria commodities at all levels o Provide IEC and other BCC materials for malaria education to all HFs/VMWs o Improve quality of services provided by VMWs through trainings and regular monthly meetings and supportive supervision

C. Strengths and weaknesses in organizational structures, managerial processes, and provision of priority health activities ✓ Strengths:

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o Four OD management committee members engage in malaria activities: OD director, Pharmacy/drug store, ODMS and HIS staff o OD management committee met on a monthly basis with all health centre chiefs. Each meeting has clear objectives and report o AOP 2017 included both the overall OD AOP and malaria OD AOP. OD conducted progress review meetings to evaluate its achievements o OD team conducted quarterly supervision to HFs for malaria and other health programs using standardize check lists o All 61 endemic villages in the 8 endemic HCs have VMWs. MMWs also established to maximize malaria services to both residents and migrant populations. Thirty two out of 46 registered private providers have enrolled in the PPM program o Rapid response team (RRT) for OD is available and this team could be trained and equipped with necessary equipment/materials for response to malaria outbreaks

✓ Weaknesses: o Although 4 OD staff have been involved in malaria activities, and only the ODMS is working full-time o All the 5 visited HCs received supervision either from OD and/or PHD o No supervision to VMW has been conducted last year in the 5 visited HCs o PPM providers and VMWs supported by GF stopped working since July 2015 due to funding issues o None of the team received program management training in the past year, and did not recall ever having received this training o Team could not solve the discrepancy between HMIS and MIS reported malaria cases. They did not conduct analysis of malaria cases besides monthly aggregate case reports o OD team admitted that still there are unregistered PPs, but they didn’t know how many there are or where they are located ✓ Recommendations: o OD Staff should be separate from RH staff. The OD should have a separate drug store in order ensure adequate supply to HFs o Revitalize all 143 VMW/MMWs and 32 PPs in PPM programs in the OD (both implementation and appropriate trainings) o Provide M&E training and program management training to the OD team, especially ODMS and HMIS staff o Support the inclusion of all needed malaria activities in the overall OD AOP 2018

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o Strengthen supportive supervision from OD to HFs and cover all the HFs in the OD. The full supervision team (ODMS, HIS, Drug store) will have to conduct quarterly visits to all HFs o Conduct supportive supervision to VMWs, particularly to those with poor performance or with no malaria cases reported to ensure the quality of malaria case detection, management and education o Coordinate and engage OD/PHD/CNM/CMEP to strengthen malaria interventions in KRV OD via regular supportive visits from CNM/PHD to ODs and from OD to HFs/VMWs/PPs using structural questionnaires/checklists o Train existing RRT for response activities to malaria case increases and/or outbreaks using existing investigation and response forms/tools for malaria elimination until the SOP for malaria outbreaks become available. CMEP will support CNM to develop and finalize malaria outbreak response SOP in Y2. (make sure it fits with capacity development plan) o Support OD to register all unregistered PPs in the OD

D. Determine health provider capacity, service availability and quality, infrastructure needs, and health care provider skills for delivery of malaria services ✓ Strengths: o OD has 12 endemic HFs and 143 VMWs/MMWs (122 VMWs to cover all 61 endemic villages and 21 MMWs) o All 143 VMWs/MMWs received malaria case management training in 2015 during CAP- Malaria project o All the 5 visited HFs have last malaria national treatment guideline 2014 in place o At least 2 people in visited HFs were involved in malaria activities and 2 people received malaria case management training in 2015 o All five HF chiefs attend regular monthly meetings at OD offices and also conducted regular monthly meetings with all HF staff. They understood well the objectives of the meeting and used it to handle technical and managerial aspects as well as training on updated guidelines, strategies and policies of the national programs o Health facility staff have access to monthly malaria reports ✓ Weaknesses: o No VMW activities in GF supported HFs since July 2015 due to lack of funding o Verification of reports were not always conducted or done appropriately o There was no engagement with PPs in any of the visited HFs/VMWs

