PMI/ARM3 Accelerating the Reduction of Malaria Morbidity and Mortality Program

Quarterly Report 25 October 1 – December 31, 2017

January 2018 PMI/ARM3 Accelerating the Reduction of Malaria Morbidity and Mortality Program (ARM3)

Quarterly Report 25 October 1 to December 31, 2017 Fiscal Year 2018, Program Year 7

Submitted to:  Michelle Kouletio, Acting Family Health Team Leader and Resident PMI Advisor/Agreement Officer’s Representative, USAID/  Alexis Y. Tchevoede, National Malaria Control Program (NMCP) Coordinator  Zannou Ahissou Robert Franck, Maternal and Child Health Director

Cover photo: From left to right Ms. Baboukari Djaria and Ms. Amirou Zoulfaou, pregnant women attended at ANC visit in Soubroukou HF, and Ouake (DCO) HZ, Credit: ARM3

PMI/ARM3, Accelerating the Reduction of Malaria Morbidity and Mortality Program (ARM3), is funded by the United States Agency for International Development (USAID), under Cooperative Agreement AID680-A-11-00001. ARM3 is managed by Medical Care Development International (MCDI) as the prime. The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or of the United States Government. Table of Contents

Acronyms ...... 4 Executive Summary ...... 5 Introduction ...... 9 Result 1: Strengthen the effectiveness of the National malaria prevention interventions ...... 10 Sub-Result 1.1a: SBCC Activities conducted in support of prevention and case management interventions ...... 10 Sub-result 1.1b: Increase coverage of intermittent preventive treatment during pregnancy (IPTp) per new national norms ...... 15 Sub‐result 1.1c: Increase universal access and utilization of LLINs ...... 18 Result 2: Improve and Implement Malaria Diagnosis and Treatment Activities in Support of the National Malaria Strategy ...... 23 Sub-Result 2.1: Improve Diagnostic Capacity and Use of Diagnostic Testing ...... 23 Sub-Result 2.2: Improve Case Management of Uncomplicated and Severe Malaria ...... 27 Sub-result 2.3: Improve integrated Community Case Management (iCCM) ...... 31 Result 3: The National Health System's Capacity to Deliver and Manage Quality Malaria Treatment and Control Investigations Strengthened ...... 35 Sub-result 3.1: Enhance the NMCP's Technical Capacity to Plan, Design, Manage and Coordinate a Comprehensive Malaria Control Program ...... 35 Sub-result 3.2: MOH Capacity to Collect, Manage, and Use Malaria Health Information for Monitoring, Evaluation, and Surveillance Improved ...... 40 Sub-result 3.3: Improve MOH Capacity in Commodities and Supply Chain Management ...... 50 Program management ...... 62 Field Office ...... 62 Home Office ...... 63 Major Activities Planned for Next Quarter (Year 7, January–March 2018) ...... 63 Financial Summary & Annexes...... 66

ARM3 Quarter 25 Report (October-December 2017) Page | 3 Acronyms

ARM3 Quarter 25 Report (October-December 2017) Page | 4 Executive Summary

ARM3 Sub-Results Key Achievements/Challenges Results  Technical assistance provided to the NMCP to integrate the revised SBCC strategy of the National SBCC Plan in collaboration with the GFATM and the CRS CATCH project o A new National Integrated Communication Plan was 1.1a: SBCC Activities developed conducted in support of  In collaboration with the NMCP, ARM3 conducted a post- prevention and case training follow-up supervision of health workers (HWs) on management interpersonal communication in NBT, TCM and 2KP HZs of interventions the Atacora Department  Provided technical assistance to the NMCP to carry out a post-training follow-up of HWs in the 3 HZs (NBT, TCM and 2KP in Atacora department on interpersonal communication to intensify BCC interventions 1.1b: Coverage of intermittent Preventive treatment during  1,060 out of 1,155 health facilities (HFs) submitted reports 1. Strengthen for July-September 2017 the pregnancy (IPTp) per new national norms  Compared to last quarter, the IPTp2 coverage increased effectiveness from 61.1% to 66.5% of the national increased malaria  Participated in the mass LLIN distribution campaign prevention organized by the NMCP in the center and southern DDS in interventions Benin o 100% of the sites were covered by SBCC activities o 2,003,723 of 1,515,744 households (HH) were inventoried (132.2%) with a predominant size of 3 - 6 persons 1.1c: Universal access o 1,921,708 HHs received LLINs out of 2,003,723 and utilization of LLIN counted (95.9%) increased o 4,363,460 LLINs distributed versus population of 4,526,622 inventoried (96.40%) o Average of 2.53 LLINs distributed per household  Technical and financial support provided to the NMCP to review, update, validate IPTp, LLIN and prompt care- seeking messages and materials  Jointly with the NMCP, supervised data collection as part of the baseline evaluation of the LLIN distribution in prioritized schools

ARM3 Quarter 25 Report (October-December 2017) Page | 5 ARM3 Sub-Results Key Achievements/Challenges Results  Finalized the updated OTSS database and trained the NMCP lab technicians at the NMCP level to use this database  In collaboration with the NMCP, conducted a post-training 2.1 Diagnostic capacity follow-up of 22 private sector lab technicians trained in Y6 and use of diagnostic  Technical and financial support provided to the NMCP with testing improved 204 standard malaria slides for use during the lab technician training sessions  Participated in training 60 newly-hired lab technicians from the public sector in malaria microscopy and RDTs o 36 newly-hired lab technicians from public sector were trained in malaria microscopy and RDTs with ARM3 technical assistance  Participated in a technical committee meeting for the 2.2 Case management introduction of injectable and rectal artesunate through of uncomplicated and HFs in Benin  Provided technical and financial support to the NMCP to 2. Improve severe malaria improved develop a database on training for malaria including a and implement training plan for a pre-service and in-service training of malaria HWs in the public and private sectors Diagnosis and  Supported the DNSP to organize three dissemination Treatment workshops of National Community Health Policy and the Activities in National guidelines for monitoring and evaluation of the support of the PIHI-COM for 112 local authorities, HWs and CHWs of the National communes of , ZE and Malaria  Participated in a workshop to review certain standards of Strategy PIHI-COM in order to obtain training modules for CHWs and tools to report the implementation of the PIHI-COM in urban and peri-urban areas  Technical assistance provided to BUPDOS to organize capacity-building for social health workers and community 2.3. Integrated facilitators on post-training follow-up, supervision and community case evaluation of CHWs in the CBGH HZ. management improved  Technical and financial assistance to DDS Zou/Collines and to the Cove-- (CoZO) and -Banté (SaBa) HZs for analyzing data collected through CHWs group monitoring sessions.  In collaboration with the DNSP and the NMCP jointly supervised CHWs in 2 HZs (SaBa and CoZo) through monthly field visits o 150 CHWs were visited o 97,65% (1,413/1,447) of children admitted for fever were tested for malaria o 86,05% (1216/1413) of those tested were positive

ARM3 Quarter 25 Report (October-December 2017) Page | 6 ARM3 Sub-Results Key Achievements/Challenges Results and received ACT as treatment

3.1 Enhance the  Participated in the 2017-Integrated Annual Work Plan NMCP’s technical (PITA) evaluation and the development of annual 2018- capacity PITA to plan, design, o ARM3 achievement rate is 88% (37/42) manage, and o NMCP achievement rate is 93% (187/189) coordinate a comprehensive  Participated in the validation of 2017-2021 National malaria control Strategic Plan for malaria control program Technical assistance provided to the NMCP to organize 2TWG meetings (BCC and M&E)

 Provided technical assistance to the NMCP to conduct a semi-annual supervision of 154 HFs within the 34 HZs o 74% of Chef-posts were trained on RMIS procedures. 3.2 MOH capacity to 3. The National o The RMIS User Guide was available in only 17% of collect, manage Health and use malaria health the health facilities visited. System’s information  Technical and financial support to Atacora and Donga DDS Capacity to for monitoring, to organize a review of their workplans Deliver and evaluation and  Technical and financial support to Borgou DDS to organize Manage surveillance improved a Radio-reality at Gamia (Bembèrèkè) Quality  Supported the Djougou-Copargo-Ouaké, , DDS Malaria Borgou, -Karimama and HZs to organize Treatment and Quarterly Malaria Indicators Review Workshop for Control decision-making Investigations  Technical and financial assistance provided to the NMCP Strengthened to pilot the process to integrate private sector in subsidized malaria commodities o Eighteen (18) private health facilities in the DCO

health zone were enrolled o Forty-nine (49) agents including twenty-five (25) women from eighteen (18) HFs were trained on LMIS 3.3 MOH capacity in and filling out management tools commodities  Supported the NMCP’s supervisory visits to private sector and supply chain HFs to oversee LMIS management and provide on-site management improved coaching in CBGH, AS and DCO HZs o # private HFs that have been supplied with malaria commodities: 16/24 in CBGH, 18/28 in AS and 11/18 in DCO o # private HFs sending monthly order report: 16/16 in CBGH, 15/18 in AS and 5/11 in DCO o # private HFs developed their monthly order report: 16/16 in CBGH, 18/18 in AS and 8/11 in DCO

