1 COAG No. 72068718CA00001

Home , Ambatolampy, Ambatomainty, Analalava, Analanjirofo, Andapa District, Andrainjato

COAG No. 72068718CA00001

TABLE OF CONTENT

I- EXECUTIVE SUMMARY ...... 6 II- INTRODUCTION ...... 10 III- MAIN ACHIEVEMENTS DURING QUARTER 1 ...... 10 III.1. IR 1: Enhanced coordination among the public, nonprofit, and commercial sectors for reliable supply and distribution of quality health products ...... 10 III.2. IR2: Strengthened capacity of the GOM to sustainably provide quality health products to the Malagasy people 15 III.3. IR 3: Expanded engagement of the commercial health sector to serve new health product markets, according to health needs and consumer demand ...... 36 III.4. IR 4: Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy people ...... 48 III.5. IR5: Increased demand for and use of health products among the Malagasy people ...... 55 III.6. Cross-Cutting Activities ...... 59 III.6.1. Gender and Social Inclusion ...... 59 III.6.2. Monitoring, Evaluation, Research, Learning ...... 61 IV- KEY CHALLENGES AND SOLUTIONS ...... 67 V- MAJOR ACTIVITIES PLANNED FOR NEXT Quarter (YEAR 3, JANUARY – MARCH 2021) ...... 68 VII- COVID-19 Activities ...... 72 VIII- FINANCIAL SUMMARY...... 75 ANNEXES ...... 76 ANNEX A - Performance Monitoring Plan (PMP) ...... 77 ANNEX B - Year 3 Workplan Update ...... 90 ANNEX C - Environmental Mitigation and Monitoring Report...... 100 ANNEX D - SUCCESS STORIES ...... 114 ANNEX E - STOCK INVENTORY AS OF DECEMBER 2020 (USAID AND PMI funded) ...... 120 ANNEX F - STOCK STATUS BY END OF DECEMBER 2020 ...... 122 ANNEX G - Descriptions of the seven quality dimensions for the RDQA ...... 125 ANNEX H - ANNEX OF THE COVID-19 Monthly Report October 2020 ...... 127 ANNEX I - Findings of the exercise for identification of drug shops and pharmacies (Atsimo Andrefana) ...... 135 ANNEX J- Details on malaria commodities redeployments ...... 138

ACRONYMS A2F Access to Finance JSI John Snow Int. ABM Accès Banque Madagascar LLIN Long Lasting Insecticide-treated Net ACCESS Accessible Continuum of Care and LMIS Logistic Management Information Essential Services Sustained System ACT Artemisinin-based Combination MCH Maternal and Child Health Therapy MNCH Maternal Newborn and Child Health ADDO Accredited Drug-Dispensing Outlet MDA Market Development Authority AGPM Grossistes Pharmaceutiques de M&E Monitoring and Evaluation Madagascar MERL Monitoring Evaluation Research and AMP Alliance for Malaria Prevention Learning ARTMIS Automated Requisition Tracking MOPH Ministry of Public Health -PSM Management Information System- MOU Memorandum of Understandings Procurement and Supply Management MSM Marie Stopes de Madagascar cCD Community-based Continuous MYS Ministry of Youth and Sport Distribution NCC National Coordinating Council CGL Comité de Gestion Logistique NGO Non-Governmental Organization CHU Centre Hospitalier Universitaire NMCP National Malaria Control Program CHV Community Health Volunteers (PNLP) CMS Credit Management System OMS Organisation Mondiale de la CNFM Conseil National des Femmes de Santé/Word Health Organization Madagascar ONP Ordre National des Pharmaciens de COP Chief of Party Madagascar CHRR Centre Hospitalier de Référence ORS Oral Rehydratation Solution Régional PA Point d’Approvisionnement CSR Corporate Social Responsibility PAIS Plan d’Action d’Intégration des Intrants CSB Centre de Santé de Base de santé CNE National Registration Committee PARC Point d’Approvisionnement Relais (Commission Nationale de Communautaire l’Enregistrement PARN Projet d'Amélioration des Résultats CoAg Cooperative Agreement Nutritionnels COGS Cost of Good Sold PDPN Plan Directeur Pharmaceutique CYP Couple Year Protection Nationale DAMM Direction de l’Agence de Médicaments PDSS Plan de Développement du Secteur de Madagascar Santé DCOP Deputy Chief of Party PMI President’s Malaria Initiative DEPSI Direction des Etudes de la Planification PMP Performance Monitoring Plan et du Système d’Information PNLIS Programme National de Lutte contre l’ DFC United States International IST/SIDA Development Finance Corporation PNLT Programme National de Lutte contre la DGFS Direction Générale de Fourniture des Tuberculose Soins PPE Personal Protection Equipment DGMP Direction Générale de la Médecine PPR Performance Plan and Report Préventive PPN Politique Pharmaceutique Nationale DGR Direction Géneral des Ressources PPS Probability Proportional to Population DHIS-2 District Health Information System - 2 Size

DLMT Direction de Lutte contre les Maladies PSHP Private Sector Humanitarian Platform Transmissibles PSI/M Population Services DLMNT Direction de Lutte contre les Maladies International/Madagascar Non Transmissible Pha-G-Dis Pharmacie de Gros de District DMPA Depot-Medroxyprogesterone Acetate Pha-Ge-Com Pharmacie à Gestion 5Intra Musculaire or Sous Cutané) Communautaire DPAL Direction PALU- PSI RBM Roll Back Malaria DPLMT Direction de la Pharmacie, des RH Reproductive Health Laboratoires et de la Médecine RDT Rapid Diagnostic Test Traditionnelle RDQA Routine Data Quality Assessment DPS Direction de la Promotion de la Santé RLA Regional Logistic Advisor DRSP Direction Régionale de la Santé SAF/FJKM Sampan’ Asa Fampandrosoana/FJKM Publique SALAMA Centrale d’Achats de Médicaments DSFa Direction de la Santé Familiale Essentiels et de Matériel Médical de DSS Division Santé Scolaire Madagascar DSSB Direction des Services de Santé de SALFA Sampan’ Asa Loterana ho an’ny Base FAhasalamana EDM Electricité De Madagascar SBCC Social and Behavior Change EFOI Entreprendre au Féminin Océan Indien Communication EMAD Equipe MAnagement du District SCM Supply Chain Management /District Management Team SDSP Service de District de Santé Publique/ EMAR Equipe MAnagement de la Région/ District Public Health Service Regional Management Team SG Secretariat Général SHOPS Plus Sustaining Health Outcomes in the EMMP Environmental Mitigation Monitoring Private Sector Plus Plan SLRC Service de la Législation, de la EUV End Users Verification Réglementation et du Contentieux FANOME Financement pour SMSR Service of Maternité Sans Risque l’Approvisionnement Non-stop en SP Sulfadoxine Pyriméthamine Médicaments SPARS Supervision Performance Assessment, FEFO First Expiry – First Out and Recognition Strategy FISA FIanakaviana SAmbatra SPD Superviseurs de Point de Distribution FP Family Planning SRD Superviseur Régional de Distribution GAS Gestion des Approvisionnements et TA Technicien Accompagnateur des Stocks TCA Total Cost Analysis GAVI Global Alliance for Vaccination and TFP Technical and Financial Partners Immunization TMA Total Market Approach GBV Gender Based Violence TMI Total Market Initiative GESI Gender Equality and Social Inclusion ToT Training of Trainers GF Global Fund TWG Technical Working Group GHSC-PSM Global Health Supply Chain – UCP Unité de coordination des Projets Procurement and Supply Management UHC Universal Health Coverage GOM Government of Madagascar UNFPA United Nations Population Fund HPN Health Population and Nutrition UNICEF United Nations of International HRD Health Regional Director Children's Emergency Fund UTGL Unité Technique de Gestion Logistique

IMPACT Improving Market Partnerships and USAID United States Agency for International Access to Commodities Together Development IR Intermediate Result USG United States Government IPTp Intermittent Preventive Treatment WISH2 Women's Integrated Sexual Health during pregnancy ACTION to ACTION IUD Intra Uterine device WHO World Health Organization WMP Waste Management Procedures ZAP Zone d’Administration Pédagogique

I- EXECUTIVE SUMMARY

In Quarter 1 the IMPACT team continued the implementation of the related Year 3 workplan approved by USAID.

Intermediate Results 1: Enhanced coordination among public, non-profit, and commercial sectors for supply and distribution of health products - During Quarter 1, the market assessment framework and the study protocol developed during the previous quarter were reviewed, adjusted, and finalized. The implementation of the surveys will begin in Quarter 2. - The ‘Data and LMIS’ subcommittee held a three-day workshop from December 2nd to 4th, 2020, led by the MOPH (DPLMT and DEPSI) with the contribution of 75 participants from all sectors (public, commercial health commodities enterprises, private non-profit, associations, and donors), to develop a roadmap for each sector. - On November 24, 2020, IMPACT disseminated the malaria market assessment findings to 50 stakeholders, including the members of the Roll Back Malaria (RBM) group and the TMA TWG. During the meeting, participants from the commercial health commodities enterprises decided to register anti-malarial commodities for severe malaria treatment, including Artesunate injectable and Artemether that had previously encountered availability issues in the market. On December 15, 2020, the first draft of the malaria roadmap specifying possible solutions to increase the availability and accessibility of malaria commodities was developed in a meeting with the TMA RBM group, including the private-for-profit sector which will be finalized, validated, and implemented in Quarter 2. - A new TMA Champion, Tiana Rabenandrasana, was identified from the private sector in December 2020 and has been added to the existing eight TMA Champions. The new Champion is the Managing Director of SK Pharma, and Vice President of the Association des Grossistes Pharmaceutiques de Madagascar (AGPM) and is familiar with the private-for-profit sector and he also has a solid background and knowledge of the public sector.

Intermediate Results 2: Strengthened capacity of the GOM to sustainably provide quality health products to the Malagasy people - Additionally, IMPACT conducted a second EUV survey and will use the findings to support the MOPH, regions, evaluated districts, and CSB to plan for corrective measures. - IMPACT continues to support the government to increase financial sustainability of the supply chain through the Total Cost Analysis. Data collection was completed, the data analysis was initiated, and different options are being considered as alternative supply chain models to be costed upon completion of the TCA. - IMPACT supported the 2021 LLIN mass campaign through participation in two workshops organized by the NMCP on the definition of the communication strategy, the communication tools, and contents of the different messages to be broadcasted. - IMPACT continued to coach and mentor the NMCP and DSFa in the quantification process (forecasting and supply planning), and support the DPMLT to oversee the public supply chain through:  Collaboration with the NMCP and DSFa to prepare the quantification technical documents for their validation by the Comité de Gestion Logistique (CGL).  Technical assistance to the NMCP in monitoring the shipment plans for the PMI and Global Fund orders and to produce and share dashboards for stock status of malaria commodities at the central level with the RBM stakeholders on a weekly basis.

 Facilitation of the development of a Terms of Reference outlining roles and responsibilities for key actors in the public sector supply chain. The ToR document has been validated by the MOPH and its TFPs on October 16th.  Provided technical assistance to the NMCP and DSFa to plan the distribution of malaria commodities and maternal health commodities to ensure availability of these commodities in the 114 districts.  Provided technical assistance and organized logistics to the EMAR and EMAD in conducting on-site formative supervision to staff at 34 district pharmacies (Pha-G-Dis) and 19 community-based pharmacies (Pha-Ge-Com) to reinforce their capacities in inventory management. More Pha-G-Dis (25) are considered high performing compared to the previous quarter (19) and none were underperforming this quarter (2 in previous quarter), according to criteria defined with the SPARS approach and related to several domains of supply chain management. - IMPACT supported the NMCP on the preparation of the LLIN mass campaign distribution:  In quarter 1, the cCD activities continued in the targeted 12 districts through social mobilization activities, distribution of vouchers, distribution of LLINs, and reporting. 80% of the LLINs planned for the 12 districts have been sent to the PARCs. 103,700 LLINs were sent to the six districts of group 1 (Brickaville: 11 900, Manakara: 26 900, Mananjary: 22 500, Toamasina II: 13 900, Tuléar II: 19 800 and Vohipeno: 8 700) and IMPACT was waiting for the forecast from the 6 districts of group 2 to plan for the distribution in Quarter 2. Guidelinesfor SBCC activities to be implemented at schools for the six districts of group 2 has been developed. A review with the operational team has been organized and joint supervisions were carried out. - The preparation of the Quarter 2 activities for the 2021 LLIN mass distribution campaign included the following:  Reception of 3,177,000 LLINs in Antananarivo and Tamatave in November and December 2020and the remaining 500,000 LLINs are expected in January 2021.  Supported financially and technically the organization of two workshops to finalize the LLIN mass campaign implementation strategy and tools, including monitoring and evaluation, and SBCC tools and messages.  Development of the LLIN strategy (including SBC strategy) and tools supported remotely by the AMP (Alliance for Malaria Prevention) team.

Intermediate Results 3: Expanded engagement of the commercial health sector to serve new health product markets, according to health needs and consumer demand - In Quarter 1, IMPACT continued to engage the private for-profit sector. Twenty-five drug shops located in the Atsimo Andrefana region accepted and signed the agreement with MOPH to collect, share, and submit LMIS data to the national system through a centralized electronic tool that is managed at the DEPSI level. - IMPACT supported commercial health commodities enterprises (i.e., drug shops, pharmacies, and pharmaceutical wholesalers) in the following ways:  Assisted the drug shop association in the Analanjirofo region to complete its official registration.  Trained 27 staff (17 men, 10 women) at partner banks on how to work with pharmacies and drug shops, including GESI-sensitive considerations.  Facilitated the disbursement of 10 loans totaling $45,563 (of which $0 was under the DFC guarantee) to health commodities enterprises by training partner bank staff in how to work with drug shops and pharmacies and by connecting potential clients with the partner banks.  Provided business training to 25 drug shop owners (14 mean, 11 women).

 Coached three drug shop owners (1 man, 2 women) who expressed interest in applying book-keeping principles and inventory management skills learned during business training.

Intermediate Results 4 Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy people - IMPACT initiated the first meeting with DPLMT and DSFa for the transfer of PA and PARC supply chain functions to the national system (Pha-Ge-Com and Pha-G-Dis). - In Quarter 1, the COGS and portfolio analysis conducted by IMPACT were finalized and the new validation process for pricing has been started and will be completed in Quarter 2 by considering the USAID, PA, and PARC committee for transfer approval. - IMPACT improved the availability of FP and MNCH products for the community-based distribution. Delayed deliveries of Sûr’Eau Pilina and Protector Plus in Year 2 were received, and the FP products were continuously available at PA. Sales achievements for Quarter 1 vs Year 3 targets are as follows:  Oral Contraceptives: 39%  Intra-Muscular Injectables: 36%  pregnancy tests kits: 53%  Sûr’Eau Pilina: 45%  Sûr’Eau 150ml: 120%  ORS: 46%, and  Pneumox: 53%. These sales enabled the low stockout rate of less than 5% at PARC and PA levels for both FP and MNCH commodities. - IMPACT achieved drone delivery at a distance of 100km which is the objective defined for the pilot phase of drone distribution. IMPACT is waiting for the results of the drone pilot evaluation, which is ongoing under the lead of USAID. IMPACT expects to receive USAID clearance for the scale up of this activity in other regions. In the meantime, IMPACT continues to use drones to deliver commodities in Maroantsetra and Mananara Nord and in the additional extension districts of Antalaha, Andapa, Mandritsara, and Befandriana Nord as agreed with USAID. The innovative delivery by drone achieved eight successful flights in Quarter 1 at distances between 50 and 100km in addition to the 75 delivery flights at distances under 50 km.

Intermediate Results 5 Increased demand for and use of health products among the Malagasy people - IMPACT ensures demand creation of health products among targeted populations, such as the promotion of the use of Sur'Eau Pilina to ensure access to safe drinking water during the rainy season. - About 1,180 radio spots were broadcasted in 39 districts of the 10-USAID supported regions (excluding 3 PARN regions) from December 09th to 20th, 2020 to increase demand for Sur'Eau Pilina and promote its use to ensure access to safe drinking water during the rainy season. - IMPACT also continued to send targeted SMS to providers such as PA, PARC, and CHVs to inform them about stock management, environmental mitigation management, and the availability of all products (Sur’Eau, Arofoitra, Protector Plus, etc.).

Cross-Cutting Gender Integration and Social Inclusion (GESI) IMPACT continued to collaborate with its GESI partners through a variety of interventions including TMA TWG sub-committees, the malaria market assessment report dissemination event, and meetings with the Ministry of Population. IMPACT also facilitated capacity building opportunities with both partners and staff to enhance their understanding and application of GESI-related principles. Finally, IMPACT actively supported communication and messaging to enhance TMA delivery and helped improve evaluation tools necessary to better understand (and subsequently address) the health commodities landscape, ensuring that the research and evaluation tools are inclusive and will reach women, men, girls, boys, and vulnerable populations.

Monitoring Evaluation, Research and Leaning - To further efforts to strengthen the LMIS and SCM M&E systems, IMPACT supported the DEPSI and DPLMT to disseminate the LMIS evaluation report and develop a roadmap for introducing a new web-based LMIS tool in the public supply chain system. A list of minimal requirements for an LMIS and a draft of the roadmap for each sector was developed. Under the lead of DPLMT and DEPSI, the roadmap will be finalized in Quarter 2 with technical support from IMPACT and different stakeholders (PMI Measure Malaria, WHO, UNICEF, etc.). The roadmap will be disseminated to the Ministry of Public Health (MOPH) and the General Secretary of the MOPH for official approval. The roadmap will also be presented to all participants of the workshop for their contribution to the implementation of the roadmap from March 2021. - The reporting rate of LMIS data from Pha-G-Dis to DPLMT was at 97% in October 2020 and 86% in November 2020.

II- INTRODUCTION

Improving Market Partnerships and Access to Commodities Together (IMPACT) is funded by the United States Agency for International Development (USAID) and led by PSI/Madagascar as the prime recipient and its consortium partners for five years from September 4, 2018 until September 3, 2023.

IMPACT supports the Government of Madagascar to improve the capacity of the Malagasy health system to ensure that quality pharmaceuticals and health commodities are available and accessible to all Malagasy people on a sustainable basis. IMPACT’s expected outcome is to increase total market performance for and use of health products and sustained health system performance. IMPACT has five intermediate results such as (i) enhanced coordination among the public, nonprofit, and commercial sectors for reliable supply and distribution of quality health products ; (ii) strengthened capacity of the Government of Madagascar (GOM) to sustainably provide quality health products to the Malagasy people; (iii) expanded engagement of the commercial health sector to serve new health markets according to health needs and consumer demand; (iv) Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy population; (v) Increased demand for and use of health products among the Malagasy people.

This report will summarize the activities carried out during Quarter 1 fiscal year 2021 by the consortium partners. The narrative provides updates on accomplishments, challenges, and solutions for Quarter 1.

III- MAIN ACHIEVEMENTS DURING QUARTER 1

III.1. IR 1: Enhanced coordination among the public, nonprofit, and commercial sectors for reliable supply and distribution of quality health products

Sub-IR 1.1 The total market for health products in Madagascar is understood and documented

IR1.1.1: Implement and monitor, and conduct the mid-term evaluation of the overarching TMA roadmap for all health products

During Quarter 1, IMPACT continued to collaborate with the directorates at the MOPH to implement the overarching TMA roadmap that is carried out through the three TMA subcommittees of the TMA TWG.

IR1.1.1.SA1 Under the leadership of the DPLMT, finalize, validate, and disseminate the Plan Directeur Pharmaceutique National (PDPN) and the Politique Pharmaceutique National (PPN), updated from Year 2

In early December 2020, the updates of the PPN and PDPN focused on the demographic data, data from PDSS and other strategic documents from MoPH. The list of new pharmaceutical firms, labs, and PharMalagasy existing in Madagascar are finalized and validated by the steering committee composed of the DPLMT, DAMM, IMPACT, and the private sector. The validated documents will be presented to the whole PPN PDPN subcommittee in mid-January 2021 before requesting the approval of the Service de la Législation, de la Réglementation et du Contentieux (SLRC), the General Secretary, and finally the Minister of Health. These documents will help the pharmaceutical sector to fight against the illicit sale of medicines through the MEDICRIME convention, regulate price policies in the private sector, and facilitate the information and data exchanges between all involved sectors.

IR1.1.1.SA2 Provide technical and financial support to the DAMM and in coordination with IR3.2, continue to amend, update, and disseminate the regulatory texts governing health commodities and conduct a plea to the competent authorities (the parliament, various ministries, professional bodies, etc.) and for their enforcement through the TMA TWG text and regulation sub-committee

During the inventory of regulatory texts governing health commodities, the ‘texts and regulations’ subcommittee identified and divided 134 texts into four different categories: political and professional orders, pharmaceutical profession, regulatory function, and health commodities. In November 2020, a timeline for the dissemination and amendment of these regulatory texts was established within the subcommittee. On December 17, 2020, the subcommittee validated a list of 60 regulatory texts that are up to date, do not require any amendments, and should be disseminated. The dissemination of these texts will proceed as follows (i) print the texts: to be dispatched during meetings of pharmacists; (ii) share the links and the website address to access the texts online; (iii) develop a guide for reading and understanding the regulatory texts. The dissemination of these texts will help to inform public and private actors about the texts and encourage the compliance of these regulatory texts. These texts will be enforced by the Secretary General of MOPH with the support of DAMM (the lead of the subcommittee) through the engagement of the private sector, especially through professional bodies (Pharmacists National Order, Pharmacists’ Association in Madagascar, Medical Doctors Oder, and Midwives and Nurses National Order) and associations (Drug shops associations based in Antananarivo and at regional levels) which will bring their support in the understanding and respect of the texts by their members, the PPN and PDPN subcommittee members who see the importance of the implementation, other directorates at the MOPH who developed and released the texts, other involved ministries (the Ministry of Justice, and the Ministry of Finance and Budget), and other entities such as the parliament.

IR1.1.1.SA3 Provide technical and financial support to the DEPSI to develop, disseminate, and implement the LMIS roadmap linked to Strategic Plan for Strengthening the Health Information System 2018-2022

The ‘LMIS subcommittee’ organized a two-day LMIS workshop at the Motel Anosy from December 2nd to 3rd, 2020 with the objective of developing a short and long term LMIS roadmap for each sector (public, private, and commercial sectors). Public health sector (Sofia, Vatovavy Fitovinany, and Analamanga regions), drug shops representatives (Atsinanana, Analanjirofo, and Analamanga regions), pharmaceutical wholesalers, and social marketing organizations (PSI and SAF/FJKM) attended at the workshop. The results of the LMIS evaluation conducted by IMPACT and the MOPH in 2019 were disseminated during the LMIS workshop. An international expert (Romain Olekhnovitch) based in France provided presentations of standard LMIS minimal requirements and examples of LMIS software.

The main outcomes of the workshop are: - Two working group sessions were set up: i) to define the LMIS minimal requirements for Madagascar based on the minimal requirement standards, LMIS evaluation results, and the local context; ii) to develop a draft of the roadmap per sector (public, commercial, and social marketing sectors). - The roadmap per sector was drafted and presented during a plenary session to all the participants. - The finalization of the roadmap for the three sectors (presented in one document) will be finalized by the end of January 2021 by a writing committee composed of the MOPH, the private sector (pharmacists and drug shops associations), and partners (WHO, UNICEF, UNFPA, Shops Plus, and IMPACT). The finalized and validated roadmap will be presented to donors for input. Implementation of the roadmap will start from March 2021.

Photo 1 : The Director of the DEPSI presenting the objectives of the LMIS Photo 2 : The private sector group discussing the minimal requirements for a workshop – December 2, 2020, © Impact LMIS system – December 3, 2020 , © Impact

IR1.1.1.SA4 Encourage, motivate, and support private sector members of the TMA TWG to actively participate at the national quantification exercise led by the MOPH for the three health areas (Malaria, FP, and MNCH).

Further details on the participation of the private sector in the quantification session will be provided in IR3.

IR1.1.1.SA5 Continue to monitor the implementation and evaluate the achievements and progress of the overarching TMA roadmap validated in Year 2 with all TMA TWG members

Following the assignment of a new Secretary General within the MOPH, the IMPACT COP, DCOP, and Senior TMA Advisor conducted an introductory visit in November 2020 to present the TMA roadmap and the efforts and progress achieved in TMA in Madagascar. The Secretary General then received more details on the overarching TMA roadmap from the DPLMT and DAMM directors. She also asked for further details on the ministerial note on the formalization of the TMA TWG from the DGMP Director. These documents will receive official approval from the Minister of Health in early Quarter 2. This approval demonstrated the MOPH engagement and commitment to the TMA approach in the health sector and will help facilitate the implementation of the overarching TMA roadmap.

IR1.1.2: Support the development and the implementation of the Malaria, FP and MNCH TMA roadmaps to ensure the availability of quality products at all levels and monitor and evaluate their execution

IR1.1.2.SA1 Provide technical support to the NMCP, the DPLMT, the national GAS committee, and the TMA Roll Back Malaria (RBM) group including the private sector to monitor the malaria TMA roadmap to ensure the availability of quality malaria products at all sectors, started in Year 2 (in coordination with IR2).

The malaria market assessment report was presented to the TMA TWG and RBM. A malaria roadmap was developed on December 15, 2020 focused on the following topics:

- Communication: under the lead of the NMCP, the implementation of the national malaria communication plan will be reinforced. PSI will share with the private for-profit sector the list of LLIN suppliers and technical

specifications of LLINs distributed through the social marketing channel and through routine and mass campaigns to encourage wholesalers to enter the market. - Commodity distribution: in collaboration with the DAMM, a list of the authorized antimalarial products will be shared to facilitate the importation of these products by pharmaceutical wholesalers (such as Artesunate). - LMIS: following the LMIS workshop in which the NMCP participated, the three sectors (public, private, and social marketing) will be requested to be involved in the implementation of the LMIS roadmap to ensure the availability of data for malaria commodities. - Capacity Building: a continuous training of drug shop agents and pharmacists on the national malaria treatment protocol will be carried out in collaboration with the association of pharmacists who demonstrated a willingness to participate (formal training or on the job-training) to ensure that the right prescription of health malaria products for treatment protocols is provided to the patients to avoid the misuse of certain malaria products (eg : the market assessment has highlighted the use of Quinine as a first intention treatment despite the WHO recommendation against such use).

- Legislation: Advocate for the removal of taxes for malaria products (for LLINs and RDTs) in the Finance Law 2022 and the acceleration and facilitation of the importation procedures for malaria commodities with DAMM. - Quantification: Continue to engage and motivate the private sector to participate in the quantification exercises for malaria products with the objective of determining the annual national needs for malaria commodities and share quantification results with them to help better prepare their orders to fill in any gaps and access the malaria market.

The malaria roadmap will be finalized in January 2021 by a restricted committee led by the NMCP and composed of the RBM members and the private for-profit sector and will be validated in March 2021.

IR1.1.2.SA2 Conduct the FP and MNCH markets assessment where the frameworks documents were finalized and validated in Year 2

Comments from USAID on all the market assessment documents were received in December 2020. The FP and MNCH frameworks have been finalized and IMPACT is preparing to begin data collection in Quarter 2 of Year 3.

IR1.1.2.SA4 Under the leadership of DSFa and in coordination with UNFPA, conduct call-to action meetings to mobilize resources necessary to secure MNCH commodities through private sector TMA TWG members

Due to the need to expand the procurement of MNCH commodities to other donors and the private-for-profit sector within and beyond the TMA TWG members, a preparation meeting was planned on December 13, 2020 with DSFa, but did not take place and is postponed to Quarter 2 due to the unavailability of DSFa who were busy in the management of the famine in the South of Madagascar.

IR1.1.3: Build the capacity of TMA Champions, with the MOPH, to successfully steward and lead the TMA TWG and subcommittees

IR1.1.3.SA1 Train two newly emerged TMA Champions on TMA 101

A participant from the private sector, M. Tiana Rabenandrasana, has stood out as an ideal TMA Champion due to his dynamism, diligence, and his engagement in TMA activities since October 2019. Prior to his position as the Managing Director of SK Pharma, and Vice President of the Association des Grossistes Pharmaceutiques de Madagascar (AGPM), Mr. Tiana served as the Administration and Finance Director within the Agence du Médicament de Madagascar. Therefore, he is familiar with both the public and the private sectors in Madagascar and he eagerly accepted the opportunity to be a TMA Champion and has been trained in TMA 101 on December 16, 2020.

Photo 3 : Mr Tiana Rabenandrasana presenting his group work during Photo 4 : Mr Tiana Rabenandrasana attending his TMA Champion the TWG TMA meeting on the malaria market training at IMPACT office – December 16, 2020 © Impact – November 24, 2020 - © Impact

IR1.1.3.SA2 Finish the advocacy training started in Year 2 and conduct refresher training sessions in leadership and advocacy for the TMI Champions

This activity had to be postponed due to the travel restrictions due to the Covid-19 pandemic, which prevented trainers from coming to Madagascar. Additionally, the Champions from the public sector have been assigned to the management of the famine in the South of Madagascar. This activity will be completed once travel restrictions are lifted and the Champions are available. Otherwise, online alternatives will be explored.

IR1.1.4: Disseminate the malaria market assessment results to the TMA TWG members

Under the leadership of the NMCP, 50 members of the TMA TWG attended the dissemination of the malaria market assessment results along with 10 members from the private sector who are interested in applying the malaria treatment protocols and integrating into the malaria commodity market.

Following the meeting, SOMAPHAR registered two new marketing authorization requests for Artesunate, and seven members from the private sector joined the RBM TMA platform to develop the Malaria TMA Roadmap. This will enable the increase of severe antimalarial products availability within the private sector which were almost nonexistent previously.

Photo 5 : TMA Roll Back Malaria members during the dissemination of the results of the malaria market assessment report – November 24, 2020, © Impact Graph 1: Breakdown of participants at the TMA TWG on the dissemination of the malaria market assessment findings

Public sector 6% 16% 12% Private sector

22% NGOs Associations 44% Donors

III.2. IR2: Strengthened capacity of the GOM to sustainably provide quality health products to the Malagasy people

Sub-IR 2.1: Health commodities and pharmaceuticals are continuously accessible and available in the public sector

IR2.1.1: Implement an integrated forecast and supply planning process for the public sector with related tools for commodity needs assessments

In Year 3, IMPACT will continue to provide continuous coaching, mentoring, and training of MoPH directorates (NMCP, DSFa, and DPLMT) and stakeholders to ensure that quality commodities reach the beneficiaries in the right quantity, at the right time, and in the right place.

IR2.1.1.SA1 Continue to provide capacity building through technical coaching and mentoring of GOM programs staff (NMCP, DSFa, and DPLMT) on forecasting and supply planning, including the use of Quantimed and Pipeline and incorporating the SALAMA (Centrale d’Achats de Médicaments Essentiels et de Matériel Médical de Madagascar) team as a key technical resource

In Year 3, IMPACT helps to build the capacity of 10 supply chain professionals from the NMCP (2), DSFa (3), DPLMT (2), DEPSI (1), and SALAMA (2) to enable them to conduct all the forecasting and annual supply plan exercises and semester reviews without external technical assistance.

During Quarter 1, IMPACT continued to support the DSFa and NMCP to finalize forecasting and supply plans of malaria and MNCH commodities developed in July and September 2020 respectively and to prepare their validation by the Comité de Gestion Logistique (CGL) led by the Secretary General (SG). The validation meeting was scheduled in December and later postponed to January 2021 due to the Secretary General’s busy agenda. While waiting the validation of the quantification plans by the CGL, DSFa, and NMCP, IMPACT proceeded with the mobilization of resources to its key partners (USAID, Global Fund, and UNFPA) and proceeded with procurement.

IR2.1.1.SA2 Provide technical and financial support to the Unité Technique de Gestion Logistique (UTGL) members to conduct annual quantifications exercises and semester reviews to ensure adequate resources are mobilized to procure malaria, FP/RH, and MNCH commodities to cover the public sector and private sector needs

In Quarter 1, IMPACT participated in the bi-annual review workshop of FP/RH products in Mahajanga from Dec 2nd to 4th, 2020 with financial support from UNFPA. - 28 participants (16 women and 11 men) analyzed the latest consumption data of FP/RH commodities reported by the 114 districts to DSFa and compared it with the services data reported by health facilities into DHIS2. Table 2 shows institutions represented at the workshop. Two members of SALAMA were invited but did not attend as they were unavailable. The private sector was not invited since the reviewed quantification plans developed in July 2020 did not take into consideration the needs of the private sector due to lack of data (both services and logistics data). The private sector will be invited in future sessions. - During the meeting, participants developed an adjusted 24-month supply plan using Pipeline software that included the quantities needed to cover the period of 2021-2022, shipment delivery dates, and resources needed to be mobilized to proceed with the commodities procurement. The table 3 shows results of the quantification review covering the period of 2021-2022.

Table 2: Participants at the quantification review workshop for FP/RH commodities # of Organizations represented participants Percentage Ministry of Health central level directions (DSFa, DGMP, SG, DGFS,DPLMT) 10 36% DRSP Boeny (EMAR) 3 11% Hospitals (CHU) 2 7% Partners technical and financial (UNFPA, UNICEF, USAID , JSI Access Collaborative , USAID IMPACT- Mahefa Miaraka and ACCESS programs) 9 32% NGO (MSM, FISA, SAF/FJKM, SALFA) 4 14% Total participants 27 100%

The table 3 below highlight quantity needed to cover the gap identified. The Annex F- is added as a dashboard to show the Stock status at the central level/SALAMA.

Table 3: Gaps of FP/RH commodities to cover the needs of the public sector and NGOs in 2021

Estimated delivery Product Funding Product Quantity Status date Costs Depo- TBD medroxyprogesterone 31/03/2021 2,898,000 Planned $2,463,300 acetate (DMPA-IM) Depo- TBD medroxyprogesterone 30/09/2021 1,367,000 Planned $1,161,950 acetate (DMPA-IM) Depo- TBD medroxyprogesterone 30/04/2021 961,400 Planned $817,190 acetate (DMPA-SC) Depo- TBD medroxyprogesterone 30/11/2021 692,000 Planned $588,200 acetate (DMPA-SC) Intra Uterine device TBD 31/08/2021 5,000 Planned $1,850 (IUD) Oral hormonal TBD 31/10/2021 717,120 Planned $193,622 contraceptive TBD Implanon NXT 31/08/2021 188,064 Planned $1,598,544 TBD Implanon NXT 30/04/2021 30,024 Ordered $255,204 Depot- UNFPA medroxyprogesterone 31/01/2021 678,000 Planned $576,300 acetate (DMPA-IM) UNFPA Implanon NXT 29/01/2021 12,024 Ordered $102,204

UNFPA Implanon NXT 31/05/2021 91,080 Planned $774,180

TOTAL $8,532,544 UNFPA commitments $1,452,684 GAP to mobilize $7,079,860

- The supply plan considers stock level parameters with a minimum of 12 months and maximum of 19 months. - UNFPA has committed to procuring Implanon NXT and DMPA-IM in 2021 for an estimated budget of 1,452,684 USD and for distribution to the public sector and NGOs. - There is an urgent need to mobilize resources estimated at 7,079,860 USD before proceeding with the commodities procurement for estimated deliveries in 2021. - A dashboard with current months of stock available at the central level warehouse/SALAMA is attached in Annex F.