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o Some laboratory staff admitted that their capacity in detecting malaria parasite using microscope is limited. Sometimes they use RDT to confirm their microscope result o No supervision to VMW/MMWs conducted in all 5 visited HF . ✓ Recommendations: o Provide M&E training including a section on analysis of case data to HF chiefs and HMIS staff in all areas, especially those in areas formerly supported by GF o Support the inclusion of all malaria activities in the overall 2018 OD AOP o Provide orientation on updated NTGs during HC monthly meetings with follow up during quarterly supportive supervision o Revitalize the functioning of VMWs in areas previously supported by GF with refresher trainings on malaria case management and reporting o Conduct supervision to VMWs/MMWs to strengthen the quality of malaria services provided by VMWs/MMWs o Replace supplies of RDTs, ACTs, scales, thermometers, gloves and recording books where needed o Strengthen capacity of laboratory staff

E. Identify gaps ✓ Gaps: o No involvement from PPM in malaria activities last year o Similar to other ODs, in areas previously supported by GF funding, many malaria related activities have been pending since mid-2015. Additionally, no case management training has been held since the new NTGs were released. This has created an urgent need to reactivate village level volunteers, retrain previous health staff, and train new health staff for the first time. This reactivation of the program will require both ensuring proper stocks of materials are available at all points of care and ensuring the staff is trained on how to complete their prevention, diagnosis, and treatment activities o No budget from government for activities is available (other than staff salaries), and there is a reliance on donors for support o Irregular supply of RDTs/ACTs HCs and VMWs/MMWs due to lack of funding from GF o No supervision to VMWs/MMWs and PPMs o Not enough malaria education material. Among 5 VMWs visited, only 4 said they had flipchart for malaria education ✓ Recommendations:

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o Engage PPM in malaria activities as soon as possible to maximize malaria services. Map all PPs and work with the PHD/OD to encourage them to register and attend monthly PPM meetings o Reorganize VMW meetings and encourage CNM to select new VMWs in areas where they might have moved out or can no longer do their job o Ensure all needed supplies (diagnosis/treatment kits, BCC materials, etc.) and trainings are provided especially among areas previously supported by GF o Work with OD to ensure supervision to all HFs/VMWs/PPs occurs to maintain their skills and adequate supplies of RDT/ACT o CMEP will work with CNM/ODMS to suggest having the PP meeting venue and supply point at each administrative district to facilitate the participation from PPs o Ensure IEC material supply to community

F. Summary ✓ Conclusion The findings show human resources as well as management capacity at the OD are limited. The 12 endemic HFs have a total of 143 VMWs/MMWs, but only 10 of them who are supported by CAP-Malaria project are still functioning. Support for the GF supported VMWs ended June 2015. There is no involvement from private providers in malaria activities with the public system since 2015. Capacity building on malaria case management has also not been provided since 2015. There is no information on ITN coverage in the OD. CMEP will closely work with all relevant stakeholders from national to grassroots level to complement all the gaps in order to improve malaria program in the OD. ✓ Key Findings o Limited capacity of OD staff on malaria program management, including no training since 2015 o Only 7% (10 out of 143) of VMWs/MMWs are functioning o Private providers are not involved in PPM activities o No capacity building on management, malaria case management, M&E supervision, RDQA, and logistic and drug management to OD, HFs, VMWs/MMWs and PPMs since 2015 o Lack of IEC materials for malaria education in GF supported areas o No information on ITN coverage on the OD ✓ Actions to Address or Findings to Incorporate for Programmatic Purposes

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1. Provide capacity building to OD, HFs, VMWs/MMWs and PPMs in the target area including training (e.g. case management, program management, M&E (Supervision tools, RDQA, and data collection tools), epi and surveillance, logistic and drug management, outbreak response, entomology) and accompanying supervision visits (See capacity building plan for more details) 2. Revitalize VMWs/MMWs and PPM participants through training, monthly meetings/supervision, and ensuring adequate supplies (e.g. RDTs/ACTs, scale, gloves, thermometer, BCC material) 3. Determine ITN coverage rates and ensure distribution of nets according to national policy throughout the OD