ARM3 Quarter 25 Report (October-December 2017) Page | 7 ARM3 Sub-Results Key Achievements/Challenges Results o # private HFs having respected the price conditions: 15/16 in CBGH, 15/18 in AS and 8/11 in DCO  Supported the NMCP to conduct a post-training follow up on the use of updated Medistock v6 and its maintenance in 34 GDRZs o Medistock v6 is available and functional in 10/10 DRZs visited o Medistock v6 is currently used in 8/10 DRZs visited  Participated in the semi-annual validation and consolidation of malaria commodities consumption data  Participated at the 10th Summit of the Global Health Supply Chain Summit (GHSCS) 2017 in Ghana

 Participated in the USAID-Benin Biannual Partner meeting held on October 5, 2017  Developed ARM3 Annual performance report Year 6  Finalized and submitted the ARM3 Annual performance report

 Participated in the RBM meeting on October 11, 2017 at Program Field Office the NMCP office management  Finalized and submitted the revised ARM3 Year 7 workplan budget and narrative to USAID on November

21, 2017  Prepared for the MCDI International division Director’s field visit to Benin from January 15 to 19, 2017

Home Office  Supported 5-person NMCP delegation at the 66th annual backstopping and meeting of the American Society of Tropical Medicine and reporting Hygiene (ASTMH) in Baltimore, USA from November 5 to 10, 2017

ARM3 Quarter 25 Report (October-December 2017) Page | 8 Introduction

Accelerating the Reduction of Malaria Morbidity and Mortality Program (ARM3) in Benin is funded by the United States Agency for International Development (USAID) and is led by Medical Care Development International (MCDI) as the prime recipient working in close partnership with the Benin Ministry of Health (MOH) through the National Malaria Control Program (NMCP) to implement the cost extension approved by USAID at the end of October 2016 for an additional period of 21 months (October 1, 2017 to June 30, 2018). ARM3 contributes to the NMCP’s goal of eliminating malaria as a public health problem in Benin by the year 2030. ARM3’s Year 7 total work plan budget is $2,148,460.

ARM3’s Year 7 goal: “To deliver quality, high impact malaria control and prevention services through public, private and community channels that contribute to a measurable reduction in malaria mortality and morbidity in Benin from 2017 to 2018.”

Main achievements during this quarter:

 Revised the Social and Behavior Change Communication (SBCC) strategy of the National SBCC Plan in collaboration with the GFATM and the CRS CATCH project;  Implemented the contingency plan developed after the withdrawal of the AIRS activities to reduce the risk of outbreaks;  Supported the NMCP in the implementation of the mass LLIN distribution Campaign in 8 departments of Central and Southern Health Zones (HZ);  Participated as trainer of the 60 newly-hired lab technicians from public sector in malaria microscopy and RDTs;  Supported new NGO partners in the implementation of the Community PIHI in the six new HZ sites under Phase II;  Participated in the validation of the 2017-2021 National Strategic Plan for malaria control; and,  Organized a Quarterly Malaria Indicators Review Workshop for decision-making, using scorecards and dashboard in selected HZ.

ARM3 Quarter 25 Report (October-December 2017) Page | 9 Result 1: Strengthen the effectiveness of the National malaria prevention interventions

During Quarter 25 (Q25), ARM3 continued to provide technical and financial assistance to the NMCP in support of prioritized prevention interventions. This quarter, ARM3 provided technical assistance to the NMCP to align the national Social and Behavioral Change Communication (SBCC) strategies with new WHO recommendations, increasing the number of desired behaviors to be promoted through key messages to target populations, including pregnant women and caregivers of children < 5 at the community and health facility level. In support of the implementation of the contingency plan in Atacora, staff supported the distribution of 500 DVDs and supervised a post-training follow-up with nurses and midwives who received training on interpersonal communication in August and September 2017. DVDs were distributed to local radio stations that have signed contracts with ARM3.

Sub-Result 1.1a: SBCC Activities conducted in support of prevention and case management interventions

Technical assistance provided to the NMCP to integrate the revised SBCC strategy of the National SBCC Plan in collaboration with the GFATM and the CRS CATCH project

From October 12 to 14, 2017, the NMCP organized a technical working group (TWG) meeting funded by ARM3 and the CATCH project, implemented by Catholic Relief Services (CRS), to revise the conceptual framework of the National SBCC strategy including the integrated communication plan for . The TWG was comprised of 25 participants (6 women) from the Ministry of Health (MOH), National Directorate of Public Health (DNSP), the NMCP, Departmental Director of Health (DDS) of Oueme and Zou, Mayor of Bohicon, ARM3 and other local and international partners. The objectives of this workshop were to analyze and validate the SBCC situational analysis to control malaria in Benin, provide critical analysis of the proposed strategies and communication approaches, as well as to align strategies with WHO recommendations and evidence-based approaches to improving SBCC interventions.

ARM3 Quarter 25 Report (October-December 2017) Page | 10

Photo 1: Participants at the results restitution workshop held in Bohicon on October 12 ‐14, 2017, Credit: ARM3

Two additional workshops were held November 23- 25 and December 27-31, 2017 to proofread and edit the revised National SBCC Strategy document (prepared during the October workshop) and design or adapt messages to WHO recommendations and strategies. Participants included 17 people (4 of them women) from the MOH, NMCP, DNSP, CRS and ARM3. In the coming months, ARM3 will work to further develop the National SBCC Strategy into operational and action plans for Benin to be disseminated at all levels of the health pyramid (National, Departmental and operational).

Photo 2: Participants at the working group during the workshop held on November 23 to 25, 2017. Credit ARM3

ARM3 Quarter 25 Report (October-December 2017) Page | 11

Provided Technical and financial support to the NMCP and DDS Atacora to implement the contingency plan developed after the withdrawal of the AIRS activities to reduce the risk of outbreaks (includes dissemination of radio messages, support to CHWs via printing of materials, radio reality shows and IPC with health workers to raise awareness about health effects and preventive measures).

ARM3 was assigned the implementation of four of the seven strategies in the Atacora contingency plan.

Table 1: Strategies and Key Activities/Results of ARM3’s implementation of the Contingency plan in Atacora

Strategy implemented Key Activities/Results  Multiplication and distribution of 500 DVDs of video clips "Palu tue" and "Mieux connaitre le paludisme pour l’éviter” produced by Ya Salam and the Association of Women Singers in Benin respectively in NBT and TMC HZs  Provision of 500 DVDs of video clips "Palu tue" and "Mieux connaitre le Communication plan adapted to socio-anthropological realities paludisme pour l’éviter” for radio station broadcasting  Supervision of local radio stations on broadcasting messages about IPTp, LLINs and prompt care-seeking  Supervision of the public mobilizers to deliver a package of messages on malaria prevention and case management in their respective communities

 Collected and analyzed data regarding the availability of malaria commodities and shared results with DDS and HZs for decision-making Ensuring the availability of  12 weekly and 3 monthly epidemiological situation reports (SITREPs) were malaria commodities produced and provided to the NMCP, USAID and other partners  These reports monitor the availability of malaria commodities at the CAME regional warehouse, DRZs and HFs  12 weekly SITREPs (# of malaria cases and deaths) were produced and reported to the NMCP and USAID for eight surveillance sites ( 1, Kotoponga, Perma, Toukountouna, , Tampégre, Boukoumbé and Manta) and Producing a weekly and monthly Kouandé and Tanguiéta Hospitals epidemiological data report  No stock-outs were experienced in the 8 surveillance sites and two selected hospitals, respectively, one month after the implementation of the contingency plan

Improving local HWs capacity for  20 nurses (9 of them women) have received post follow-up training on IPC in 20 effective case management health centers of NBT, TCM and 2KP HZs in Atacora.

ARM3 Quarter 25 Report (October-December 2017) Page | 12

Photo 3: Working session between the CRAMS of HZ management team of NBT, the Radio DINABA FM staff of Boucoumbe and the ARM3 BCC Manager on October 10, 2017 in Boucoumbe. Credit ARM3

In collaboration with the NMCP, ARM3 conducted a post-training follow-up supervision of Health workers on interpersonal communication in NBT, TCM and 2KP HZs of the Atacora Department

In collaboration with the NMCP, ARM3 conducted a post-training follow-up in three HZs (NBT, TMC and 2KP) of the Atacora department where 20 nurses and midwives had been trained in interpersonal communication (IPC). The follow-up aimed to verify the effectiveness of the training in supporting health workers’ acquired competencies in raising community awareness, enhancing women's knowledge and uptake of IPTp, and of prompt care-seeking, to assess health workers’ performance and to carry out corrective actions if necessary. The main strengths observed during the post-training follow-up were:

 Regular organization of educational sessions in health facilities and in advanced strategy to the community  Good communication between HWs and women  Confidence of pregnant women and mothers / caregivers of children < 5 who are motivated to attend at the ANC visit  Attentive listening by HWs during awareness session and behavioral change communication interventions

As the single weakness, most of the trained staff failed to brief their colleagues who had not participated in the IPC training, indicating less than optimal knowledge dissemination.