In the next quarter, IMPACT will collaborate with JSI/ACCESS Collaborative and WISH2ACTION Options projects to support the DSFa to organize a stakeholder’s call-to-action meeting under the leadership of the SG to mobilize adequate resources and proceed with the procurement of FP/RH commodities. The stakeholders will include UNFPA, UCP-World Bank (Unité de coordination des Projets), JSI ACCESS COLLABORATIVE, USAID, WISH2 ACTION, Agence Française de Development, Union European, SALAMA, and the Ministry of Budget and Finance. In case the gap is not covered, DSFa will review assumptions and stock levels parameters used to project forecasting and explore mechanisms for engaging the private sector.

IR2.1.1.SA3 Coordinate with GHSC-PSM (Global Health Supply Chain – Procurement and Supply Management) on generation of orders and tracking shipments/deliveries of malaria and FP/RH commodities procured with USG funding and according to agreed upon supply plans

During Quarter 1, IMPACT entered new orders into the ARTMIS-PSM software and coordinated with GHSC- PSM to monitor shipments of procured malaria and FP/RH commodities according to the agreed upon estimated delivery dates. Furthermore, IMPACT provided technical assistance to the NMCP to monitor shipment plans for the PMI and Global Fund orders in the pipeline and to produce a dashboard for stock status of malaria commodities at the central level. The stock status dashboards at the central level have been shared with all RBM stakeholders during the weekly meetings organized every Tuesday.

The status of ongoing order shipments procured by PMI (malaria commodities) is highlighted in the tables below.

Table 4: Status of shipments of PMI procured malaria commodities

Requested Quantity Quantity MOP Product Status delivery Date (unit) (packs) reference

Artesunate/Amodiaquine 25/67.5 Estimated delivery MOP 1-Apr-21 135,650 5,426 mg Tablet, 25 x 3 Blister Pack Tablets date of July 31,2021 FY2020 Artesunate/Amodiaquine 25/67.5 Pending funding MOP 31-Oct-21 59,175 2,367 mg Tablet, 25 x 3 Blister Pack Tablets analysis FY2020 Long clarifications Artesunate/Amodiaquine 50/135 mg process with PMI. MOP 25-Jan-21 115,375 4,615 Tablet, 25 x 3 Blister Pack Tablets Estimated delivery FY2020 date of May 31,2021

Artesunate/Amodiaquine 50/135 mg MOP 1-Apr-21 842,125 33,685 Estimated delivery Tablet, 25 x 3 Blister Pack Tablets date of July 2021 FY2020 Artesunate/Amodiaquine 50/135 mg Pending funding MOP 31-Oct-21 445,250 17,810 Tablet, 25 x 3 Blister Pack Tablets analysis FY2020 Long clarifications Artesunate/Amodiaquine 100/270 process. Estimated MOP 25-Jan-21 67,125 2,685 mg Tablet, 25 x 3 Blister Pack Tablets delivery date of May FY2020 31,2021

Artesunate/Amodiaquine 100/270 MOP 1-Apr-21 560,400 22,416 Estimated delivery mg Tablet, 25 x 3 Blister Pack Tablets FY2020 date of July 2021 Artesunate/Amodiaquine 100/270 Pending funding MOP 31-Oct-21 219,175 8,767 mg Tablet, 25 x 3 Blister Pack Tablets analysis FY2020 Long clarifications Artesunate/Amodiaquine 100/270 process. Estimated MOP 25-Jan-21 67,500 2,700 mg Tablet, 25 x 6 Blister Pack Tablets delivery date of May FY2020 31,2021 Artesunate/Amodiaquine 100/270 MOP 1-Apr-21 532,975 21,319 Estimated delivery mg Tablet, 25 x 6 Blister Pack Tablets FY2020 date of July 2021

Artesunate/Amodiaquine 100/270 Pending funding MOP 31-Oct-21 231,575 9,263 mg Tablet, 25 x 6 Blister Pack Tablets analysis FY2020 Malaria Rapid Diagnostic Test (RDT) Technical review MOP HRP2/pLDH (Pf/PAN) Cassette, 25 26-Feb-21 2,000,000 80,000 documents in FY2020 Tests preparation Malaria Rapid Diagnostic Test (RDT) Supplier assignment MOP HRP2/pLDH (Pf/PAN) Cassette, 25 1-Apr-21 2,243,550 89,742 in progress FY2020 Single Test Kits Malaria Rapid Diagnostic Test (RDT) Clarifications in MOP HRP2/pLDH (Pf/PAN) Cassette, 25 31-Oct-21 1,375,475 55,019 progress FY2020 Single Test Kits Malaria Rapid Diagnostic Test (RDT) Clarifications in MOP HRP2/pLDH (Pf/PAN) Cassette, 25 31-Oct-21 1,361,050 54,442 progress FY2020 Tests Long clarifications Artesunate (w/ 1 Amp NaHCO3 5% + process. Estimated MOP 25-Jan-21 100,000 100,000 1 Amp NaCl 0.9%) 60 mg Vial, 1 Set delivery date of April FY2020 17,2021 Artesunate (w/ 1 Amp NaHCO3 5% + Order in preparation MOP 1-Apr-21 311,000 311,000 1 Amp NaCl 0.9%) 60 mg Vial, 1 Set FY2020 Delayed, estimated Sulfadoxine/Pyrimethamine 500/25 MOP 9-Dec-20 1,500,000 10,000 delivery date of April mg Tablet, 50 x 3 Blister Pack Tablets 28,2021 FY2020

(Campaign Bulk) LLIN 190x180x170 Estimated delivery MOP cm (LxWxH), Single Pyrethroid 11-Jan-21 500,000 500,000 date of January FY2020 Rectangular (White), 1 Each 31,2021

The requested delivery date of Sulfadoxine-Pyrimethamine (SP) was December 2020 but has been delayed due to COVID-19 pandemic at the manufacturing plant. Tentative arrival date is now set to April 2021.

Table 5: Status of ongoing shipments of USAID FP/RH commodities Requested Quantity Product delivery Quantity(packs) Status FY reference in unit Date Male Condom (Latex) Lubricated, Protector Plus v2, Order Released for 53 mm, 48 Pcs/Dispenser, 90 31-Mar-21 2,306,880 534 FY2020 Fulfillment Disp/Case, 4320 Pieces [Thai Nippon]

Etonogestrel 68 mg/Rod, 1 Rod Order Awaiting Tech 30-Jun-21 41,040 41,040 FY2020 Implant, 1 Each Pack Approval

Mission requested to Pregnancy Test Kit, hCG, Urine, 31-May-21 350,200 7,004 put this order on FY2020 50 Each hold

Requested Quantity Product delivery Quantity(packs) Status FY reference in unit Date Order split: first delivery of 1,005,000 vials (client Depo (IM) clarifications in Medroxyprogesterone Acetate 31-Jan-21 2,127,500 2,127,500 process) and a FY2020 150 mg/mL (1 mL) Vial, w/ AD second delivery of Syringe, 1 Each 1,122,500 vials (Pending PSM Source Processing) Levonorgestrel/Ethinyl Recipient and USAID Estradiol 150/30 mcg + Fe 75 30-Jun-21 2,890,944 2,890,944 Approval submitted FY2020 mg, 28 Tablets/Cycle (PS), 1 to PSM in January Cycle

IMPACT will continue to monitor the status of shipments together with GHSC-PSM to anticipate any action to avoid delays.

IR2.1.2: Increase the capacity of the MOPH to provide oversight to public SCM

IR2.1.2.SA1 Technically and financially support the UTGL to organize bi-annual meetings to jointly plan activities of all partners in the supply chain; to analyze routine data on key indicators including stock outs in public hospitals and CSBs; and to evaluate past achievements and plan appropriate corrective measures

During Quarter 1, IMPACT participated in the NMCP review workshop organized from December 7th to 11th at the Novotel hotel in Antananarivo. IMPACT supported the two NMCP staff who are charged with management of commodities through coaching and joint preparation to evaluate achievements throughout 2020 and plan activities for 2021 to improve stock management of malaria commodities. In 2020, 100% of orders submitted on a quarterly basis were analyzed and approved by the NMCP and the Central level GAS committee and commodities were shipped to the 114 districts. In 2021, the NMCP implemented the following activities, with IMPACT’s support: 1) Analyzed logistics data reported and plan for resupply of malaria commodities to the 114 districts on quarterly basis 2) Mobilized appropriate resources to procure 85% of quantities of ACT and 81% of RDTs by both Global Fund and PMI following the annual quantification exercise held in June 2020 and 3) Track orders in Pipeline and ensure adherence to the supply plans.

IR2.1.2.SA2 Support the UTGL to organize a workshop to validate and disseminate the updated Terms of Reference with clear tasks and responsibilities for key actors in the public sector supply chain in light of the changing organizational chart of the Ministry of Health

This ToR document was developed to outline roles and responsibilities for key actors in the public sector supply chain and has been revised with the inclusion of the central, regional, and district health facility levels. This document aims to 1) increase leadership of regional and district teams in terms of supply chain management of essential health commodities, 2) Reinforce the spirit of the performance monitoring system of stock inventory management, 3) build capacity of supply chain professionals at all levels of the supply chain, and 4) improve timely reporting of quality logistics data.

During this quarter, IMPACT supported the UTGL to: - Finalize and disseminate the ToR document. The amended ToR emphasizes the creation of UTGL and GAS committees at regional and district levels as coordination mechanisms to better support the improvement of the supply chain at the community level. The ToR clearly articulates roles and responsibilities of 19 different involved actors while in the previous version from 2017, there was only 9 actors identified. The coordination committees will result in improved governance of the public supply chain of essential health commodities. - Organize a validation workshop of the ToR document on October 16th, 2020 in Antananarivo (Hotel Astauria) with 20 representatives of various directions of the MOPH (NMCP – PNLIS – PNLT – CNTS- Direction de Lutte contre les Maladies Non Transmissible (DLMNT), DLMT, DSSB, DSFa, SG’s office, DGFS, Direction Général des Ressources (DGR), Direction Régionale dela Santé Publique (DRSP) Analamanga, SDSP Itasy, the technical and financial partners (Mahefa Miaraka, ACCESS, UNICEF, USAID, UNFPA, European Union, Organisation Mondiale de la Santé (OMS), JSI Access Collaborative), and SALAMA. - Draft a dissemination note to be signed by the SG to enforce the implementation of the ToR document. The note was submitted to the SG in December but has not yet been signed.

IR2.1.2.SA3 Technically support the central level GAS Committees to develop quarterly distribution plans for malaria, MNCH, and FP/RH products based on reports/orders submitted by Pha-G-Dis. Commodities will be transported to districts through the service contract signed between IMPACT and SALAMA

Malaria During Quarter 1, IMPACT coached two new NMCP professionals to control the management of the malaria commodities and supported the national malaria GAS committee to ensure the availability of malaria commodities to the 114 districts. The coaching is provided on weekly basis to strengthen the professionals’ capacity on how to: - Collect and analyze logistics data reported by the 114 districts (115 Pha-G-Dis) to the NMCP and compare them with projections made during the forecasting. The logistics data collected include stock available at the end of the month, quantities received from SALAMA, quantities distributed to CSB, average monthly consumption, and stock status at their respective level. Through the analysis, the NMCP staff were able to detect abnormal situations in terms of commodities consumption and recommend corrective measures to districts and regions. - Prepare and conduct seven virtual meetings with the 114 districts and 22 regional teams in Madagascar, and national malaria GAS committee members to validate their quarterly report orders (Rapport – bons de commande) for the resupply of malaria commodities. During the meetings, the NMCP provided feedback on the comparison between logistics data and the services data (# of people tested, # of malaria cases treated, and # of pregnant women that received SP) reported through DHIS2 and validated jointly the quantity of malaria commodities to be transported to the 115 Pha-G-Dis. - The table 7 below summarizes the quantities transported to districts in Quarter 1. - A total of 151 district orders-reports (74 emergency orders and 77 cyclic/regular orders) have been submitted to NMCP. - Follow-up closely the malaria commodities distribution plans of 114 districts submitted to SALAMA to avoid unnecessary delays. During the quarter, IMPACT and UCP-Global Fund transported 14 emergency orders to complement those transported by SALAMA. IMPACT is working with NMCP, SALAMA, and the districts to sensitize the districts to improve the routine ordering and reduce the inefficient emergency orders.

Table 6: Quantity distributed to 115 Pha-G-Dis in Quarter 1 Year 3 for both PMI and Global Fund procured malaria commodities Total quantity Quantity delivered to 115 Quantity delivered to 115 delivered to 115 Product specifications Unit Pha-G-Dis in October 2020 Pha-G-Dis in November 2020 Pha-G-Dis in Quarter 1 both PMI and PMI Global Fund PMI Global Fund Global Fund Artesunate/Amodiaquine 25/67.5 mg Tablet, 25 x 3 blister 17,450 750 - 14,200 32,400 Blister Pack Tablets

Artesunate/Amodiaquine 50/135 mg Tablet, 25 x 3 blister 279,525 - 34,800 125 314,450 Blister Pack Tablets Artesunate/Amodiaquine 100/270 mg Tablet, 25 x 3 blister 82,825 - - - 82,825 Blister Pack Tablets Artesunate/Amodiaquine 100/270 mg Tablet, 25 x 6 blister 240,400 - 26,850 - 267,250 Blister Pack Tablets

Artemether/Lumefantrine (5kg-15kg)20/120 mg Dispersible Tablet, 30 blisters blister 1,620 - 30 - 1,650 per pack

Artemether/Lumefantrine (15kg-25kg)20/120 mg Dispersible Tablet, 30 blisters blister - 270 64,770 - 65,040 per pack

Artesunate (w/ 1 Amp NaHCO3 5% + 1 Amp NaCl vial - 65,260 600 26,832 92,692 0.9%) 60 mg Vial, 1 Set

Malaria Rapid Diagnostic Test (RDT) HRP2/pLDH (Pf/PAN) Cassette, 25 Single Test Kits test kit 1,720,100 292,625 - 255,150 2,267,875

Sulfadoxine/Pyrimethamine 500/25 mg Tablet, 50 x 3 tablet - 9,150 - 524,100 533,250 Blister Pack Tablets

During the Quarter 1, the remaining stock of 66,690 treatments of Arthemether-Lumefantrine (AL) at SALAMA have been shipped to districts. The AL was procured in 2020 to overcome shortages in Madagascar and delivery delays of AS/AQ due to the COVID-19 pandemic.

MNCH: IMPACT provided technical assistance to the DSFa/Service of Maternité sans risque (SMSR) to coordinate the management of MNCH commodities (MgSO4, Gentamycin, Oxytocin, and Misoprostol).

During Quarter 1, IMPACT supported the SMSR to:

- Analyze available stock of USAID-funded MNCH commodities (MgSO4, Gentamycin, and Oxytocin) stored at SALAMA and plan their distribution to 66 districts. - Collaborate with the GHSC-PSM to transfer 260,000 ampoules of Oxytocin to Malawi by end of October 2020 to avoid risk of expiration. - Collect requests and support distribution of Oxytocin to private sector health facilities. - Plan a distribution of Misoprostol in collaboration with ACCESS to cover all the 22 regions: 30,135 packs with 4 tablets of Misoprostol for basic health centers (CSB) forecasted for 100 districts and 36,729 packs of Misoprostol with 3 tablets for community volunteers working in the 58 USAID supported districts. Transportation will be organized earlier in January 2021. - Request approval from UNFPA to transport the UNFPA procured Misoprostol. The UNFPA approval was granted in December 2020.

Table 7: Quantities of USAID funded MNCH commodities distributed in Quarter 1 Quantity Quantity Quantity Quantity delivered in delivered in transferred in delivered in Total quantity Technical Unit October November November December 2020 distributed during specification 2020 (public 2020 (public 2020 to (FBO and the quarter sector) sector) Malawi private sector) GENTAMICINE 10MG/ML INJ - ampoule - - - 8,100 8,100 AMP 2ML - (20MG) MAGNESIUM SULFATE 50% ampoule - - - 15,110 15,110 INJ.AMP.10ML - BTE OXYTOCINE 10UI/ML INJ. ampoule 205,000 1,400 260,000 19,550 485,950 AMP. 1ML - B

At the end of Quarter 1, there were still 425,960 ampoules of Oxytocin stocked at SALAMA with a high risk of expiring in June 2021. With existing national requirements for the shelf life of medicines, this stock will no longer be accepted through the public sector. IMPACT will continue to collaborate with SHOPS Plus to explore distribution of this Oxytocin through faith-based organizations and private clinics before the expiration date.

Family Planning/Reproductive Health

IMPACT participated in the Family Planning Logistical Sub-committee monthly meeting organized on December 4th, 2020 to analyze the stock status of UNFPA commodities stored at SALAMA and managed by DSFa, IMPACT (social marketing), Marie Stopes de Madagascar (MSM), and FISA. Based on the stock available in the country, the following actions were decided to avoid stock outs or expiration of FP commodities: - Consumption of oral contraceptives is less than predicted resulting in an overstock at the district level: 19 months (combined oral contraceptives) and 45 months (Progestin-only contraceptive). This situation is due to a decrease of people requesting FP services during the lockdown imposed by COVID-19. The table 8 inserted below shows data reported by FISA in 2020. Throughout the next year, DSFa will collaborate with regions, districts, and partners to increase demand for FP services by sensitizing the population through media campaigns and community outreach, increasing access though mobile clinics, and setting up youth friendly clinics. Additionally, IMPACT will support the DSFa in the careful monitoring of the supply plan.

- UNFPA should follow up on the planned shipments of Implanon NXT and DMPA-IM to avoid stock out as the current stock on hand is estimated to cover five and three months, respectively. A delivery is planned in January 2021. - The global production of Sayana Press had been suspended, which may lead to an increased consumption of DMPA-IM. There is a UNFPA shipment planned of 600,000 vials of DMPA-SC arriving in the country in January 2021 and dedicated for social marketing to community distributions in 2021.

Table 8: Figures reported by FISA highlighting the decrease in consumptions due probably to COVID-19 (annual standard calendar from January to December): Projected consumptions - Quantification in June 2020 Accurate consumptions- Quantification review in Product Q1 Q2 Q3 Q4 TOTAL Q1 Q2 Q3 Q4 TOTAL Microgynon 14 026 14 462 14 898 15 333 58 720 9 406 5 843 14 898 15 333 45 480 Microlut 597 624 651 677 2 549 257 208 651 677 1 793 Noristérat 6 866 7 490 8 115 8 740 31 211 3 121 3 121 8 115 8 740 23 097 Dépo-provera 28 118 28 974 29 830 30 685 117 607 5 740 5 253 29 830 30 685 71 508 Sayana press 11 178 11 286 11 395 11 503 45 361 2 436 2 379 11 395 11 503 27 713 DIU 233 251 269 286 1 039 74 32 269 286 661 Implant 3 077 3 348 3 618 3 889 13 932 1 209 2 317 3 618 3 889 11 033

IR2.1.2.SA4 Provide technical assistance to support selected district level GAS Committees to analyze consumption reports from the CSB and plan resupply of malaria, MNCH, and FP/RH products.

During Quarter 1, the Regional Logistics Advisors (RLA) collaborated with: - EMAR in 8 supported regions (out of 13) to organize UTGL meetings to analyze stock status at Pha-G-Dis and take corrective measures. - EMAD in 43 districts (out of 78) to organize district GAS committee meetings to analyze stock status at Pha- Ge-Com, validate CSB orders, and plan for the distribution to the commune level. - The RLA will continue to sensitize and encourage other UTGL and GAS committee members to meet in a quarterly basis.

During these UTGL and district GAS committee meetings, the redeployment of malaria commodities was planned. The tables below summarize the redeployment organized during Quarter 1.

Table 9: Malaria commodities redeployed from 14 Pha-G-Dis to other 38 Pha-G-Dis and 5 CSB (details on redeployment is provided in annex J) Product Specifications Unit Total quantity Unit price Total price (USD) redeployed in (USD) Quarter 1 Artesunate/Amodiaquine 25/67.5 mg treatment 1,571 0.28 $ 439.88 Tablet, 25 x 3 Blister Pack Tablets Artesunate/Amodiaquine 50/135 mg treatment 302 0.37 $ 111.74 Tablet, 25 x 3 Blister Pack Tablets Artesunate/Amodiaquine 100/270 treatment 966 0.55 $ 531.30 mg Tablet, 25 x 3 Blister Pack Tablets Artesunate/Amodiaquine 100/270 treatment 723 0.96 $ 694.08 mg Tablet, 25 x 6 Blister Pack Tablets Artesunate INJ (w/ 1 Amp NaHCO3 5% + 1 Amp NaCl 0.9%) 60 mg Vial, 1 vial 157 1.60 $ 251.20 Set Malaria Rapid Diagnostic Test (RDT) HRP2/pLDH (Pf/PAN) Cassette, 25 test 3,550 0.24 $ 852.00 Tests

Product Specifications Unit Total quantity Unit price Total price (USD) redeployed in (USD) Quarter 1 Sulfadoxine/Pyrimethamine (SP) 500/25 mg Tablet, 150 Tablets tablet 466,800 0.13 $ 60,684.00

Total value in USD $ 63,564.20

The high quantity of SP redeployed constitutes the leftover quantity of SP shipped to Marolambo district for the mass drug administration organized in 2020. The quantity of SP has been redeployed mainly to the districts of the other three regions (Alaotra Mangoro, Antsinanana, and Analanjirofo).

The RLA will continue to support the UTGL and district GAS committee meetings in Quarter 2 and will emphasize on the importance to compare statistics services and logistics data to detect abnormal stock situations and adopt corrective measures.

IR2.1.2.SA5 Strengthen the capacity of selected Regional (EMAR) and District (EMAD) teams to conduct on-the-job supervisions visits and implement the SPARS (Supervision, Performance Assessment, and Recognition Strategy) with the aim of increasing Pha-G-Dis stock managers’ ability to correctly manage essential medicines and commodities (including reporting and use of existing LMIS tools). The SPARS tool integrate assessment of Environmental and Climate risks related to management of pharmaceuticals and will be applied in selected 78 districts in the 13 USAID supported regions

IMPACT collaborated with other partners (UCP, Mahefa Miaraka, ACCESS, etc.) to support the EMAR and EMAD to conduct on-site formative supervision and trainings of district pharmacy (Pha-G-Dis), and community-based pharmacy (Pha-Ge-Com) personnel to reinforce their capacities to implement the inventory management manual focusing on SOPs on proper stock management, use of LMIS tools (CHANNEL, paper- based LMIS tools), updating Average Monthly Consumption (AMC) to correctly estimate needs, and use of the report/order forms in case of the need to resupply.

In this quarter, the RLA supported the EMAR and EMAD to conduct formative supervision to 34 Pha-G-Dis and 19 Pha-Ge-Com. Through the supervision visits, the RLA completed on-the-job trainings for 64 supply chain professionals (23 men, 41 women):

- 3 newly recruited EMAR staff were oriented on the stock management cycle to enable them to monitor stock availability within their regions. - 38 EMAD staff were trained on stock management as well as use of CHANNEL software to report LMIS data. - 19 personnel of Pha-Ge-Com/CSB were trained on completion of stock cards and compliance for best storage practices, including temperature control, quarantine of expired medicines, and proper destruction of waste and expired products.

Four stock managers in Centre Hospitalier de Référence Régional (CHRR) pharmacies (out of 8) were trained on stock inventory management in the 13 supported regions. During Quarter 1, the SPARS methodology and questionnaire were applied during the supervision visits and scores from FY20 Quarter 4 to FY21 Quarter 1 were compared to track progression. IMPACT aims to support the districts to increase their composite SPARS scores by at least five points over the baseline or the previous year (or reach 90% of the composite score).

Table 10: Performance categorization of 34 Pha-G-Dis supervised in FY21, Quarter 1 Performance of Pha-G-Dis # districts- FY20, # districts – FY21, Difference Quarter 4 Quarter 1 High Performing (score > 80%) 19 25 6 Moderate performing (50 %< score>80%) 13 9 -4

Under performing (score < 50%) 2 0 -2 TOTAL 34 34 0

From the table 11, IMPACT observed that: - 6 moderate performing Pha-G-Dis in Year 2, Quarter 4 have improved and moved to the high performing category with SPARS scoring above 80% in Year 3, Quarter 1. A total of 25 Pha-G-Dis (out of 34 supervised or 74%) are currently considered high performing. - 4 Pha-G-Dis remained in the moderate performing category with SPARS scores between 50% and 80%. A total of 9 Pha-G-Dis (out of 34 supervised or 26%) are considered moderate performing. - 2 of the underperforming Pha-G-Dis improved and moved to moderate performing. There is no underperforming Pha-G-Dis (among the 34 supervised or 0%).

Note that a composite SPARS score evaluates six domains: 1) Human resources 2) Inventory control system 3) Stock management and availability of inputs 4) Appropriate conditions of warehousing and storage 5) Good governance and 6) Distribution and reporting. Each criterion is evaluated separately and according to a list of questions and indicators defined in the SPARS grid. The final score determines the level of performance of the Pha-G-Dis.

The RLA will continue to track the implementation of plans developed to increase the scores and help more Pha-G-Dis achieve a high performing status. The RLA will share the scoring of the 34 Pha-G-Dis supervised in Quarter 1 during the regional and district coordination meetings in the next quarter. Also, the RLA will disseminate the EUV survey findings in the seven regions sampled for the EUV and facilitate development of appropriate action plans.

Table 11: Highlights of Quarter 1 supervisions visits findings using SPARS # of Pha-G-Dis Identification of the Pha-G-Dis Comments 13 Pha-G-Dis with an increase Fenerive Est, Maroantsetra, Toamasina 1, The districts improved the calculation of 5% or more with the Toamasina 2, Tuléar 2, Ambilobe, Diego 2, of quantities for resupply and composite SPARS score Isandra, Lalangina, Morafenobe, Antsiranana ordering. The districts are stocked (compared to Year 2, Quarter 1, Vohibato, Andapa according to required minimum- 4). The increase of the score maximum levels. is calculated and compared to the baseline score of the previous quarter 16 Pha-G-Dis with an increase Antanambao Manampotsy, Brickaville, The districts still need to improve stock of less than 5% with the Mahanoro, Vatomandry, Morombe, Toliara management. The districts still need to composite SPARS score 1, Antsirabe 1, Mahajanga 1, improve the calculation of quantities (compared to Year 2, Quarter Ambohimahasoa, Fianarantsoa 1, Maintirano, for resupply, the LMIS reporting, and 4)) . The increase of the score Manja, Antsohihy, Antsirabe 2, Ifanadiana, capacity of stock managers. is calculated and compared to Vohipeno. the baseline score of the previous quarter

# of Pha-G-Dis Identification of the Pha-G-Dis Comments 4 Pha-G-Dis with a decrease Mahajanga (decrease of 3%); The districts need to improve the of less than 5 % with the Morondava (decrease of 2%), calculation of quantity for resupply composite SPARS score Sambava (decrease of 2%) and ordering. The districts were either (compared to Year 2, Quarter Manakara (decrease of 2%). stocked out or understocked on some 4)) . The increase of the score products. is calculated and compared to the baseline score of the previous quarter 2 Pha-G-Dis were evaluated Marolambo: Score of 75% The district of Marolambo will for the first time (baseline) and Farafangana (non USAID supported): continue to implement recommended with the composite SPARS score of 53% (the district was evaluated as actions and be supervized by the score between 53% to 75% part of the IMPACT support to Insitut Pasteur EMAR and EMAD with support of the de Madagascar in stock management of RLA. malaria commodities through the study being For Farafangana district, IPM should conducted). reinforce the capacity of the district to implement corrective actions suggested by the RLA.

IR2.1.2.SA6 Evaluate and discuss the SPARS approach and assessments through quarterly meetings of regional UTGL and district GAS committees in selected districts to define and implement corrective actions to improve supply chain performance. The incentive/motivation process will apply to the districts' highest performers

This activity is planned in the next quarter during the coordination meetings organized by regions and districts.

IR2.1.2.SA7 In coordination with DPLMT, DSFa, SALAMA, DRSP, and SDSP, conduct call-to action meetings to mobilize resources necessary to upgrade the storage standards and conditions of the Pha-G-Dis to the best practice standards in order to maintain good quality of stored commodities (renovation, cold chain, pallets, shelves, thermometers, management tools, etc.)

In Quarter 1, IMPACT distributed 67 thermometers to 41 Pha-G-Dis in the USAID-supported regions to monitor daily temperature of their storerooms and cold chain. The Pha-G-Dis beneficiaries were identified through the supervision visits. The temperature monitor is fundamental to ensure proper storage conditions of medicines.

IR2.1.2.SA9 Organize coordination meetings with key partners (ACCESS, Mahefa Miraka, UCP, UNICEF, PIVOT, INTERAIDE, IPM) both at central, intermediate, and peripheral levels to plan interventions to support the supply chain of the priority health areas (malaria, FP, and MNCH) at all levels

The RLA have organized 15 coordination meetings with key partners (IMPACT, UCP, ACCESS, Mahefa Miaraka, ONG Pivot, INTERAIDE) in 9 (out of 13) supported regions: Antsinanana, Sava, Diana, Sofia, Boeny, Menabe, Atsimo Andrefana, Haute Matsiatra, and Vakinankaratra. Through these coordination meetings, participants have: - Monitored implementation of past recommendations. - Shared ongoing activities to improve supply chain at district and commune levels for better coordination and synergy. - Evaluated the functionality of UTGL and GAS committees and define actions to implement to ensure these committee are operational.

Table 12: Partner’s coordination meetings organized in Quarter 1 Year 3 Regions Meetings organized October November December Atsinanana 1 Sava 1 1 1 Diana 1 Sofia 1 Boeny 1 Menabe 1 1 Atsimo anderfana 1 1 1

Haute matsiatra 1 1 Vakinakaratra 1 TOTAL 5 6 4

Note that the best practice is to organize at least a quarterly meeting.

IR2.1.3: Support efforts to strengthen the LMIS and SCM M&E systems

IR2.1.3.SA1 Following the LMIS evaluation and subsequent strategic plan to improve the LMIS, support the Ministry of Health to select new LMIS software and to prepare for a small-scale demonstration

During the past 24 months, IMPACT conducted an in-depth evaluation of the existing LMIS for both the public and private sectors. The LMIS evaluation report has been disseminated during the workshop organized from December 2nd to 4th at Motel Anosy in Antananarivo under the leadership of the LMIS TMA sub-committee. During this workshop, IMPACT supported the DPLMT and DEPSI to use the findings of the evaluation in the public sector to: - Confirm the need to change the existing LMIS tool (CHANNEL) to a new web-based tool. - Agree on minimum criteria necessary to select the new LMIS tool. - Develop a road map for the upcoming five years (2021- 2024) including the introduction of the web-based LMIS tool.

Planned activities for Quarter 2: - Finalize the LMIS evaluation workshop report and the road map (January 2021). - Demonstrate various existing web based LMIS tools to inform the choice of the appropriate tool for Madagascar (January 2021). - Select of the new LMIS web-based tool following the defined minimum requirements (February 2021). - Organize a resources mobilization workshop to acquire commitments from other stakeholders mainly Global Fund, Global Alliance for Vaccination and Immunization (GAVI), USAID, WHO, UNICEF, UNFPA, SALAMA, UCP, European Union to support priority activities in the LMIS roadmap (March 2021).

IR2.1.3.SA2 Conduct two End User Verification surveys in randomly selected facilities in the USAID supported regions and support the MOPH (UTGL or DPLMT, the NMCP, and DSFa) to implement corrective measures addressing previous weaknesses. Also mobilize interest in the MOPH to conduct a NSCA and to assist in the selection of what kind of survey and the mobilization of funds

During this quarter, IMPACT collaborated with GHSC- PSM to conduct a second EUV survey. The questionnaires were uploaded in the SurveyCTO software.

- The survey sample included 66 basic health centers (CSB), 3 hospitals (CHRD), 16 PHA-G-Dis, and 1 central medical store (SALAMA). For the first time, 16 CHV were included for malaria commodities data collection. - A list of 34 products was considered: Malaria (11) FP/RH (8), and MNCH (15) commodities. Five new MNCH commodities were added to the list of products to be surveyed: Paracetamol, Chlorhexidine, ORS only, Zinc only, and the combination of ORS-Zinc. - Data collection took place from October 18th to November 18th, 2020. - Data analysis and report writing was completed, and the reports were drafted.

Below are the highlights of key findings from the EUV survey conducted in October 2020 and compared to results of the previous EUV survey conducted in January 2020:

Table 13: Key findings for malaria commodities

Indicator January 2020 October 2020 Stock Management % of the health facilities visited had at least one formulation of AS-AQ and/or AL in 96% 100% stock % of health facilities had a pediatric Artemisinin-based Combination Therapy (ACT) 64% 86% formulation (for under 5 years) available Case Management % of children under 5 years diagnosed with malaria were not treated with an ACT 29% 34% formulation Facility Management % of health facilities had the updated version of the standard treatment guidelines 46% 18% (or protocol?) % of the storage rooms visited had a thermometer inside 0% 59%

There is a progress towards key indicators except the presence of the malaria case management protocol physical copies in visited facilities. The PNLP is planning to disseminate physical copies of the protocol in January 2021.

Table 14: Key findings for FP/RH commodities Indicator January 2020 October 2020 % of health facilities registered stocked out on the day of the visit Combined Oral contraceptive (Microgynon/Combination3/ZinniaF) 23% 22% Depot-medroxyprogesterone acetate- IM (Depo-Provera/Triclofem/Contrasafe) 27% 25%

Depot-medroxyprogesterone acetate- SC (Sayana Press) 28% 38% % of health facilities visited with updated stock cards Combined Oral contraceptive (Microgynon/Combination3/ZinniaF) 33% 31% Depot-medroxyprogesterone acetate- IM (Depo-Provera/Triclofem/Contrasafe) 38% 39%

Depot-medroxyprogesterone acetate- SC (Sayana Press) 38% 34%

Table 15: Indicator: % of health facilities stocked within the established minimum and maximum stock levels (on the day of the visit)- FP/RH

Combined Oral Depot- Depot-medroxyprogesterone contraceptive medroxyprogesterone acetate- SC acetate- IM Stock level Jan-20 Oct-20 Jan-20 Oct-20 Jan-20 Oct-20

Stocked out 14% 0% 4% 5% 21% 0% Understocked 43% 22% 39% 53% 37% 18% Appropriately stocked 10% 33% 22% 21% 16% 27% Overstocked 33% 44% 35% 21% 26% 55%

The numerator for this indicator is the number of facilities that are stocked according to the maximum/minimum policies, and the denominator will be the facilities that currently manage the commodities and have an updated stock cards for that product that has at least 1.5 months of in-stock days on it during the period under review and complete data for the number of units issued. The minimum required in Madagascar is two months of stock (MoS) and a maximum of four MoS at CSB level, and respectively three and six months for hospitals.