Discussion

Two of the ODs (Krokor and Phnom Kravanh) shoulder nearly all the malaria burden with an Annual Parasite Incidence 16-26 times higher than the other three on average. They are also some of the least resourced ODs and will need more support and potentially different strategies than the others. Krokor is especially weak as it was moved from being a district hospital to an operational district last year. No additional staff or training has been provided to the hospital staff which are expected to take on additional responsibilities. Nearly all HFs (except a few previously supported by CAP-Malaria) have not had malaria supported activities (VMW monthly meetings, supervision/training for VMWs/HF/OD) since the middle of 2015. There is an urgent need to restart VMW monthly meetings/trainings, and ensure proper training/supervision of HF and OD staff.

One of the most important items that came out of the assessment was the need for retraining of health staff. At the OD level this includes training in program management, monitoring and evaluation, logistic and drug management, epidemiology and surveillance, outbreak response, entomology, and supportive supervision. In addition to these broader trainings rapid response teams and entomology teams need to be established (or supported where they exist) and may require additional training over time. There is also a need have OD provide training to HFs and ensure supportive supervision occurs and HFs have the skills needed to perform their job.

The need for ODs to identify focal points responsible for PPs was clear. The focal points can help identify PPs, and organize meetings to register/recruit PPs into the PPM scheme. Following initial recruitment they will need periodic training and support. This should be provided by the OD focal point with CMEP staff supporting that work.

In areas with large numbers of mobile and migrant populations (especially in Krakor and Phnom Kravan districts) there is a need to better identify and reach at risk individuals. This may include village stratification and better identifying at-risk villages or populations. Efforts should be

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made to develop strategies that can better reach these populations, especially forest goers and not only those in villages with VMWs. This may require targeting them in non-traditional ways or locations, such as through middle men or at job locations within the forest.

Supporting the OD to complete operational aspects of the job is also needed, especially ensuring quality of upcoming AOPs and ensuring funding and materials needed for malaria activities are included in the plan and available at all levels of care. CMEP team should also assist in supervising, monitoring, and periodically reviewing and evaluating the implementation of the AOP. This could also include supporting the development of health coverage maps at OD/HFs where needed.

The need for training at HF level was also raised, especially relating to monitoring and evaluation (including data analysis and producing basic figures), case management (including updated NTGs), and possibly microscopy (where needed). OD staff should provide supervision and ensure collaboration between HFs and PPs, micro-plans for malaria are updated, appropriate supervision to VMWs and outreach activities are conducted, and drugs & RDTs are available at all points of care (including at VMW houses). As there has been no training, outreach, or support to VMWs for the past several years this will be no small task. CMEP should continue to provide support to OD staff and HFs to ensure VMW networks are re-established and all needed materials are available for all HFs and VMWs.

The greatest need for VMWs at the moment is simply to be retrained on case management and reporting and restart monthly meetings. They will also need to be provided basic supplies of RDT, ACT, scales, thermometers, gloves and recording books where needed. Once these basic things have happened there will be a need to encourage VMWs to increase their effectiveness and ensure they are testing all suspected cases according to the decision tree chart in the NTGs.

Gender Considerations It is important to address gender-related barriers to prevention and treatment in all interventions. The most at-risk groups identified were men from age 15-45 who spend significant time inside the forest. Risk groups can also include women who work on plantations near forest or who do farming inside the forest. Malaria risk based on gender was not identified as the main risk was spending time inside/near the forest, however it is important to consider targeting approaches for prevention and treatment based on gender. While young men working the forest were identified as the highest-risk, health education activities often reached women and children outside the forest who were home during the daytime and often failed to reach the most at risk (men working in the forest and men/women working in plantations). No stigma (as may be found with sexually transmitted or other diseases) was associated with receiving malaria diagnosis or treatment or sleeping under bednets. If there was an insufficient number of nets in the house women and children often used them first leaving men unprotected, however transmission rarely occurred in the village.

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CMEP will work to ensure that all education, prevention, diagnosis, and treatment includes those most at risk and is available to all regardless of gender. This includes working to identify companies or individuals who employ people in the forest/on plantations and ensuring they have access to prevention, diagnosis and treatment.

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