ARM3 Quarter 25 Report (October-December 2017) Page | 13 Recommendations:

•Conduct at least conduct two IPC formative To DDS supervisions per year at all HFs

•Organize quarterly supervision to assess the To HZ knowledge, attitudes and practices of health workers

To HWs •Use the participants' manual on IPC distrubuted during the training

RESULTS: SBCC activities in support of prevention and case management interventions conducted

Y7 Source Indicator Baseline Target Q25 Results

89.1% Households Mass distribution ce25) % of Source: Mass who know the 89.1% campaign households who distribution causes of evaluation report know the causes campaign malaria will (2014) of malaria evaluation report reach 95% (2014) ce26) % of households who 62.9% Households 62.9% Mass distribution know about the Source: Mass who know campaign advantages of distribution about the evaluation report using an LLIN campaign advantages of (2014) evaluation report using an LLIN (2014) will reach 70% Note: ce = cost extension

ARM3 Quarter 25 Report (October-December 2017) Page | 14 Sub-result 1.1b: Increase coverage of intermittent preventive treatment during pregnancy (IPTp) per new national norms

Based on the Routine Malaria Information System (RMIS), 1,060 out of 1,155 HFs submitted reports for July-September 2017. Compared to last quarter, the IPTp2 coverage increased from 61.1% to 66.5%. Some of the HZs increased their rate between Quarter 2 and Quarter 3 (FY 2017), particularly in the - Athieme HZ (from 52.98% to 68.86%) and in the Kandi--Ségbana HZ (from 39.68 % to 53.38%).

These increases can be explained by the recent training of about 1,253 HWs on malaria case management and IPTp by the NMCP with technical assistance from ARM3. In addition, between January and September 2017 ARM3 supported the DPP by printing and disseminating 1,500 daily maternal, neonatal and child health/FP registers (C5), 1,500 maternal and child health activities report forms (C6) and 60,152 mother cards (C3) at all HFs.

Furthermore, other HZs experienced a decrease in IPTp coverage particularly in Bembèrèkè-Sinendé HZ (from 93% to 71.6%) and -- HZ (from 73.48% to 58.06%), presumably due to the mass LLIN distribution campaign conducted in October, and the preponderance of incomplete data during the end-of-year season.

Data from October 2017 to December 2017 will be only available after the validation sessions planned by the NMCP for March 2018.

Figure 1: IPTp 2 coverage during ANC visits from July 2011 to September 2017

NMCP revised IPTp protocol: at least 100 2 doses to be administered until 90 child birth 80 NMCP revised its IPTp protocol WHO recommends 3 66.5 70 revised to recommend at least 3 60.960.5 60.161.1 60 doses of IPTp doses of SP 57.7 51.9 46.7 47.8 50 45.1 44.5 44.5 39.3 42.8 43 41.7 36.839.538.536.8 36.4 38.3 40 32.831.6 30 28.1

Percentage 20 10

0

Oct-Dec Oct-Dec Oct-Dec Oct-Dec Oct-Dec

July-Sept July-Sept July-Sept July-Sept July-Sept

Oct-Dec*

Jan-Marc Jan-Marc Jan-Marc Jan-Marc Jan-Marc

April-June April-June April-June April-June April-June

July-Sept* July-Sept*

Jan-Marc* April-June* 2011 2012 2013 2014 2015 2016 2017

RMIS data from July 2016 to September 2017 are not yet validated by NMCP Source: RMIS data

ARM3 Quarter 25 Report (October-December 2017) Page | 15 RESULTS: Coverage of IPTp uptake per new national norms increased

Y7 Indicator Baseline Source Target FY18 Q1 Results 1.a) % of women who have Women who receive 22.8% (Total) completed a pregnancy in two or more doses of

the last two years who 3% SP during their last 24.2% (Urban) DHS 2011-2012 received two or more Source pregnancy within the 21.8% (Rural) doses of IPTp during that DHS 2006 last two years will reach

pregnancy 85% 1.b) % of women who have Women who receive completed a pregnancy in three or more doses of the last two years who 12.5% SP during their last 12.5% MICS 2014 received three or more Source pregnancy within the doses of IPTp during that MICS 2014 last two years in pregnancy intervention areas will reach 65% RMIS results are 65.5% from April to June (71,652/107,821) 2017 and July to Proportion of women July to September September 2017. 1. c.) % of women attending attending antenatal 2017 antenatal clinics who 28.1% clinics who receive Data from April to receive IPTp2 under direct Source IPTp2 under direct June 2017 and July observation of a health RMIS observation by a to September 2017 worker 2011 health worker will 61.1% have not yet been reach 85% (70,814/115,935) validated by the April to June 2017 NMCP and may change. RMIS results are 32.16% from April to June (8,968/27,889) 1. d.) % of women attending 2017 and July to July to September antenatal clinics who receive Proportion of women September 2017. 2017 IPTp3 under direct attending antenatal (based on 222 observation of a health clinics who receive Data from April to HFs) worker IPTp3 under direct June 2017 and July to

observation by a health September 2017 have -- 38.96% worker will reach 65% not yet been (4,450/11,421) validated by the April to June 2017 NMCP and may (based on 99 HFs) change. 0 ARM3 Reports 21) # of health workers Source 0 trained in IPTp using U.S. ARM3 FY6 Target : 60 Government (USG) funds Records 2011

ARM3 Quarter 25 Report (October-December 2017) Page | 16 37.23% (573/1,539) HMIS results are 0 July to September from April to June ce32) % of targeted HF Source: Targeted HF reporting 2017 2017 and July to reporting on IPTp3 DHIS2 on IPTp3 will reach 95% September 2017. 2015 12.67% (195/1,539) April to June 2017

ARM3 Quarter 25 Report (October-December 2017) Page | 17 Sub‐result 1.1c: Increase universal access and utilization of LLINs

ARM3 participated in the LLIN mass distribution campaign and jointly with NMCP, ARM3 supervised data collection as part of the baseline evaluation of the LLIN distribution in prioritized schools.

Technical and financial assistance provided to the NMCP to develop and implement the baseline and evaluation protocols and conduct the LLIN distribution in prioritized schools

A technical committee composed of the NMCP and ARM3 reviewed technical and financial proposals to conduct the implementation of the baseline study and to develop the evaluation protocol for the LLIN distribution in primary schools. The protocol presented by LEADD was selected and a contract was signed once the protocol was validated by USAID and the NMCP. The objectives of this assessment were to estimate the level of LLIN coverage of targeted households prior to LLIN distribution in public primary schools; determine the rate of LLIN use; determine the proportion of targeted households that have at least one child in CI and/or CM2 classes in a public school; and to recommend evidence-based adjustments in the implementation of the strategy.

Training of surveyors and supervisors

From December 15 to 16, 2017, 22 persons (2 women) were trained, 20 of whom were trained as surveyors and 2 as Supervisors. The objectives of the training were to:

 Present the context of the assessment  Present the protocol, including the methodology, and  Present data collection tools as well as the expectations/roles of each member of the team

The training was followed by the distribution of tasks and geographical assignment of the supervisory teams.

Data collection

Data collection covered the following randomly selected HZs: d’-Calavi, Tori-bossito, Zè, Bohicon, , Covè and

From December 21 to 23, 2017 a team composed of the NMCP and ARM3 conducted external supervision of data collection to assess the process of data collection, compliance with the guidelines, and data quality. The team covered the Atlantique DDS and Zou DDS.

The next steps will be for the consultant (Dr Virgile Capo Chichi, PhD in Epidemiology and health, who was in charge of conducting the baseline, to produce a preliminary report. This report will take the comments and amendments provided by the NMCP and its partners into account before validating the final report.

Technical and financial support to the NMCP on the implementation of the LLIN mass distribution campaign in 8 departments of the South

The second round of LLIN distribution took place from October 19 to 22, 2017 throughout the 8 DDS in South and central Benin (Zou-Collines, Oueme-Plateau, Atlantic and Mono-Couffo). The official

ARM3 Quarter 25 Report (October-December 2017) Page | 18 launch was held in (DDS of Oueme) on October 19, 2017 and was chaired by Dr. Allasane SEIDOU, the Minister of Health, the WHO country representative, the USAID mission, local authorities, neighboring communities, the MOH staff and its partners.