Table 16: Key findings – MNCH commodities

Indicator January 2020 October 2020 % of health facilities registered stocked out on the day of the visit Magnesium_sulfate_inj_5mg_10mL 63% 35% Oxytocin_inj_10_IU 19% 35% Gentamicin_sulfate_inj_80mg 23% 15% Misoprostol 51% 79% % of health facilities equipped with cold chain and monitor the temperature at least once a day 75% 82% % of warehouses (Pha-G-Dis, hospitals Pharmacies and Pha-Ge-Com) visited that manage stocks of maternal, newborn, and child health 45% 48% products and had at least one (1) refrigerator

Key Challenges :

- Some staff dedicated to stock management have not yet been trained. - Vertical programs products are stored separately in several storage spaces/locations and are not systematically integrated into Pha-Ge-Com and Pha-G-Dis due to insufficient storage space. - Management tools such as the stock cards are not constantly available and consistently correctly completed despite the importance of stock cards in respecting the minimum-maximum required stock levels. Fifty two percent of the Pha-G-Dis and 34% of the CSB and hospitals visited are correctly completing the stock cards. - Stock out rates are still high for some commodities due to the logistical problems encountered at all levels of the supply chain during the lockdown period imposed during the COVID-19 pandemic.

Key Recommendations:

- Implement a continuous quality improvement approach for inventory management at the Pha-G-Dis and Pha-Ge-Com levels.

- Strive for an improvement in the availability of products at all levels (central/SALAMA, district, and health facilities) within the maximum-minimum levels required to ensure that orders are fulfilled in the adequate quantities. - Disseminate the standard treatment guidelines and other guidelines to improve case management. - Strengthen collaboration among USAID-funded projects to build capacity at district and commune levels (refresher trainings, supervisions, mentoring, etc.), especially on the use of stock cards, temperature monitoring, and proper storage of Oxytocin within a cold chain.

Further details of the EUV surveys are included in the reports submitted to USAID for review and approval in January 2021.

IR2.1.4: Support NMCP in the implementation of Community-based Continuous Distribution (cCD) of LLIN in 12 districts

During Quarter 1, IMPACT continued the implementation of social mobilization to promote the use of LLINs, the distribution of LLINs, and the reporting in the 12 targeted districts. In Year 2, IMPACT experienced a delay due to restrictions related to the COVID-19 pandemic which impacted the start of the distribution (low quantity of LLIN distributed) in the six districts of group 2. To address the delay, the NMCP, with the technical and financial support of IMPACT, organized a reflection workshop in Quarter 1 (October 22nd, 2020) to analyze the challenges, develop a catch-up plan (including at the PA and Kom’lay levels), and intensify households visits and LLIN distribution to target households. The workshop allowed for the adjustment of cCD strategies in relation to COVID-19 and for the development of the catch-up plan for the next five months.

IR2.1.4.SA1 In coordination with the National Malaria Control Program (NMCP), Roll Back Malaria (RBM) and PMI, continue to organize a coordination meeting to ensure the storage, transportation of LLIN, registration, and distribution including voucher distribution, and the 301,600 LLINs for cCD to 12 targeted districts

- 103,700 LLINs were sent to the 6 districts of group 1. At the end of December 2020, there were still 197,900 LLINs in stock at the central warehouse. IMPACT is waiting for the forecast of consumption for the 6 districts of group 2 and for National Coordinating Council (NCC's) decision on whether or not to send these quantities (197,900 LLINs at the central level) of LLINs in Quarter 2 of FY2021.

Table 17: Number of LLINs transported from PARC and PAs to Kom’Lay (Cumulative) Household level (% achievement PARC level PA level Kom’Lay level compared to # of LLINs received by Kom’Lay) Targeted Targeted Targete LLINs to LLINs to LLINs LLINs d LLINs LLINs LLINs Number be be received transporte % to be received % % distributed % of PARC transpor received by d to PARC receive by PA by Kom’Lay ted to by Kom’Lay d by PA PARC Kom’Lay Total of 12 12 985,400 787,500 80% 787,500 757 200 96% 757,200 587 578 78% 541,638 92% Districts

- 80% of the LLINs planned for the 12 districts have been sent to the PARCs.

- As a result, at the end of Quarter 1, a total of 541,638 out of the 985,400 LLINs representing 55% of the target were received by the households. - IMPACT will need more sensitization in the community and to the Kom’Lay members to increase the recovery of LLINs from the PAs because the performance at this level remains at 78%, which is explained by the long administrative process used for the payment of the transportation fees. In Quarter 2, IMPACT will organize community dialogues for more mobilization of the community in the recovery of LLINs. - The distribution of the remaining 245,862 LLINs is planned for Quarter 2.

IR2.1.4.SA2 Reinforce the M&E system to collect, analyze and disseminate accurate and timely data on LLIN distributed through continuous distribution in 2,917 Kom'Lay

- IMPACT organized a biannual review of the cCD’s operational team. This review aimed to think about lessons learned, exchange experience between districts, and implement corrective measures if needed. Field activities resumed for the 51 TA and 08 Sup TA from November 2020. - Joint supervisions were carried out in the Vatovavy Fito Vinany region, including monitoring of activities, supervision of cCD actors at every level, and quality control of data. This activity allowed for the strengthening of LLINs traceability (after the problem of stolen LLINs), RDQAs, and the orientation of accompanying TAs.

Graph 2: LLINs situation distributed with reporting rate

- There was also the constraint in relation to the LLINs stock available at PARC and PA level for some districts during Quarter 1. - Regarding the low reporting rate in December, the completeness will be improved in January 2021 through TA supervision, and collaboration with CSB chiefs and other partners (ACCESS) on data collection at rural Fokontanys.

IR2.1.4.SA3 Continue to disseminate Social Behavior Change through mass media campaigns, household visits, radio spots, posters, SMS, etc. to mobilize households and school children in the 12 targeted districts to correctly use and maintain LLINs

- Advocacy with the School Health Division of the Ministry of National Education (MEN) to organize and implement school-level actors orientation (School Directors and Teachers) on cCD activities in the six districts of group 2.

- A guide for the Chief of ZAP orientation to cCD activities has been developed (SBCC activities for students and parents and the use of SBCC school materials). There is a collaboration between the MOPH and MEN on the integration of SBCC activities at schools focused on malaria prevention.

IR2.1.5: Support NMCP in the design of 2021 LLIN mass campaign distribution strategy, its implementation and the distribution of 3,677 million LLIN procured with USAID/PMI’s fund

IR2.1.5.SA4Support technically and financially the NCC in planning, logistics, and distribution activities for the 3,677,000 LLINs procured under PMI/USAID funding for the mass campaign distribution to more than 5,161,000 population in 4,228 fokontany, 353 communes, 22 districts in 03 regions (Atsinanana, Atsimo Andrefana, and Vatovavy Fitovinany). CRM will be considered for the storage and during transportation

- IMPACT received 3,677,000 LLINs funded by PMI/USAID at the central warehouses identified by IMPACT in Antananarivo and Tamatave. The remaining 500,000 LLINs are expected to be delivered at the port of Tamatave on January 12, 2021. - IMPACT actively participated in various workshop sessions through teleconference with AMP consultants who supported Madagascar in the preparation for the mass distribution strategies including the related documents. - Two workshops were held under the lead of the MoPH through the NMCP for pooling of revised strategies and the finalization of the mass campaign tools where USAID/PMI and Global Fund, the MoPH, and partners such as WHO, UCP, ACCESS, Mahefa Miaraka, PMI Measure Evaluation, and IMPACT have attended.

IR2.1.5.SA5 Contribute to social mobilization activities at all levels in collaboration with the NCC's communication subcommittee

- The communication strategy has been developed and the communication plan is being finalized with the NMCP and the AMP consultant. - Review of the content of the SBCC tools according to the lessons learned from 2018 mass campaign.

IR2.1.5.SA6 Assist NMCP in implementing a M&E system, with a real-time data collection and setup reporting documentations of the 2021 LLIN campaign

In Quarter 1, IMPACT conducted an analysis of potential existing tools to be used for data collection at the community level during the implementation of the 2021 LLIN campaign. The table 18 below summarizes the type of tools identified to date.

Table 18 : Type of tool identified for data submission at community level

Type of tool Advantages Inconveniences SMS on mobile - Easy to use as it is common in all mobile - High risk of data entry error. The data sender phones phones, including very simple models. needs to use a separator (space, comma, etc.) to space the entry between two entries of two variables. - No data entry control for data consistency. STK (Sim Tool Kit). - Easy to use. The question/indicator appears on - Only one mobile company has the experience A menu the screen one after another, hence risk of in its use. integrated in the data entry reduced. - The development of the menu and the SimCards. - One mobile company already has experience insertion of the menu in the SimCard is with its use (Telma). managed in Mauritius, which is a company who prepares the SimCards for Telma. - All maintenance and modifications need to be done in Mauritius. No possibility to conduct a remote update of the menu. - Long process for the creation of the menu and its insertion in the SimCards. - Data entry control is limited.

Android SMS - Easy to develop: Everyone who has a - Need a smartphone with an Android system, background in programming can develop the which requires a large budget to cover all the application under Android. CSB/community. - Installation can be completed online using Internet connection. - Adapted at community level where Internet connection is a challenge. - High performance on data quality control that can be integrated instantaneously during data entry. - Use of SMS from smartphones to submit data which is ideal in rural areas with limited Internet connection.

Next steps for Quarter 2 : - Present the above analysis presented in the table 18 to the NMCP and the USAID HMIS group in order to identify the appropriate tool. - IMPACT will select one agency through an open bid.

IR2.1.5.SA7 - In collaboration with NMCP and the financial contribution from RBM, work closely with the technical assistance from the Alliance Malaria Prevention (AMP) in the preparation and monitoring of the implementation of activities on technical, SBC, and logistical aspects for the 2021 LLIN campaign

- Three AMP consultants, Dr. Marcy Eskine, M Diouf, and Valence Nimbona, provided remote support from November to December 2020 to the NMCP and IMPACT teams in preparation for the 2021 LLIN mass campaign. - During Quarter 1, the AMP consultants supported the country to finalize the following documents:  the LLIN campaign implementation plan,  the timeline for the LLIN campaign activities,  the risk analysis and mitigation plan,  the detailed budget,  the LLIN micro planning,

 the development/adaptation of reporting and logistics tools  the management of COVID-19 action plan

Once finalized, these documents will be validated by the NMCP and the CCN in Quarter 2.

Sub-IR 2.2: The public-sector supply chain achieves financial sustainability

IR2.2.1: Based on total cost analysis (TCA) of the public supply chain, prepare evidence to analyze different supply chain alternatives on the total cost to determine progressive integration of commodities managed by vertical programs into SALAMA circuit and reduce dependence to donor funding for different cost categories of the supply chain

IMPACT supported the TCA steering committee to complete the data collection and perform the data analysis. The TCA will provide evidence to support the MOPH in identifying alternative supply chain strategies to explore the financial sustainability and efficiency. In addition, findings from the TCA will determine the progressive integration of commodities managed by vertical programs into SALAMA and will reduce the dependence on donor funding for the supply chain different cost categories such as costs for tendering process, quality assurance, human resources, storage, and transportation at all levels of the supply chain.

IR2.2.SA1 Finalize the total cost analysis and prepare to support the MOPH to identify alternative supply chain strategies to plan to explore oppose different modeling of the effects on the total cost of proposed changes in the supply system and identify next steps for piloting alternative supply chain options.

During Quarter 1, the TCA data collection continued at the central medical store/SALAMA, 16 Pha-G-Dis, 47 Pha-Ge-Com, 17 district hospitals, 4 CHRR, 3 CHU, and 10 CHRD. Then, the data was entered into LQAS19 (Lot Quality Assessment Sampling) for data quality checks and the analysis was conducted. The TCA report is scheduled to be finalized and disseminated in Quarter 2.

IR2.2.SA2 Build capacity of the relevant GOM staff to use the modeling sheet for monitoring the impact of proposed alternative supply chain models on the total cost

IMPACT supported the TCA TWG to develop a first draft of document describing different options for alternative supply chain models. In Quarter 2, the document will be ready for guiding discussions with a larger group of professionals representing the MOPH, SALAMA, private sector, and technical and financial partners to select one or two options for Madagascar based on the findings from the TCA.

IR2.2.SA3 Support UTGL to develop a new strategic plan for integration of all essential medicines and commodities (PAIS) through the unique circuit of SALAMA

The MoPH aims to integrate the management of all health commodities through a unique distribution mechanism, from SALAMA to districts and to commune levels. The integration will improve efficiency and utilization of available financial resources for better performance of the public supply chain.

During Quarter 1, IMPACT supported the MOPH in the development process for a new 5-year strategic integration (PAIS) document for 2021- 2024. The following activities were conducted:

A rapid qualitative assessment to analyze vertical programs ‘products that are currently integrated into the public supply chain.

IR2.2.2: Reinforce the capacity of the MOPH to oversight and monitor the management of FANOME.

This activity will start in Quarter 3 once the TCA report is available, and findings will serve to update the management of FANOME.

III.3. IR 3: Expanded engagement of the commercial health sector to serve new health product markets, according to health needs and consumer demand

Sub-IR 3.1: Commercial actors are incentivized to expand into new health product markets

IR3.1.1: Strengthen partnership with PSHP and non-PSHP members in participating to the implementation of solutions on transportation, supplying, supervising and providing data collection and reporting about the priority health areas (malaria, FP, MNCH) health products, and in coordination with IR4, support private sector engagement (PSE) in procurement of health commodities such as YES condom and Sur’Eau 150 ml.

During Quarter 1, to facilitate the implementation of these partnerships and collaboration between the pharmaceutical and commercial sectors on supply/importation and distribution of socially marketed products, meetings were held with supply chain and logistic departments of IMPACT, EDM, SOMAPHAR, and the NGO Vanille Durable. It was decided that IMPACT’s Regional Logistics Advisor (RLA) will inform and present the Memorandum Of Understanding (MOU) on transportation between IMPACT and Electricité De Madagascar (EDM) and between IMPACT and NGO Vanille Durable to the MoPH regional representative in order to engage the MOPH in the implementation and coordination of the transportation of health commodities.The transportation of health commodities from Pha-G-Dis to Pha-G-Com by the NGO Vanille Durable and the EDM company is for free.

Since EDM and Vanille Durable operate respectively in Atsinanana and SAVA regions, they accepted and committed by signing an MOU to transport for free of charge health commodities from districts to communes.

During Quarter 1, Blue Ventures purchased from PSI and transported the following Social Marketing products using their own funding from Mahajanga I to CHVs Mahajanga II. This is a part of ongoing support from Blue Ventures and the social marketing products are for the community where they operate.

Table 19: Social marketing products purchased from PSI and transported by Blue Ventures in Boeny Health commodities Quantity Destination Microgynon 30 plaquettes Sayana press 100 doses Mahajanga II – Rojo 50 pieces Communes of Andranoboka and Pneumox 500 plaquettes Mariarano Sûr’Eau Pilina 1000 pochettes

In addition, SOMAPHAR supported IMPACT in the transportation of social marketing products from Antananarivo to Atsinanana (Volume: 4.60m3, value: 118,000,000 MGA / 31,891 $; 1$=3,700 MGA).

Table 20: Health commodities transported by SOMAPHAR Health commodities Quantity Destination Date Protector plus NF 720 presentoir 1x48 Safety box Triclofem 346 pièces Seringue 1ml pour 34,560 pièces Triclofem 10/12/2020 Sureau pilina FINI 13 200 pochettes 1x20 Triclofem (1x 2 880 doses) 34 560 doses

Zinc 3,704 blisters ZINNIA F 18,144 cycles Tamatave I and II Protector plus NF 4,500 presentoir 1 x48 Rojo FINI 180 pièces Safety box Triclofem 749 pièces 07/01/2021 Seringue 1ml pour 74,880 pièces Triclofem Sureau 150ml 2,480 bouteilles Triclofem (1x 2 880 doses) 74,880 doses

IR3.1.2: Set up and strengthen the LMIS for the private sector (drug shops, pharmacies and pharmaceutical wholesaler).

Identification of drugs shops and pharmacies that will share their LMIS data In coordination with MoPH/DPLMT, four regions (Atsimo Andrefana, Vatovavy Fitovinany, Sofia, and Menabe) were selected in Year 3 to randomly identify drugs shops and pharmacies that will share LMIS data. In Quarter 1, the process started in Atsimo Andrefana to identify pharmacies and drug shops:

Table 21: Number of drug shops and pharmacies visited Targeted outlets Achieved Region Observations Pharmacies Drug shops Pharmacies Drug shops Atsimo Andrefana 9 25 7 25 32/34 signed agreement letter

The agreement letter was developed with the MOPH to formalize the participation of drug shops and pharmacies to share LMIS data. The sustainability issue will be discussed during the next TMA LMIS subcommittee meeting to identify with DPLMT/DEPSI methods to sustain this collaboration.

Two pharmacies did not sign: - One pharmacy closed definitely. - The owner of the other pharmacy was absent during team’s visit. The IMPACT regional team will return to the pharmacy to complete the same process that was done with other pharmacies.

Key findings during the field visit are presented in Annex I.

Conduct training of the pharmacies and drug shops on LMIS data collection and submission using electronic tool After the LMIS workshop that took place from December 2nd to 4th, 2020, a meeting between IMPACT and the provider (the agency that develops the LMIS software for drug shops) was organized on December 15th to present the LMIS minimal requirements identified during the workshop. The LMIS software was updated accordingly. IMPACT will train the drug shops on the new LMIS software in Quarter 2. Each drug shop will receive one tablet that was purchased by IMPACT in Year 1. The drug shops will pay for the tablets and IMPACT

is exploring a mechanism (under discussion within IMPACT consortium partners) for the distribution of the tablets. A note about this mechanism was drafted and will be finalized in Quarter 2 to be submitted to USAID for approval. Additionally, to encourage LMIS data sharing, the Tablet will be provided with significant discount, a software on stock and financial management will be installed in the Tablet, drug shops will be trained on the use of the new software, and finally, they will be supervised to reinforce the use of the new software as post-training assistance.

IR3.1.3: Continue to involve PSHP and non PSHP members (Wholesalers and pharmacies) to participate in the implementation of the TMA roadmap finalized and validated in Year 2

During Quarter 1, the private sector members (participants listed in table 22) attended two workshops organized by the MoPH with the objective to: i) encourage the private sector to be involved in the importation of the malaria commodities such the artesunate injectable following the dissemination of the malaria market assessment report and ii) motivate them to integrate and participate in the national quantification exercises.

In December, the private sector members participated in the three-day LMIS workshop. They actively participated during all sessions, especially in the identification of minimal requirements for LMIS tools and in the draft of the LMIS roadmap for the private sector, which will be validated in Quarter 2.

Table 22: Private sector participation in TMA during Quarter 1

Date Session Number of participants Participants from the private sector November Malaria Market Assessment 7 pharmaceutical wholesalers 24th 2020 Dissemination 2 drug shops 11 1 mutual health provider 1 health materials and equipment seller December Logistic Management 3 representatives of drug shops and 02-04th Information System (LMIS) drug shop associations 2020 Workshop 5 representatives of pharmacies and 9 “Ordre national des pharmaciens” (ONP) 3 representatives from pharmaceutical wholesaler’s associations

IR3.1.4: Support professional associations to oversee the functionality of health businesses

IR3.1.4 SA1: Formalize new drug shop associations and revitalize the existing regional drug shop associations

The existence of active regional drug shop associations will be essential in establishing the ADDO program, which functions around groups of drug shops. The drug shops associations will also facilitate communication between IMPACT and individual drug shops, to coordinate LMIS data collection using tablets, under IR3.1.2. During Quarter 1, IMPACT supported drug shops in the Analanjirofo region to complete the official registration of the Association des Dépôts de Médicaments d’Analanjirofo (ADMRA), which was officially established in December 2020.

In December during the regulatory compliance awareness-raising session held with DPLMT for drug shops in Sambava, a meeting was held to create an association for drug shops in the Sava region. The IMPACT team emphasized that members of the association must be drug shops operating legally, with licenses in the name of the current owners. In some districts of Sava, such as Andapa, drug shop associations exist which have allowed both legal and illegal drug shop owners to participate. To support the creation of a Sava regional association, a template of statutes and internal rules was shared with future drug shops members who indicated interest.

Table 23: Number of Regional Drug Shop Associations Created

Year 3 Actual Years 1-2 Actual Year 3 Target QUARTER 1 1 Formal drug shop associations created 1 (Atsinanana) 4 (25%) (Analanjirofo)

IR3.1.4 SA2: Support the development of business management capacity-building within associations by training potential peer trainers.

During the drug shop business training session in Sambava in December 2020, the IMPACT team continued to identify dynamic candidates to be Peer Trainers:

- Selection criteria were the same as in previous regions: (i) geographic location (trying to maximize the number of different districts which have a peer trainer), (ii) dynamism of candidates, (iii) strong communication skills, and (iv) proactive participation during the training. - 12 potential peer trainers were identified (six women and six men): four from the Vohémar district, five from Andapa, and three from Sambava. - All the identified potential trainers expressed their interest in acting as peer trainers.

Identified peer trainer candidates from the regions planned for IMPACT business training in Years 1 and 2 (Analanjirofo, Atsinanana, Boeny, Diana, and Sava), will be invited to participate in a training of trainers (ToT) in Quarter 3, to ensure that the newly established regional associations will have expertise and value-added services, such as business training seminars, to offer their members. The ToT was originally planned for approximately 15 peer trainers (estimating three trainers from the first five regions receiving drug shop training), so in regions with more than three potential candidates identified, additional selection criteria may need to be applied to restrict the number of participants and ensure the quality of the ToT.

Table 24: Number of Potential Drug Shop Peer Trainer Candidates Identified Year 3 Actual Years 1-2 Actual QUARTER 1 0* (Analanjirofo) Identified peer trainer 12 5 (Atsinanana) candidates (Sava**) 6 (Boeny) *The peer trainer concept was introduced after the drug shop training was conducted in Analanjirofo in Year 1. The president of the newly formalized association has agreed to help IMPACT identify potential peer trainers in that region. **Drug shop business training planned for the Diana and Sava regions in Year 2 were replaced by video training because of the COVID-19 pandemic. The IMPACT business trainers recorded videos of their oral

training presentations accompanying the training slides. These videos are provided on both DVDs and USB flash drives, along with full sets of the printed training materials, and sent to PSI regional offices. Drug shop owners are then invited to go pick up these training kits and watch the videos and read the manual at home at their own pace. After about 10 days, the IMPACT team begins making follow-up calls with the drug shop owners to see if they have any questions, and to begin collecting training test results from the owners who have completed the training. When COVID-19 travel restrictions are relaxed, the IMPACT team can also make a short trip to the region for in-person meetings with drug shops for the DPLMT information sessions and to encourage the creation of a regional drug shop associations.

Due to limited completion of the video training in the Sava region, an in-person training was conducted there in December. A trip is tentatively planned to the Diana region in Quarter 2 in order to identify peer trainer candidates.

IR3.1.5: Increase access to finance for private health commodities supply chain stakeholders/Expand supply-side financing

IMPACT continues working with USAID partner banks Accès Banque Madagascar (ABM) and Baobab Banque Madagascar to build the institutions’ capacity to meet the financing needs of health enterprises, by training bank staff on the characteristics of the sector and how to better serve it and by developing new bank products tailored to the needs of health enterprises. In addition, IMPACT is working to establish partnerships with other financial institutions, to reach more enterprises in the health commodities supply chain.

Train and support USAID partner banks in credit analysis and loan structuring for health commodities businesses. During this first quarter, IMPACT trained 27 partner bank staff members from Sambava branches (17 men and 10 women) and identified 3 staff for each bank to be the health focal points or “champions” for their regional colleagues as a way to ensure the institutional memory of health training, given high staff turnover within the banks. The staff trained included: - 14 loan and account officers from Baobab and - 13 loan and account officers from ABM.

In addition to topics introducing bank staff to private sector health commodities distribution chains, appropriate market approaches for this sector, and the financial products offered by their banks which would interest pharmacies and drug shops, for the first time, GESI topics such as information on the market potential and financing needs of women drug shop and pharmacy owners were included in the training content. The new GESI materials were intended to sensitize the loan officers to the specific needs and market potential of women drug shop owners and pharmacies. In Quarter 2, the IMPACT team will work to make the content of these training seminars shorter (not more than one hour), while keeping the information compelling for bank staff.

Six new medical sector “champions” (three from ABM Sambava and three from Baobab Sambava) were identified during Quarter 1. These champions will serve as information resources for their regional colleagues on all questions related to the health sector.

Table 25: Number of Bank Staff Trained on Working with Health Commodities Enterprises Year 3 Actual Years 1-2 Actual Year 3 Target QUARTER 1 27 Sambava Baobab 14 (8 30 Bank staff trained 211 (105 men, 106 women) men, 6 women) (90%) ABM 13 (9 men, 4 women)

Increase utilization of financial products and tools developed with partner banks in previous years (e.g., pharma loans, motorbike loans, etc.).

ABM: - The pharmaceutical wholesaler working with ABM and IMPACT on the Pharmaloan product is still reviewing the MOU and has not yet signed. - As lending activities pick up again following the COVID-19 pandemic slow-down, IMPACT will work with the bank to expand motorbike loans in additional regions. - During a meeting with the ABM Managing Director in December, he informed the team that the bank was reorganized in Quarter 1, creating four new departments for a more customer-oriented structure: customer acquisition, customer services, customer problem resolution, and credit risk department. - The bank has assigned a new contact point for the DFC guarantee. The new dedicated bank staff for the USAID partnership were trained in using DFC’s Credit Management System (CMS) on a guarantee claim submission procedures on December 14th. - One ABM loan to a pharmacy has been restructured due to COVID 19-related revenue issues, and the restructuring approval request was submitted to DFC.

Baobab: - A new General Manager has been appointed at the bank. - A committee composed of IMPACT/SHOPS Plus Access to Finance team members and the bank marketing team was created to develop a new marketing approach and products for the private health sector. The new marketing plan will be implemented once approved by bank management in Quarter 2.

Table 26: Loans Disbursed to Health Commodities Enterprises by Partner Banks Years 1-2 Actual Year 3 Quarter 1 Actual Year 3 Targets Non- % Non-DFC Total DFC Total Total DFC loans DFC Achiev loans Loans loans Loans Target loans ed Number of loans disbursed by 15 6 21 3 0 3 ABM Men 6 3 9 2 0 2 Women 8 3 11 1 0 1 Unknown 1 0 1 0 0 0 Number of loans disbursed by 26 6 32 7 0 7 Baobab Men 14 3 17 4 0 4 Women 11 3 14 3 0 3 Unknown 1 0 1 0 0 0 Total number of loans disbursed 41 12 53 10 0 10 100 % Men 20 6 26 6 0 6 Women 19 6 25 4 0 4 10 10% Unknown 2 0 2 0 0 0 Value of loans disbursed by $53,442 $44,347 $97,789 $4,429 $0 $4,429 ABM Men $17,282 $8,525 $25,807 $4,364 $0 $4,364 Women $35,249 $35,822 $71,071 $65 $0 $65 Unknown $911 $0 $911 $0 $0 $0 Value of loans disbursed by $67,845 $31,442 $99,287 $41,134 $0 $41,134 Baobab Men $40,321 $22,769 $63,090 $3,069 $0 $3,069 Women $27,095 $8,673 $35,768 $38,065 $0 $38,065 Unknown $429 $0 $429 $0 $0 $0 $120,00 Total value of loans disbursed $121,287 $75,789 $197,076 $45,563 $0 $45,563 38% 0 Men $57,603 $31,294 $88,897 $7,433 $0 $7,433 Women $62,344 $44,495 $106,839 $38,130 $0 $38,130 Unknown $1,340 $0 $1,340 $0 $0 $0

Ten loans totaling $45,563 were disbursed to 10 health commodities enterprises in Quarter 1, of which 4 were to women-owned businesses.

Continue development of financial risk mitigation mechanism to health commodities enterprises. The development of financial risk mitigation mechanism will resume in Quarter 2.

Implement partnerships with other financial institutions to facilitate access to finance in regions not covered by the existing partner banks. Discussions with KRED, the micro-finance branch of BNI, have been suspended due to an apparent lack of interest from the potential partner, which has shifted its interests towards wholesalers and pharmacies rather drug shops. Prospections of other financial institutions will be developed during Quarter 2.

IR3.1.6: Provide business strengthening capacity building to health commodities enterprises and develop partnerships with private companies to sustain training

IR3.1.6 SA1: Update business-strengthening training curricula for drug shops based on comments and remarks from previous trainings

In Year 2, IMPACT developed video training materials in order to be able to provide distance business training to drug shops during the COVID-19 lockdown and travel ban. Video training kits were distributed in the Diana and Sava regions, and 22 drug shop owners in Diana were able to pick up the kits and complete the video training, as verified with post-training phone interviews. However, in Sava, only 13 drug shops picked up the video training kits and even fewer completed the training. The low participation rate is attributed to several factors: drug shop contact information was difficult to obtain (only the Médecins Inspecteurs for the Vohemar and Sambava districts, and the DRS, were helpful in providing contact information); a large number of drug shops in the region are operating without valid licenses; a poor road access made it difficult for drug shops to travel and pick up the video kits. IMPACT therefore decided to conduct an in-person training in Sambava in December 2020. The team combined the in-person training with some of the video training materials, to show the participants how to better use the videos materials later at home for reference or to refresh their understanding of topics.

IR3.1.6 SA2: Provide initial business-strengthening training to drug shops in four new proposed regions

On December 10-11, 2020, the first joint IMPACT-DPLMT mission for Year 3 was held in Sambava. The DPLMT team led a half-day information session on the legal and regulatory framework. This session also helped to identify active legal and illegal drug shops in the region. Starting this year, DPLMT has accepted to provide an awareness-raising session to illegal drug shops in a separate room, during which DPLMT and DRSP explained the reasons that drug shop licenses are considered irregular and show the procedures to the illicit drug shops to remedy their status. The illegal drug shops reported that the session was helpful because they were unaware that they were not operating legally and can now undertake the necessary procedures to formalize their activity. For DPLMT, illegal drug shops are those which i) are operating with a license which was delivered to someone else, or (ii) with forged licenses.

Given the high proportion of drug shops operating illegally in Sava, DPLMT asked IMPACT to support a supervision mission to identify regional drug shops which do not have a valid license or are otherwise non- compliant with regulations. The supervision report will be sent to USAID by mail along with the responses to the Quarter 1 report.

The mandatory information session was followed by an optional 1.5-day business training, conducted by IMPACT. Drug shops were required to cover their own transportation and lodging costs during the training if they wished to attend. Three of the four districts in the region were represented: Andapa, Sambava, and Vohémar. As usual, pharmaceutical whole-sale partners of IMPACT were given the opportunity to co-sponsor the training, and SOMAPHAR shared the cost of this event. This approach will help ensure the sustainability of the training and gives the companies opportunities to interact with drug shops, strengthening business relationships between wholesalers and the drug shops and creating a base for future collaboration with regional associations.

Key Findings: - No drug shops from the Antalaha district attended the awareness-raising campaign, although the same communication channel (radio broadcast) was used for all four districts. An investigation of the reasons for the lack of participation of drug shops from Antalaha is ongoing.

Table 27. Drug Shop Attendance at DPMLT Regulatory Information Session in Sava District Number of Drug Shops in DPLMT Number of Drug Shops at DPLMT Database Information Session Sambava 24 15 Andapa 48 11 Vohémar 28 11 Antalaha 20 0 TOTAL 120 37 Source: DPLMT Back to Office Report

- Drug shop owners in the Sava region have a higher level of education than drug shop owners trained in other regions, which facilitated the training and made participation more active. 15 out of 25 of the training participants (60%) have high school diplomas and eight out of 25 (32%) had attended university. Knowledge improvement from training was 18% (average pre-test score of 51%; average post-test score of 60%). - Using a mix of the in person and video training material helps participants to familiarize with materials they can use at home. On the other hand, in-person explanation is more understandable for the participants. - In order to mitigate the risk of dealing with illegal drug shops, SOMAPHAR selected two larger pharmacies in Sava to be its partners where drug shops can buy products from SOMAPHAR at reduced prices. SOMAPHAR will not sell directly to drug shops in Sava unless they come to Antananarivo.

Table 28: Number of Drug Shops Attending Awareness Sessions and Business Training Year 1-2 Year 3 Actual Quarter 1 Target Actual 101 25 Sava 125 Number of people trained in business and financial (64 men, 37 (14 men, 11 (20%) management women) women) 85 (47 men, 37 Sava* Number of drug shops attending regulatory 38 women) (21 men, 16 NA information session led by DPLMT women) *In addition, 14 illegal drug shops received an awareness-raising session on regulatory compliance from DPLMT and DRSP in a separate room.

Sensitization session of 10 Irregular drugs shops led by DPLMT Drug Shop regulatory information session in Sambava on and DRSP Sava, © Impact December 10, 2020, © Impact

Drug Shop business training in Sambava from December 10 to Ms RAZAFINDRALOBA, drug shop owner in Andapa, 11, © Impact shown how to use the debtors’ book, © Impact

IR3.1.6 SA3: Provide one-to-one business coaching to enterprises/individuals identified as potential peer trainers or key partners in health commodities supply chain

To reinforce the implementation of newly acquired knowledge, training sessions are followed by one- on-one coaching for selected participants. Coaching sessions are usually conducted at the drug shops, in order to observe the existing management tools used by the drug shop owners and to explain to her

View of Mr Jean de Dieu TSILANIZARA’s drug shop in Andapa or him how to use the new tools provided during with three of his vendors, © Impact the training session. Following the training in Sambava, coaching was grouped in the Andapa district, focusing on three identified potential peer trainers. Due to time constraints, candidates in other districts could not be reached during this mission.

IR3.1.6 SA3: Provide one-to-one business coaching to enterprises/individuals identified as potential peer trainers or key partners in health commodities supply chain

To reinforce the implementation of newly acquired knowledge, training sessions are followed by one-on-one coaching for selected participants. Coaching sessions are usually conducted at the drug shops, in order to observe the existing management tools used by the drug shop owners and to explain to her or him how to use the new tools provided during the training session.

Following the training in Sambava, coaching was grouped in the Andapa district, focusing on three identified potential peer trainers. Due to time constraints, candidates in other districts could not be reached during this mission.

Key findings: - The three coached drug shops have each been in business from more than seven years and work closely with doctors at the public hospital or CSBs to supply of health commodities which the community might need. - Most of drug shops in Andapa used the logo of pharmacies and are generally referred to as “pharmacy” by the population. - During the coaching, some recommendations were given to the vendor/owner on how to better comply with drug shop regulations. - A follow up call or coaching should be conducted in one to two months, to check on the improvement of the drug shop management.

Table 29. Number of Drug Shops Receiving One-to-One Coaching Year 3 Actual Years 1-2 Actual Year 3 Target QUARTER 1

3 Sambava 20 Drug Shops Coached 16 (10 men, 6 women) (1 man, 2 women) (15%)

IR3.1.6 SA4: Continue collaboration with training providers to integrate IMPACT training content into existing curricula for pharmacies and drug shops.

The discussion with FORMASANTE is continuing. IMPACT is identifying new potential partners interested in collaborating to develop business management training for drug shops and pharmacies in Madagascar, i.e. wholesalers and pharmaceutical labs. Contacts with some prospects like SOMAPHAR and other labs have been initiated.

IR3.1.6 SA5: Develop new technology methods for providing remote training to drug shops and pharmacies.