As a key implementation partner of the 2017 National LLIN Distribution Campaign, ARM3 actively participated in the four working sub-committees that were set up: Coordination, Logistics, Monitoring & Evaluation, and Communications. The success of the distribution was attributed to strong population mobilization and to the commitment of local authorities. A total of 4,363,460 LLINs were distributed during this second round.

Lessons learned during the first round of LLIN distribution in the North from August 17 to 20, 2017 in the 4 DDS of the northern region of Benin (Borgou, Alibori, Atacora and Donga) were used to improve the organization of the second phase. In this round, key messages were posted outside the sites during the distribution, there was in increased focus on IPC during the distribution training sessions, and a thorough review of the total population size per household was completed to adjust allocations of nets in order to avoid insufficient LLINs.

Table 2: Geographical Coverage

Coverage Departments Number of areas to cover Number of areas covered (%) ATLANTIQUE 718 718 100% LITTORAL 165 165 100% MONO 400 400 100% COUFFO 450 450 100% OUEME 492 492 100% PLATEAU 364 364 100% ZOU 527 527 100% COLLINES 444 444 100%

Table 3: Number of LLINs distributed per department

Number of LLINs Number of LLINs Number of LLINs Percentage of Departments forecasted received distributed LLINS distributed ATLANTIQUE 933, 650 1,047,666 1,001,212 95.57% LITTORAL 454,950 505,768 464,697 91.88% MONO 332,600 319,896 312,416 97.66% COUFFO 498,000 476,258 473,069 99.33% OUEME 736,000 733,830 699,340 95.30% PLATEAU 418,750 407,878 400,332 98.15% ZOU 572,250 562,237 547,958 97.46% COLLINES 481,350 473,089 464,436 98.17% SOUTH 4,427, 550 4,526, 622 4,363, 460 96.40%

ARM3 Quarter 25 Report (October-December 2017) Page | 19

The main results of this campaign are as follows:

 100% of the sites were covered by SBCC activities  2,003,723 HHs were enumerated, 32.2% more than the expected number of 1,515,744 HHs, with most of the households having 3 to 6 persons  1,921,708 HH received LLINs out of 2,003,723 counted (95.9%)  4,363,460 LLINs distributed versus the 4,526,622 population inventoried (96.40%)  On average, 2.53 LLINs were distributed per household

Figure 2: Lessons learned during the second round of LLINs mass distribution in the South and Central Benin

Strengths Weaknesses Constraints/Difficulties

• Availability of commodities • Mismanagement of coupons • Delay in the delivery of LLINs by (LLINs); by certain HZs led to the the supplier; • Full involvement of TFPs redeployment of additional • Inadequate logistical plan; (technical and financial coupons from other areas; • Delay in campaign budget partners) in all phases of the • Delay in the provision of validation; campaign; financial resources; • Stock-out of coupons in certain • Active collection and real-time • Delay in payment of surveyors areas, impacting the feedback of data during the and distributors; redeployment plan of the census and distribution phases; • Insufficient public mobilizers in registers; • Use of CommCARE for timely some areas due to the • Anomaly of some registers reporting; geographical coverage; (insufficient pages, absence of • Day-to-day summaries by • Intense mobilization of central numbers); supervision teams; actors due to two distribution • LLIN transportation issue due to • Availability of management rounds; and, floods (rainy season) making data and validation of data at • Delay in the selection of some localities inaccessible; and, decentralized level (HZ); and, different service providers for •Change in the initial distribution • Social mobilization. campaign operations due to plan to cover all registered slow validation of the households. procedures manual and procurement plan.

ARM3 Quarter 25 Report (October-December 2017) Page | 20

Photo 4: Dr. Alassane Seidou, the Minister of Health delivering his speech at the official launch of the LLINs mass distribution in Avrankou, Porto Novo. Credit ARM3

ARM3 also provided technical support to the NMCP by participating in the training of journalists and local radio stations manager located in central and Southern departments. The training focused on airing messages and raising community awareness as part of the national SBCC campaign for the mass distribution of LLINs.

ARM3 Quarter 25 Report (October-December 2017) Page | 21 RESULTS: Increase universal access and utilization of LLINs Y7 Indicator Baseline Source Target FY18 Q1 Results

% of pregnant women 47% MICS 2014 2) % of pregnant women 20% who slept under an who slept under an LLIN Source DHS LLIN the previous 74.6% (total) the previous night 2006 night in intervention 72.1% (Urban) DHS 2011-2012 areas will reach 85% 76% (Rural) % of children under five 20 % 3) % of children < 5 who who slept under an Source DHS slept under an LLIN LLIN the previous night 73% MICS 2014 2006 the previous night in the intervention

areas will reach 85%

% of households with a

4) % of households with a pregnant woman 74.6% (total) 25% pregnant woman and/or and/or children under- 72.1% (Urban) Source DHS DHS 2011-2012 children under five that five that own at least 76% (Rural) 2006 own at least one LLIN one LLIN will reach 4

more than 60% 0.07% (79/120490) July to ce34) % of pregnant Pregnant women aged September 41.9% Source women aged 15-49 who 15-49 who received LLIN 2017 RMIS 2015 received LLIN during a during a ANC visit will

ANC visit reach 50% 1.57% (1,893/120,490) April to June 2017 0.12% (99/85,354) This poor performance July to was due to the mass September distribution of LLINs. ce35) % of child who 51.4% Source Child who received LLIN 2017 Indeed, during the received an LLIN during RMIS 2015 during immunization mass distribution immunization activities activities will reach 60% 1.95% campaign, the routine (1,798/92,205) distribution was on April to June hold. 2017

ARM3 Quarter 25 Report (October-December 2017) Page | 22 Result 2: Improve and Implement Malaria Diagnosis and Treatment Activities in Support of the National Malaria Strategy

ARM3 provided technical assistance to the NMCP in the training of health workers to improve case management of uncomplicated and severe malaria by using microscopy and Rapid Diagnostic Tests (RDTs).

Sub-Result 2.1: Improve Diagnostic Capacity and Use of Diagnostic Testing

ARM3 provided technical assistance to NMCP in their therapeutic efficacy study of antimalarials in Benin. Additionally, ARM3 supported the NMCP in conducting a private sector post-training follow-up of lab technicians trained during Y6. In collaboration with the home office team, ARM3 provided financial assistance to the NMCP in purchasing 204 standard malaria slides for use during training sessions for lab technicians. Moreover, under the NMCP’s leadership, ARM3 provided financial and technical assistance to update the OTSS database and to train public sector lab technicians on its use. Finally, ARM3 participated in the training of 36 newly-hired lab technicians from the public sector in malaria microscopy and use of RDTs. Under the leadership of the NMCP, finalize the updated OTSS database and train the NMCP lab technicians at the NMCP level to use this database

On November 9, 10, and 20, 2017, the NMCP organized the validation of the new, updated OTSS database with the ARM3 financial and technical support. Nine participants (2 women) from the NMCP and ARM3 attended this session.

The overall objective of the workshop was to validate the updated OTSS database, specifically to test the new application, explain how it works, and help participants familiarize themselves with the application.

The session was structured into three sections based on data entry, an explanation of updates, and analysis and editing of data collected. Each section was developed by the IT consultant, Mr. Kévin Gounou.

The following recommendations were provided to the IT Consultant to make the OTSS database more user- friendly:

1) Insert private HFs in the database 2) Develop a guide for data entry operators

A session was then held on November 20, 2017 to verify that all recommendations were implemented, and the new, updated database was finalized in December 2017.

ARM3 Quarter 25 Report (October-December 2017) Page | 23

Photo 5: Lab and chemio sensibility staff of the NMCP and ARM3’s staff during OTSS database validation in Bohicon. Credit ARM3

In collaboration with the NMCP, conduct a post-training follow-up for 10 days to 22 private sector lab technicians trained during Y6 (participation of the ARM3 diagnostic Manager only)

From December 26, 2017 to January 11, 2018, ARM3 provided technical and financial support to the NMCP in their organization of a post-training follow-up of 22 laboratory technicians from the private sector who were trained from August to September 2017.

These 22 lab technicians were from private health facilities in the departments of Oueme, Plateau, Atlantique and Littoral. Two teams of supervisors, composed of 3 NMCP staff members and the ARM3 diagnostic Manager, facilitated the on-site supervision.

The overall objectives of the post-training follow-up were to:

 Conduct a rapid inventory of equipment and lab commodities used in the biological diagnosis of malaria  Check the availability of reference documents and hand-outs  Verify whether internal quality control is done regularly  Check the compliance to established laboratory norms and standards  Ensure correct reporting of results and the timely transmission of results  Ensure proper completion and interpretation of RDTs  Assist in writing rapid plans for solving identified problems.

Results of this activity are expected for the next quarter (QR26).

ARM3 Quarter 25 Report (October-December 2017) Page | 24 Participate as trainer of the 60 newly-hired lab technicians from public sector in malaria microscopy and RDTs (participation of the ARM3 Diagnostics Manager only)

From December 5 to 23, 2017, three sessions of 5-day trainings were held in Bohicon and by the NMCP to train 60 newly-hired lab technicians. ARM3’s technical support focused on the training of 36 microscopists from public health facilities (32) and private health facilities (4) (13 women total) from 12 health departments.

The objective of these training sessions was to strengthen the technical capacity of lab technicians in malaria microscopy and RDTs, specifically to:

 Review the different sections of the National Malaria Control Policy  Produce microscopy and thin smears according to standards and guidelines  Identify microscopically the plasmodia species and the stages of parasitic development  Quantify parasites correctly  Control sources of error in the diagnosis of malaria and apply appropriate corrective measures

A pre-test and a post-test were conducted. These included a theoretical exercise (a series of 20 questions) and a practical exercise that assessed the reading of 12 thick/thin blood smear, both negative and positive, with variable densities. Practical skills were assessed using the following indicators: sensitivity, specificity, species identification, concordance, and parasites counting.

Figure 3: Results of the practical evaluation

100% 91% 89% 90% 88% 90% 80% 74% 67% 68% 70% 60% 50% 43% 39% 40% 30% 20% 16% 10% 0% Sensitivity Specificity Concordance Pf Identification Parasite Counting

Pre-test Post-test

A clear improvement was seen in the identification of P. falciparum parasites, form 39% pre-test to 91% post-test. Despite the improvement in the practical results obtained, regular monitoring of qualified microscopists should be organized to further improve on their skills. However, the parasite counting and Pf identification should be improved as the current values respectively 43% and 91% remained below compared to the recommended peripheral level microscopists of 50% and 95%.

ARM3 Quarter 25 Report (October-December 2017) Page | 25 Support the NMCP for providing 204 standard malaria slides to assess the control quality of RDTs results and to use during the lab technicians training sessions

During November-December 2017 ARM3, in collaboration with the home office team, identified a resource partner who could provide pre-validated slides (via PCR and WHO-certified level 1 expert microscopist) that fulfilled quality criteria and that could be used to develop Benin’s peripheral microscopists’ proficiency testing panel.

A technical assessment was completed and information such as transport of slides was received. Taking into account the existing budget for this activity, 204 slides were purchased instead of the 100 slides originally planned. Three boxes with 204 standardized slides were received on December 29, 2017 and delivered to the NMCP on December 30, 2017. The first set was for parasite detection and Species identification, the second set for parasite counting, and the third set for pr-ECA. The NMCP evaluated the quality of 10% of the slides according to the terms of the contract with the supplier. These slides will be used during a training session or for a post-training follow-up in malaria microscopy to strengthen the lab technicians’ technical capabilities.

RESULTS: Diagnostic Capacity and Use of Diagnostic Testing Improved

Y7 Indicator Baseline Source Target FY18 Q1 Results 99.1% (112/113) PY5 Q4 results from OTSS Proportion of

5) % of targeted health centers 100% health centers that with the of HFs with personnel trained have the following: ability to OTSS Round 17 was in diagnostics 1) personnel perform completed nationwide (113/113) trained in malaria 95.8% biological in July 2016 by the

diagnostics, 2) no Source diagnostics NMCP and ARM3’s 99.1% stock-outs affecting OTSS for malaria teams. of HFs with no stock out in malaria diagnostics 2011 (either Data provided by 113 diagnostics commodities for 7 or more days, microscopy or facilities OTSS R18 (112/113) 3) a functional rapid data treatment is

microscope (non- diagnostic ongoing. 100% RDT facilities only) testing) will of HFs with a functional be >90% microscope (non-RDT facilities only) (113/113) 22) # of health Source workers trained in ARM3 malaria diagnostics ARM3 Reports Records FY18 Target: 60 0 (RDTs or microscopy) 2011 with USG funds

ARM3 Quarter 25 Report (October-December 2017) Page | 26 RESULTS: Diagnostic Capacity and Use of Diagnostic Testing Improved

Y7 Indicator Baseline Source Target FY18 Q1 Results

92.9 % (all ages) (662,780/713,588) RMIS results are from 94.1% < 5 (290,747/308,906) April to June 2017 90% of 36.7% 91.9% ≥ 5 and July to suspected (372,033/404,682) September 2017. 6) Percent of malaria cases 17.5% < 5 July to September 2017 suspected malaria will be tested via 52.6% ≥ 5 Data from April to cases submitted to microscopy/RDTs 93.1 % (all ages) June 2017 and July to laboratory testing Source : (504,710/542,295) September 2017 have

RMIS 93.9% < 5 (201,465/214,479) not yet been validated

2012 92.5% ≥ 5 by the NMCP and may (303,245/327,816) change. April to June 2017

Sub-Result 2.2: Improve Case Management of Uncomplicated and Severe Malaria

ARM3 provided technical assistance to the NMCP to update and validate the national malaria case management guidelines on the use of injectable Artesunate as the first line of treatment of severe malaria and its training materials. In addition, ARM3 supported the NMCP in its launch of activities regarding the implementation of a comprehensive training database for both pre-service and in-service training of health providers through a consultation conducted by the IRSP.

Technical and financial assistance to the NMCP to organize a validation session at the national level of the injectable and rectal artesunate (IA/RA) documents developed with the support of ARM3

ARM3, along with the NMCO and USAID, participated in a technical committee meeting for the introduction of injectable and rectal artesunate through 15 hospitals in Benin and the introduction of rectal artesunate in remote health facilities as a pilot program. A technical core was established to pilot the introduction process composed of different specialists such as a Parasitologist, a Gynecologist, a Pediatrician, a Resuscitator, an Internist, a Pharmacist, a Midwife and an Epidemiologist.

The main findings during the data collection field visit were that HWs don't comply with the national protocol and guidelines, there is a lack of training and documentation in the Medicine and Maternity wards, and there is use of many drugs to treat severe malaria.

ARM3 Quarter 25 Report (October-December 2017) Page | 27 The following recommendations were concluded at the end of the field visit:

Update training materials for qualified health workers on severe malaria case management in hospitals

Drafts of the manual and guide should be available by the end of January 2018

Review the budget of the introduction to allow the chronogram to be followed

Plan activities for January 2018 under the NMCP responsbility

Implement activities before March 31, 2018 when ARM3 will end

Provided technical assistance and oversight to the IRSP in the development of the training plan, which began in Year 6, and to the NMCP in its validation including payment of remaining balance and the establishment of a roadmap to implement recommendations

ARM3 provided technical and financial support to the NMCP to develop a database with a training plan for pre-service and in-service training of health providers in the public and private sectors. This plan includes the setup of a training database of NMCP personnel, the review of the strategies developed by the MOH to provide in-service training to its staff and the identification of training needs for newly-recruited staff.

Based on information collected by ARM3, the curricula used in trainings is not always in compliance with malaria control protocols and the consultant team (Regional Institute of Public Health) will provide recommendations as well as a roadmap for the implementation of the training plan. In October 2017, the contract was signed with IRSP when the protocol was validated by the NMCP and USAID.

On November 7, 2017, a technical meeting was held at the IRSP office in Ouiddah where 12 participants from the NMCP (1), DNSP (2), DPP (1), DSME (1), IRSP (4) and ARM3 (4) attended. This session was intended to review the protocol, methodology, expected results, specify the timeline of the consultancy and clarify the role of different stakeholders.

The following objectives have been assigned to the consultant:

 Inventory the different training courses on malaria that HWs benefited from over the last three years, both for public and private sectors

ARM3 Quarter 25 Report (October-December 2017) Page | 28  Create a database for all kind of trainings on malaria, all categories of trained staff, trainers, venues and dates of training  Articulate the need for malaria trainings of different types at each level (national, departmental and operational) following a needs assessment  Determine training needs at Medical Schools, ENATSE1, FSS2, INMèS3, ENIIAB4  Identify the need of training for teachers in health schools in order to introduce the national malaria guidelines into training curricula  Propose a mechanism for periodic monitoring & evaluation, update the training plan and database with associated tools

With ARM3, the DNSP should provide all reference tools to consultants that will enable them to propose a tool for the evaluation of training at the community level.

Next steps

 The IRSP should send an official letter to ARM3 with a clear outline indicating what documents the MOH can assist them with.  The NMCP and ARM3 will help the IRSP in collecting needed information on trainings carried out over the last three years at the MOH.