In Quarter 1, the team conducted a comparative analysis of remote and in-person training methods based on feedback from the first video distance learning provided to drug shops in Diana and Sava. Results will be finalized and shared in Quarter 2.

Sub-IR 3.2: GOM facilitates the work of the commercial sector

IR3.2.1: Facilitate high-level advocacy by the commercial sector to expand favorable FP policies and regulations (this activity will be covered under IR1 through TWG/AMT subcommittee in charge of Regulations).

During Quarter 1, IMPACT contributed to the update of the national pharmaceutical policy document (PPN) and the development plan of the pharmaceutical sector (PDPN) through the texts and regulations TMA TWG sub-committee. The activity is reported under IR1.

On December 8th, following a request from the Union of Pharmacists in Madagascar, which wishes to strengthen its collaboration with the project, the IMPACT team organized a working meeting with a delegation of the Union led by its President to discuss ways to collaborate and relaunch activities to fight against counterfeiting and the illicit market of medicines in Madagascar (10 participants). The newly appointed Minister of Public Health granted a hearing to a delegation from the Union of Pharmacists and IMPACT, where he agreed to hold a meeting in January 2021 to reactivate the interministerial committee to fight against the illicit drug market.

IR3.2.2: Foster sustainable capacity development in regulatory reforms within the GOM. IMPACT has been designated to represent all the Technical and Financial Partners (TFPs) within the new National Registration Committee (Commission Nationale de l’Enregistrement or CNE) officially appointed in September 2020.

The following activities were performed this quarter: - Actively participated in two CNE meetings organized on September 30th and November 25th to review market authorization applications submitted to DAMM and related to vertical programs and SALAMA products. The CNE requested additional information for almost 75% of the dossiers submitted by SALAMA. - Attended the first meeting organized on October 22nd to discuss the review of the SALAMA MOU and include the harmonization of the SALAMA prequalification process with the registration of medicines done by DAMM. At the end of the meeting, a joint committee was established to finalize the update of this MOU between SALAMA and DAMM. - Supported DAMM to organize a resource mobilization meeting on December 3rd to strengthen its capacities in terms of operations and financial management, human resources capacity development, and equipment (laboratory machines and IT). 18 participants attended the meeting and decided to write an advocacy document to share with various stakeholders to formalize the request for support. - The MOU between the MOPH and TFPs on the quality assurance of medicines has been signed in December and is ready for implementation.

IR3.2.3: Develop and pilot an accreditation program for retail drug depots.

In order to move forward with the implementation of the ADDO pilot project, IMPACT contributed to drafting a ministerial decision relating to the creation and establishment of the ADDO Steering Committee which has been submitted for validation and signature by the MOPH authorities. Once the ministerial decision is signed, IMPACT will support the DPLMT and DAMM to organize the first meeting with the appointed members to validate the pilot phase roadmap and select the two regions for the pilot.

IR3.2.3SA1 Develop an advocacy guide to facilitate the creation and functioning of regional drug shop associations

IMPACT continued to collect necessary documents to develop the advocacy guide in the next quarter.

IR3.2.3SA2 Develop a roadmap for accreditation program for retail drug depots (ADDO)

IMPACT has developed a draft of ADDO roadmap that will be reviewed and validated by the steering committee when officially formalized.

IR3.2.3SA3 Support the steering committee to revise the list of medicines for accredited drug shops

This activity is scheduled in Quarter 2 under the leadership of the TMA sub-committee for regulatory work.

III.4. IR 4: Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy people

Sub-IR 4.1.1: Socially marketed products are continuously available at convenient and accessible locations IR4.1.1: Distribution of socially marketed products across ten (10) regions for MNCH and FP/RH products and distribution of only FP/RH products in three (3) PARN Regions through PARCs and PAs

In Quarter 1, IMPACT continued to distribute a range of socially marketed FP/RH and MNCH products to support the 13 USAID-supported regions. Table 30 and 31 show the distribution of FP/RH and MNCH health products comparing to the Year 3 targets.

Table 30: Distribution of FP/RH commodities in Quarter 1 Year 3 Quarter 1 Achievement COMMENTS FP PRODUCTS Target Achievement in terms of % Oral contraceptives were continuously available in Quarter 1. . 23,300 blisters of Zinnia F were allocated as starter kits to 4,660 CHV in the 3 regions of OC : Zinnia F ACCESS (Vatovavy Fito Vinany, Atsimo (Community 1,811,124 707,342 39% Andrefana, Atsinanana) Channel) . 8,385 blisters as starter kits to 1,677 CHV in the 3 regions in PARN (Vakinankaratra, Amoron’i Mania, Haute Matsiatra) that are managed by ACCESS. . Each CHV received 5 blisters. Triclofem was continuously available in Quarter 1. The distribution followed the number of regular users of injectables with safety stocks for PA/AC. IMPACT noticed that due to the stock out of Injectable (Depo- Sayana Press through May 2020, the users of Provera/TRICLOFEM) injectables increase, the PARC and PAd supply 1,547,022 552,521 36% (Community more the intra-muscular. Channel) . 22,350 doses of Triclofem were allocated to 4,470 CHVs in the 3 regions of ACCESS. . 8,385 doses were allocated for 1,677 CHVs in PARN zones as starter kits. . Each CHV received 5 doses.

Year 3 Quarter 1 Achievement COMMENTS FP PRODUCTS Target Achievement in terms of % 5,002,560 units of the Protector Plus male condom were received in November 2020. The target includes the community and commercial distribution channels. IMPACT distributed only to the community-based distribution in Quarter 1 which explains the low achievement. The price of Protector Plus is recommended to be increased in the portfolio FP condom Protector analysis, but this document is under final review in Plus (Community Quarter 1. 1,682,808 211,104 13% and Commercial Channels) . 50,112 units of Protector Plus were allocated to 4,932 CHV of the 3 regions of ACCESS (Vatovavy Fito Vinany, Atsinanana, Atsimo Andrefana). . 16,848 units were allocated to 1,677 CHV in the 3 regions of PARN (Vakinankaratra, Haute Matsiatra, Amoron’i Mania) of which ACCESS is in charge. . Each CHV received 10 condoms. The procurement of this product is not yet FP Youth Condom initiated and will wait for the dialogue with the Yes (Commercial 346,000 N/A N/A private sector to take over this product. Notice Channel) that Yes With You strawberry has an AMM validation since March 2020. In Quarter 1, Sayana Press was continuously available. However, IMPACT only achieved 16% of the annual target in Quarter 1 because the regular users of injectable contraceptives continued to use Triclofem more than Sayana Press due to the Sayana Press long period of stock out of Sayana Press. This (Community 498,073 81,607 16% explains the low achievement for Quarter 1. Channel) . 13,410 doses of Sayana Press are allocated to 4,470 CHV in the 3 regions of ACCESS. . 5,031 doses were allocated to 1,677 CHV in the 3 PARN regions as starter kits. . Each CHV received 3 doses of Sayana Press.

IMPACT received 400,000 pregnancy test kits in December 2020 and achieved 73% of the annual target for 2021. This is due to the training in Mahefa Miaraka zones: SAVA, DIANA, and Melaky. IMPACT has allocated 40,520 pregnancy test kits to Mahefa Miaraka in DIANA, MELAKY, and SAVA: . 36,790 as starter kits for 3,679 CHV in the 3 Pregnancy Test regions with 10 kits per CHV, (Community 103,000 75,635 73% . and kits to be used during the training: 9 kits Channel) for EMAR, 42 kits for the ToT of the CSB, and 3,679 kits for the CHV. ACCESS has also begun the training for 400 CHV in Vatovavy Fito Vinany so IMPACT also allocated 4,000 pregnancy test kits to those 400 CHV (10 kits per CHV), 89 kits for the ToT of the CSB, and 20 kits for EMAD and EMAR.

Table 31: Distribution of MNCH Commodities in Quarter 1 Year 3 Target MNCH Year 3 Quarter 1 % Year 3 COMMENTS PRODUCTS Target Achievement achieved The achievement is high. This result included 7,900 starter kits of ORS/Zinc ORS/ZINC allocated to 3,950 CHV of the 3 regions of ACCESS DTK 60,673 27,774 46% (Atsinanana, Atsimo Andrefana, Vatovavy Fito Vinany). (Community) The achievement without the starter kits is 32.7% in Quarter 1. Using commercial and punctually to community-based distribution channels. High achievement in Quarter 1. This includes 10,441 bottles distributed to the community channel to avoid stockouts in the Sur’Eau 150 community channel while waiting for the new arrival of Sûr’Eau 267,500 322,095 120% ml Pilina. The target of Sûr’Eau 150 ml was set assuming that only very few quantities would be procured in 2020 depending on the project income collected. However, IMPACT procured more products than planned and Sûr’Eau 150 ml was in high demand due to the COVID-19 pandemic. IMPACT received 4,078,400 tablets of Sûr’Eau Pilina in November 2020 by sea shipment. The high rate of achievement is due to: . The allocation of 12,515 tablets of Sûr’Eau Pilina to 2,503 Sur Eau Pilina CHV of ACCESS in 3 regions (Atsinanana, Atsimo Andrefana, (67mg 2,793,000 1,253,340 45% Vatovavy Fito Vinany). Each CHV received 5 blisters of 20 Tablet) tablets of Sûr’Eau Pilina. (Community) . The product was also restocked to replace the Sûr’Eau 150 ml from the PARC and PA after a partial stock out caused by a delay of arrival. Arofoitra distributed in Quarter 1 included 1,505 tubes of Arofoitra allocated to 301 CHV in 2 districts of ACCESS zones in Arofoitra Tamatave II and Benenitra. This was the only allocation that could (CHX 7,1%) 31,289 3,765 12% be completed according to the availability of stock in PSI’s (Community) warehouses. Arofoitra is running out of stock as the quantity ordered in 2020 has not yet arrived and is expected in February 2021. The distribution in Quarter 1 included 12,096 blisters as starter batches to 4,032 CHV in the 3 regions of ACCESS. Each CHV Pneumox received 3 blisters of Pneumox. In October 2020 and November (amoxicilline) 134,567 71,919 53% 2020, the distribution of this product is still higher than the (Community) normal average monthly consumption due to the COVID-19 context which explains the high achievement.

A monthly coordination meeting between IMPACT, ACCESS, and Mahefa Miaraka was held on November 20th, 2020 to coordinate the work and cooperation between these partners. Actions for the topics presented in table 32 were discussed between the three projects for better coordination.

Table 32: Results of the discussion per topic identified Topic Actions/Issues/Resolutions Last Mile Distribution (public sector). IMPACT and ACCESS collaborated to sensitize districts to collect, verify, and submit requests of reimbursement of transportation fees for CSB and CHV. In every monthly meeting between EMAD and the Heads of CSB, the LMD strategy will be explained, and the two programs will support the CSB and CHV to prepare the requests. In the next quarter, it is expected that more CBS and CHV will submit the requests of reimbursement to districts, and then to UCP.

Perspective on CHANNEL software and a follow-up tool In December, the DPLMT with its stakeholders agreed to a need of to monitor the availability of stock at Pha-G-Dis. changing the LMIS software. A road map was developed and described under MERL. GAS committee. The 78 supported districts have established a GAS committee to better coordinate activities to increase access to essential commodities. IMPACT and ACCESS will continue to support the well-running of the GAS committee and provide technical and financial GAS district committees. In Quarter 1, all the 78 districts committees’ members participated in the virtual meetings organized by the PNLP to validate quarterly orders. In the next meeting, the team will draft a proposal of agenda and content of the meeting to orient the GAS committee to run an efficient meeting Stockout in malaria commodities: ACT for children at the The possible transfer of the CSB of Soaloka, Ankavandra, central level and advocacy to the DPLMT to transfer the Betsipolitra and Ankondromena from Miandrivazo to Pha-G-Dis of supply of the CSB in Soaloka, Ankavandra, Betsipolitra, Tsirianomandidy will be discussed with DPLMT. and Ankondromena (which belongs to the region of Miandrivazo but is located in Melaky region) to the Pha- G-Dis of Tsirianomandidy. Compiled reports and purchase orders from CHV Two separate Report- Orders (Rapports- Bons de commande) will be submitted by the CSB to Pha-G-Dis for resupply of malaria commodities. A note from the Secretary General is being drafted to officialise the use of the two Report-Orders and will be disseminated once signed. Social marketing pricing of Arofoitra CHX A product analysis for Arofoitra was completed in January and February 2021 with a small survey about the barriers to use to define whether the barriers are really related to the pricing and whether or not to decrease it. Preparatory meeting for the review of quantification for The quantification review workshop was held in Majunga as FP commodities planned from November 30th to described under IR2.1. December 4th 2020. Scaling up the use of pregnancy tests (zones to be The pregnancy test kits were introduced to 3 zones of Mahefa identified by Mahefa Miaraka). Miaraka (DIANA, SAVA and Melaky) after Sofia, Menabe. Transfer of PA/PARC: Announcement of the transfer of 15% of PARC and PA and collaboration between IMPACT and MSH to identify Pha-G-Dis with good performance. Support to SMSR team (DSFa): it is recommended that Meeting is scheduled in February 2021. Such as IMPACT staff are more involved in the transfer or transportation of health commodities which are necessary for the proper functioning of the project activities and to avoid recurrent disruptions at the community level. The status of shipment of Misoprostol to SDSP is IMPACT and ACCESS worked together to support the EMAD to available. plan for distribution at the CBS level. In the next quarter, an update will be shared on the status of this distribution.

The next coordination meeting will take place in March 2021. Due to COVID-19 and to respect social distancing, field supervision of PARC and PA is maintained at every two months. Remote supervision and data collection by phone are alternated with the frequency of the field visits (every two months as well).

Table 33: Data reporting rate PARC&PA DATA REPORTING Q1Y3 oct-20 nov-20 déc-20 Data reporting 992 996 992 Number of PARC&PA 993 996 994 The number of PARC and PA increased every month due to the extension of ACCESS areas.

In December 2020, 35 PAs and 2 PARCs were recruited in 3 districts of BOENY (Ambato Boeny, Majunga II, Port Bergé) following the extension of ACCESS in the region.

IR4.1.3: Expand last-mile distribution and emergency distribution through a pilot to deliver health products using drones.

IMPACT continued to deliver FP and MNCH products by drone to PA from Maroantsetra as the central point of delivery (base). Two activities were completed for the drone activity in Quarter 1: 1. Delivery

From October to December 2020, 83 successful flights were recorded: - Maroantsetra: 75 successful delivery flights for 19 out of 20 PA. - Mananara Nord: 8 successful flight tests for 7 out of 18 PA.

The number of flights per distance is detailed in the graph 3&4 bellow:

Graph 3: Number of delivery flights per distance Graph 4: Number of delivery flights per month in Quarter 1

25 22

20 38 15 12 10 8 6 33 Number of of Numberflight 5 2 0 0- 25 km 26- 50 km 51- 100 km 22

oct.-20 nov.-20 déc.-20 0 10 20 30 40

Delivery flights up to 50 km were conducted with the PA located in Maroantsetra and the flights conducted beyond 50 km were for PA in Mananara Nord.

The graph 4 shows the total number of delivery flights recorded per month during Quarter 1. The needs of PA increased per month, thus, the number of flights increased accordingly.

Table 34: Quantity of FP and MNCH products delivered by drone 2020 October November December Total Triclofem (Dose) 1,020 1,800 2020 4840 Seringue (unit) 1,020 420 2020 3460 Sayana Press (dose) 90 210 120 420 Arofoitra (Tube) 15 20 60 95

Pneumox (blister) 70 290 230 590 Sur'Eau Pilina (Pocket of 2 blisters) 40 100 140 Zinnia (blister) 1,428 3,150 1,954 6,532 Rojo (unit) 4 5 9 SRO (Sachet) 50 70 120

These quantities and products came from the orders received (based on needs) from PA in Maroantsetra during Quarter 1. IMPACT conducted flight tests to Mananara Nord which were successful. The departure was from the Maroantsera take off point and the products were dropped off to the PA located in Mananara Nord.

2. Field visit of USAID in Maroantsetra

From the December 9th to 13th 2020, USAID Madagascar represented by Dr Hajarijaona RAZAFINDRAFITO (Health Systems Strengthening Senior Advisor), PSI Madagascar represented by Daniel CRAPPER (Country Representative of PSI Madagascar), and Gilbert ANDRIANANDRASANA (Chief Of Party of IMPACT) were in Maroantsetra for a field visit related to the drone pilot activity. ACCESS and Mahefa Miaraka were also represented during this field visit. The following were the main activities conducted during the visit:

- Courtesy visit at the SDSP (Adjoint Technique of the M.I and the Responsible of Malaria commodities and vaccination) based in Maroantsetra to discuss the SDSP expectations. - Visit to the PARC in Maroantsetra to observe the storage and the availability of health products and explain the drone delivery system and drug packaging demonstration. - Visit the drone take-off point in Maroantsetra and assisted with the take-off and landing demonstration. - Visit to Aerial Metric’s office to observe the manufacturing of drone equipment, ideas for the next innovation (delivery to more than 100km), and discussion about the drone projects external assessment.

Visits in community level included:

- Visit to the Mayor of Ankofabe, Andranofotsy, and Ankofalava to talk about their experiences with the IMPACT project at the community level. - Visit to PAs of Ankofabe, Andranofotsy, and Ankofalava for a demonstration of the receipt of packages delivered by drone, analysis of availability of the products, verification of management tools, checking the price of the products.

Courtesy visit at the SDSP in Maroantsetra, © Impact Visit of the the take-off point of the drone, © Impact

Visit of the Mayor of Ankofabe, © Impact Reception of the delivery box containing health commodities by the PA of Ankofabe in Maroantsetra, © Impact

IR4.1.4: In collaboration with IR2, DSFa, DPLMT and DSSB, develop, finalize and validate the scored criteria, standard and process to transition from PARC and PA to Pha-G-Dis and Pha-Ge-Com

- The definition of the criteria for the transfer of PA and PARC to Pha-Ge-Com and Pha-G-Dis was initiated with the DPLMT and DSFa. - Meetings with the DPLMT and DSFa were held separately to introduce the activity to these two directions of the MOPH and working session with the DRSP of Boeny was held because Boeny is among the regions having high scores in the SPARS Grid used by RLA to improve performance of Pha-G-Dis. This working session aimed to discuss the possibility to begin the transfer in the two IMPACT districts of Soalala and Mitsinjo before the scale up in the other districts of Boeny. - The next step is to set up a transfer committee composed of all the actors from MoPH, SALAMA, ACCESS, and IMPACT to identify, set-up, and validate the criteria and select the areas where the transfer will begin.

IR4.1.6 : Define a product monitoring system and conduct a study of a product tracking system

Since Year 2, IMPACT explored technological solutions such as barcodes to mitigate the leakage of FP products. A conference call with the supplier was held in December 2020 to discuss and adjust the scope of work related to the barcodes project. The scope of work will be finalized in Quarter 2.

IR4.1.7 : Ensure preventive measure against COVID-19

- The distribution of Personal Protection Equipment (PPE) to PARCs and PAs to prevent COVID-19 continues while performing work and distribution at PARC and PA by respecting gestures and barriers. - SPD has spaced out the supervision visits to every two months and conducted remote supervision as an alternative using phone calls in order to reduce in-person contact.

Sub-IR 4.1.2: Socially marketed products achieve cost recovery at an affordable price for consumers

IMPACT analyzed the COGS of the social marketing products and a slight increase of price for some FP products was proposed to improve cost recovery and sustainability . The new price validation process has been initiated

and will be achieved in Quarter 2 by considering the USAID and the PA and PARCs committee of transfer approval. This will be accompanied by communication toward the actors such as CHV, PARC, PA, and ACCESS.

III.5. IR5: Increased demand for and use of health products among the Malagasy people

IR5.1.1 : In collaboration with the TMA TWG demand creation subcommittee led by the MOPH (DPS), develop and implement activities to increase demand and health products safe use through the National Communication Plan developed in Year 2

Table 35: Description of the TMA TWG Demand Creation 6th Meeting Meeting Objective Date and Participants Key outcomes venue Sixth meeting of 1- To present the December - Private Sector - Review and enhancement of the the TMA TWG draft of the 18th, 2020 (pharmaceutical messages developed by the demand creation communication at IMPACT’s wholesalers, steering committee: subcommittee led plan for the safe office pharmacist unions, o on the purchase of health by the MOPH and rational use of SALAMA): 6 commodities at accredited (DPS) health participants. establishments to fight against commodities that - Public Sector: 4 illegal drugs sales. Example of was developed by participants. messaging: “Purchase your the steering - NGOs (Mahefa medicines at pharmacies, committee Miaraka, IMPACT): hospitals or drug shops." composed by the 6 participants. o on the rational use of MOPH (DPS, medicines for all health areas. AMM, DPLMT) Total: 16 (male: 8; - Development of messages on: and IMPACT. female:8) o Rational prescription of 2- To refine the medicines targeting health care draft of messages providers. developed by the o The management of spoiled, steering expired, and unused drugs. committee and develop new ones.

IR5.1.2 : Provide technical and financial support to MOPH communication activities that are linked to the IMPACT mandate

- IMPACT participated in two workshops organized by the NMCP for the LLIN mass distribution campaign in 2021:  From November 16th to 20th, 2020 in Antsirabe the national communication strategy was developed.  From December 14th to 18th, 2020 in Antsirabe communication tools such as posters, job aids, and messages were created.

- IMPACT attended at the NMCP annual review from December 7th to 11th in Antananarivo and supported the NMCP communication team to compile the achievements of 2020 vs the action plan and prepare the annual communication workplan (Plan de Travail Annuel -PTA) for 2021.

- Consequently, IMPACT’s communication activities for 2021 were integrated in the national malaria communication workplan (PTA 2021), including the mass LLIN distribution campaign and the Community- based Continuous Distribution (cCD) communication interventions. - On December 10thand 11th, IMPACT technically and financially supported the DPLMT to identify and raise awareness to drug shops in Sambava (for details see IR3.1.6.SA2). 175 radio advertisements and 56 TV ads (scrolling text) from December 2nd to 8th were aired in four districts of the SAVA region to invite them to the information sessions on legal and regulatory framework held by DPLMT. - In collaboration with the Gender, Equity, and Social Inclusion team, IMPACT participated in the celebration of the 16 days of activism lead by the Ministry of Population. IMPACT’s contributions to this event included:  Broadcast of 1,800,000 SMS in collaboration with Foundation Axian in the 10 USAID-supported regions on December 9th to target women and men over 15 years old who use the Telma network. The message was “Dare to denounce! You have the right to be taken care of and to receive appropriate care and health commodities in case of violence.” The message was validated by the Ministry of Population.  Publication of an article in the Midi Madagascar newspaper on December 19th on equity of access to medicines for women through an interview with Dr. Hortense RANDRIANAIVO, who holds several positions such as the President of the Pharmacists' Association of Madagascar and is a TMA Champion from the private sector.  Publication on Facebook of the above article published in the Midi Madagascar’s newspaper.  Awarding prizes for those who participated in the quiz during the event organized by the Ministry of Population the November 25th at Parvis Analakely , such as t-shirts, hats, and hand washing devices funded by IMPACT.

IR5.1.3 : Conduct communication campaigns for promoting health products of the three prioritized health areas (Malaria, FP and MNCH) through radio, TV spots, job aids, and digital communication (including social media) incorporating gender messaging to promote and use health commodities for population and providers

IR5.1.3.SA1 Conduct communication activities (broadcast radio and TV spots, produce printed media, organize events, etc.) to different target populations (general population and health service providers, including CHVs) to promote the use of health products for the three prioritized health areas (Malaria, FP, and MNCH), in collaboration with DPS, NMCP, and DSFa

Radio Spots Broadcasted To increase demand of Sur'Eau Pilina and promote its use to ensure access to safe drinking water during the rainy season, 1,180 radio spots were broadcasted in 39 districts out of 60 through the 10-USAID supported regions from December 09th to 20th, 2020.

Table 36: Radio Spots Broadcasted Number of Number of Number of spots aired Communicati Dates Region Districts Radio from the radio Districts on Campaign Covered Stations station in the region Mahajanga I, Mahajanga II, and Boeny 3 3 72 Marovoay Toamasina I, Toamasina II Vatomandry, Brickaville, Atsinanana 7 6 216 Marolambo, Tanambao, Manampotsy, and Mahanoro Maroantsetra, Vavantenina, Analanjirofo 4 4 144 Fenerive Est, and Mananara Nord

Manakara,Vohipeno, Vatovavy 5 3 108 Ifanadiana, Ikongo, and Fitovinany December Mananjary Sur’Eau Pilina 09 to 20, Radio Spots Morondava, Mahabo, and 2020 Menabe 3 2 72 Miandrivazo Melaky 1 1 36 Morafenobe Atsimo Toliara I, Toliara II, and 3 3 108 Andrefana Ampanihy Antsiranana I, Antsiranana II Diana 5 5 180 Ambilobe, Nosy Be, and Ambanja Antalaha, Vohémar, Andapa, SAVA 4 5 180 and Sambava Antsohihy, Befandriana Nord, Sofia 4 2 72 Bealalana, and Analalava Total 39 34 1,188

SMS Broadcasted IMPACT continued to send targeted SMS to providers such as PA, PARC, and CHVs to inform them about: - Environmental mitigation management: especially the stock management of spoiled and expired medicines. - The availability of products. CHVs were also reminded to encourage their communities to adopt good behaviors on how to use products.

Table 37 : Summary of SMS sent during Quarter 1 – Targeting Providers

HEALTH MESSAGES ENGLISH TARGET NETWORK NUMBER PERIOD AREA TRANSLATION OF PEOPLE Quarter 1 REACHED ORANGE Salama, Atokano (through the toerana ny fanafody Hi all, set apart all PARC + system simba sy lany daty spoiled and expired PA + ‘INTERNAL EMMP ary atero eny medicines. Take CHV+ 5,507 02/11/2020 PLATFORM’ amin’ny them to the health PHA-G- which can send tobimpahasalamana. center. Thank you! Dis SMS to target Mankasitraka! people)

HEALTH MESSAGES ENGLISH TARGET NETWORK NUMBER PERIOD AREA TRANSLATION OF PEOPLE Quarter 1 REACHED Ampatsiahivo ny ORANGE Remind the father raimpianakaviana ny (INTERNAL to the normal dose fatra fanome ny ACT PLATFORM) of ACT and he also ary taperina has to respect the 3 hatramin’ny farany MALARIA days, which is the CHV 4,903 27/11/2020 ny fanafody nomena optimal duration of mandritra ny telo the treatment. No andro. Malagasy tsy Malagasy will die of ho fatin’ny malaria! tazomoka ! Hi all, inform the ORANGE benefit for using (INTERNAL Salama e, Ampitao umbilic ointment to PLATFORM) amin’ny mpisafo all pregnant women kibo eny amin’ny at the antenatal CSB ny tombony consultation (ANC) MNCH amin’ny fampiasana CHV 08/12/2020 at the health center. 4,914 Arofoitra amidy eny One tube of amintsika AC. Tube Arofoitra is enough iray monja hoan’ny for one newborn zaza menavava iray. umbilicus treatment. Salama e, 100% ny ORANGE tombony azo Hi all, be aware that (INTERNAL amin’ny fivarotana selling Sûr’Eau pilina PLATFORM) Sûr’Eau pilina. helps you to earn MNCH CHV 5,008 15/12/2020 Vonjivonjeo malaky 100% of profit. Go eny amin’ny PA fa to the PA! First izay tonga aloha come first served! mahazo aloha.

IMPACT and ACCESS held a coordination meeting on December 9th to implement communication activities in order to increase demand for Arofoitra: - IMPACT will provide a ready-made TV spot which will be broadcasted by ACCESS. - ACCESS will print posters and job aids on Arofoitra using existing documents from IMPACT where Misoprosol was added. - A communication plan was also developed which is co-branded by USAID, ACCESS, and PSI.

IR5.1.3.SA2 Increase demand creation of health products by using mobile sound systems organized and conducted by the IMPACT communication team

To strengthen radio spots broadcasted for Sur’Eau Pilina, IMPACT held social mobilization events at the community level. The communication team carried out 63 animations with 19,375 people reached in 12 districts in seven USAID-supported regions (Diana, Boeny, Analanjirofo, Atsimo Andrefana, Vatovavy Fitovinany, SAVA, Menabe). Sales of Sur’Eau Pilina by CHVs demonstrated the uptake of the product. CHX, Sur’Eau 150 ml (which substituted Sur’Eau Pilina during the stock out), and Protector Plus condoms were also promoted during the same social mobilization events.

IR5.1.4 : Provide technical and financial support to the Ministry of Youth and Sport (MYS) to develop and implement Youth SBC activities In collaboration with the Ministry of Youth and Sport and Blue Ventures, IMPACT provided the logistics and human resources support for the Youth leaders training session which will be held in Quarter 2.

III.6. Cross-Cutting Activities Cross-cutting activities focus on five aspects: Monitoring, Evaluation, Research, Learning, and Gender/Social Inclusion.

III.6.1. Gender and Social Inclusion All activities planned for the first quarter have been achieved.

GESI 1: Continue support for IMPACT TMA approach and GESI integration through relevant technical working groups and platforms Organized Collaborative Opportunities with GESI Partners and Strengthened Capacities

On December 11, 2020, IMPACT organized a meeting with GESI partners Conseil National des Femmes de Madagascar (CNFM) and Entreprendre au Féminin Océan Indien (EFOI). These meetings provide collaborative opportunities for GESI partners and IMPACT staff to come together to discuss and support IMPACT’s goals and TMA approach. Nine representatives (all women) from the GESI partners will engage in the two TMA subcommittees (Text and Regulation; PPN and PDPN) and two related TWGs (Communication and Demand Creation; Malaria alongside Roll Back Malaria).

In addition, EFOI attended IMPACT’s Malaria Market Assessment dissemination event, and CNFM participated in the Ministry of Population’s gender TWG. IMPACT will continue to engage with its GESI partners and meet monthly to support efforts to incorporate a gender lens across all health sector activities. Sessions include orientations and collaborative opportunities with the different elements of IMPACT’s work such as A2F and communications, space to share achievements integrating GESI in their respective spheres of influence, and strategies to support IMPACT goal’s through sub-committee and TWG involvement.

GESI 2: Build capacity of IMPACT staff and partners to better understand and deliver gender-responsive programs and services

Table 38: Contributed to IMPACT Partner Capacity Enhancements Session Content Participants Form Period GESI capacity - Potential of health 27 (10F, 7M) regional In-person training led by December 9- building for product distribution bank staff in Sava1 A2F team using 13, 2020 commercial sector and supply markets presentations including partners - Inclusive approach GESI-integrated materials for clientele - Loans for women entrepreneurs Ongoing support to - Equality and equity SPDs and Superviseur Physical gathering led by November social marketing - Discrimination and Régional de SPDs and SRDs (formerly 2020 distribution team stigmatization Distribution (SRDs) trained with integrated on integrated GESI - Women’s economic training PAs and GESI concepts) in their component empowerment PARCs intervention sites

1 Bank staff training counted under IR3.1.5 above.

Table 39: Strengthened IMPACT Staff Capacity in GESI-related Themes Session Content Participants Form Period GESI refresher - Gender equity and 59 malaria Online course November 2020 course equality department staff (videos and - Social inclusion Direction PALU knowledge checks) - Gender-based (DPAL) violence - GESI integration in programs Pause and Reflect - Analysis of Malaria 10 (6F, 4M) from In-person session December 16, 2020 session Market Assessment IR2, IR4, regions facilitated by GESI survey and ITNs (Regional Director, Advisor Regional Coordinator), KM, M&E, malaria (Chief of Malaria Department), distribution, A2F, and capacity building teams

Illustrative lessons from the pause and reflect session include: - While LLIN mass distribution in the country reaches groups of varying characteristics (i.e. women, men, different wealth quintiles, etc.), the private sector market distributes the lowest number of nets, despite having the lowest per unit cost. - The general population does not purchase LLINs at the pharmacy despite being the best priced overall. - Persons in the middle socio-economic brackets face the highest purchase prices. (Reasons will be explored at a continuation pause and reflect session in February 2021). - Mass distribution strategies should consider a TMA approach to target beneficiaries according to wealth quintiles and the timing of mass distribution should align with the durability of LLINs2. - Routine distribution should be done after mass distribution. - Recommendations within the Malaria Market Assessment report must be more actionable.

GESI 3: Champion inclusive messaging in communication, learning, and investigation materials Developed and Disseminated TMA Factsheet

IMPACT developed the fact sheet Using the Total Market Approach to Ensure Equity of Access to Health Products in Madagascar, which outlines the total market approach, how a TMA can be used to improve access to health commodities, how integrating GESI lenses may impact health programs and activities, and strategies for integrating GESI into a TMA. Fifty copies of the factsheet were distributed during the Malaria Market Assessment dissemination event held on November 24, 2020 to all sectors (public, private, social marketing) and partners.

2 ITNs last 12 months, while mass distribution campaigns are only every 3 years.

Produced and Published Private Sector-related Newspaper Article and Circulated Messaging for 16 Days of Activism Against Gender-based Violence The global advocacy campaign “16 Days of Activism Against Gender-based Violence (GBV)” runs annually from November 25th (International Day for the Elimination of Violence Against Women) to December 10th (Human Rights Day). During this time, IMPACT developed an article highlighting a female pharmacy owner who is also a doctor, entrepreneur, and one of the TMA champions. The article was featured in Midi Madagascar newspaper. IMPACT also developed and aired GBV prevention and response SMS messaging which were broadcasted through mobile phones, and IMPACT’s Facebook and YouTube accounts. (For additional details refer to IR5.)

Integrated GESI Lens into MNCH Market Assessment Framework IMPACT integrated a GESI lens in reviewing the study protocol and framework of the MNCH market assessment including relevant questions and suggested approaches to MNCH topics as relevant. The research integration opportunity is in line with including GESI considerations from design phase. Going forward, tools such as questionnaires and survey instruments will be reviewed as necessary to ensure GESI considerations are captured in assessment implementation.

III.6.2. Monitoring, Evaluation, Research, Learning

6.1.1. Monitoring and Evaluation CC 1: Strengthen LMIS with the use of DHIS2 as data analysis and dissemination tool for the three sectors: public, social marketing, and commercial (pharmaceutical wholesalers, pharmacy, and drug shops).

- In Quarter 1, IMPACT provided technical assistance to the DPLMT and DEPSI to develop the ToR and participated in the three-day LMIS assessment report workshop held from December 2nd to 4th , 2020 at the Motel Anosy in Antananarivo where representatives from the MoPH at the central level, DRSP, SDSP, and USAID implementing partners (Mahefa Miaraka, ACCESS, Measure Evaluation, Shops Plus), WHO, UNICEF, SALAMA, UCP (MoPH Program Coordination Unit), the Association of Drug Shops, the National Order of Pharmacists, and pharmaceutical wholesalers attended. Two keys outcomes were obtained from the workshop : the LMIS minimum requirements according to country LMIS needs and the draft of the LMIS roadmap for the three sectors (public, private for non-profit, and commercial health commodities enterprises). - The helpdesk continued to support the DPLMT to analyze issues identified at the Pha-G-Dis level, provide solutions and help for submitting high reporting rates to DPLMT. The main issues during Quarter 1 are presented in the table 40:

Table 40: Main issues and recommendations/solutions from Pha-G-Dis during Quarter 1 Main issues Recommendations/Solutions Vohémar: The desktop computer was - IMPACT provides a desktop to the Pha-G-Dis provider to ensure stock damaged and unusable and no management and monthly data reporting. This desktop will arrive in Channel report since October 2020 Vohémar at the beginning of January 2021. Antsalova, and Befandriana Nord: - Antsalova and Befandriana Nord: The FANOME Manager at the SDSP There are no providers at the Pha-G- has ensured data entry by using CHANNEL. The recruitment process for Dis to ensure the data processing in the two Pha-G-Dis providers is ongoing and led by DPLMT to be Channel since 2017 in Antsalova and in completed by the end of January 2021. July 2020 in Befandriana Nord, - Besalampy: The Medical Doctor Inspector (MDI) was trained on CHANNEL to complete the data entry for the monthly reporting, but this activity depends on his availability.

Ambositra and Mananara Nord: The - Identify new Pha-G-Dis providers by the end of January 2021 as agreed providers have resigned with DPLMT. - The EMAD will ensure the data entry of the Pha-G-Dis monthly report into CHANNEL.

Graph 5: Reporting and completeness rate to Channel vs DHIS2 in Quarter 1 (CHANNEL=78; DHIS2=1,790)

100% 97% 93% 93% 80% 86%

60%

40%

20%

CHANNEL DHIS2

The reporting rate for both Pha-G-Dis and Pha-Ge-Com is stable at high rates of more than 86%. The CHANNEL reporting rate is lower in November linked to promptness issues, which is the main objective of the Year 3. IMPACT will maintain the high reporting rates for the next quarters.

CC1.SA2 : Financially support the Internet connection for Atsimo Andrefana, Boeny, and Melaky regions and their 20 SDSPs in order to improve data collection and reporting

The provision of internet connection for the three DRSPs and 20 SDSPs has been revised according to the IMPACT Year 3 budget approved by USAID. Some technical specifications were reviewed and the procurement process will be relaunched. The table 41 provides the contract status for SDSP and DRSP.

Table 41: Contract status of the Internet connection per SDSP/DRSP

REGION (n=3) District (n=20) Mobile company Status of contract

Benenitra, Beroroha, Morombe, Ongoing, to be completed by ATSIMO Toliara II, Betioky Atsimo, Ampanihy TELMA Box 9 the end of January 2021. As a ANDREFANA Ouest, Sakaraha, Toliara I precaution, while waiting for Ankazoabo Atsimo AIRTEL Box the approval of the workplan Mahajanga I et Mahajanga II TELMA Fiber optic and budget for Year 3, BOENY 6 Marovoay, Soalala TELMA Box IMPACT suspended the Ambatoboeny, Mitsinjo ORANGE procurement process that Besalampy AIRTEL Box started in Year 2. The procurement resumed from MELAKY 5 Ambatomainty, Antsalova, ORANGE December 2020. Maintirano, Morafenobe

CC 2 SA2: Support technically and financially the DEPSI and DPLMT to ensure that routine data quality assessment (RDQA) is conducted every Quarter at all levels for the three sectors and the data validation process is set up

RDQA exercises were conducted in November and December 2020 in seven districts: Ambatolampy, Antanifotsy, , Antsirabe II, Mahanoro , Toamasina II , Analalava, and Befandriana Nord. The RDQA team was composed of IMPACT, DPLMT, DSFa, and the EMAR and EMAD staff of the respective districts.

Table 42: Summary of the entities visited for the RDQA exercise REGION DISTRICT Pha-G-Dis Pha-Ge-Com PARC PA VAKINANKARATRA Ambatolampy 1 2 1 1 VAKINANKARATRA Antanifotsy 0 2 1 2 VAKINANKARATRA Antsirabe II 1 2 1 2 ATSINANANA Mahanoro 1 2 1 2 ATSINANANA Toamasina II 1 2 1 2 SOFIA Analalava 1 2 0 1 SOFIA Befandriana N 1 2 1 2 TOTAL 6 14 6 12

Graph 6: Summary of the results of RDQA

100% 92% 92% 92% Data Quality Parameter

80% Availability 88% Accuracy Completeness 60% 68% 90%

40% Precision 99% 100% Timeliness 20% Pha-G-Dis (=6) Pha-G-Dis Overall Data System Overall Data 100% 100% Verification ScoreAssessment Score Quality Score 3 Confidentiality Integrity 1 2

100% Data Quality Parameter 85% 81% 83% 80% Availability 78% 60% Accuracy 79% 80% Completeness

40% Precision 82% 100% Timeliness 20% Overall Data System Overall Data 86% 89% Pha-Ge-Com (n=14) Pha-Ge-Com Verification Score Assessment Quality Score 3 Confidentiality Integrity 1 Score 2

100% 93% 97% 95% Data Quality Parameter 80% Availability 60% 100%

Accuracy86% 83% Completeness 40%

20% Precision 91% 100%Timeliness

PARC (n=06) PARC 0% Overall Data System Overall Data 92% 100% Verification Score Assessment Quality Score 3 Confidentiality Integrity 1 Score 2

94% 93% 94% 100% Data Quality Parameter

80% Availability 98% 60%

Accuracy88% 95%Completeness 40%

20% Precision 94% 100% Timeliness PA (n=12) PA 0% Overall Data System Overall Data 94% 96% Verification Assessment Quality Score 3 Confidentiality Integrity Score 1 Score 2

Score 1: Average on overall data verification score for the seven quality dimensions Legend (Average (availability, completeness, timeliness, integrity, confidentiality, precision, accuracy) score) Score 2: Qualitative system assessment of the strengths and weaknesses of the data 90% and above management and reporting system functional areas. A series of questions are used to 80% - 89% state the average score based on the responses. Below 80% Score 3: Average score on data quality: “Overall Data Verification Score” + “System Assessment Score.”

 The overall data quality score is ranging from 83% among Pha-Ge-Com to 92% among Pha-G-Dis, 94% among PA, and 95% among PARC.

Table 43: The main issues affecting data quality at the Pha-G-Dis, Pha-Ge-Com, and PA level (At the PARC level, no serious issues to be reported) Responsible for Entity Main issues Recommendations monitoring Pha-G- Accuracy (Ambatolampy, Antsirabe II, - Each program manager should validate Medical doctors Dis Toamasina II, Analalava, Befandriana data before finalizing the report to be /EMAD/Pha-G-Dis Nord): data entry issues in CHANNEL vs submitted to DPLMT. responsible stock monitoring sheets Pha-Ge-  Availability (Behenjy in SDSP of - Train CSB staff in the use of health Medical doctors Com Ambatolampy; Ampitatafika in SDSP commodities management tools (stock /EMAD/ACCESS/ of Antanifotsy; Mahanoro and monitoring sheets). The training will be IMPACT Betsizaraina in SDSP of Mahanoro; discussed and planned in collaboration Analalava and Befotaka in SDSP of with ACCESS in Quarter 2. Analalava) - Support the SDSPs to distribute the stock - Stock monitoring sheets were monitoring sheets and other available but not correctly filled by the management tools to the CSBs. CSB, - The Medical Inspector is encouraged to To be discussed - No stock monitoring sheets available check the data entered in DHIS2 using a with ACCESS which led to the use of another tool sample of RMA. like a notebook.  Accuracy (Behenjy in SDSP of Ambatolampy; Mahanoro an SDSP of Mahanoro; Analalava and Befotaka in SDSP of Analalava): Entry issues RMA versus DHIS2.: there were wrong entries of RMA data into DHIS2 PA Accuracy During their supervisions from Quarter 2: SRD/SPD - Stock monitoring sheet versus DHIS2 - SRD should be involved in the validation (Mahanoro, Fanandrana). process of the data entered in DHIS2. - New PA not yet trained on - Train the new PA on commodities commodities management (Behenjy). management.

6.1.2. Research CC3. Implementing studies to feed the design of the FP and MNCH market assessment

The main research activities were focused on the design of the FP and MNCH market assessment data collection tools:

- Outlet Survey and Household Survey: The study protocols and the questionnaires were developed based on the updated version of the market assessment framework. The sample size is to select 47 sample sub- districts or communes (31 rural and 16 urban) to be selected through Probability Proportional to Population Size (PPS) and visited. - Household Survey: The study protocols and the questionnaires were developed based on the updated version of the market assessment framework. The sample size is about 4,080 household (2,140 rural and 1,940 urban). - FP key informant interviews: IMPACT started technical preparation (qualitative approach) including translation of the questionnaire from English into French/Malagasy, and training materials (monitoring sheets of the interview, interview techniques, ethics, etc.). - Preparation of all procurement (car rental, recruitment, venue for the training, equipment for interviewers: protective mask, hydroalcoholic gel, etc.) related to the three studies (outlet survey, household survey, and key informant interview) were initiated.

Trainings and data collection will be implemented in Quarter 2 for the three components.

CC5. Implementing other study to inform program intervention CC5.SA.1 Conduct a study to understand the barriers and motivations for antenatal visits and IPTs use among pregnant women

During Quarter 1, the activity related to this study was mainly focused on the recruitment of interviewers and the administrative/procurement process. Trainings for supervisors and interviewers and data collection are planned in Quarter 2.

6.1.3. Knowledge Management CC 6: Support the IMPACT project team in developing and collecting success stories and documenting IMPACT's innovations in the field

CC 6. SA1: Assist technically the IMPACT field teams (RLA, SRD, SPD, Axian Foundation Representative, PSI Regional Coordinators, etc.) to collect success stories and project's innovations based on provided template

In Quarter 1, IMPACT: - Developed a success story and photography guide to orient IMPACT staff in capturing the project’s success in the field. - Updated and simplified the success story template used during Year 2 so that it will be an easy tool for all staff to document project results and highlight progress against indicators including quotes from project beneficiaries. This tool with the guide were shared with all IMPACT staff.

Five success stories were collected in Quarter 1 using the revised template: - Pha-G-Dis of Antalaha: Increase of LMIS data completeness rate which is the result of laptop donation from IMPACT and continuous supportive supervision. - Manakara district: Using an efficient system to ensure on time delivery of LLINs face to insecurity in rural communes. - Mahanoro: Pha-Ge-Com comply with storage standards and procedures which is the result of supportive supervision. - GESI partners help bring women’s voices to the table, advocating for empowerment and equal access to health commodities. Details are presented in Annex D.

CC 6. SA2: Post success stories through IMPACT’s online platforms and USAID Madagascar (Website and social media) and other platforms

In Quarter 1, IMPACT success stories were published on the following platforms:

- USAID Facebook page on October 5th: The story of a CHV in the rural village of Ambodivonta Fokontany in Vatomandry district. The success story documented how she helps her community to prevent diarrhea by using Sur’Eau Pilina to purify water. - DEPSI LMIS semester newsletter in December 2020: How to use Helpdesk to improve data reporting rates from districts to the DPLMT.

IV- KEY CHALLENGES AND SOLUTIONS

Table 44 : Key challenges and solutions encountered in Quarter 1 Key Challenges Solutions IR2 Stock levels of malaria commodities at the central level  Weekly monitoring of orders in pipeline to detect any delays warehouse/SALAMA are under the minimum in the procurement process. requirement. This situation was due to delays of  Share weekly stock status with RBM stakeholders to keep shipments from vendors. members updated on malaria commodity situation at central level.  Emergency transportation of malaria commodities to address the critical situations of stock at district level. Risk of expiration of Oxytocin overstocked at SALAMA  Organized a transfer of 260,000 ampoules to Malawi. with an expiration date of June 2021.  Distributed needed quantities to the private sector (FBO organizations and private facilities).  Continue to explore opportunities to distribute the product before June 2021. TCA data collection took longer than planned at  Provided better explanation about the TCA questionnaire to SALAMA. Data collection will now be completed in SALAMA to get accurate data. January 2021, which delayed the analysis and report writing. Huge gap of funding to procure FP/RH commodities as  Support DSFa to organize call-to-action meetings under the per the supply plan developed to cover the needs of the leadership of the Secretary General to mobilize necessary public sector. funding to secure FP/RH commodities.  Monitor the consumption of overstocked FP commodities (combined oral contraceptives, progestatin-only contraceptive) in the public sector and organize redeployment to other sectors to avoid risk of expiration and to overcome stock out. cCD and Mass Campaign Distribution data reporting in national DHIS2 based at Development of a recovery plan by the IMPACT team with district DEPSI was delayed from October to November 2020 responsible to avoid delays in distribution and speed-up reporting due to the absence of TAs with contract suspended in in the DHIS2 system. October. These TAs ensure the entry of validated data in DHIS2.

Gap in the required funding for preparatory activities The identified funding gap for the preparatory activities was for the 2021 LLIN mass campaign submitted in the realignment of the NMF2 budget by the Prime Recipients (UCP and PSI) and these activities will be prioritized before June 2021 in the NMF2 grant. A2F (A2F) Virtual training may be less effective than in- Analysis of efficiency and effectiveness of virtual vs. in-person person training training to be conducted for confirmation (A2F) Absence of drug shop contact details in the Keep the database updated through multiple information sources: DPLMT database IMPACT regional team, MOPH regional representatives (A2F) High turn-over rate of the partner bank staff Identify and train contact persons among the senior staff, who are requires frequent re-training for new contact person. more stable.

(A2F) Difficult to provide a very brief but comprehensive Internal discussion to shorten the content. training including different topics (GESI, medical sector approach, financial) for partner bank staff. (A2F) Incomplete data from drug shops surveys for the Additional research through one-on-one approach to complete the identification of their financial needs information. GESI

Key Challenges Solutions (GESI) Three Pause and Reflect sessions were planned (GESI) Plan for the three sessions included in the Year 3 and for Year 3 with IMPACT staff. The first session held in leverage additional opportunities where relevant to incorporate Quarter 1 revealed more interest than anticipated by more learning. participants. Data quality assurance is a challenge with in-person Calling during remote supervision and data control during in-field supervisions only occurring every two months and supervision. remote supervision of PA and PARC.

V- MAJOR ACTIVITIES PLANNED FOR NEXT Quarter (YEAR 3, JANUARY – MARCH 2021)

IR 1: Enhanced coordination among the public, nonprofit, and commercial sectors for reliable supply and distribution of quality health products

- Signature of the TMA roadmap by the General Secretary of MOPH and dissemination to all TWG members. - Approval of the update of the PPN PDPN documents by the decision makers of the MOPH (beyond the DPLMT directorates). - Dissemination of selected texts and regulations related to the pharmaceutical sector and health commodities that do not need to be amended; and selection of texts and regulations that need amendments by the texts and regulations subcommittee. - Finalization of the LMIS roadmap by the LMIS subcommittee. - Conduct the FP and MNCH market assessments. - Advocacy training and virtual tour of the TMA activities in Vietnam for the TMA Champions.

IR 2: Strengthened capacity of the GOM to sustainably provide quality health products to the Malagasy people

- Organize the CGL meetings to validate quantification plans for malaria and MNCH commodities. - In collaboration with UNFPA, UNICEF, and USAID, support DSFa to mobilize resources to procure FP/RH commodities. - Organize a meeting with SALAMA to ensure full integration of MNCH commodities through its procurement process. - Conduct formative supervisions of 60 Pha-G-Dis using the SPARS methodology and score performance. - Finalize the TCA. - Organize a supply plan review for supply plans of malaria commodities. - Introduce NSCA to partners and plan for its implementation.

Community-based Continuous Distribution (cCD) of LLIN in 12 districts - Technically and financially support the CSB chiefs in the organization of a quarterly review of Kom'Lay members to monitor activities. - Continue orientations with the School Health Division on the malaria prevention activities and the cCD for school actors in the districts of group 2. - Close collaboration with the NMCP and the SDSPs (districts) for cCD activities in the 12 targeted districts and prepare the transition to the 2021 LLIN mass campaign.

2021 LLINs mass campaign - Proceed with the duplication of management tools, reporting tools, and SBCC support for the 2021 LLIN mass campaign.

- Finalize the 2021 LLIN mass campaign strategic documents (mass campaign action plan, communication plan, and logistics action plan). - In collaboration with the NMCP, recruit support staff for IMPACT and NMCP. - Support the NMCP in the revision of training documents for implementers of the 2021 LLIN mass campaign. - Support the NMCP in setting up the reporting system in DHIS2 and the real-time reporting system for 2021 LLIN mass campaign activities.

IR 3: Expanded engagement of the commercial health sector to serve new health product markets according to health needs and consumer demand

Partnership with private sector In terms of partnerships, IMPACT will continue to: - Ensure the continuity for the implementation of MOUs for the transportation of health commodities with Aqualma, Blue Ventures, SOMAPHAR, EDM, and NGO Vanille Durable, in coordination with the MOPH. - Identify new partnerships (companies, associations, etc.) to support the MOPH in the transportation of health commodities, supply, etc. - Train drugshops in Atsinanana Region on the tools developed (tablets) for LMIS data submission. - IMPACT will maintain coordination with the MOPH/DPLMT for the LMIS data submission from private outlets and the results from the identification of outlets completed in Atsimo Andrefana will be shared with the MOPH. For Quarter 2, the identification of outlets in the Vatovavy Fitovinany region is planned with MOPH and IMPACT local representatives.

A2F and business strengthening capacity building - The duration and methodology for the drug shop training on the updated version of the LMIS data collection tool will be tested by a sample of drug shops. After the test and the approval from USAID related to equipment donations, a training will be conducted for the Atsinanana region. - Formalize new drug shop association in the region of Atsimo Andrefana. - Increase utilization of financial products and tools developed with partner banks (e.g., pharma loans, motorbike loans, etc.). - Provide initial business-strengthening training to drug shops in the regions of Atsimo Andrefana and Diana (refresher session). - Provide one-to-one business coaching to enterprises/individuals and continue to identify potential peer trainers with the support of the formalized regional associations. The coaching session will immediately follow the initial business while in the regions. - Continue to negotiate partnership(s) with training providers to integrate IMPACT training content into existing curricula for pharmacies and drug shops.

IR3.2 - Support DAMM to develop an advocacy document to raise funding for its restructuring to improve the GBT scores. The document will be sent to key donors: WHO, USAID, European Union, UCP, Agence Française de development, UNFPA, UNICEF, and others. - Review and finalize the registration manual. - Organize the first meeting with the formal ADDO steering committee to prepare the pilot phase.

IR 4: Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy people

- Proceed with the preparation for the transfer of PA and PARC to Pha-Ge-Com and Pha-G-Dis. In Quarter 2, IMPACT will organize the establishment of the committee involved in the transfer and validation of criteria for the transfer and selection of the districts where the transfer will occur. - Initiate price increase of some FP products (Oral Contraceptive, Injectable, Condoms) to improve sustainability and cost recovery. - Dialogue with the private sector to entice commitment of the private sector to supply and introduce social marketing products in the private sector. - Delivery by drone in Mananara Nord at a distance between 50 and 100 km.

IR 5: Increased demand for and use of health products among the Malagasy people

- The TMA TWG demand creation subcommittee led by the MOPH (DPS) will finalize the communication plan for the safe and rational use of health commodities and will integrate the activities to be held in order to respond to the four specific objectives: 1) The purchase of health commodities at accredited establishments, 2) the use of drugs wisely and rationally, 3) the rational prescription of medicines for health care providers and 4) the management of spoiled, expired, and unused drugs. - To continue to maintain the interest of the members, and to strengthen their capacity in the implementation of the communication plan on the safe and rational use of health commodities, training sessions on communication strategies will also be organized for the members of TMA TWG demand creation subcommittee. - Technically and financially support the NMCP to begin implementing the communication activities for the 2021 LLIN mass distribution campaign. Activities will include the production of the communication tools (posters, banners, etc.) and advocacy efforts to engage the GOM and have their support on the mass distribution campaign. Examples of support from the GOM include the Ministry of Communication could facilitate the broadcast of radio spots and radio programs and the Ministry of Interior will be involved through the collaboration with the “Chef Fokontany.” IMPACT will also organize the official handover of LLIN offered by the US Government to the MOPH. - Broadcast radio and TV spots to support the new price for Protector Plus condoms and will continue to conduct sensitization activities for the cCD. - Organize a workshop from January 25th to 29th to strengthen the communication capacity of the regional communication field teams. Several sessions will be held on topics including photography, the creation of success stories, the administration of survey forms to evaluate the impact of the communication campaigns, etc. - In February 2021, Organize the first training session with the MYS and Blue Ventures for youth leaders in Atsimo Andrefana.

Cross-cutting

GESI In Quarter 2, GESI interventions will include: - Regular meetings with GESI partners and capacity strengthening through coaching, mentoring, and training opportunities. - Second Pause and Reflect session with IMPACT staff (possible theme: malaria case study) to improve learning and enhance adaptive management.

- Collaboration with A2F team to develop training curriculum for bank partner headquarter staff to emphasize reaching new or unserved and marginalized clients, therefore extending health commodities supply and distribution markets (engagement as needed through A2F team). - Development of additional GESI KM resources (possible theme: private sector and GESI). - Opportunity for IMPACT’s M&E team to improve GESI integration in research tools and protocols.

MERL Monitoring and Evaluation - Support the implementation of the LMIS roadmap: finalization of the LMIS roadmap document and budget, selection of the LMIS software, and start the procurement of the LMIS software. - Ensure the effectiveness of the internet connection for the 3 DRSPs and 20 SDSPs. - Improve RDQA tools: collection method, data validation protocols, etc. - Set up the M&E unit and train the actors in the use of the data collection tools for the 2021 LLIN campaign. - Provide technical support for the implementation of the data collection system from pharmacies and pharmaceutical wholesalers.

Research - Finalize the study protocol, questionnaire; recruitment and training of data collectors; and start data collection for following studies:  Outlet Survey (FP and MNCH market assessment),  Household Survey (FP and MNCH market assessment),  Qualitative key informant interviews (FP and MNCH market assessment).  IPTp study on barriers and motivation on SP use.

Knowledge Management - Based on the progress against indicators in Quarter 1, continue to support IMPACT staff in finding topics for success stories and innovations in the field. - Provide stories to the USAID communications team to be published on their online platforms (Facebook page and Website) and to other partner platforms. - Contribute in the documentation on the use of logistics data to inform decision-making.

VII- COVID-19 Activities

IMPACT has a total budget of $1,310,300 for the fight against COVID-19, which includes $610,300 of redirection funding from cancelled and/or postponed activities and $700,000 of supplemental funding. The purpose of the two funding streams is to (i) help the GOM to purchase and transport health and expendable commodities (infection prevention products) from the central level to districts and communes (ii) sensitize Malagasy people in the 13 USAID-supported regions on COVID-19, and (iii) train hygienists and health workers at the regional health facilities on waste management and infection prevention and control (IPC).

Redirection Funding IR2.1.11.1 Transportation of COVID-19 expendable equipment and supplies from PSI central warehouses to districts  USAID/IMPACT supported the transportation of expandable equipment and supplies (hydroalcoholic gels, bleaches, soaps, hand towels, frontal thermometers, household gloves, hand washing devices, etc.) from 3 CCOR/DRSP to their respective districts as follows: Melaky (8 districts), Vakinankaratra (4 districts), and Diana (2 districts). These expandable equipment and supplies were provided by USAID/ IMPACT to the MoPH. Details per region are provided in Annex H/Table 1.  USAID/IMPACT financially supported the cost of car rental and fuel for the transportation of 28 Polymerase Chain Reaction (PCR) and 18 GeneXpert specimens as detailed below: o 28 specimens for PCR from Fianarantsoa to IPM Antananarivo o 15 specimens for GeneXpert from Antsiranana II (10) and Antsiranana I (5) to Antsiranana o 3 specimens for GeneXpert from Manakara (2) and Mananjary (1) to Ifanadiana IR2.1.12 Provide technical and financial support on COVID-19 to the MOPH at central and regional requests.  USAID/IMPACT donated expendable equipment and supplies to: - 12 CCOR/DRSP of Analanjirofo, Atsinanana, Atsimo Andrefana, Menabe, Vatovavy Fito Vinany, Haute Matsiatra, Boeny, Sofia, SAVA, Diana, Vakinakaratra, and Melaky regions. The donation for Amoron’i Mania was completed in September. - 78 Pha-G-Dis in 13 USAID-supported regions. - 21 drug shops in Analanjirofo (3), Boeny (5), Diana (3), and SAVA (10). The 21 drug shops are the remaining that received the expandable equipment and supplies in October. - 15 pharmacies in Diana (6) and SAVA (9). - 20 CSB in Atsinanana (8) and Analanjirofo (12). The 20 CSB identified by the DRSPs and shared with IMPACT that did not yet receive donation in the previous months. Donations included a total of 5,486 bottles of hydroalcoholic gels 500 ml, 1,086 cans of bleach 5L, 1,170 and 335 rolls of trash bags of 30L and 100L respectively, 149 cans of virucide 5L, 3,836 hand towel rolls, 1,260 bottles of hand washing liquid soap, 1,470 bottles of liquid soap 1L, 410 brush brooms, 20 frontal thermometers, 48 sprayers for disinfection, 934 hand washing devices, 7,919 washable protective masks, 1,194 posters, and 3,000 flyers (sensitization on hand washing and the use of masks). Details are presented in Annex H/Table 2.  Disinfection of PSI’s 10 offices, 11 warehouses, and 23 vehicles was conducted four times (once per week) by external providers. Details per region are provided in Annex H/Table 3. IR5.1.2: Provide technical and financial support to contribute to the MOPH activities IMPACT attended four virtual meetings organized by the Commission for Communication on Risk and Community Engagement (CCRCE) led by the Direction de la Promotion de la Santé (DPS) of the MoPH at the central level:

 Three virtual meetings with the mass communication sub-committee where IMPACT as an active member were held to present the findings of the Knowledge, Attitude and Practice (KAP) survey led by the MOPH and conducted by CAPSULE agency to assess the communication activities. Main findings show that: 98% of the respondents knew COVID-19, 79% perceived the risk to be infected by the COVID-19, 83% knew that COVID-19 may kill people, 76% knew that everyone can be infected, and the National radio (73%) and TV (79%) channels were reported as the main source of information on COVID-19. New messages were elaborated based on these KAP survey results.  One virtual meeting with the bloggers, vloggers (bloggers who used video), and influencers on Facebook to discuss new communication strategies (content of messages and channels) adapted for the coming back to a normal routine. The new messages are under finalization within DPS. Details of these virtual meetings are summarized in Annex H/Table 4. IR5.1.3 Conduct communication campaigns against COVID-19 through radio, TV spots, job aids, and digital communication  Conducted 78 community mobilizations on prevention to COVID-19 using mobile sound systems in 8 districts (Vatomandry, Manakara, Manja, Antalaha, Analalava, Antsohihy, Sambava, Toamasina II) on average of nine communes per district. Approximately 23,900 people were sensitized (estimation based on number of people attending the sensitization sessions).

Financial reporting: COVID-19 related Expenditures, October

Total Total spent MCH FP DA- Cumulative Total Comments funding this month Water expenditure Commitment approved (COVID only)

Redirection funding 610,300$ 45,924$ 22,962$ 22,962$ - 330,231$ -

Supplemental Funding IR2.1.10 Procurement of health commodities (infection prevention products) for COVID-19 USAID/IMPACT procured and donated the following supplies (bleaches, trash bags, hand towels, liquid soaps, household gloves, frontal thermometers, hand washing devices, etc.) to 8 hospitals in 5 regions as detailed below:  Haute Matsiatra (CHU Andrainjato, CHRR Tambohobe)  Boeny (CHU Mahavoky, CHU PZGA Androva)  Atsinanana (CHU Morafeno, CHU Analankininina)  Analanjirofo (CHRR Fénerive-est)  Atsimo Andrefana (CHU Mitsinjo Betanimena) Details are presented in Annex H /Table 5. IR2.1.11.1 Transportation of COVID-19 expendable equipment and supplies from PSI central warehouses to districts USAID/IMPACT donated and transported expendable equipment and supplies (garbage bins, soap powder, basins 50l, chamois, hand towels, washable protective masks, etc.):  From Toamasina to 02 hospitals (CHRR Fénerive Est and CHU Analakininina)  From Antananarivo to CCOR/DRSP of Vakinankaratra region in Antsirabe Details are presented in Annex H/Table 6

IR5.1.3 Conduct communication campaigns against COVID-19 through radio, TV spots, job aids, and digital communication  IMPACT continued to broadcast TV and radio spots. The main contents of the messages are (i) strengthening social distancing measures; (ii) indicating preventive measures for vulnerable populations (elderly people, pregnant women, people with chronic disease such as diabetes, high blood pressure, etc.), and (iii) home monitoring of asymptomatic people. 1,223 TV and 3,061 radio spots were aired through 23 TV and 41 radio stations through the 13 USAID-supported regions from October 1st to 15th. Details of the broadcasting are presented in Annex H/Table 7.

Financial reporting: COVID-19 related Expenditures, October

Total Total spent MCH FP DA- Cumulative Total Comments funding this month Water expenditure Commitment approved (COVID only)

Supplemental 700 000$ 273 399$ - - - 700 025$ - funding

VIII- FINANCIAL SUMMARY

Table 45: Financial summary

Estimated Actual Total Estimated Obligated Expenditures remaining Description Expenditures Amount Amount Oct - Dec 2020 Funds as of as of Sep 2020 Dec 2020 Malaria 10,534,986 4,877,456 670,485 4,987,044 MCH 6,695,795 4,615,484 625,771 1,454,540 31,985,102 FP/RH 7,079,520 4,552,331 590,805 1,936,385 COVID-19 700,000 426,626 273,399 (25) TOTAL $ 31,985,102 $ 25,010,301 $ 14,471,897 $ 2,160,460 $ 8,377,944

ANNEXES

ANNEX A - Performance Monitoring Plan (PMP) Note: - PMI Quarterly report is attached in an Excel File sent with this Quarter 1 Year 3 Performance Report - HPN Quarterly report is available on DHIS2 website https://data.mis-psimada.org/

Year 3 USAID IRs and Reporting Measure % of achievement. Indicator Achievement Sub-IRs to of Unit Target Observations/Deviation explanations Quarter 1 Intermediate Outcomes/Outputs Short-term Outcomes SO2 PPR Couple Year Protection (CYP) in USG supported 207,447 742 ,945 28% of the Year 3 target achieved. (IR 2.9) USAID programs IMPACT does not purchase FP products for the public Public sector N/A N/A sector, hence no CYPs to report. Private for nonprofit sector 207,447 646,039 32% of the Year 3 target achieved. Number There is no LMIS data available for commercial sector analysis. The process to obtain LMIS data is ongoing through the TMA TWG LMIS sub-committee led by the Commercial sector 0 96,906 MOPH (DEPSI). IMPACT expects that pharmaceutical wholesalers will start to share LMIS data from the end of Quarter 2. IR1: Enhanced coordination among public, non-profit, and commercial sectors for supply and distribution of health products IR1.1. The total market for health products in Madagascar is understood and documented 25% of the Year 3 target achieved. IMPACT held a TMA GOM-led TMI TWG (Technical Working Group) TWG meeting on November 24th (at least one meeting PMP meets at least four times a year as a forum for IR1.1.9 Number 1 4 per quarter) to present the results of the malaria IMPACT consultations and roundtables between public, non- market assessment and to develop the roadmap profit, and commercial stakeholders accordingly. IR2: Strengthened capacity of the GOM to sustainably provide quality health products to the Malagasy people IR2.1. Health commodities and pharmaceuticals are continuously accessible and available in the public sector IR2.1.1 PMP Average stockout rate at service delivery points (IR2.4.1 USAID (SDP) of tracer essential drugs (MCH, malaria) IR3.1.3) ACT New born 33% 10% Since January 2020, the central level stocks were insufficient to cover the needs of Pha-G-Dis and to ACT Infant 32% 10% upgrade their stock level to the maximum required. The situation is due to the delay of international Public sector PhaGDis Malaria ACT Adolescents Percent 21% 10% delivery to Madagascar. Therefore, the central GAS committee imposed a rationing system and shipped to districts only enough quantities to have a stock level of ACT Adult 28% 10% 3 months maximum. The low stock levels at the district level led to this situation of stock outs. In Year 3

Year 3 USAID IRs and Reporting Measure % of achievement. Indicator Achievement Sub-IRs to of Unit Target Observations/Deviation explanations Quarter 1 Quarter 1, ACTs were delivered to Madagascar and will be shipped in the next quarter to districts to increase stock availability and reduce stock outs. Rapid Diagnostic Madagascar has a sufficient stock at the central level 3% 10% Test (RDT) and shipped enough quantities to districts. Sulfadoxine- Madagascar has a sufficient stock at the central level 6% 10% pyrimethamine (SP) and shipped enough quantities to districts The central stock levels were under the minimum Injectable required, which was not enough to ensure the stock 35% 10% Artesunate availability at SDSP. The Pha-G-Dis had quinine injectable as an alternative solution. Oxytocin (10 IU The availability of some MNCH products remains a 15% 10% Injection) problem due to: Magnesium Sulfate - Logistics problems encountered at all levels of the 65% 10% (500mg Inj) public supply chain during the lockdown period imposed following the COVID-19 pandemic. Gentamicin (20mg 87% 10% - The Oxytocin available at the central level is expiring inj) in June 2021. SMSR (Safe Motherhood Service) reduced quantities to ship to districts to avoid risk of expiration. Also, facilities with cold chain to store the Oxytocin are estimated at only 61%. MCH - Few SDSP sent orders to SMSR in Quarter 1: Magnesium sulfate (16 out of 114), Gentamycin (20mg inj) (15 out of 114). The 99 CSB reported to Gentamicin (80mg 61% 10% order Gentamycin through the FANOME. The inj) MgSO4 is not available at SALAMA.