RESULTS: Case Management of Uncomplicated and Severe Malaria Improved Y7 Indicator Baseline Target FY18 Q1 Results Source 78.56% all cases (425/541)

85% of patients (all 78.65%(210/267) < 5 7) Percent of patients (all ages) who tested

ages) who tested positive 83.55% positive for malaria EUV 78.46% (215/274) ≥ 5 for malaria (via Source (via microscopy or Atlantic/Littoral

microscopy or RDT) who EUV RDT) will receive an report, March 2016 all ages received an anti-malarial 2012 effective anti-malarial 52.03% (64/123) (ACT)

RDT-all ages 85.41 % (363/425)

8) Percent of patients (all < 5% of patients (all 25.85% 1.82% all cases ages) who tested negative ages) who tested Source (9/494) EUV for malaria (via negative for malaria EUV Atlantic/Littoral microscopy or RDT) who (via microscopy or 2012 1.20% (3/251) < 5 report, March 2016 received an anti-malarial RDT) will receive an 2.47% (6/243) ≥5

1 ENATSE : Ecole Nationale de Formation des Techniciens Supérieurs en Santé Publique et en Surveillance Epidémiologique 2 FSS : Faculté des Sciences de la Santé 3 InMes : Institut national médico sanitaire 4 ENIIAB : Ecole Normale des Infirmiers et Infirmières Adjoints du Benin

ARM3 Quarter 25 Report (October-December 2017) Page | 29 RESULTS: Case Management of Uncomplicated and Severe Malaria Improved Y7 Indicator Baseline Target FY18 Q1 Results Source effective anti-malarial (ACT) Micro-all ages 0% (0/103)

RDT-all ages 2.27% (9/397) Supervision is provided to at least 9) Percent of targeted HFs 93% 90% of health workers that received supervision Source nationwide with

OTSS malaria-related Post-training supervision 100% (22/22) 2016 responsibilities at least once every three months

Percent of children 10) Percent of children 13.1% under five with under-five with suspected MICS 2014 <1% suspected malaria malaria (fever) in the last (fever) in the last two two weeks who received Source weeks who received treatment with ACTs within 12.3% DHS 2006 treatment with ACTs in 24 hours of onset of their (13.5%) Urban DHS 2011-2012 targeted areas will symptoms (11.2) Rural increase to 25%

65% of mothers/ 11) Percent of mothers/ caretakers who sought caretakers who sought treatment with the <1% treatment with the use of use of ACTs for their 42.9%

ACTs for their <5 children under-five children 50% (Urban) DHS 2011-2012 Source with suspected malaria with suspected 36.8% (Rural) DHS 2006 (fever) within 24 hours of malaria (fever) within onset of their symptoms 24 hours of onset of their symptoms 0 12) Number of schools of Source nursing and educational ARM3 institutions that have 0 ARM3 Reports Program FY7 Target: 0 updated their malaria activities guidelines and curriculum report 2011 0 23) Number of health Source workers trained in case ARM3 0 FY7 Target : 60 ARM3 Reports management with ACTs Program with USG funds activities report 2011

ARM3 Quarter 25 Report (October-December 2017) Page | 30 RESULTS: Case Management of Uncomplicated and Severe Malaria Improved Y7 Indicator Baseline Target FY18 Q1 Results Source 21/50 Source 43) # of hospitals that ARM3 received a refresher Program FY7 Target : 25 NA ARM3 Reports training for severe malaria activities management report 2011 Targeted Hospitals ce46) % of targeted received ETAT Hospitals received ETAT NA NA ARM3 Reports supervision by DDS supervision by DDS teams teams will reach 90%

Sub-result 2.3: Improve integrated Community Case Management (iCCM)

During this quarter, ARM3 supported the DNSP in the organization of three dissemination workshops on the National Community Health Policy (NCHP) and the National guidelines for monitoring and evaluation of the PIHI-Com in the AZT HZ. ARM3 also participated in a workshop to review certain standards of PIHI- COM in order to update CHWs training modules and tools for reporting the PIHI-COM implementation in urban and peri-urban environments. In addition, ARM3 provided technical assistance to BUPDOS-NGO by setting-up a capacity-building workshop for social health workers and community facilitators on post- training follow-up, supervision and evaluation of CHWs in the CBGH HZ , DDS ZOU-COLLINES , COVE- ZAGNANADO-OUINHI (CoZO) and SAVALOU-BANTE (SaBa) HZ. Finally, in collaboration with the DNSP and the NMCP, ARM3 jointly supervised CHWs in 2 HZs through monthly field visits (SaBa and CoZo).

Technical and financial support to the DNSP and NMCP on the update, validation, printing and dissemination of the: National Community Health Policy, PIHI-C Monitoring & Evaluation guide, Manual of Procedures and management tools for data quality audit, SOP for malaria testing and treatment at community level for uncomplicated and severe malaria

ARM3 provided a technical and financial support to the DNSP to conduct three dissemination workshops of the National community health policy (NCHP) and the monitoring &evaluation guide of PIHI-c (M&EG) for local authorities, HWs and CHWs respectively for the commune of ALLADA on December 12, 2017, TOFFO on December 20, 2017 and ZE on December 21, 2017 in collaboration with SIAN SON and the AZT HZ team.

ARM3 Quarter 25 Report (October-December 2017) Page | 31

Photo 6: HWS and CHWs participating at the dissemination workshops of the National Community Health Policy and the National guidelines for monitoring in Toffo . Credit ARM3

Table 4: Distribution of participants at the dissemination workshops of NCHP & M&EG

Number of participants TOTAL

Local authorities HWs CHWs Others

M F M F M F M F

ALLADA 11 1 4 12 0 0 4 1 33

TOFFO 9 1 4 8 10 1 7 0 40

ZE 13 1 4 5 9 0 5 2 39

TOTAL 33 3 12 25 19 1 16 3 112

In addition, from November 21 to 23, 2017, the DNSP organized a workshop to review certain standards of PIHI-COM in order to update CHWs training modules and management tools for reporting the PIHI-COM in urban and peri-urban areas. ARM3 has actively contributed to reviewing the training materials (manual for participants and a facilitator guide), specifically the communication techniques and the aligning of the pregnant women, women who recently gave birth and newborn interventions to the new protocol. The monitoring of children <5 was also updated.

A pre-test of the revised management tools was also recommended to be organized in Abomey-Calavi and 2 & 3 HZs on March 2018.

ARM3 Quarter 25 Report (October-December 2017) Page | 32 Technical assistance provided to new NGO partners implementing Community PIHI in the six new health zones sites under Phase II (Savalou-Bante; Cove-Zagnanado-Ouinhi; Allada-Ze-Toffo; Abomey-Calavi-So-Ava; CBGH; Cotonou 2& 3)

Following the launch of the second phase of the PIHI-COM in six new HZs (Savalou-Bante; Cove-Zagnanado- Ouinhi; Allada-Ze-Toffo; Abomey-Calavi-So-Ava; CBGH; Cotonou 2& 3) by USAID in southern Benin, the granted local NGO, BUDPOS, requested technical support from ARM3 to enhance the capabilities and skills of their respective staff on the following topics:

1. Technical assistance provided to BUPDOS to train its health workers and community facilitators on post-training follow-up, supervision and evaluation of CHWs in the CBGH HZ.

On December 20 to 23, 2017, ARM3 technically supported the BUPDOS team and the DNSP to organize a training session to conduct post-training follow-up, supervision and evaluation of CHWs. This training was attended by 4 HWs and 250 CHWs (38 women).

2. Technical and financial assistance to DDS ZOU and COLLINES and to the COVE-ZAGNANADO- OUINHI (CoZO) and SAVALOU-BANTE (SaBa) HZ to analyze data collected through CHWs group supervision.

Under the leadership of the HZs team of Savalou-Bante (Saba) and Cove-Zagnanado-Ouinhi (CoZo), a workshop was organized with technical support from ARM3 to use community data for decision-making.

Results:

 A total of 87 participants attended (30 participants for SaBa HZ and 57 from CoZo)  Using data collected by CHWs , participants practiced different types of data analysis and how to identify decisions according the results of the analysis.

In collaboration with the DNSP and the NMCP, jointly supervise CHWs in 10 HZs through monthly field visits using the supervision framework to assess RDT testing, use of ACTs and data quality control

During this quarter, Savalou-Bante (SaBa), and Cove-Zagnanado-Ouinhi HZs were visited by the team of supervisors, which included HZs teams, the DNSP departmental level and an ARM3 team. Thirteen (13) sites were visited (10 in SaBa and 3 in CoZO). A total of 150 CHWs (118 men and 32 women) received supervision, 109 in SaBa and 41 in CoZo.

Parameters assessed included the quality of data generated during the implementation of PIHI-COM. This was done by reviewing data collection registers and providing feedback when needed. Additionally, the team verified and checked how records were completed and the use of management tools.

ARM3 Quarter 25 Report (October-December 2017) Page | 33 Main Results of the monthly group supervision:

Table 5: Distribution of CHWs visited

Sites # of CHWs # HWs visited

HZ # total of Sites # of CHWs Total M F NGOs HWs sites visited in HZ

SABA 21 10 144 109 88 21 6 4

CoZo 10 3 44 41 30 11 6 4

Total 31 13 175 150 118 32 12 8

This quarter, 150 CHWs were reached compared to 78 CHWs last quarter. This increase is due to a better planning by the HZs of the joint supervision.