In Year 3 (From QUARTER 2, so this year 2021), the MNCH commodities will be fully integrated in the FANOME distribution system and will be sold via SALAMA. ACT New born 3.6% 10% Despite challenges encountered with logistics issues Pha-Ge-Com Malaria and low stocks levels at central and district levels, CSB ACT Infant 5.7% 10% stock out rates were under the target. This is due to

Year 3 USAID IRs and Reporting Measure % of achievement. Indicator Achievement Sub-IRs to of Unit Target Observations/Deviation explanations Quarter 1 ACT Adolescents 9.2% 10% RLA efforts to support the District GAS committees to analyze stocks levels within a region and organize ACT Adult 8.9% 10% redeployment between districts and CSB. Rapid Diagnostic 3.8% 10% The stock is sufficient to distribute to all levels. Test (RDT) Sulfadoxine- 8.2% 10% The stock is sufficient to distribute to all levels. pyrimethamine (SP) Data is not available in DHIS2. The use of the new Injectable version of RMA that integrates “Injectable Artesunate” N/A 10% Artesunate will start from February 2021. The LMIS data for the related products will be available from that period. Oxytocin (10 IU The availability of MNCH products remains a problem 41.0% 10% Injection) due to: - Logistics problems encountered at all levels of the Magnesium Sulfate supply chain. 36.0% 10% (500mg Inj) - Only 61% of facilities have equipment to ensure Gentamincin (20mg proper storage conditions of the Oxytocin through a 49.0% 10% cold chain. MCH inj) - Only CSBs SONU is ordering and dispensing Magnesium sulfate, but the calculation is among all CSB as the list of CSB providing SONU is not available Gentamicin (80mg 49.0% 10% in DHIS2. inj) - Stock levels of Gentamycin is better at CSB/ Pha-Ge- Com since they can dispense Gentamycin purchased from FANOME. ORS/Zinc DTK 0% 5% (Community) Sur Eau Pilina (67mg 0% 5% tablet) (Community) Private for nonprofit sector PARC MCH Arofoitra (CHX Percent 1% 5% 7,1%) (Community) Pneumox (amoxycilline) 0% 5% (Community)

Year 3 USAID IRs and Reporting Measure % of achievement. Indicator Achievement Sub-IRs to of Unit Target Observations/Deviation explanations Quarter 1 Pregnancy Test 3.6% 5% (Community) ORS/Zinc DTK 0.4% 5% (Community) Sur Eau Pilina (67mg 0.5% 5% tablet) (Community) Arofoitra (CHX 0.1% 5% PA MCH 7,1%) (Community) Pneumox (amoxycilline) 0.5% 5% (Community) Pregnancy Test 0.6% 5% (Community) Average stockout rate of contraceptive commodities IR2.1.2 PPR at Service Delivery Points by family planning Percent (HL7.1.3) USAID methods Implantable Hormonal 46% 10% Contraceptives Injectable Hormonal 20% 24% Contraceptives (Depo provera) The FP commodities were available at the central Injectable Hormonal 30% 21.5% level/SALAMA throughout the year. However, due to Contraceptives (Sayanna Press) the lockdown imposed for COVID-19, SALAMA PhaGDis encountered logistics issues and could not transport Public sector Percent Intrauterine Devices 31% 19% the commodities on time, which explained the stock Oral Hormonal Contraceptive. out in Quarter 1. 30% 10% Microgynon Oral Hormonal Contraceptive. 18% 19% Microlut Implantable Hormonal PhaGeCom 5.5% 5% Contraceptives

Year 3 USAID IRs and Reporting Measure % of achievement. Indicator Achievement Sub-IRs to of Unit Target Observations/Deviation explanations Quarter 1 Injectable Hormonal 6.7% 5% Contraceptives (Depo provera) Data is not available in DHIS2. The use of the new Injectable Hormonal version of RMA that integrates “Sayanna Press” will N/A 5% Contraceptives (Sayanna Press) start from February 2021. The LMIS data for the related products will be available from that period. Intrauterine Devices 0.6% 5% Oral Hormonal Contraceptive. 7.8% 5% Microgynon Oral Hormonal Contraceptive. 2.6% 5% Microlut Oral Contraceptive 0% 5% (Community) Injectable (Community) 0% 5% PARC FP Condom Protector Plus 0,7% 5% (Community) Sayana Press 0,7% 5% Private for nonprofit sector Percent Oral Contraceptive 0,4% 5% (Community)

Injectable (Community) 0,5% 5% PA FP Condom Protector Plus 0,8% 5% (Community) Sayana Press 0,8% 5% Number of facilities where USAID provided support PMP IR2.1.14a for IPC and/or WASH for COVID-19, by type of USAID support (training and commodities) Number Receiving 117% of the target achieved. One hospital added in Supplemental health Hospital 7 6 Boeny (Manarapenitra hospital) due to the increase of funding commodities COVID-19 cases identified.

Year 3 USAID IRs and Reporting Measure % of achievement. Indicator Achievement Sub-IRs to of Unit Target Observations/Deviation explanations Quarter 1 104% of the target achieved. Following a resurgence of Vehicle COVID-19 73 70 cases in the 3 regions, 3 vehicles (ambulances) were added: 2 in Haute Matsiatra and 1 in Atsinanana. DRS\CCOR offices 13 13 100% of achievement DRS\CCOR vehicles 26 26 100% of achievement IMPACT Regional Offices and Warehouses 22 22 100% of achievement IMPACT Regional vehicles 23 23 100% of achievement Redirection 122% of the target achieved. Following the initiative of funding the distribution department, the PAs and PARCs in the PA and PARC 1,167 960 3 cCD districts (Farafangana, Vangaindrano, and Bekily) outside the IMPACT regions have been equipped. 207 in addition to the 970 in the 13 regions. Drug shops 143 143 100% of achievement CSB Number 354 340 104% of achievement 248% of the target achieved. Due to the resurgence of Training on Supplemental COVID-19 cases, the DRSP requested support for the waste training of CHRD staff (extension to the district level, funding Public hospital Number 119 48 management instead of the regional headquarters level only). This second training explained the significant increase of number of people trained. Number of health workers and PMP Supplemental hygienists who received COVID- IR2.1.14b Number 823 846 97% of achievement. USAID funding 19 training on waste management PMP Number/Percentage of required supply plans 17% of the Year 3 target achieved because the MCH IR2.1.16 2 12 IMPACT submitted to GHSC-PSM during the quarter. supply plan was not yet submitted to GHSC-PSM. 25% of the Year 3 target achieved. The supply plan and Malaria 1 4 Number PPMRM have been submitted. 25% of the Year 3 target achieved. The supply plan was FP/RH 1 4 submitted by DSFa to GHSC-PSM for FP commodities of the public sector.

Year 3 USAID IRs and Reporting Measure % of achievement. Indicator Achievement Sub-IRs to of Unit Target Observations/Deviation explanations Quarter 1 0% of the Year 3 target achieved. The supply plan is MCH 0 4 not required the GHSC-PSM. Because from this year IMPACT will not purchase MCH products. IR2.2. The public-sector supply chain achieves financial sustainability PMP Percent of product that is unusable due to expiry or IR2.2.1 Percent IMPACT damage Expiry SALAMA Percent 0% 1% 0% Damaged Expiry 5% The target is reached. There are not many quantities PhaGDis Percent 0.7% Damaged expired at the district level. Expiry The data on the quantities redeployed are often reported and accounted for in the same box as the

expired and damaged quantities in the old CSB RMA. PhaGeCom Percent 6.8% 5% With the implementation of the new RMA in February Damaged 2021, this information will be well matched, and this rate will be corrected. IR3: Expanded engagement of the commercial health sector to serve new health product markets, according to health needs and consumer demand IR3.1. Commercial actors are incentivized to expand into new health product markets 10% of the Year 3 target achieved. Although IMPACT PMP Number of loans (in general) disbursed to businesses support has helped partner banks to continue to lend IR3.1.2 Number 10 100 IMPACT (excluding service providers) to the health sector during the COVID-19 pandemic, the number of loans being disbursed has slowed. PMP Value of loans (in general) disbursed to businesses IR3.1.3 USD 45,563 120,000 38% of the Year 3 target achieved. IMPACT (excluding service providers) PMP Number of people trained in business and financial IR3.1.4 Number 25 20% of the Year 3 target achieved. IMPACT management 125 IR4: Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy people

IR4.1. Socially marketed products are continuously available at convenient and accessible locations

PMP IR4.1.2 Number of socially marketed products distributed IMPACT Number FP OC Community 707,342 1,811,124 39% of the Year 3 target achieved:

Year 3 USAID IRs and Reporting Measure % of achievement. Indicator Achievement Sub-IRs to of Unit Target Observations/Deviation explanations Quarter 1 - Products are continuously available with a 0% stockout rate. - IMPACT provided starter batches (representing 2% of the achievement) to the CHV as a revolving fund. - The target was based on the 2019 regular users, which was increased during Year 2. This resulted in the higher sales in Quarter 1. In Quarter 2, IMPACT will update the PMP based on the Year 2 approved report. 36% of the Year 3 target achieved: - Since Sayanna Press was out of stock until May 2020, the users of Sayanna Press have switched to using Depo-Provera. It is noticed that the Sayana Press regular users represented 25% of the Injectable (Depo-Provera/TRICLOFEM) Community 552,521 1,547,022 injectables regular users. - About 10% continued to use intra-muscular injectable instead of going back to subcutaneous. - In addition, IMPACT allocated starter kits of intra- muscular injectable as revolving fund for CHVs, representing 2.3% of the achievement. 13% of the Year 3 target achieved. - The target includes the community and commercial distribution channels. IMPACT distributed only to the community-based distribution in Quarter 1 FP Condom Protector Plus (Community) 211,104 1,682,808 which explain the low achievement. - The Protector Plus will be redistributed to the commercial channel, when the FP portfolio analysis is approved expected in Quarter 2. 0% of the Year 3 target achieved. There was no product to distribute. When the portfolio analysis is approved by USAID, the procurement of this product will be FP Youth Condom Yes (Commercial) 0 346,000 discussed with the private sector. IMPACT will also initiate the discussion with the private sector to ensure the distribution of Yes condoms for the future.

Year 3 USAID IRs and Reporting Measure % of achievement. Indicator Achievement Sub-IRs to of Unit Target Observations/Deviation explanations Quarter 1 16% of the Year 3 target achieved. The regular users of injectable contraceptives continued to use Triclofem Sayana Press 81,607 498,073 (intramuscular injectable) instead of Sayana Press due to the long period of stock out of Sayana Press. 41% of the Year 3 target achieved: - Including 8.3% of the product allocated as starter kits to 3,950 CHV in the 3 regions of ACCESS ORS/Zinc DTK (Community) 27,774 60,673 (Atsinanana, Atsimo Andrefana, and Vatovavy Fito Vinany). - The achievement without the starter kits is 32.7% in Quarter 1. 120% of the Year 3 target achieved: - The target was previously defined assuming that the product will be transferred to the private sector and only the remaining stock from 2019 was supposed to be distributed. - However, in 2020, it was decided to procure an additional quantity of Sur’Eau 150ml (IMPACT could Sur Eau 150 ml Commercial 322,095 267,500 procure 400,000. So, 132,500 bottles more), which MCH were arrived only in Quarter 1 of Year 3. The quantity to distribute in Year 3 is indeed greater than the defined target. - 10,441 bottles (4% of the target) were distributed to the community channel to avoid stockouts at the CHV level while waiting for the new arrival of Sûr’Eau Pilina. 45% of the Year 3 target achieved: - IMPACT provided 12,515 tablets of Sûr’Eau Pilina as starter kits to 2,503 CHV for 3 regions of ACCESS (Atsinanana, Atsimo Andrefana, and Vatovavy Fito Sur Eau Pilina (67mg tablet) (Community) 1,253,340 2,793,000 Vinany). The starter kits represent 1% of the achievement. - When Sur’Eau Pilina was available, IMPACT withdrew Sur’Eau 150ml from PARC and PA, and

Year 3 USAID IRs and Reporting Measure % of achievement. Indicator Achievement Sub-IRs to of Unit Target Observations/Deviation explanations Quarter 1 replaced it with Sur’Eau Pilina, which boosted the sales. 12% of the Year 3 target was achieved: - Including 1,505 tubes of Arofoitra allocated as starter batches to 301 CHV in 2 districts of ACCESS zones namely Tamatave II and Benenitra. Arofoitra (CHX 7,1%) (Community) 3,765 31,289 - Arofoitra is running out of stock as the quantity ordered in 2020 did not arrive as planned. Because of the delay of delivery by the supplier. It should be in November 2020. This last order is expected to be received in February 2021. 53% of the Year 3 target was achieved: - In October and November 2020, the distribution of Pneumox was still higher than the average monthly consumption. IMPACT will conduct routine data analysis and a small survey among PARC and PA that Pneumox (amoxycilline) (Community) 71,919 134,567 will be used to gain more understanding for the significant increase of sales in Quarter 1. - 12,096 blisters were provided to 4,032 CHV as starter batches in the 3 regions of ACCESS (Atsinanana, Atsimo Andrefana, and Vatovavy Fito Vinany), representing 16.8% of the achievement. 73% of the Year 3 target was achieved. The high achievement was due to the use of product during trainings organized in Mahefa Miaraka zones: SAVA, Pregnancy Test (Community) 75,635 103,000 DIANA, and Melaky.

IR5: Increased demand for and use of health products among the Malagasy people/Output/Activity PMP Only 3.2% of the Year 3 target achieved. See IR.5.4 Number of mass media spots aired 1,188 37,000 IMPACT explanation below per health area. Number Broadcasting on malaria is planned as follows: - Quarter 2 for cCD, Health area MALARIA 0 17,000 - Quarter 3 for ITPp and case management, and - Quarter 4 for the mass campaign distribution

Year 3 USAID IRs and Reporting Measure % of achievement. Indicator Achievement Sub-IRs to of Unit Target Observations/Deviation explanations Quarter 1 Broadcasting on FP is planned as follow: - Quarter 2 to support the new price for Protector FP 0 10,000 Plus male condoms. - Quarter 4 for the celebration of Contraceptive Day 11.9%, broadcasting on Sur’Eau Pilina was completed in MCH 1,188 10,000 Quarter 1 from December 9th to 20th, 2020 in 10- USAID-supported regions. Number of people reached through USAID- PMP IR5.4a supported mass media, including social media USAID (disaggregated by channel, sex, and age). 102% achievement Radio 2, 775,893 2,719,862

69% of the target achieved. The objective is based on the TV stations that collaborated with IMPACT in Year 1 with coverage of 30 districts. However, during the implementation of the activity in Year 2, it was noticed TV 529,162 771,149 that the real geographic coverage was reduced into 22 Mass media Number districts which was not the number initially agreed with Supplemental Type of channel some TV stations. This explains the number of people Funding reached. 15-24 years old 1,454,224 1,536,045 95% achievement 25-49 years old 1,850,831 1,954,966 95% achievement Female 1,550,053 1,657,941 93% achievement Male 1,755,003 1,833,070 96% achievement Social Media Facebook 12,004 12,431 97% achievement Printed media Posters, Jobaids, and Flyers 5,174,128 5,274,388 98% of the Year 3 target achieved. 120% of the target achieved. Production of 15 clash PMP Number of COVID-19 radio spots info broadcasted through radio channels and IR5.4b Number 18 15 USAID developed/adjusted additionally there were 3 new TV spots as requested by DPS of the MOPH. 116% of the target achieved. There was an additional PMP IR5.4c Number of COVID-19 radio spots disseminated Number 16,389 14,085 broadcast of 2,160 radio spots due to the clash info USAID shows also being aired on the radio.

Year 3 USAID IRs and Reporting Measure % of achievement. Indicator Achievement Sub-IRs to of Unit Target Observations/Deviation explanations Quarter 1 PMP 110% of the target achieved. The remaining 1,223 TV IR5.4d Number of COVID-19 TV spots disseminated Number 6,630 5,985 USAID spots were broadcast in October 2020. PMP IR5.4e Number of IEC/BCC printed tools distributed 458,600 464,000 99% of the target achieved. USAID 55% of the target achieved. All job aids initially planned Job Aids Number 6,600 12,000 were produced except the production of job aids for Type of material support schools that were cancelled after school closure Posters 214,000 214,000 100% achievement Flyers 238,000 238,000 100% achievement PMP Number of messages disseminated through IR5.4f Number 10 10 100% achievement USAID electronic platforms (SMS) For COVID-19 related indicators, this PMP represents the final achievements during the six months of implementation of the COVID-19 workplan. For the indicators: IR2.1.1, IR2.1.2, and IR2.2.1, IMPACT does not present the % of achievement in the column “% of achievement. Observations/Deviation explanations » due to difficult interpretation of the percentage between achievements and targets on these indicators. This is already agreed with USAID.

ANNEX B - Year 3 Workplan Update

Timeline FY21

Quarter 1 Description of the Activity Outcome/Expectation Status Comments

Code Oct Nov Dec 20 20 20 Sub-activity Sub-activity Activity Code Activity Intermediate Result 1 Enhanced coordination among public, non-profit, and commercial sectors for supply and distribution of health products 1.1 The total market for health products in Madagascar is understood and documented Implement and monitor, and conduct the TMI roadmap for all health products The implementation of the operational plan of the IR1.1.1 mid-term evaluation of the overarching TMA X X X Ongoing implemented, monitored and evaluated TMA roadmap roadmap for all health products The malaria RBM group and the TMA TWG members (including the private sector) drafted a malaria Support the development and the Malaria, FP, and MNCH TMI roadmaps roadmap for antimalarial product on December 15, implementation of the Malaria, FP and MNCH and their operational plan are 2020. IR1.1.2 TMA roadmaps to ensure the availability of X X X Ongoing developed, implemented, and The FP and MNCH market assessment documents got quality products at all levels and monitor and monitored. approved by USAID in December 2020. IMPACT is evaluate their execution preparing the study protocols to start the data collection in Quarter 1 of Year 3. Build the capacity of TMA Champions, with One TMA Champion from the private sector has IR1.1.3 the MOPH, to successfully steward and lead TMI champions trained X X X Ongoing emerged and was trained to join the panel of TMA the TMA TWG and subcommittees Champions. Disseminate the TMA results from roadmap analyses, studies and market assessments to The malaria market assessment findings were all key stakeholders, with the leadership of TMA FP and MNCH roadmaps and presented to the RBM group and the TMA TWG IR1.1.4 the TMA Technical Working Group, and in market assessments disseminated to X X X Ongoing members (including the private sector) on November collaboration with the IMPACT Knowledge key stakeholders. 24, 2020 Management platform

Intermediate Result 2 Strengthened capacity of the GOM to sustainably provide quality health products to the Malagasy people IR 2.1 Health commodities and pharmaceuticals are continuously accessible and available in the public sector Implement an integrated forecast and supply A revised supply plan was developed for FP/RH planning process for the public sector with Supply plan is developed and commodities. There is no plan to review supply plans of IR2.1.1 X X X Ongoing related tools for commodity needs implemented malaria and MNCH as the quantification were not yet assessments approved by the CGL.

Two staff of NMCP, two staff of DSFa were coached and mentored to analyze data on consumption of Increase the capacity of the MOPH to provide Capacity of the MOPH is improved at all IR2.1.2 X X X Ongoing malaria and MNCH commodities reported by districts oversight to public SCM levels on SCM (through DHIS2 and CHANNEL). The analysis resulted in planning distributions to 114 Pha-G-Dis. IMPACT supported the DPLMT and DEPSI to prepare Support efforts to strengthen the LMIS and Resilient SCM and M&E systems are in the agenda, content, presentations of the LMIS IR2.1.3 X X X Ongoing SCM M&E systems place workshops and support the public sector to use findings to develop a road map. - Organization of a workshop of reflection to adjust strategies and develop the catch-up plan achieved. Support NMCP in the implementation of All documentation and tools needed for - Semi-annual review of the operational team IR2.1.4 Community-based Continuous Distribution Community-based Continuous X X X Ongoing carried out. (cCD)of LLIN in 12 districts Distribution are ready - 541,638 LLINs distributed in the 12 12 targeted districts

- Review of LLIN campaign strategies carried out, strategic documents being finalized with AMP Support NMCP in the design of 2021 LLIN consultants. mass campaign distribution strategy, its All documentation and tools needed for IR2.1.5 X X X Ongoing - Management tools, reporting tools and SBCC implementation and the distribution of 3,677 the 2021 mass campaign are ready supports revised and in the process of finalization. million LLIN procured with USAID/PMI’s fund - Acquisition of LLINs: 3,177,000 LLINs received at Tana and Tamatave.

IR 2.2 The public-sector supply chain achieves financial sustainability Based on total cost analysis of the public The data collection for the TCA has been conducted to supply chain, prepare evidence to analyze SALAMA and randomly selected 16 Pha-G-Dis, 47 Pha- different supply chain alternatives on the Adjust and implement strategies on Ge-Com, and 17 district hospitals, 4 CHRR, 3 CHU and total cost to determine progressive IR2.2.1 supply chain system for the total cost X X X Ongoing 10 CHRD. Then, the data was entered into LQAS19 (Lot integration of commodities managed by based on the total cost analysis Quality Assessment Sampling) for data quality checks. vertical programs into SALAMA circuit and Data analysis and writing report will continue in reduce dependence to donor funding for QUARTER 2 different cost categories of the supply chain

Reinforce the capacity of the MOPH to This activity has been postponed to Quarter 2 as IR2.2.2 oversight and monitor the management of New FANOME margin defined X X Ongoing depending to TCA findings. FANOME

Intermediate Result 3 Expanded engagement of the commercial health sector to serve new health product markets, according to health needs and consumer demand IR 3.1 Commercial actors are incentivized to expand into new health product markets Strengthen partnership with PSHP and non- PSHP members in participating to the implementation of solutions on transportation, supplying, supervising and MOU/contract signed between PSHP or providing data collection and reporting about non-PSHP members and IMPACT on IR3.1.1 X X X Ongoing the priority health areas (malaria, FP, MNCH) transportation of health products and health products, and in coordination with IR4, CSR support private sector engagement (PSE) in procurement of health commodities such as YES condom and Sur’Eau 150 ml Set up and strengthen the LMIS for the 40 Pharmacies, 100 drug shops, and 4 Field visit done in Atsimo Andrefana. 7 Pharmacies IR3.1.2 private sector (drug shops, pharmacies and wholesalers submitted LMIS data on a X X X Ongoing and 25 drugshops signed participation letter on pharmaceutical wholesaler). monthly basis submitting LMIS data Continue to involve PSHP and non PSHP PSHP and non-PSHP members Private sector participation in 2 workshops: members (Wholesalers and pharmacies) to IR3.1.3 participated in TMA TWG X X X Ongoing - Malaria market assessment dissemination participate in the implementation of the TMA meetings/workshops LMIS workshops (drafting roadmap) roadmap finalized and validated in Year 2 - 27 bank staff trained from Baobab and ABM SAVA Increase access to finance for private health 100 loans for $120,000 to health branches. 90% achieved. IR3.1.5 commodities supply chain commodities enterprises. Number of X X X Ongoing - 10 loans (10% achieved in number disbursed) for an stakeholders/Expand supply-side financing trained staff = 30 amount of $45,563 (38% achieved for amount)

- Living documents to be improve during the regional training sessions - 25 drug shops trained in SAVA - 25% of the year target Provide business strengthening capacity achieved building to health commodities enterprises - 03 drug shops coached in SAVA (15% annual target IR3.1.6 Number of people trained =125 X X X Ongoing and develop partnerships with private achieved) companies to sustain training - Started with the analysis of feedback from the first video distance learning from DIANA and SAVA. Discussion with HQ about this analysis in progress.

IR 3.2 GOM facilitates the work of the commercial sector This activity is covered under IR1 through. TWG/AMT Subcommittee in charge of Regulations IMPACT organized a working meeting with a delegation Facilitate high-level advocacy by the of the Union of the Pharmacists to discuss ways to commercial sector to expand favorable FP collaborate and relaunch activities to fight against FP policies and regulations are IR3.2.1 policies and regulations (this activity will be X X X Ongoing counterfeiting and the illicit market of medicines in favorable for commercial sector covered under IR1 through TWG/AMT Madagascar. The newly appointed Minister of Public subcommittee in charge of Regulations). Health granted a hearing to a delegation from the Union of Pharmacists and IMPACT, where he agreed to hold a meeting to reactivate the interministerial committee to fight against the illicit drug market Participated in two Comité National d’Enregistrement (CNE) meetings to review market authorization The medicines prequalified by SALAMA, Foster sustainable capacity development in applications submitted to DAMM and related to IR3.2.2 WHO, and other donors will be X X X Ongoing regulatory reforms within the GOM vertical programs and SALAMA products. The CNE registered by DAMM requested additional information for almost 75% of the dossiers submitted by SALAMA. IMPACT contributed to drafting a ministerial decision relating to the creation and establishment of the ADDO Steering Committee which has been submitted for Develop and pilot an accreditation program ADDO is piloted within selected drug validation and signature by the MOPH authorities. IR3.2.3 X X X Ongoing for retail drug depots. shops The ADDO draft model for Madagascar is to be developed with the regulatory framework and the training curriculum as well as the two regions of implementation selected. Intermediate Result 4 Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy people

IR 4.1 Socially marketed products are continuously available at convenient and accessible locations Distribution of socially marketed products across ten (10) regions for MNCH and FP/RH MNCH and FP commodities were delivered to 10 FP/RH (13 regions) and MNCH (10 IR4.1.1 products and distribution of only FP/RH X X X Ongoing USAID supported regions and only FP products were regions) health products available products in three (3) PARN Regions through distributed to the 3 PARN supported regions PARCs and PAs Establish a motivation system for PAs and PARCs and follow up on their quarterly Motivation system of PAs and PARCs Evaluation of the PARCs and PAs during Quarter 1 of IR4.1.2 performance to address supply chain X X X Ongoing are executed the Year 3 will be done in January 2021. inefficiencies in social marketing in order to prevent stock out. Expand last-mile distribution and emergency Drone pilot phase implemented and 83 delivery flight tests to Maroantsetra and Mananara IR4.1.3 distribution through a pilot to deliver health X X X Ongoing scaled up to other regions Nord products using drones. In collaboration with IR2, DSFa, DPLMT and 4% of PARCs and PAs officially DSSB, develop, finalize and validate the transferred into the public sector and IR4.1.4 scored criteria, standard and process to X X X Ongoing Criteria of the transfer defined receive ongoing monitoring and transition from PARC and PA to Pha-G-Dis and capacity building from the SPD. Pha-Ge-Com Select and introduce socially marketed products through the private sector FP products portfolio analysis completed. COGS Suppliers selected for the health IR4.1.5 (pharmaceutical and commercial channels) X X X Ongoing analysis completed. FP products to be introduced in the products following the results of the Products portfolio private sector selected accordingly. and COGS analysis Linkage mitigation of products is Define a product monitoring system and contact with the supplier by conference call held in IR4.1.6 available, and drugs can be tracked to X X X Ongoing conduct a study of a product tracking system December 2020. Scope of work to elaborate ensure quality. Each IMPACT employee, PA, and PARC PPE were distributed to PA and PARC and barriers IR4.1.7 Ensure preventive measure against COVID-19 has access to expendable equipment X X X Ongoing measures were continued to be respected while the and supplies to protect against Covid-19 distribution team perform their activities IR 4.2 Socially marketed products achieve cost recovery at an affordable price for consumers

A study on the quantification of needs

Leverage TMA findings from IR 1 to adjust the conducted and Marketing Authorization

current product marketing mix and continue Application submitted for Yes with You FP marketing Mix updated. to propose options for the optimization of condoms. Contract with the supplier IR4.2.1 X X X Ongoing the current socially marketed products signed and procurement initiated to

portfolio financial sustainability and explore start distribution. Introduction of new

brand extension of Yes With You condoms brands of pharmaceutical products

explored

Intermediate Result 5 Increased demand for and use of health products among the Malagasy people The TMA TWG demand creation subcommittee led by In collaboration with the TMA TWG demand the MPOH (DPS) held its 6th meeting at IMPACT’s office creation subcommittee led by the MOPH Within TMA TWG, activities on demand on December 18th, 2020. The draft of the (DPS), develop and implement activities to IR5.1.1 creation and use of health products are X X Ongoing communication plan on the safe and rational use of increase demand and health products safe developed and implemented health commodities was presented and some use through the National Communication improvements were contributed by members. Plan developed in Year 2

Provide technical and financial support to MOPH communication activities linked -Technically and financially contribution to the IR5.1.2 MOPH communication activities that are to the IMPACT mission are supported X X Ongoing celebration of the 16 days of activism linked to the IMPACT mandate financially and technically - 1,180 radio spots were broadcasted in 39 districts of Conduct communication campaigns for the 10-USAID supported regions from December 09th promoting health products of the three to 20th, 2020 prioritized health areas (Malaria, FP and -Social mobilization at the community level were held MNCH) through radio, TV spots, job aids, and Market size increased for health IR5.1.3 X X Ongoing to promote the use of Sur’Eau Pilina, CHX, Sur’Eau 150 digital communication (including social products. (which substituted Sur’eau Pilina during the stock out), media) incorporating gender messaging to and Protector Plus condoms promote and use health commodities for -SMS broadcasted was sent on the management of population and providers spoiled and expired medicines to PA, PARC, CHVs Provide technical and financial support to the Youth centers revitalized and Youths Preparation of the first training session in Atsimo IR5.1.4 Ministry of Youth and Sport (MYS) to develop are trained on leadership, health X X Ongoing Andrefana region in February in collaboration with MYS and implement Youth SBC activities products, and behavior change and Blue Venture Cross Cutting Gender

- CNFM and EFOI members of 4 TWG subcommittees and attended meetings Continue support for IMPACT TMA approach - Monthly meeting held December 11th GESI partners and other organisms GESI 1 and GESI integration through relevant X X X Completed - EFOI engaged in Malaria Market Assessment integrated through TMA TWG technical working groups and platforms dissemination event -CNFM integrated in Ministry of Population gender technical working group -A2F team trained bank partners staff with GESI- updated tool -Previously trained SRDs and SPDs conducted GESI Build capacity of IMPACT staff and partners sessions with PAs and PARCs in their intervention sites IMPACT staffs have good understanding GESI 2 to better understand and deliver gender- X X X Completed - First Pause and Reflect session on Malaria Market on gender program responsive programs and services Assessment and ITN held December 16th - Online GESI refresher course completed by 59 staff members in November

- Factsheet on TMA and GESI produced and distributed among partners of public, private, social marketing, and commercial sectors Champion inclusive messaging in - A2F factsheet development ongoing GESI is integrated in the communication GESI 3 communication, learning, and investigation X X X Completed - Article on women’s empowerment and and research tools materials pharmaceutical sector developed and published in newspaper - MNCH market assessment framework evaluated to integrate GESI lens Cross Cutting MERL Monitoring and Evaluation Strengthen LMIS with the use of DHIS2 as High performance of the LMIS used for - A workshop to develop the LMIS data analysis and dissemination tool for the decision-making at all levels (central, roadmap for three sectors was held in December. The CC1 three sectors: public, social marketing, and regional, district, and commune) with a X Ongoing finalization of this roadmap is scheduled for January commercial (pharmaceutical wholesalers, large participation from the private for 2021. pharmacy, and drug shops). profit sector. Support technically and financially the DEPSI - Data quality improved and and DPLMT to ensure that routine data recommendations on data quality quality assessment (RDQA) is conducted - RDQA exercises were conducted in 6 Pha-G-Dis, 14 CC2 issues shared throughout Madagascar X Ongoing every Quarter at all levels for the three Pha-Ge-Com, 6 PARC and 12 PA - Data validation process is approved by sectors and the data validation process is set the MOPH up (with a protocol approved by the MoPH).

Research Findings from the qualitative survey Implementing studies to feed market among key informants, household -designing the draft of study protocol (Outlet Survey) CC3 assessment design for FP/MNCH Market survey, and outlet survey are available X Ongoing -starting the procurement activities based on the draft assessment for the market assessment designs for of the study protocol FP and MNCH

-Procurement preparation prior the data collection Implementing other study to inform program Strategies are adjusted based on the CC5 x x Ongoing planned for Quarter2 intervention findings from study results

Knowledge Management

Support the IMPACT project team in  Developed Success Story and photography developing and collecting success stories and The visibility of IMPACT's activities is guidelines. CC6 x x x Ongoing documenting IMPACT's innovations in the increased  Simplified success story template and shared to field IMPACT staff

ANNEX C - Environmental Mitigation and Monitoring Report

100

Table : Summary number of the outlets visited

Number of % of outlets Number of field Type of Outlet Total per Outlet Outlets Visited visited teams Public Sector SALAMA/Central Warehouse 0 6 0% Pha-G-Dis 30 78 38.4% 13 RLA CSB/Pha-Ge-Com 13 1,734 0,75% Nonprofit Sector (social marketing) Warehouse 5 15 33.3% PARC 71 71 100% 28 SPD PA 925 925 100%

Achievements for COVID-19 activities are limited to the end of October 2020 when the funding for these activities ended.

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OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION 1. Capacity building through technical workshops and training to enhance coordination and distribution of quality health products. 1. Technical 1.1.2. Provide supervision of CSB providers Infrastructure and non-medical equipment for infection Outstanding Issues: Need to ensure that assistance, trainings, by using Rapid Monitoring Tool to assess prevention: all the CSB have non-medical equipment workshops, and tools infrastructure and equipment for - handwashing device with a bucket to prevent infection and contamination. developed must handwashing, infection prevention - Soap for washing hands include appropriate (decontamination and containers for - Tissues for cleaning Recommendations: Provide general management infectious waste), waste cans, safety boxes, - Chlorinated water recommendations to all CSB through practices for facilities etc. collaboration with ACCESS and continue of health commodities - During the supervision visit, all 13 CSBs were equipped with non- to visit CSB in the next quarters. and integrate sound medical equipment to prevent infection and contamination. The procedures to manage RLA congratulated the Head of the CSBs and recommended for and properly dispose them to keep up the good work. of health care waste (including expired Issues: None health products). Resolution: None 1.1.3. Provide CSB providers with: garbage Medical equipment for infection prevention: Outstanding Issues: Need to ensure that cans & gloves for ordinary waste; sharps - Safety box all the CSB have medical equipment for containers and gloves; handwashing device - Sharps containers infection prevention. with a bucket to catch handwashing water - Gloves - Garbage disposal Recommendations: Provide general recommendation to purchase and store - All the 13 CSB visited were equipped with medical equipment for medical equipment for infection infection prevention. The RLA congratulated the Head of the CSBs prevention to all CSB through and recommended for them to keep up the good work. collaboration with ACCESS and continue to visit CSB in the next quarters. Issues: None Resolution: None 1a (Activity type 1: 1) Use of host country developed processes, 1a1) Review of the adequacy of existing SOPs: Outstanding Issues: No SOPs available. Support to healthcare SOPs and standards will be promoted; facilities and systems however, these processes must be assessed Results and issues: Only the “hand washing” SOP is used and Recommendations: Support the MOPH [1.2] to evaluate whether they adequately posted in CSB, hospitals, and CCOR/DRSP offices. to create SOPs for all epidemic diseases ) Support or provide address potential health and safety and (not only for COVID-19). technical assistance environmental impacts of the operation of Resolution: IMPACT and the MOPH created operational When the SOP is created, verify that the to develop processes, healthcare services and generated wastes. documents for the training using the contingency plan from the document adequately addresses the SOPs, and standards MOPH. potential health and safety and for aspects of environmental impacts of the operation 102

OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION healthcare such as 2) If no SOPs exist or gaps are identified, 1a2a) Verification of the development and implementation of of healthcare services and generated waste management, develop and implement SOPs in accordance SOPs: wastes. disinfection, and with best management practices service delivery Result: Hand washing devices are readily available and disinfection - Ensure that the districts and CSB have 3) When adequate waste management of shoes and tires at the entrance. Waste is well managed in trash read the SOP and clearly understood the procedures (WMP) are not available, bags and trash bins that were donated from USAID/IMPACT. content and implemented correctly. develop and implement a WMP that addresses management of waste streams Issues: Difficulty to send the donations to the remote CSBs. associated with healthcare services. See USAID’s Integrated Resolution: Advocate to the SDSP to prioritize the donation of Waste Management Plan for additional supplies to CSB in remote areas. guidance. 1a2b) Accordance of the operation with the SOP

Result: The SOP created through the contingency plan was aligned to the best management practices of the hospitals targeted to the training of the waste management.

Issues: None Resolution: None 1a3) Verification of the development and revision of WMP Outstanding Issues: No WMP available.

Result and issues: There is no WMP available. Recommendations: Support the MOPH Resolution: IMPACT and the MOPH used training curriculum to create WMP for all epidemic diseases developed by the MOPH composed of the Infectious diseases (not only for COVID-19). manager and hygienist manager working at hospitals targeted for the waste management training. 1b (Activity type 1: 1) Training/curricula/ supervision that 1b1) Respect of the best appropriate management practices during Outstanding Issues: None Support to healthcare creates waste as part of the training will training and supervision. Recommendations: None facilities and systems address appropriate best management [1.3]). Support to practices concerning the proper Result: The post –training supervision activity was assigned to the healthcare facilities management of healthcare waste, sample MOPH. and systems: training, handling and disposal, and PPE use. PPE technical assistance, must be provided to trainers, if dictated by Issues: None and capacity building the type of training. Resolution: None of health care 1b2) PPE provided and used by trainers: Outstanding Issues: None workers, waste Recommendations: None

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OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION workers, staff, 2) Trainers will be equipped with PPE, as Result: No training and no PPE donation was conducted in community health dictated by the type of training. Quarter 1 Year 3 because of no funding for COVID-19 after October care workers, and 2020 volunteers in areas of 3) Training on waste management, storage Issues: N/A PPE use, waste of commodities, disinfection, and PPE use Resolution: N/A management, must be in accordance with the USAID 1b3a) Interview with participants to verify training was Outstanding Issues: None procurement, storage, guidance and best standard of practice conducted: Recommendations: None and disposal of promoted by local authorities at the time of commodities, and the training. PPE for healthcare and waste Result: No interview conducted in Quarter 1 Year 3 because of no disinfection workers depends on the setting, personnel, funding for COVID-19 after October 2020 and type of activity. See WHO’s Rational Use Issues: N/A of PPE for COVID-19. Resolution: N/A 1b3b) Use of the supervision checklist developed from the training Outstanding Issues: None curricula to ensure compliance by health care workers. Recommendations: None

Result: No supervision conducted in Quarter 1 Year 3 because of no funding for COVID-19 after October 2020 Issues: N/A Resolution: N/A 2. Social Marketing, Education, & Social Behavior Change Communication (SBCC). 2a (Activity type 1: 1) Stay informed about ways to prevent 2a1) Updates made to activities and training procedures to include Outstanding Issues: None Communication, COVID-19 transmission over the course of COVID-19 best practices as appropriate. Recommendations: None outreach, planning - the activities, including where appropriate, [1.1]). Social behavior training staff and beneficiaries on social Result: Teams in the field were regularly sensitized on the change: distancing, PPE use, and disinfection. mitigation measures of COVID-19 (systematic use of PPE and SHA communications, Guidance can be found from local (hand sanitizer) gel during the activities and to respect social outreach, planning authorities or at the following websites: distancing). ●CDC’s Coronavirus Disease Site ➔ Commodities (mask and SHA gel) have been made available ●WHO Geng your Workplace Ready for Issue: no non-compliance noted COVID-19 Resolution: none ●UNICEF, WHO, IRCF Key Messages and 2a2) Use of remote trainings and meetings. Outstanding Issues: None Actions for COVID-19 Prevention and Recommendations: None Control in Schools Result: Until the end of October, IMPACT was teleworking, so all meetings were conducted through virtual conferences. Issues: no non-compliance noted Resolution: none

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OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION 2) Where appropriate and available, remote 2a3) Local regulations on the size of gatherings and travel Outstanding Issues: None training and other non-face to face advisories integrated into activities. Recommendations: None communications will be utilized when possible until the risk of Result: For sensitization activities, communication teams avoided infection passes. meetings. Issues: Sensitize people without organizing gatherings. 3) Local COVID-19 regulations on the size of Resolution: Field communication teams delivered messages gatherings and travel advisories will be through mobile sound systems across the city (using vehicles that followed. respected social distancing). 3. Storage, management, distribution, transportation & disposal of public health commodities & equipment. 3. Storage, 3.1.1. Include in training curriculum how to Nonprofit sector Management, properly manage expired (properly logged), Number of PSI central warehouse, PARC, and PA trained on Outstanding Issues: None Distribution & obsolete or surplus commodities for PSI expired, obsolete, and surplus commodities: Disposal of Public central warehouse, PARC, PA and public Type Male Female Total Health Commodities & sector (SALAMA/central warehousing, Warehouse 5 4 9 Recommendations: Equipment PhaGDis, PhaGeCom and CSB). A disposal PARC 21 50 71 - Maintain regular training of warehouse plan will be created and will be available for PA 389 536 925 workers on management of expired, the trainees following the national Some of the warehouses had more than two people trained. surplus, and obsolete commodities. guidelines. Curriculum will be adapted to - Reminder of good management of different literacy or education levels to Result: All PARC and PA visited received on-the-job training on expired, surplus, and obsolete ensure effective understanding management of expired, obsolete, and surplus commodities. commodities and capacity building will be continuously performed during the Issues: None supervision visits. Resolution: None Public sector Number of public sector persons trained: Outstanding Issues: None

Type Male Female Total Recommendations: SALAMA N/A N/A N/A - During supervision visits, the RLAs Pha-G-Dis 12 27 39 are always conducting a CSB/Pha-Ge-Com 7 7 14 training/refresher training on the management of expired products Some of Pha-Ge-Com and Pha-G-Dis have more than two people and waste management. trained. - The district GAS committee is involved in decision making in the Result : event of redeployment (in case of

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OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION - In Quarter 1, the 39 Pha-G-Dis and 14 CSBs supervised were overstocks) or on the destruction of trained in waste and expiry management. products (obsolete). - The RLA also shared job aids on good storage and warehousing - The GAS committee is coached by the practices and management of expired products. RLA to better quantify inputs to order - The RLAs shared soft copies of the guidelines for destroying in respect of the stock levels required products with the 39 Pha-G-Dis service providers. (maximum and minimum stocks levels) to avoid overstocks and risk of Issues: None expiration. Resolution: None 3.1.2. Regularly check expiry date of Nonprofit sector commodities during monthly visit of PSI Number of expired, obsolete, and surplus products at PSI’s central Outstanding Issues: None central warehouse, PARC, PA and public warehouse, PARC, and PA: sector (SALAMA/central warehousing, Recommendations: PhaGDis, PhaGeCom and CSB). Product Expiry Surplus Obsolete - Continue trainings to maintain zero Warehouse 0 0 0 expired, obsolete, and surplus products “If there are expired products in the PARC 0 0 0 at warehouses, PARC, and PA. warehouse, the supervisor will take PA 0 0 0 - Reminders and capacity building will be appropriate action to rectify the practice" provided consistently. Result: - No expired, surplus, and obsolete conmodities were identified. - Principles of storage, management, distribution, and disposal of public health products and equipment are respected.

Issues: None Resolution: None Public sector Number of expired, obsolete, and surplus products in the public Outstanding Issues: None sector: Product Expired Surplus Obsolete Recommendations: SALAMA 0 0 0 - Remove expired products from the Pha-G-Dis 0 88,444 0 shelf and store in the quarantine Pha-Ge-Com 176 0 0 area.

- Remind the districts to proceed with Result: the destruction of products - In Quarter 1, 10 Pha-G-Dis and 5 Pha-Ge-Com have expired according to the standards and products still quarantined withih their storage. procedures. 106

OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION - The Pha-G-Dis of Fenerive Est destroyed its expired products, - Support the districts with the use of - . the obsolete input-register. - Remind the GAS committees to Issues: anticipate actions to avoid expiration - During the supervision, the RLAs noted the presence of (for example: return of products to products already expired in 10 Pha-G-Dis and 5 Pha-Ge-Com. Pha-G-Dis, redeployment to nearby These products were stored in the quarantine spaces. districts, hospitals, and clinics, etc.).

Resolution and actions: - The RLA supported the providers to remove expired products from the shelves and to store them in the quarantine spaces. - The RLAs also supported five Pha-G-Dis to record obsolete products in a register for traceability. - The RLA immediately advocated to the Medical Inspector and Head of CSB to destroy obsolete products in compliance with the standard operating procedures. - The RLA supported the district GAS committees to better estimate needs to avoid overestimations which can lead to expiration. 3.1.3. Provide guidelines and appropriate Nonprofit Sector communication tools on storage conditions Number of PSI central warehouses, PARC, and PA having guidelines Outstanding Issues: None for each product by following standard and communication tools: guidelines for Proper Storage and Recommendations: distribution of Health Commodities for PSI QUARTER 1 Total - Ensure guidelines are not obsolete and central warehouse, PARC, PA and public Warehouse 5 15 update the guidelines as needed. sector (SALAMA/central warehousing, PARC 71 71 PhaGDis, PhaGeCom and CSB) PA 925 925 - Always check the quality and availability of the guidelines and

communication tools. Result:

- All supervised warehouses have appropriate guidelines on

storage conditions. - Availability and visibility of appropriate communication tools and guidelines for PARC and PA are respected.

Issues: None Resolution: None Public Sector 107

OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION Number of public sector that have guidelines and communication Outstanding Issues: None tools: SALAMA N/A Recommendations: Pha-G-Dis 27 30 90% Collaborate with ACCESS to assess needs CSB/Pha-Ge- 8 13 61,5% of communication tools and dispatch Com them to CSB in all the 13 USAID- supported regions. Issues: 27 out of 30 Pha-G-Dis and 8 out of 13 CSB visited did not have guidelines and communication tools. Resolution: The RLAs dispatched communication support to 3 Pha-G-Dis and 5 CSBs. Communication support includes: inventory and storage guidelines, expiry management guide, roles and responsibilities of all actors in the public supply chain, and job aids. 3a (Activity type 3: 1) Procure health commodities that comply 3a1a) Review of product specifications to ensure they meet host Outstanding Issues: None Procurement and with host country and international country and international regulatory, shipping, and packaging training [3.1]). regulatory, shipping, and packaging requirements. Recommendations: Continue Procurement or requirements to ensure that only collaboration with GHSC-PSM to ensure logistics support appropriate products enter the supply Result: 100% of USAID procured products and shipped in the all product specifications meet the WHO (distribution and system. This includes products that are country meet the country regulations. and host country regulations. transport) for manufactured at facilities that meet good healthcare manufacturing practice (GMP) certification Issues: None commodities, requirements, as recommended by the Resolution: None diagnostic kits, PPE, WHO or are pre-qualified by WHO 3a1b) Maintain copies of procurement records (e.g., Outstanding Issues: None and equipment for manufacturing records, Certificate of Analysis, test data, regulatory response to emerging 2) Develop and implement an inspection and certificates, etc.) and copies of quality documentation on file. Recommendations: Continue filing threats quality assurance process for assessing and procurements records as required. monitoring product quality. Considerations Result: All documents are reviewed before shipment and include, but are not limited to: recorded. This includes manufacturing records, certificate of ●Selecng reliable and veed suppliers: analysis, test data, regulatory certificate, and certificate of quality. ●Using exisng quality assurance mechanisms established by WHO Issues: None ●Establishing a system to report poor Resolution: None quality, expired, or defective products; and 3a2) Verification of the development and implementation of the Outstanding Issues: Tool to detect and ●Performing regular pre- and post-shipment quality assurance process. monitor expired products is not yet testing. implemented.

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OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION Result: Quality assurance process is already part of the routine Recommendations: Collaborate with the assessment and monitoring of product quality. A system for Monitoring and Evaluation team to have 3) Develop and implement SOPs for the safe detecting expired products is being developed with the Monitoring the tool available in Quarter 2. distribution of health commodities being and Evaluation team. transported in bulk in motorized vehicles. 4) Develop and implement SOPs for the safe Issues: Tool to detect and monitor expired products is not yet transport of samples and supplies being implemented. transported in bulk in motorized vehicles. Resolution: Supply chain meeting has been organized to help reporting quality, expired or defective products issues. In parallel, other systems of detection (inventory checking and excel tables) are being used. 3 and 4) Verification of the development of the SOP and Outstanding Issues: Use of tools should comparison with the standard SOP developed by WHO/USAID. be monitored, and users should be accompanied during implementation. Result: Tools on safe transportation has been fully dispatched to Recommendations: warehouses, PA, and PARC. To ensure tools are correctly posted and Issues: None understood, an online training will be Resolution: None performed during Year 3. 3b (Activity type 3: Activities will be conducted following 3b) Site visits to verify that SOPs were implemented. Include dates Outstanding Issues: Procurement and guidelines and must comply with local, of visits, findings, and any non-compliance issues. - Reduced supervision visits due to travel training [3.2]). national, USAID, or its own organizational restrictions. Training, capacity environmental policies. Result: - Lack of training on the need to building, technical Supervisions visits completed: implement SOPs and supervisions with assistance of health  Diana: October 24th - 25th follow-ups workers responding to  CSB Analanjirofo: October 26th - 27th and COVID-19  CHRD1 and CSB1 in Soanierana Ivongo: December 10th - Recommendations: 11th. - Supervision plans and reporting need to be included in the training sessions.  Supervision visits completed with MOPH teams only or The supervision is recommended to be with USAID. completed by the SDSP/DRSP staff  Existence of hand washing devices and disinfection of during their regular visits. shoes and tires at the entrance of each site. - Prioritize shipment of expendable  Waste is well managed in sharps containers and garbage equipment and supplies to remote CSB. bins with pedals donated by USAID/IMPACT.  Secure outdoor waste with fencing.

Issues: 109

OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION - IMPACT noticed inappropriate wearing of washable protective masks by hospital workers in some sites visited. - Insufficient supplies in remote CSB. - Some supervision visits were cancelled due to restrictions of travel. - Lack of training on the need to implement SOPs and supervisions with follow-ups. Resolution: - The use of protective masks was rectified. - Developed a plan to prioritize shipments of expendable equipment and supplies to remote CSB. 4. Climate Risk Management 5.1. Proper storage 5.1.1.2. Organizing capacity building through Nonprofit and transportation of technical workshops and training to enhance Number of people from PSI central warehouse, PARC, PA: Outstanding Issues: None commodities and LLIN coordination and distribution of quality Type Male Female Total Recommendations: IMPACT is health products: among PSI central Warehouse 5 3 8 conducting supervision visits of all PARC warehouse, PARC, PA and public sector PARC 21 50 71 and PA every quarter to verify (SALAMA/central warehousing, PhaGDis, PA 389 536 925 compliance of the training received. PhaGeCom and CSB), and those responsible Actually, Madagascar is ranked ‘high for sending commodities and LLINs. All warehouse workers were trained on proper storage and vulnerable’ to climate trends (20 of 181 transportation of commodities/LLINs. countries) based on climate projections. Almost the entire country is exposed to Issues: None cyclones which strike an average 3-4 Resolution: None times per year. Cyclones and heavy rain events lead to high flood risk everywhere (less severe in southwest). The southern regions in particular, however, suffer recurring drought.

Public sector Number persons from public sector trained: Outstanding Issues : None Type Male Female Total Recommendations : IMPACT is SALAMA 0 0 0 conducting supervision visits of selected Pha-G-Dis 20 35 55 Pha-G-Dis and CSB to verify compliance CSB/Pha-Ge-Com 9 5 14 of the training received. Some of the Pha-Ge-Com and Pha-G-Dis have more than two people trained 110

OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION

Issues: None Resolution: None (Rating risk: Low) Percentage of communication activities scheduled for COVID-19 Outstanding Issues: None and conducted during the dry season (May-October). Recommendations: None 5.2.1.1 Not applicable for low risk activities. The project should be scheduled during dry Result: The communication activities scheduled for COVID-19 was season. conducted during dry season (May-October) and no issues were encountered. Accepted risk and opportunities: An opportunity is to integrate climate and Issues: None 5.2. Activity Type 1 — weather into support for disease Resolution: None Communication, surveillance, disease reporting, and outreach, planning. information dissemination. An opportunity is to integrate how the environment and climate contribute to pandemics and infectious disease occurrence during trainings. An accepted risk is that infrastructure may be damaged by extreme weather events where trainings, research, IT, etc occur. The project should be included in national or regional contingency plan if any. 5.3. Activity Type 1 — (Rating risk: Moderate) COVID-19 support has been reviewed and organized in accordance Outstanding Issues: None Support to healthcare Identified climate risks are: flood, cyclone, with the evolution of the number of cases in the regions: Recommendations: None facilities and systems landslide, evapotranspiration, humidity, and increased temperatures Results: IMPACT continued to distribute expendable equipment and supplies to 20 CSB (8 in Atsinanana and 12 in Analanjirofo) identified by the DRSPs that did not receive donation 5.3.1.1 Programs that address climate and in the previous months. weather sensitive diseases should consider conducting surveillance on the periphery of 8 hospitals that had COVID-19 cases, received expendable disease ranges, or where diseases are likely equipment and supplies: to spread due to change in weather or climate. If COVID-19 is being directly considered,  Haute Matsiatra: CHU Andrainjato, CHRR Tambohobe then revisit at a later date when we know  Boeny: CHU Mahavoky, CHU PZGA Androva 111

OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION how the spread of COVID-19 is, or isn’t,  Atsinanana: CHU Morafeno, CHU Analankininina affected by weather and climate.  Analanjirofo: CHRR Fénerive-Est  Atsimo Andrefana : CHU Mitsinjo Betanimena

Issues: None Resolution: None (Rating risk: Moderate) No specific issues encountered in October at the end of the COVID- Outstanding Issues: None 19 grant. This activity did not happen during the implementation Recommendations: None 5.3.2.1 If construction is included that of the COVID-19 program under IMPACT. requires a design team or engineer, then construction activities should consider climate risks during the design phase and be approved by relevant design engineers or firms. The equipment and infrastructure in this activity should not be exposed to climate risks (landslides, floods) and should also be resilient to evapotranspiration, cyclones, dust / sand infiltration, to corrosion). A water tank system and a temperature stabilization system for logistics products and equipment should be considered.

Accepted risk and opportunities: While potentially likely in some areas, supply chain disruption, and supply demand increase, due to extreme climate and weather events is an accepted risk in many instances. Delivery and logistic teams should consider climate and weather as best as possible as highlighted in previous columns. 5.4. Activity Type 3 — (Rating risk: Low) Number of supply chain disrupted due to extreme climate change Outstanding Issues: None Procurement, training and weather events. Recommendations: None 5.4.1.1 Not applicable for low-risk activities... Result: PA and PARC are prepared for climate risks, such as cyclone, so they have stocks of health commodities according to

112

OUTSTANDING ISSUES, PROPOSED ACTIVITY MITIGATION MEASURES SUMMARY FIELD MONITORING/ISSUES/RESOLUTION RESOLUTION Accepted risk and opportunities: While the prevision of the rainy season which is called “stock asara” or potentially likely in some areas, supply chain safety stock for each product. Thus, supply chain disrupted due to disruption, and supply demand increase, climate change and extreme weather events will be avoided. due to extreme climate and weather events may be an accepted risk in some instances. Issues: None Delivery and logistic teams should consider Resolution: None climate and weather as best as possible as highlighted in previous columns.

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ANNEX D - SUCCESS STORIES

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Success story 1: Pha-G-Dis of Antalaha: Increase of LMIS data completeness rate as a result of laptop donation from IMPACT and continuous supportive supervision

For almost two years, the Pha-G-Dis of Antalaha were unable to meet the promptness and completeness goals of reporting LMIS data through the CHANNEL management tool due to the lack of a dedicated laptop for CHANNEL. This resulted in poor performance of the SDSP leading to difficulties in the management of health commodities.

To address this issue, in July 2020 USAID, through the IMPACT project, donated a laptop computer to the Pha-G-dis provider. This was followed by technical assistance and on-the-job training by IMPACT’s Regional Logistics Advisor (RLA) and the MoPH district team during supervision visits.

As a result of combined efforts of the Pha-G-Dis provider, RLA, and MoPH district team, the Antalaha SDSP is now able to meet the Antenaina Marise, Pha-G-Dis service provider of Antalaha and deadline of sending LMIS reports, which enables better logistics data Rakotobe Sitraka, RLA of SAVA region during official donation of laptop visibility and better management of health commodities within the to the Pha-G-Dis of Antalaha, © Impact Pha-G-Dis. Data completeness rates progressively increased from 0% in January 2020 to 100% in October 2020.

The SDSP Technical Assistant said: “IMPACT, through technical support of the RLA, helped us a lot in improving LMIS. With this new laptop, we are confident that complete data reports would be submitted on time.”

Antenaina Marise, Pha-G-Dis service provider of Antalaha, stated: “IMPACT is real support for us. For months, there was no computer to use which was really stressful as I had to borrow other colleagues’ computers to enter data and deadlines were never met. Currently, submitting data is no more an issue.”

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Success story 2: Manakara district: Using an efficient system to ensure on time delivery of LLINs face to insecurity in rural communes

Under the lead of the National Malaria Control Program (NMCP), IMPACT continues to assist the MoPH in implementing the LLIN cCD by storing LLINs at the IMPACT warehouse and transporting LLINs to PARC and PA in 12 targeted districts.

In Manakara, LLIN transportation from the regional warehouse to communes in the district is quite challenging due to insecurity, remoteness of some communes, and lack of transportation. Sahasinaka, a commune located at 53 kilometers from Manakara, is the only commune which has regular transport by train to Manakara.

To ensure that LLINs arrive at communes on time, a great coordination and organization between PAs has been done spontaneously. The PAs of the district identified a PA focal point to be in charge of organizing a group trip to Sahasinaka (group trip is the safest way to travel due to insecurity), consolidating the LLIN needs of PAs, collecting the LLINs at the regional warehouse and transporting them to Sahasinaka by train, and identifying young people to help transport the LLINs from Sahasinaka to rural communes on their backs. Group travel for expedition of LLIN on men’s back to surrounding communes from Sahasinaka, © Impact Elysé RAZAFIMAHARO, a PA in the commune of Fenomby, was chosen to be the focal point. Elysé is a farmer and the father of four children and he has served as a PA since 2012. Elysé organizes the group trip of PAs and finds young people from his commune to transport LLINs to other communes.

As a result of this organization, compliance with the deadline for the arrival of LLINs at the commune level was respected and 100% of LLINs arrived on time in the communes and were available at community sites on the distribution days. Before, due to lack of transportation means, especially in remote communes, LLINs remained in Sahasinaka for months which delayed distribution. Group travel and organized transport through community members remains the only effective means to ensure the on-time arrival of LLINs in remote locations.

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Success story 3: Mahanoro: Pha-Ge-Com comply with storage standards and procedures as a result of supportive supervision

In the Pha-Ge-Com of CSB Betsizaraina Mahanoro, commodities were not managed according to standards and procedures. During the first supervision visit of the CSB Betsizaraina in June 2020 by a team composed of a representative of the DPLMT, the Technical Assistant of the SDSP of Mahanoro, IMPACT RLA, and led by the EMAD of the Mahanoro SDSP, it was found that health commodities were not managed properly, and that storage standards and procedures were not respected.

To address the issue, IMPACT, under the lead of MoPH district team, provided capacity building for the CSB Chief, Dispensing Officer, and the staff of the Pha-Ge-Com to improve commodity management: completion of management tools, health commodity management and ensuring data reporting.

During the second visit in November 2020, IMPACT noticed that storage rules had been adopted, management tools were up to date, the application of calculations on the commodities orders were being completed, expiration dates were being monitored and managed, etc. ZAFIMANGA Brigitte Annick, a 33- year-old woman and mother of two children has held the position of Pha-Ge-Com provider for 5 years.

“From now on, I can say that the health commodities in our CSB are well managed by our team and in compliance with standards and procedures. We are no longer afraid of being supervised, on the contrary, supervision has guided us towards performance,” says ZAFIMANGA Brigitte Annick.

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Success story 4: GESI partners help bring women’s voices to the table, advocating for empowerment and equal access to health commodities

“Gender should be mainstreamed. It can’t be done by a small unit — it needs to be done by each and every person. It’s everybody’s business, and we have to mainstream it.”3 -World Health Organization Director-General Dr. Tedros Adhanom

In 2019, IMPACT conducted a gender analysis in Madagascar which produced findings and recommendations relevant to women, men, and the health commodities sector, including: - There is a perceived balance between men and women in management-level positions in the public, commercial, and social marketing sectors. - There are social and cultural barriers that prevent women and girls from rising to the highest levels of decision-making and influence and limit their ability to benefit from health interventions. - Women and girls are more vulnerable to gender-based violence if they do not follow cultural norms to attend to unpaid household chores and care work. - Women working in the formal and informal economies are more vulnerable to harassment, discrimination, and a range of safety risks.

With this is mind, IMPACT worked to implement an inclusive strategy and build strong and sustainable partnerships with women’s and human rights organizations. In doing so, Conseil National des Femmes de Madagascar (CNFM) and Entreprenariat Féminin Océan Indien (EFOI) were engaged as gender equality and social inclusion (GESI) partners to support IMPACT in its implementation of an inclusive Total Market Approach (TMA) and bring the voices of women, girls, youth, and marginalized groups forward in health-related decision-making processes.

As a first step, CNFM and EFOI were integrated as members of the IMPACT-supported and government-run TMA Technical Working Group to help strengthen gender balance among members and promote diverse voices and perspectives in policy and decision-making. Building off this engagement, the partners have now also been successfully integrated into several sub-committees including: Communication and Demand Creation, Fighting against Malaria, Text and Regulation, and Policy and National Pharmaceutical Director Plan. In addition to these opportunities, IMPACT, over the course of its CNFM and EFOI representatives meet with IMPACT GESI Advisor implementation, will engage with GESI partners through during technical assistance meeting, © Impact interactive meetings and coaching opportunities to share priorities, lessons learned, and problem-solving strategies to strengthen capacities to address barriers to gender equality and social inclusion in the health commodities supply chain.

3 Keeling, A., Dhatt, R., and Doshi, L. Opinion: There is no road to UHC without gender equality and women’s empowerment. (1 February 2019). 118

In November and December 2020, IMPACT facilitated two sessions with the GESI partners to discuss the impact of counterfeit commodities on public health, which most significantly affects marginalized and vulnerable populations; the lack of knowledge and awareness in communities related to the right to be treated at health centers by qualified health professionals, particularly as it relates to issues with self-medication and low understanding to finish prescribed medicines; and the importance of including the GESI partners in conversations related to updating text, policies, and laws around access to health commodities and services so that they can provide perspectives and help advocate for more equal and equitable practices.

In continuing to support their engagement and contributions to IMPACT’s mission, the next session with the GESI partners will be occur in Quarter 2 and focus on women’s empowerment and access to finance in order to improve women’s networks and contributions to health and pharmaceutical enterprises as well as stimulate learning exchange, encouragement, and mentorship opportunities.

Looking ahead, IMPACT’s strategic partnerships with CNFM and EFOI will help strengthen the capacity of government stakeholders to serve as advocates for GESI (within their respective spheres) and support the sustainability of a gender- integrated TMA beyond the life of the program. By taking these active steps to engage and proactively include the voices of marginalized groups in a more inclusive way, IMPACT supports a more-inclusive health commodities supply chain and system.

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ANNEX E - STOCK INVENTORY AS OF DECEMBER 2020 (USAID AND PMI funded)

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MALARIA COMMODITIES (SALAMA)

Quantity in Quantity in Expiry Technical specifications Unit packs units date Sulfadoxine/Pyrimethamine 500/25 mg Tablet, 50 x 3 tablet 1-avr.-22 Blister Pack Tablets 333 49,950 Artesunate/Amodiaquine 50/135 mg Tablet, 25 x 3 Blister treatment 1-oct.-22 Pack Tablets 12,146 303,650 Artesunate/Amodiaquine 50/135 mg Tablet, 25 x 3 Blister 1-janv.- treatment Pack Tablets 1,503 37,575 22 Artesunate/Amodiaquine 50/135 mg Tablet, 25 x 3 Blister 1-janv.- treatment Pack Tablets 516 12,900 22 Artesunate/Amodiaquine 100/270 mg Tablet, 25 x 6 Blister treatment 1-oct.-22 Pack Tablets 18 450 Artesunate/Amodiaquine 100/270 mg Tablet, 25 x 6 Blister treatment 1-févr.-22 Pack Tablets 1,065 26,625 Artesunate/Amodiaquine 100/270 mg Tablet, 25 x 6 Blister treatment 1-févr.-22 Pack Tablets 1,940 48,500 Malaria Rapid Diagnostic Test (RDT) HRP2/pLDH (Pf/PAN) test 1-mai-22 Cassette, 25 Single Test Kits 2,458 61,450

MNCH COMMODITIES (SALAMA)

Quantity in Quantity in Expiry Technical specifications Unit packs units date

OXYTOCINE 10UI/ML INJ. AMP. 1ML - B/10 ampoule 1-juin-21 29,656 296,560

OXYTOCINE 10UI/ML INJ. AMP. 1ML - B/10 ampoule 1-juin-21 33,440 334,400

TOTAL QUANTITY 630,960

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ANNEX F - STOCK STATUS BY END OF DECEMBER 2020

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Table 1: Dashboard at central level, End of December - Malaria Note: the quantities of AS/AQ for 2-11 months, AS/AQ 6-13 years and AS/AQ 14 years and above highlighted in green have arrived in the country as planned in January. The quantities of AS/AQ 1-5 years will be shipped by air during the Month of January.

Stock On Donor/ Hand/ Forecasted AMC Months Shipments Months Estimated Product funding SALAMA (End (quantification) of stock planned of stock arrival date source of Dec 2020) ASAQ 2 - 11 187,650 8,1 GF 20-Jan-21 months, tablet, 83,255 23,124 3,6 135,650 5,9 PMI 31-July-21 treatment 44,500 1,9 PMI 31-Oct-21 717,450 5,3 GF 20-Jan-21 ASAQ 1- 5 years, 115,375 0,9 PMI 31-May-21 426,125 134,153 3,2 tablet, treatment 842,125 6,3 PMI 31-July-21 445,246 3,3 GF 31-Oct-21 225,475 3,0 GF 20-Jan-21 67,125 0,9 PMI 31-May-21 ASAQ 6- 13 302,050 4,0 GF 26-Feb-21 years, tablet, 72,775 75,156 1,0 treatment 560,400 7,5 PMI 31-July-21 219,175 2,9 PMI 31-Oct-21 67,125 0,9 PMI 31-May-21 237,725 3,2 GF 20-Jan-21 ASAQ 14 years 67,500 0,9 PMI 31-May-21 and above, 75,875 79,245 1,0 257,750 3,4 GF 26-Feb-21 treatment 532,975 7,1 PMI 31-July-21 219,175 2,9 PMI 31-Oct-21 311,000 5,1 PMI 30-Apr-21 Artesunate 382,849 61,213 6,3 100,000 1,6 PMI 28-Apr-21 injectable, vial 196,250 3,2 GF 14-Jul-21 2,000,000 2,8 PMI 28-Feb-21 Rapid diagnostic 2,243,554 3,2 PMI 1-Apr-21 5,825,450 707,540 8,2 test - kit 1,222,125 1,7 GF 14-Jul-21 3,632,583 5,1 PMI 31-Oct-21 1,500,000 3,3 PMI 28-Apr-21 SP 1,308,750 454,583 2,9 4,419,900 9,7 GF 14-Jul-21 QUININE tablet 186,000 40,484 4,6 126,000 3,1 GF 20-Jan-21 Artesunate 54,740 8,7 GF 1-Feb-21 38,590 6,287 6,1 suppositories 115,476 18,4 GF 14-Jul-21 Primaquine 120,800 4,811 25,1 125,000 26,0 GF 17-Jul-20

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Table 2: Dashboard at central level/ SALAMA- Family planning (public sector only)

Stock On Hand at Product AMC MOS Shipment Supplier Receive Date SALAMA, Nov 2020

Combined Oral 1,878,762 97,100 19 568,480 UNFPA 01/2021 contraceptive Depo-medroxyprogesterone 518,794 195,898 3 1,278,000 UNFPA Unknown acetate(DMPA IM) Depot- medroxyprogesterone 577,800 88,241 7 600,000 UNFPA 01/2021 acetate(DMPA SC) No new Intra Uterine Device (IUD) 3,889 559 7 procurement yet

IMPLANON XT 58,597 14,041 4 91,645 UNFPA Unknown

LEVOPLANT 45,654 9,100 5 111,000 UNFPA 01/2021

Progestin- only oral 543,720 12,165 45 contraceptive

Table 3: Dashboard at central level/ SALAMA- MNCH Stock on hand, December Product Unit Comment 2020 The product is no longer shipped to districts due to expiry date of June 2021. The product is at high risk of OXYTOCINE 10UI/ML INJ. AMP. 1ML Ampoule 425,960 expiry. IMPACT will continue to explore the possibility of distributing the product through the private sector

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ANNEX G - Descriptions of the seven quality dimensions for the RDQA

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Data Quality Parameter Descriptions The extent to which data and its supporting documentation are available. Review availability of the indicator source documents for the selected reporting period. 1- Availability Source documents depends on the indicator but will often refer to client intake forms, registers, cards redeemed vouchers, etc. Specify the name of the documents reviewed. Complete means that the document contained all the required entries of the indicator as appropriate. 2-Completeness Review completeness of the indicator source documents for the selected reporting period.

The degree to which the data correctly reflects what they were intended to 3-Accuracy measure. It is also known as validity. Accurate data correctly measure actual events, cases, units, etc. The extent to which data is up-to-date (current) and is made available on time. Review the timeliness of documents received from the site for the selected 4-Timeliness reporting period. Reports can either be summary reports or reports of aggregated data that is submitted to the next reporting level e.g. regional or district level. The extent to which data is protected from unauthorized changes or manipulation. 5-Integrity Review the source document for any indication of unauthorized (accidental or deliberate) insertion, modification or destruction of data. 6-Confidentiality The extent to which information or data is protected and kept secure.

The extent to which data is collected with the level of detail required to 7-Precision measure the indicator e.g. disaggregation by commodity type, etc.

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ANNEX H - ANNEX OF THE COVID-19 Monthly Report October 2020

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Table 1: Expendable equipment and supplies provided and transported by IMPACT from regions to district

PLACE OF DESTINATION QUANTITY DEPARTURE 20 hydroalcoholic gels 500ml, 40 cans of bleach 5L, 31 soap powder 1Kg, 5 brush brooms, 180 rolls of hand towel, 16 bottles of liquid soap, 6 household SDSP MORAFENOBE gloves, 20 mops, 2 frontal thermometers, 49 washable protective masks, 15 hand washing devices.

20 hydroalcoholic gels 500ml, 34 cans of bleach 5L, 25 soap powder 1Kg, 5 brush brooms, 150 rolls of hand towel, 13 bottles of liquid soap, 6 household SDSP AMBATOMAINTY gloves, 17 mops, 2 frontal thermometers, 40 washable protective masks, 12 hand washing devices.

20 hydroalcoholic gels 500ml, 40 cans of bleach 5L, 31 soap powder 1Kg, 5 brush brooms, 180 rolls of hand towel, 16 bottles of liquid soap, 6 household SDSP ANTSALOVA gloves, 20 mops, 2 frontal thermometers, 49 washable protective masks, 15 hand washing devices.

20 hydroalcoholic gels 500ml, 32 cans of bleach 5L, 23 soap powder 1Kg, 5 brush brooms, 140 rolls of hand towel, 12 bottles of liquid soap, 6 household SDSP BESALAMPY gloves, 16 mops, 2 frontal thermometers, 28 washable protective masks, 11 hand washing devices. DRSP MELAKY 40 hydroalcoholic gels 500ml, 18 cans of bleach 5L, 24 soap bar 1Kg, 11 brush brooms, 11 rasta brushes, 40 rolls of trash bag 30L, 40 rolls of hand SDSP MORAFENOBE towel, 28 bottles of hand washing soap, 200 chamois, 15 mops, 19 cups, 2 sprayer for disinfections, 20 sprayers.