However, services offered by CHWs still remain low because the average number of cases treated per month is 1.8 in SaBa and 7.7 in CoZo, and the average of households receiving home visit is only 2.8 in SaBa and 9.7 in CoZo compared to the national standard of 10. This situation can be explained by the stock out of certain materials such as gloves for the achievement of RDTs, raincoats, boots, torches and the out of stock of malaria commodities and the absence of regular supervision visits by Chef posts.

Table 6: Cumulative distribution of children under-five (with fever) tested and results of RDT testing during the CHWs supervision

% of RDTs Children % of % of RDTs Children with <5 tested children RDT with <5 with RDT Health (of those positive negative fever tested Positive negative Zones with fever) results (c) = (D) (F) results (A) (E)= (B) (B)/(A) (G)= (F)/(B) (D)/(B)

SaBa 385 365 94,80% 302 82,73% 57 15,61%

CoZO 1,062 1,048 98,68% 914 87,21% 111 10,59%

Total 1,447 1,413 97,65% 1,216 86,05% 168 11,88%

ARM3 Quarter 25 Report (October-December 2017) Page | 34 During this period, 1,447 children under 5 years old with fever were supported by the CHWs of the two HZs. This indicates that an average of 97.65% (1413/1447) of children admitted for fever were tested. Among those tested, 86.05% (1216/1413) were positive and received treatment with an ACT.

Figure 4: Strengths, Weaknesses and Recommendations of the monthly joint supervision of CHWs

Strengths Weaknesses Recommendations • Not enough time for • Simplify management some HFs to analyze tools for better use and data collected for understanding by CHWs decision‐making • Strengthen capacity of • Good collaboration • Most CHWs only Chef posts to analyze data between HF teams and collected and use results local NGOs to organize develop their monthly statistical reports during for decision-making the CHWs' group •Introduce good practice supervision the monthly group supervision of sharing experiences • Home visit does not during the monthly group promote IPTp uptake supervision • CHWs experienced a • Encourage CHWs' stockout of ACTs for >30 participation in data days at some HFs analaysis at the HF level

Result 3: The National Health System's Capacity to Deliver and Manage Quality Malaria Treatment and Control Investigations Strengthened

Sub-result 3.1: Enhance the NMCP's Technical Capacity to Plan, Design, Manage and Coordinate a Comprehensive Malaria Control Program

ARM3 provided technical support to the NMCP in their organization of three technical working groups (TWG) for BCC and Monitoring& Evaluation clusters. ARM3 also participated in the review of the 2017 - Integrated Annual Work Plan (PITA) and the development of the 2018 annual PITA. Finally, ARM3 contributed to the validation of the 2017-2021 National Strategic Plan for malaria control in Benin.

ARM3 Quarter 25 Report (October-December 2017) Page | 35 Participate in the development and review of the annual PITA

From December 18 to 20, 2017, the NMCP has organized a workshop in Lokossa to review its 2017- Integrated Annual Work Plan (PITA) 2017 and develop one for 2018 with technical support from ARM3. This workshop was attended by 29 participants (9 women) from the NMCP, USAID, OMS, ARM3, CRS, CREC, DPP and DPMED, and was chaired by the Chief of Minister of Health office.

The objectives of the meeting were to assess the progress achieved for 2017-PITA and to develop the 2018- PITA in collaboration with all partners.

The assessment of initial activities planned versus those achieved by the NMCP and its partners are summarized in the table below.

Table 7: Summary of the Implementation of 2017-PITA

# of # of # of # of in Activities activities completed process activities Achievement planned initiated activities activities not rate Structures achieved

(A) (B) (C) (D) (E) (G) = (C)/(B) ARM3 55 42 37 5 13 88% CREC 6 6 1 5 0 17% NMCP 240 189 187 2 51 99% DPMED 10 6 5 1 0 83% TOTAL 311 243 230 13 68 95%

The table above shows that the ARM3 achievement rate was 88% due to the delay of funds available to the NMCP; this delay affected some ARM3 activities implementation. Additionally, staff turnover, newly- hired untrained staff and the failure to replace retired individuals affected the performance and achievements of targets. Another factor that affected the ARM3 achievement rate was the the increase in demands and portfolio of the NMCP due to their influx of funds from various agencies (USAID, GFATM and others) to implement malaria projects; this resulted in the unavailability of the NMCP staff to implement planned activity with ARM3.

The draft 2018-PITA established during the workshop contains 152 activities. By components, these activities are distributed as follows:

ARM3 Quarter 25 Report (October-December 2017) Page | 36 Figure 5: Distribution of number of activities of 2018-PITA

40 38 35 28 30 25 19 20 20 14 15 8 10 5 2 0 IPT LLIN ACT DIAGNOSTIC BCC-IEC PROGRAM M&E MANAGEMENT

At the end of the workshop, the following recommendations were made: Recommendations Responsible Parties Timelines Ask the SPPV and DPMED to clearly First Week of January 2018 define their respective activities for NMCP, DPMED the 2018-PITA Ensure that absent partners submit First Week of January 2018 their 2017 PITA assessment and 2018- NMCP and its partners PITA to the NMCP at the next RBM meeting

Validation of the 2017-2021 National Strategic Plan for malaria control

A meeting to validate the National Strategic Plan (NSP) for malaria control for 2017-2021 was held in Bohicon from December 27 to 28 2017, and organized by the NMCP with financial support from GFATM. The validation meeting was attended by 51 participants, including the NMCP, DPP, LNCQ, the DRFMT, the CREC, the DSIO, the IRSP, FSS, ARM3 , USAID, CNLS-TP, BUDDOS and the national consultant.

The new NSP is built around the following three objectives:  Goal 1: Reduce the incidence of malaria by 25% by 2021 (compared to 2015)  Goal 2: Reduce the mortality rate by 25% by 2021 (compared to 2015)  Goal 3 : Strengthen program management capacity at all levels

8 components were identified to achieve the objectives: 1. Malaria prevention 2. Chemoprophylaxis 3. Parasitological diagnosis of malaria 4. Anti-malarial treatment 5. Malaria control 6. Social and behavior change communication

ARM3 Quarter 25 Report (October-December 2017) Page | 37 7. Supply chain management, and 8. Monitoring and evaluation.

Main contributors to the NSP’s implementation are the GoB, GFATM, USAID/PMI, UNICEF and WHO; however, there remains a funding gap of 26,414,431,263 XOF (approximately 50,243,100 USD) as the required budget is 192,231,590,411 XOF (365,645,000 USD) for 5 years (2017-2021).

Provided Technical Assistance in the Organization of TWG Meetings in BCC and M&E

1. The M&E TWG The M&E Technical Working Group (TWG) meeting was held on November 21, 2017 at the NMCP office, and was attended by 26 participants (9 women) from USAID, NMCP, APC, GFATM, CRS, AIRS, Chemonics, OMS and ARM3. The following points were discussed:

 Situation of the cohort study conducted by the NMCP in DCO (Djougou-Copargo-Ouake) HZ as an intervention zone and BS (Bembèrèkè-Sinendé) as a control zone  Presentation of the protocol and the evaluation data collection tool after the LLIN campaign  Update on the protocol for the baseline assessment of LLIN distribution in schools, and discussions on developing a roadmap for improving RMIS

The purpose of the 2017 cohort study was to compare the impact of indoor residual spraying on children ages 0 to 59 months between two health zones, Djougou-Coparco-Ouaké (DCO) in DCO - Donga and Bembèrèkè-Sinendé in the Borgou. Indeed, DCO benefited from indoor residual spraying while Bembèrèkè- Sinendé did not. Data collection was conducted between March and September 2017, but a slight delay was experienced due to the national mass LLIN distribution campaign and administrative procedures at the GFATM.

The NMCP shared the protocol and data collection tools for the post-campaign evaluation and asked participants to provide comments before their finalization.

Finally, ARM3 shared information with participants regarding the upcoming baseline and evaluation protocols for the LLIN distribution in prioritized schools.

2. The BCC TWG

The NMCP office held a BCC TWG on November 22, 2017, which was attended by twelve (12) people (3 women) from ARM3, ABMS-PSI and the NMCP.

The objectives of the meeting were to prepare proofreading of the draft of the Integrated Communication Plan for malaria control and to update the management of radio and TV contracts.

The first point was devoted to finalizing the agenda and TOR of a workshop to collect and review comments and proofread the integrated communication plan. It took place in Bohicon from November 23 to 25, 2017. Subsequently, the debate focused on the contractual deadline for radios and TV involved in the mass LLIN distribution campaign in the north that has expired while those in the southern and center will continue until December 2017.