40 hydroalcoholic gels 500ml, 18 cans of bleach 5L, 24 soap bar 1Kg, 11 brush brooms, 11 rasta brushes, 40 rolls of trash bag 30L, 40 rolls of hand SDSP AMBATOMAINTY towel, 28 bottles of hand washing soap, 200 chamois, 15 mops, 19 cups, 2 sprayers for disinfections, 20 sprayers.

40 hydroalcoholic gels 500ml, 18 cans of bleach 5L, 24 soap bar 1Kg, 11 brush brooms, 11 rasta brushes, 40 rolls of trash bag 30L, 40 rolls of hand SDSP ANTSALOVA towel, 28 bottles of hand washing soap, 200 chamois, 15 mops, 19 cups, 2 sprayers for disinfections, 20 sprayers.

40 hydroalcoholic gels 500ml, 18 cans of bleach 5L, 24 soap bar 1Kg, 11 brush brooms, 11 rasta brushes, 40 rolls of trash bag 30L, 40 rolls of hand SDSP BESALAMPY towel, 28 bottles of hand washing soap, 200 chamois, 15 mops, 19 cups, 2 sprayers for disinfections, 20 sprayers. 70 hydroalcoholic gels 500ml, 5 cans of bleach 5L, 10 bottles of bleach 1L, 2 rolls of trash bag 30L, 10 rolls of hand towel, 2 sprayers for disinfections SDSP AMBILOBE 16L, 80 washable protective masks, 40 bottles of hand washing soap, 25 bottles of liquid soap 500ml, 64 hand washing devices. DRSP DIANA 80 hydroalcoholic gels 500ml, 5 cans of bleach 5L, 10 bottles of bleach 1L, 2 rolls of trash bag 30L, 10 rolls of hand towel, 2 sprayers for disinfections SDSP AMBANJA 16L, 80 washable protective masks, 40 bottles of hand washing soap, 25 bottles of liquid soap 500ml, 72 hand washing devices.

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PLACE OF DESTINATION QUANTITY DEPARTURE 22 bottles of hydroalcoholic gels 500 ml, 30 bottles of bleach 1L, 9 cans of bleach 5L, 22 soap bar 1Kg, 22 soap powder 1Kg, 9 bottles of liquid soap 1L, 12 bottles of hand washing soap 300ml, 92 rolls of hand towel, 10 cups 1L, CSB ANTANIFOTSY 120 chamois, 23 rolls of trash bag 30L, 22 mops, 5 brush brooms, 5 rasta brushes, 1 sprayer for disinfection 5L, 1 frontal thermometer, 5 household gloves, 10 hand washing devices. 4 bottles of hydroalcoholic gels 500 ml, 4 cans of bleach 5L, 2 soap bar 1Kg, 2 soap powder 1Kg, 4 bottles of liquid soap 1L, 5 bottles of hand washing CHRD ANTANIFOTSY soap 300ml, 15 rolls of hand towel, 1 cup 1L, 12 chamois, 6 rolls of trash bag 30L, 2 mops, 2 brush brooms, 2 rasta brushes, 1 frontal thermometer, 2 household gloves, 2 hand washing devices. 24 bottles of hydroalcoholic gels 500 ml, 30 bottles of bleach 1L, 9 cans of bleach 5L, 20 soap bar 1Kg, 24 soap powder 1Kg, 9 bottles of liquid soap 1L, 12 bottles of hand washing soap 300ml, 29 rolls of hand towel, 10 cups 1L, CSB AMBATOLAMPY 120 chamois, 25 rolls of trash bag 30L, 24 mops, 5 brush brooms, 5 rasta brushes, 1 sprayer for disinfection 5L, 1 frontal thermometer, 5 household gloves, 10 hand washing devices. 4 bottles of hydroalcoholic gels 500 ml, 4 cans of bleach 5L, 2 soap bar 1Kg, 2 soap powder 1Kg, 4 bottles of liquid soap 1L, 5 bottles of hand washing DRSP VAKINAN- CHRD AMBATOLAMPY soap 300ml, 15 rolls of hand towel, 1 cup 1L, 12 chamois, 6 rolls of trash KARATRA bag 30L, 2 mops, 2 brush brooms, 2 rasta brushes, 1 frontal thermometer, 2 household gloves, 2 hand washing devices. 26 bottles of hydroalcoholic gels 500 ml, 30 bottles of bleach 1L, 9 cans of bleach 5L, 20 soap bar 1Kg, 26 soap powder 1Kg, 9 bottles of liquid soap 1L, 12 bottles of hand washing soap 300ml, 108 rolls of hand towel, 10 cups 1L, CSB BETAFO 120 chamois, 27 rolls of trash bag 30L, 26 mops, 5 brush brooms, 5 rasta brushes, 1 sprayer for disinfection 5L, 1 frontal thermometer, 5 household gloves, 10 hand washing devices. 20 bottles of hydroalcoholic gels 500 ml, 30 bottles of bleach 1L, 9 cans of bleach 5L, 20 soap bar 1Kg, 20 soap powder 1Kg, 9 bottles of liquid soap 1L, 12 bottles of hand washing soap 300ml, 84 rolls of hand towel, 10 cups 1L, CSB FARATSIHO 120 chamois, 21 rolls of trash bag 30L, 20 mops, 5 brush brooms, 5 rasta brushes, 1 sprayer for disinfection 5L, 1 frontal thermometer, 5 household gloves, 10 hand washing devices. 15 bottles of hydroalcoholic gels 500 ml, 30 bottles of bleach 1L, 19 cans of bleach 5L, 15 soap bar 1Kg, 15 soap powder 1Kg, 9 bottles of liquid soap 1L, 10 bottles of hand washing soap 300ml, 64 rolls of hand towel, 15 cups 1L, CSB MANDOTO 120 chamois, 16 rolls of trash bag 30L, 15 mops, 4 brush brooms, 4 rasta brushes, 1 sprayer for disinfection 5L, 1 frontal thermometer, 4 household gloves, 5 hand washing devices.

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Table 2: Donation from USAID/IMPACT to CCOR/DRSP, CSB, drug shops & pharmacies and Pha-G-Dis

DATE PLACE RECIPIENT ARTICLES & QUANTITY 448 hydroalcoholic gels 500ml, 200 rolls of trash bag 30L, 90 cans of bleach 5L, 150 soap powder 1Kg, 120 soap bar 1Kg, 65 brush brooms, 40 rasta brushes,1150 rolls of hand towel, 140 bottles of hand 10-23-2020 MAINTIRANO DRSP & CCOR MELAKY washing soap 300ml, 80 bottles of liquid soap, 40 household gloves, 95 cups, 200 bottles of bleach 1L, 175 mops, 1000 chamois, 100 sprayers, 10 sprayers for disinfections, 10 frontal thermometers, 1000 washable protective masks, 75 hand washing devices.

360 bottles of hydroalcoholic gels 500 ml, 180 cans of bleach 5L, 3 bottles of bleach 1L, 250 bottles of hand washing soap 250ml, 5 bottles of liquid soap 1L, 60 soap powder 1Kg, 120 rolls of trash bag DRSP & CCOR HAUTE 30L, 120 rolls of trash bag 100L, 240 rolls of hand towel, 360 10-30-2020 FIANARANTSOA MATSIATRA chamois, 60 brush brooms, 120 mops, 63 household gloves, 45 plastic bucket 15L, 45 cups 1L, 3500 flyers, 348 posters (sensitization, masks, prevention), 70 hand washing posters, 730 washable protective masks, 144 hand washing devices.

350 bottles of hydroalcoholic gels 500 ml, 180 cans of bleach 5L, 250 bottles of hand washing soap 250ml, 5 bottles of liquid soap 1L, 60 DRSP & CCOR VATOVAVY soap powder 1Kg, 120 rolls of trash bag 30L, 120 rolls of trash bag 10-21-2020 MANAKARA FITOVINANY 100L, 240 rolls of hand towel, 360 chamois, 60 brush brooms, 120 mops, 60 household gloves, 22 hand washing posters, 730 washable protective masks.

800 bottles of hydroalcoholic gels 500 ml, 70 cans of bleach 5L, 70 of bottles of virucide 250ml, 450 bottles of liquid soap 300ml, 300 rolls DRSP & CCOR ATSIMO 10-09-2020 TOLIARA of trash bag 100L, 250 rolls of trash bag 30L, 150 rolls of hand towel, ANDREFANA 250 chamois, 90 brush brooms, 80 mops, 45 plastic bucket 15L, 45 cups 1L.

3 CSB (TANAMBAO, 6 bottles of hydroalcoholic gels 500 ml, 3 cans of bleach 5L, 06 10-28-2020 TOLIARA SANFIL, BETANIA) bottles of hand washing soap 300ml, 20 hand washing posters, 3 household gloves, 4 hand washing devices.

180 bottles of hydroalcoholic gels 500 ml, 200 bottles of bleach 1L, 90 cans of bleach 5L, 140 soap bar 1Kg, 172 soap powder 1Kg, 130 hand washing soap 300ml, 90 liquid soap 1L, 949 rolls of hand DRSP & CCOR towel, 95 cups 1L, 1464 chamois, 200 rolls of trash bag 30L, 170 10-13-2020 ANTSIRABE VAKINANKARATRA mops, 45 brush brooms, 45 rasta brushed, 10 sprayers for disinfections 5L, 130 sprayers 500ml, 10 frontal thermometers, 45 household gloves, 750 washable protective masks,75 hand washing devices.

DRSP & CCOR 10-13-2020 TOAMASINA 150 hand washing devices. ATSINANANA 8 CSB (MAHANORO, 80 mops, 20 garbage bins stainless, 400 sterile compress, 50 hand 10-26-2020 ATSINANANA BRICKAVILLE) washing devices. 12 CSB (SAINTE-MARIE, 100 bottles of hydroalcoholic gels 500 ml, 637 rolls of hand MAHAMBO, FENERIVE- towel, 100 liquid soap 1L, 24 soap powder 1Kg, 20 cans of virucide 10-28-2020 ANALANJIROFO EST, FOULPOINTE, 5L, 38 mops, 20 rolls of trash bag, 51 garbage bins with pedal, 161 SOANIERANA-IVONGO, sterile compress 30*30, 62 washable protective masks. VAVATENINA,) 550 bottles of hydroalcoholic gels 500 ml, 100 bottles of bleach 1L, DRSP & CCOR BOENY 90 cans of bleach 5L, 30 cans of virucide 5L, 35 rolls of trash bag 10-21-2020 MAHAJANGA Drug shops & 100L, 125 rolls of hand towel, 60 chamois, 150 hand washing soap, pharmacies 50 mops, 20 brush brooms, 30 plastic bucket 15L, 4 trash bin 120L, 6 plastic buckets with rasta brush, 30 cups 1L, 216 soap, 7 sprayers for

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DATE PLACE RECIPIENT ARTICLES & QUANTITY disinfections, 450 washable protective masks, 75 hand washing devices.

625 bottles of hydroalcoholic gels 500 ml, 100 cans of bleach 5L, 40 cans of virucide 5L, 7 sprayers for disinfections, 125 rolls of hand towel, 60 chamois,7 plastic bucket with rasta brush, 35 rolls of trash 10-21-2020 ANTSOHIHY DRSP & CCOR SOFIA bag 100L, 30 plastic bucket 20L, 30 cups 1L, 50 mops, 20 brush brooms, 216 soap, 1280 washable protective masks, 75 hand washing devices.

500 bottles of hydroalcoholic gels 500 ml, 50 cans of bleach 5L, 100 bottles of bleach 1L, 3 cans of multi-surface disinfectant 5L, 5 cans of virucide 5L, 30 rolls of trash bag 30L, 25 rolls of trash bag 120L, 120 DRSP & CCOR DIANA rolls of hand towel, 40 chamois, 10 plastic bucket with rasta brush, 10-16-2020 ANTSIRANANA Drug shops & 250 bottles of liquid soap 500ml, 240 hand washing soap, 10 pharmacies household gloves, 10 plastic bucket with rasta brush, 5 trash bin 120L, 14 sprayers for disinfections 16L, 500 washable protective masks, 275 hand washing devices.

400 bottles of hydroalcoholic gels 500 ml, 35 cans of bleach 5L, 4 cans of virucide 5L, 30 rolls of trash bag 30L, 120 rolls of hand towel, 40 chamois, 180 bottles of liquid soap 500ml, 75 hand washing DRSP & CCOR SAVA & devices, 200 bottles of liquid soap 500ml, 4 trash bin 120L, 4 plastic 10-22-2020 SAMBAVA Drug shops & bucket with rasta brush, 6 household gloves, 15 rolls of trash bag pharmacies 120L, 2 cans of multi-surface disinfectant 5L, 100 hand washing posters, 800 posters (sensitization, masks, prevention), 3000 flyers, 7 sprayers for disinfections 16L, 500 washable protective masks.

690 bottles of hydroalcoholic gels 500 ml, 45 cans of bleach 5L, 50 bottles of virucide 250ml, 220 rolls of trash bag 30L, 200 rolls of 10-15-2020 MORONDAVA DRSP & CCOR MENABE trash bag 100L , 100 rolls of hand towel, 410 bottles of liquid soap 250ml, 200 chamois, 50 brush brooms, 50 mops, 30 plastic bucket 15L, 30 cups 1L, 750 washable protective masks.

SDSP MAHABO, 5 bottles of hydroalcoholic gels 500 ml, 4 cans of bleach 5L, 5 bottles 10-16-2020 MORONDAVA MORONDAVA, of hand washing soap 300ml, 20 hand washing posters, 3 household MIANDRIVAZO gloves, 4 hand washing devices

Drug shops & 38 bottles of hydroalcoholic gels 500ml, 136 posters (masks, 10-02-2020 TOAMASINA pharmacies sensitization, prevention), 38 bottles of Sûr’Eau, 57 washable ATSINANANA protective masks, 15 hand washing devices. Drug shops & 55 bottles of hydroalcoholic gels 500ml, 66 posters (masks, 10-05-2020 FENERIVE-EST pharmacies sensitization, prevention), 44 bottles of Sûr’Eau, 22 hand washing ANALANJIROFO devices. 10-05-2020 13 USAID- 390 bottles of hydroalcoholic gels 500 ml, 156 cans of bleach 5L, to supported 78 Pha-G-DIS 2340 washable protective masks, 156 boxes of surgical gloves. 10-16-2020 REGIONS

Table 3: Disinfection of PSI offices, warehouses, and vehicles

REGIONS ITEMS DISINFECTED PROVIDERS DIANA 1 Office/1 Warehouse ATSINANANA 1 Office/1 Warehouse/1 Vehicle VAKINANKARATRA 1 Office/1 Warehouse BHL SAVA 1 Office/1 Warehouse ANALANJIROFO 3 Vehicles HAUTE MATSIATRA 1 Office/1 Warehouse ALEO MISOROKA

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REGIONS ITEMS DISINFECTED PROVIDERS VATOVAVY FITOVINANY 1 Office/1 Warehouse MELAKY 1 Office/1 Warehouse RINDRA CONSULTING BOENY 1 Office/1 Warehouse/2 Vehicles ALITIA SOFIA 1Office/1 Warehouse/2 Vehicles RAKOTONIAINA ATSIMO ANDREFANA 1 Office/1 Warehouse SUD ENVIRONNEMENT VAKINANKARATRA/ATSIMO ANDREFANA/MELAKY/ HAUTE 8 Vehicles STATION SERVICE MATSIATRA MENABE/ SAVA/ VATOVAVY 6 Vehicles DRIVER HIMSELF (with sprayed bleach) FITOVINANY/DIANA

Table 4 : Details of the virtual meetings organized by the CCRCE led by DPS

NUMBER OF SUB-COMMITTEE MAIN SUBJECT PERIOD MEETINGS - Revision of COVID-19 messages based on results of KAP (Knowledge, Attitude, and Practice) survey and Qualitative survey conducted by the Capsule Agency. - Follow up of communication activities: sketches and October 05th, 15th, 03 Mass communication broadcasting of TV and radio spots. 22nd - Discussions on mass-media communications and channels to be produced that are appropriate for the context of progressive coming back to normal life after stabilization of COVID-19 in Madagascar The meeting was organized by the MoPH, Ministry of Communication, the TFPs facilitated by DPS and IMPACT Bloggers, vloggers, and attended by 30 participants. 01 and influencers on Participants discussed on new communication strategies October 08th, 2020 Facebook (content of messages and channels) in the context of progressive coming back to normal life after stabilization of COVID-19 in Madagascar Table 5: WASH and waste management equipment provided by USAID/IMPACT and distributed to hospitals

PLACE RECIPIENT ARTICLES & QUANTITY CHU MITSINJO 6 plastic bucket 20L, 56 garbage bin with pedal, 1,000 washable protective TOLIARA BETANIMENA masks. 120 bottles of bleach 1L, 40 rolls of trash bag 100L, 2375 rolls of hand towel, 50 mops, 100 bottles of liquid soap 1L, 66 soap powder 1Kg, 30 CHU ANDRAINJATO household gloves, 6 brush brooms, 6 rasta brushes, 6 jerrycan 20L, 11 frontal thermometers, 260 boxes of surgical gloves, 24 bottles of Betadin dermal 125 ml, 30 hand washing devices.

100 bottles of bleach 1L, 65 soap powder 1Kg, 71 rolls of trash bag 100L, FIANARANTSOA 71 rolls of trash bag 30L, 1992 rolls of hand towel, 40 mops, 92 bottles of liquid soap 1L, 30 household gloves, 6 brush brooms, 6 rasta brushes, 6 plastic bucket 15L, 6 plastic bucket 20L, 6 soubique,6 rakes, 2 CHRR TAMBOHOBE wheelbarrow metallic, 66 garbage bin with pedal, 18 frontal thermometers, 100 boxes of surgical gloves, 3500 flyers, 300 posters (sensitization, masks, prevention), 70 hand washing posters, 850 washable protective masks. 167 hand washing devices.

CHU MORAFENO, 134 cans of bleach 5L, 2304 rolls of hand towel, 40 rolls of trash bag, 192 TOAMASINA CHU bottles of liquid soap 1L, 226 soap powder 1Kg, 50 household gloves, 10

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PLACE RECIPIENT ARTICLES & QUANTITY ANALANKINININA, mops, 6 brush brooms, 6 rasta brushes, 6 soubique, 6 plastic bucket 15L, 6 PNEUMOLOGY plastic bucket 20L, 6 rakes, 2 wheelbarrows metallic, 94 garbage bin with DEPARTMENT pedal, 1 trash bin 50L, 1 trash bin 120L, 12 jerrycan 20L, 97 betadine yellow, 46 frontal thermometers, 407 hand washing devices.

992 sterile compress, 14 hand washing posters, 2 trash bin 120L, 12 hand FENERIVE-EST CHRR FENERIVE-EST washing devices. 2 bottles of hydroalcoholic gels 500 ml, 20 cans of bleach 5L, 20 cans of virucide 5L 1337 rolls of hand towel, 30 rolls of trash bag 100L, 2 bottles of liquid soap 1L, 16 soap powder 1Kg, 31 household gloves, 45 mops, 3 brush brooms, 3 rasta brushes, 2 plastic bucket with rasta, 3 soubique, 3 CHU MAHAVOKY plastic bucket 15L, 3 plastic bucket 20L, 1 rake, 1 wheelbarrow metallic, 2 trash bin 120L,6 jerrycan 20L, 2 sprayers for disinfection, 12 betadine yellow, 13 frontal thermometers, 800 washable protective masks, 29 hand washing devices. MAHAJANGA 2 bottles of hydroalcoholic gels 500 ml, 20 cans of bleach 5L, 20 cans of virucide 5L 1337 rolls of hand towel, 30 rolls of trash bag 100L, 2 bottles of liquid soap 1L, 16 soap powder 1Kg, 31 household gloves, 45 mops, 3 brush brooms, 3 rasta brushes, 2 plastic bucket with rasta, 3 soubique, 3 CHU PZGA ANDROVA plastic bucket 15L, 3 plastic bucket 20L, 1 rake, 1 wheelbarrow metallic, 2 trash bin 120L,6 jerrycan 20L, 2 sprayers for disinfection, 12 betadine yellow, 13 frontal thermometers, 900 washable protective masks, 29 hand washing devices.

Table 6 : USAID/IMPACT donations transported to hospitals and CCOR/DRSP

DEPARTURE DESTINATION ITEM QUANTITY GARBAGE BIN STAINLESS STEEL WITH CHU ANALAKINININA PEDAL 12 L - PIECE 50 TOAMASINA GARBAGE BIN STAINLESS STEEL WITH CHRR FENRIVE EST PEDAL 12 L - PIECE 25 SOAP POWDER 1KG - PIECE 30 BASINS 50L - PIECE 30 CCOR/DRSP CHAMOIS - PIECE 300 ANTANANARIVO ANTSIRABE HAND TOWEL - ROLL 300 WASHABLE PROTECTIVE MASKS - PIECE 1 000

Table 7 : TV and radio spots broadcasted on COVID-19

Number of Number of Campaign Region Districts districts spots aired Boeny 3 216 Majunga I- II/Marovoay Vatomandry/Mahanoro/Maroantsetra/Marolambo/Toama Atsinanana 7 189 sina I - II/ Tanambao Manampotsy Broadcasting of Analanjirofo 3 108 Fenerive Est/Vavatenina/ Mananara Nord radio spots on Menabe 1 108 Morondava COVID-19 Vakinankaratra 2 216 Antsirabe I-II Amoron'i Mania 2 216 Ambositra/ Fandriana Haute Matsiatra 4 324 Fianarantsoa I -II/ Lalangina/ Vohibato

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Number of Number of Campaign Region Districts districts spots aired Vatovavy 3 81 Vohipeno/Manakara/Mananjary Fitovinany Atsimo 4 189 Toliara I - II/Sakaraha/ Ampanihy Andrefana Diana 5 432 Antsiranana I -II/Ambilobe/Ambanja/Nosy Be Sava 4 432 Sambava/Antalaha/Vohémar/Andapa Sofia 2 216 Antsohihy/Mampikony Melaky 1 118 Morafenobe National National Coverage Coverage 216 All through through RNM RNM Total of radio 38 3,061 spots Boeny 2 130 Mahajanga I -II/Marovoay Atsinanana 2 195 Toamasina I-II Menabe 1 65 Morondava Vakinankaratra 2 65 Antsirabe I -II Haute Matsiatra 2 130 Fianarantsoa I -II/ Lalangina V7V 2 84 Manakara/Mananjary Atsimo 2 42 Toliara I- II Broadcasting of Andrefana TV spots on Diana 2 130 Antsiranana I- II COVID-19 Sava 1 65 Antalaha Sofia 1 65 Antsohihy National National Coverage Coverage through TV through TV 252 All stations on stations on Satellite Satellite Total TV spots 17 1,223

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ANNEX I - Findings of the exercise for identification of drug shops and pharmacies (Atsimo Andrefana)

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Drug Shops n =?? Pharmacies n = ??

Sex disaggregation of drug shop owners Sex disaggregation of drug shop owners

39% of drug shop owners are men and 61% are Comparing drug shop owners, 71% are men and 29% women are women

Most of the drug shop owners have a university degree. This may facilitate the training

Tools used in Drug shops Tools used in Pharmacies

68% of drug shops do not use tools. Only 7% are 57% of Pharmacies are using electronic tools and using excel and 25% are using books 43% are using books

Drugs shops affiliated with financial institutions Pharmacies affiliated with financial institutions 61% of drug shops are not affiliated with financial All pharmacies are affiliated with financial institutions. 39% are affiliated with BOA Bank. institutions

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Drugs shops suppliers Pharmacies suppliers 75% of drug shops are supplied by wholesalers and 100% of pharmacies are supplied by wholesaler 21% by pharmacies importers.

Main findings: - 68% of drug shops do not use tools. Only 7% are using excel and 25% are using books. - 57% of Pharmacies are using electronic tools and 43% are using books. - None of the drug shops and pharmacies are reporting data to the MOPH as MOPH does not request data from them. - The majority of drug shops do not manage their stock, but only the sales status/situation (They are only interested in sales not stock management). However, they were motivated to learn how to use stock management tool. This is an opportunity to introduce tools and build capacity for these commercial actors. The training will be provided by MOPH and IMPACT - Drug shops location are covered by internet. It will facilitate data report.

The following findings are already shared with each responsible in IMPACT: - 90% of drug shops and pharmacies underlined the stock out of malaria commodities (ACT and SP) during the past months. - PSI collects malaria data (health commodities availability) from the drug shops on a monthly basis or on an occasional basis depending on the location of the drug shops. 50% of the drug shops are involved in this reporting to PSI, which demonstrates their willingness to share data. - Sales of illegal health products in the region

Compared to regions previously visited by IMPACT, the drug shops in Atsimo Andrefana are located in more rural areas and gathering them in Toliara for the capacity building training will be a challenge. IMPACT will propose holding capacity building sessions in two different locations chosen to convene drug shops so that more drug shops can attend.

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ANNEX J- Details on malaria commodities redeployments

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Malaria commodity redeployments - Pha-G-Dis to Pha-G-Dis

Quantity Pha-G-Dis Pha-G-Dis Date of the Technical specification - product (treatment/ provider beneficiary redeployment tablet/ vial/ tests) Artesunate/Amodiaquine 25/67.5 mg Tablet, ANTANIFOTSY 13 BETAFO Oct-20 25 x 3 Blister Pack Tablets Artesunate/Amodiaquine 50/135 mg Tablet, ANTANIFOTSY 20 BETAFO Oct-20 25 x 3 Blister Pack Tablets Artesunate/Amodiaquine 100/270 mg ANTANIFOTSY 58 BETAFO Oct-20 Tablet, 25 x 3 Blister Pack Tablets Artesunate/Amodiaquine 100/270 mg ANTANIFOTSY 227 BETAFO Oct-20 Tablet, 25 x 6 Blister Pack Tablets ANTANIFOTSY QUININE 300mg 300 MANDOTO Oct-20 Artesunate INJ (w/ 1 Amp NaHCO3 5% + 1 ANTANIFOTSY 2 Antsirabe 2 Oct-20 Amp NaCl 0.9%) 60 mg Vial, 1 Set Artesunate INJ (w/ 1 Amp NaHCO3 5% + 1 Mandoto 20 BETAFO Oct-20 Amp NaCl 0.9%) 60 mg Vial, 1 Set Artesunate INJ (w/ 1 Amp NaHCO3 5% + 1 Mandoto 5 Antsirabe 2 Oct-20 Amp NaCl 0.9%) 60 mg Vial, 1 Set Artesunate INJ (w/ 1 Amp NaHCO3 5% + 1 MAHAJANGA I 15 SOALALA Oct-20 Amp NaCl 0.9%) 60 mg Vial, 1 Set Sulfadoxine/Pyrimethamine 500/25 mg MANJA 11,400 MORONDAVA Oct-20 Tablet, 150 Tablets Sulfadoxine/Pyrimethamine 500/25 mg BELO SUR MANJA 12,600 Oct-20 Tablet, 150 Tablets TSIRIBIHINA Sulfadoxine/Pyrimethamine 500/25 mg MANJA 16,200 MAHABO Oct-20 Tablet, 150 Tablets Sulfadoxine/Pyrimethamine 500/25 mg MANJA 10,800 MIANDRIVAZO Oct-20 Tablet, 150 Tablets Artesunate/Amodiaquine 25/67.5 mg Tablet, BETIOKY 900 AMPANIHY Oct-20 25 x 3 Blister Pack Tablets Artesunate/Amodiaquine 50/135 mg Tablet, SAKARAHA 200 AMPANIHY Oct-20 25 x 3 Blister Pack Tablets Artesunate/Amodiaquine 25/67.5 mg Tablet, AMPANIHY 250 TULEAR II Oct-20 25 x 3 Blister Pack Tablets BETIOKY SUD QUININE 300mg 300 TULEAR II Oct-20 BETIOKY SUD QUININE 300mg 200 TULEAR I Oct-20 Artesunate/Amodiaquine 50/135 mg Tablet, BETIOKY SUD 75 SAKARAHA Oct-20 25 x 3 Blister Pack Tablets Artesunate/Amodiaquine 25/67.5 mg Tablet, BETIOKY SUD 25 TULEAR II Oct-20 25 x 3 Blister Pack Tablets Artesunate INJ (w/ 1 Amp NaHCO3 5% + 1 BETIOKY SUD 10 TULEAR II Oct-20 Amp NaCl 0.9%) 60 mg Vial, 1 Set Sulfadoxine/Pyrimethamine 500/25 mg Marolambo 27,000 Tamatave I Oct-20 Tablet, 150 Tablets Sulfadoxine/Pyrimethamine 500/25 mg Marolambo 27,000 Tamatave II Oct-20 Tablet, 150 Tablets Sulfadoxine/Pyrimethamine 500/25 mg Marolambo 27,000 Brickaville Oct-20 Tablet, 150 Tablets

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Quantity Pha-G-Dis Pha-G-Dis Date of the Technical specification - product (treatment/ provider beneficiary redeployment tablet/ vial/ tests)

Sulfadoxine/Pyrimethamine 500/25 mg Marolambo 32,400 Vatomandry Oct-20 Tablet, 150 Tablets Sulfadoxine/Pyrimethamine 500/25 mg Marolambo 21,600 Mahanoro Oct-20 Tablet, 150 Tablets Sulfadoxine/Pyrimethamine 500/25 mg Antanambao Marolambo 10,800 Oct-20 Tablet, 150 Tablets Manapotsy Sulfadoxine/Pyrimethamine 500/25 mg Marolambo 43,200 Fenerive Est Oct-20 Tablet, 150 Tablets Sulfadoxine/Pyrimethamine 500/25 mg Marolambo 43,200 Vavatenina Oct-20 Tablet, 150 Tablets Sulfadoxine/Pyrimethamine 500/25 mg Marolambo 16,200 Soanierana Ivongo Oct-20 Tablet, 150 Tablets Sulfadoxine/Pyrimethamine 500/25 mg Marolambo 5,400 Sainte Marie Oct-20 Tablet, 150 Tablets Sulfadoxine/Pyrimethamine 500/25 mg Marolambo 21,600 Mananara nord Oct-20 Tablet, 150 Tablets Sulfadoxine/Pyrimethamine 500/25 mg Marolambo 5,400 Maroantsetra Oct-20 Tablet, 150 Tablets Sulfadoxine/Pyrimethamine 500/25 mg Marolambo 10,800 Ambatondrazaka Oct-20 Tablet, 150 Tablets Sulfadoxine/Pyrimethamine 500/25 mg Marolambo 10,800 Amparafaravola Oct-20 Tablet, 150 Tablets Sulfadoxine/Pyrimethamine 500/25 mg Marolambo 10,800 Andilamena Oct-20 Tablet, 150 Tablets Sulfadoxine/Pyrimethamine 500/25 mg Marolambo 32,400 Anosibe Anala Oct-20 Tablet, 150 Tablets Sulfadoxine/Pyrimethamine 500/25 mg Marolambo 32,400 Moramanga Oct-20 Tablet, 150 Tablets Sulfadoxine/Pyrimethamine 500/25 mg Marolambo 5,400 Tsaratanana nord Oct-20 Tablet, 150 Tablets Artesunate/Amodiaquine 25/67.5 mg Tablet, ANTANIFOTSY 17 BETAFO Nov-20 25 x 3 Blister Pack Tablets Artesunate/Amodiaquine 50/135 mg Tablet, ANTANIFOTSY 7 BETAFO Nov-20 25 x 3 Blister Pack Tablets Artesunate/Amodiaquine 100/270 mg ANTANIFOTSY 13 BETAFO Nov-20 Tablet, 25 x 3 Blister Pack Tablets Artesunate/Amodiaquine 100/270 mg ANTANIFOTSY 171 BETAFO Nov-20 Tablet, 25 x 6 Blister Pack Tablets Artesunate/Amodiaquine 25/67.5 mg Tablet, Bealanana 100 Ambanja Nov-20 25 x 3 Blister Pack Tablets Artesunate/Amodiaquine 100/270 mg Bealanana 175 Ambanja Nov-20 Tablet, 25 x 6 Blister Pack Tablets Artesunate/Amodiaquine 100/270 mg Bealanana 175 Ambanja Nov-20 Tablet, 25 x 3 Blister Pack Tablets Artesunate/Amodiaquine 25/67.5 mg Tablet, Bealanana 250 Port Berge Nov-20 25 x 3 Blister Pack Tablets

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Quantity Pha-G-Dis Pha-G-Dis Date of the Technical specification - product (treatment/ provider beneficiary redeployment tablet/ vial/ tests)

Artesunate/Amodiaquine 100/270 mg Bealanana 150 Port Berge Nov-20 Tablet, 25 x 6 Blister Pack Tablets Artesunate/Amodiaquine 100/270 mg Bealanana 675 Port Berge Nov-20 Tablet, 25 x 3 Blister Pack Tablets Malaria Rapid Diagnostic Test (RDT) Analalava 3,550 Mampikomy Nov-20 HRP2/pLDH (Pf/PAN) Cassette, 25 Tests Sulfadoxine/Pyrimethamine 500/25 mg Ikalamavony 10,800 Ambositra Nov-20 Tablet, 150 Tablets Artesunate INJ (w/ 1 Amp NaHCO3 5% + 1 Betioky Sud 90 Morombe Dec-20 Amp NaCl 0.9%) 60 mg Vial, 1 Set Sulfadoxine/Pyrimethamine 500/25 mg MORONDAVA 21,600 BETAFO Dec-20 Tablet, 150 Tablets

Recap

DISTRICTS Q1 Pha-G-Dis providers 14 Pha-G-Dis beneficiaries 35

Malaria commodity redeployments - CHRR to CSB

Quantity Date of the CHRR provider Technical specification - product CSB beneficiary (treatment) redeployment

Artesunate/Amodiaquine 25/67.5 mg Tablet, CHRR MANAKARA 5 OSIEM Nov-20 25 x 3 Blister Pack Tablets Artesunate/Amodiaquine 25/67.5 mg Tablet, CHRR MANAKARA 3 CSB U Manakara Nov-20 25 x 3 Blister Pack Tablets Artesunate/Amodiaquine 25/67.5 mg Tablet, CHRR MANAKARA 2 CSB Tanakidy Nov-20 25 x 3 Blister Pack Tablets Artesunate/Amodiaquine 25/67.5 mg Tablet, CHRR MANAKARA 6 CSB 1 Filadelfia Nov-20 25 x 3 Blister Pack Tablets Artesunate/Amodiaquine 100/270 mg CHRR MANAKARA 10 CSB 1 Filadelfia Nov-20 Tablet, 25 x 3 Blister Pack Tablets Artesunate/Amodiaquine 100/270 mg CHRR MANAKARA 25 CSB U Manakara Nov-20 Tablet, 25 x 3 Blister Pack Tablets Artesunate/Amodiaquine 100/270 mg CHRR MANAKARA 10 OSIEM Nov-20 Tablet, 25 x 3 Blister Pack Tablets

Recap DISTRICTS Quarter 1 CHRR Provider 1 CSB beneficiaries 5

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