ARM3 Quarter 25 Report (October-December 2017) Page | 38

Technical and financial support to Atacora and Donga to review their annual workplans through Malaria Officer Participation

From December 10 to 13, 2017 the DDS in Atacora and Donga organized a workshop in Porga to review their respective HZs’ workplans with ARM3 technical and financial support. This workshop was attended by 33 participants (8 women) from the two DDS, including departmental hospital directors and HZ teams.

The objectives of this workshop were to:  Assess the achievement rate of each HZ workplan versus activities planned during the 2017 project year  Analyze and review the defined strategies to improve health indicators in both departments  State better approaches and strategies for good performance in 2018

Recommendations to improve the overall performance of both DDS  Continue malaria epidemiological surveillance to better track trends and use results for decision- making  Set up a small technical committee to explore appropriate post-PBF strategies  Reinforce the auditing of maternal and neonatal deaths at all levels  Advocate for mass treatment with ACTs for malaria control (to be done by the NMCP and DDS)

Technical and financial support to Borgou DDS to organize Radio-reality at Gamia (Bembèrèkè)

In collaboration with the NMCP, the DDS of Borgou, Bembèrèkè-Sinendé HZ and local authorities, ARM3 organized on October 16 , 2017 a community awareness / radio reality show in the district of Gamia, commune of Bembèrèkè, with the local community radio FM NONSINAN.

The main objectives were to raise community awareness on:  The use of LLINs, ANC visits, the promotion of at least 3 doses of IPTp  Prompt care-seeking within 24 hours of the onset of fever  Use of RDTs to confirm malaria and the use of ACTs for the treatment of malaria

This activity attracted 300 people of all ages and a contest held to measure women's knowledge and practices related to IPTp uptake. The format of the contest was a quiz show with 16 pregnant women and mothers of children under the age of 5, representing 12 villages of the Gamia district. Prizes were awarded to winners included bed nets, malaria DVDs and t-shirts with malaria messages.

At the end of the event, Community Health Workers (CHWs) provided leaflets on IPTp, ACTs and LLINs to participants.

ARM3 Quarter 25 Report (October-December 2017) Page | 39 RESULTS: NMCP’s Technical Capacity to Plan, Design, Manage and Coordinate a Comprehensive Malaria Control Program Enhanced Y7 Indicator Baseline Target Y7 Q1 Results Source The NMCP technical 15) # of NMCP 7 working groups technical working group (monitoring and (monitoring and Source evaluation, supply M&E : 1 ARM3 Program evaluation, supply chain, ARM3 chain, BCC : 1 activities report communications, and Program communications, and case management) activities case management) are meetings report 2016 meeting regularly as planned

ce53) # of DDSs work plans ARM3 Program supported by the malaria NA FY18 Target : 2 4 activities report officers

Sub-result 3.2: MOH Capacity to Collect, Manage, and Use Malaria Health Information for Monitoring, Evaluation, and Surveillance Improved

ARM3 continued to provide technical support to the NMCP on the semi-annual supervision of 120 health centers on RMIS performance, to organize the quarterly Malaria Indicators Review Workshop for decision- making, and to provide weekly and monthly malaria data situational reports (SITREP) in 8 sentinel sites in Atacora where the IRS project was discontinued.

Technical assistance to the NMCP to conduct the semi-annual supervision of 120 health centers on RMIS performance and data collection in 6 DDS

From October 30 to November 11, 2017, ARM3 provided technical assistance to the NMCP to conduct a semi-annual supervision of 154 HFs within the 34 HZs. Six teams composed by the NMCP at national, departmental and HZs levels and ARM3 covered six departments. Specifically, ARM3 supported the supervision of Alibori, Mono, Couffo, Oueme, Plateau and Zou departments.

The objectives were to:  Assess health workers’ knowledge regarding the use of the PNLP1 data form  Improve health workers’ knowledge of how to do the internal quality control of completed forms  Check coherence of data collected using a randomized technique  Assess the concordance between data collected in PNLP1 and primary data sources  Make recommendations to solve problems identified in order to improve the quality of data

The methodology consisted of visit HFs using a standard supervision grid, verifying physical documents (registers, stock paper, ACT copybooks), and providing feedback to health workers on data collection and quality assurance.

ARM3 Quarter 25 Report (October-December 2017) Page | 40 Constraints identified by RMIS users in the field:  Only 74% of Chef-posts were trained on RMIS procedures  The RMIS User Guide was available in only 17% of the health facilities visited  The rate of good counting primary source and extended coherence to PNLP1 and B5a was still low

Compared to the last supervision held in September 2016, there was an improvement in the quality of data, a table comparing the two supervisions can be found below.

ARM3 Quarter 25 Report (October-December 2017) Page | 41 Table 8: Summary of the results during the semi-annual supervision at 6 DDS

All 6 Borgo Ataco Zou/Col Mono/ Oueme/Pl DDS Indicators u/Alib ra/Do Atlantique/Littoral lines Couffo ateau (Avera ori nga ge) % of HZ Medical Coordinator (Chef-post) trained on RMIS among those supervised 69.7% 61.1% 96.2% 59.1% 88.0% 65.4% 74.0% Availability of RMIS user guide 33.3% 0% 8.0% 9.1% 26.9% 11.5% 17.0% Availability of PNLP1 data forms (at least 3) 97.1% 100% 92.3% 95.5% 92.3% 92.3% 94.7% HWs level of knowledge on uncomplicated malaria data collection procedures 71.4% 94.4% 88.5% 81.8% 96.2% 76.9% 83.7% HWs level of knowledge on severe malaria data collection procedures 71.9% 94.4% 96.2% 81.8% 96.2% 76.9% 85.3% HWs level of knowledge on malaria commodities data collection procedures 68.6% 94.4% 88.5% 72.7% 92.3% 73.1% 80.4% Accuracy of uncomplicated data (comparing PNLP1 and primary sources) 64.7% 94.4% 80.8% 86.4% 92.3% 61.5% 78.3% Accuracy of severe data (comparing PNLP1 and primary sources) 74.2% 94.4% 92.3% 77.3% 92.3% 53.8% 79.9% Accuracy of malaria commodities data (comparing PNLP1 and primary sources) 68.8% 83.3% 92.3% 72.7% 88.5% 65.4% 78.0% Good counting of malaria data in primary sources 42.4% 50% 73.1% 88.9% 80.8% 50% 62.8% Accuracy of malaria data (comparing to PNLP1 and B5a) 36.4% 76.5% 80% 78.9% 73.1% 56.0% 64.1% HWs level of knowledge on the timeliness of health facility data 97.0% 100% 100% 90.5% 88.5% 100% 96.0%

Table 9: Comparison of results of the two last supervisions (Sept 2016 and Oct-Nov 2017)

Indicators Results Sept 16 Results on Oct-Nov 17 % of chef-post trained 33.6% 74% HWs level of knowledge on the timeliness of health facility data 94% 96% HWs accuracy of malaria data compared to PNLP1 and B5 45.1% 64.1% The good counting of malaria data in primary sources 48.6% 62.8%

ARM3 Quarter 25 Report (October-December 2017) Page | 42 Recommendations:

• Train newly-hired staff and those who were not able to correctly fill out all forms • Transmit the revised RMIS guide printed by ARM3 and made available to the NMCP to the Statisticians during the next data For the NMCP validation workshops • Decentralize to HZ and DDS-level supervision and data quality assurance activities to check and ensure the quality of data that will be sent to NMCP

• Carry out briefings on the filling out of the RMIS form during the For the HZs statisticians monthly meetings • Check the quality of data before making data entries

• Check the quality of data in DHIS2 and provide feedback on data For DDS Statitistician inconsistencies for their correction

Technical and financial assistance provided to selected health zones to organize Quarterly Malaria Indicators Review Workshop for decision-making, using scorecards and dashboard (private sector will be included)

Between November and December 2017, ARM3 supported DCO, Banikoara, Parakou-Ndali, Malanville- Karimama and Bassila HZs to organize the Malaria Quarterly Indicators Review Workshop for decision- making. Participants at these workshop are presented below:

ARM3 Quarter 25 Report (October-December 2017) Page | 43 Table 10: Distribution of the participants at the Malaria quarterly indicators review

Health Zones # participants # Women PROVENANCE

Djougou-Copargo- DDS; Health Zone 62 23 Ouakè coordinator; Doctors Banikoara 40 8 Heads of commune; HZ Statistician; DRZ; Local Parakou-N’Dali 25 5 authorities and a COGECS Malanville-Karimama 40 12 Representative, NMCP Bassila 41 11 and ARM3.

The objectives of the workshop were to:

 Assess the level of execution of recommendations during the last supervision round  Assess the achievement rate of the quantitative indicators in each health center and zone  Identify the constraints encountered for malaria case management and share good practices  State recommendations for improving results

ARM3 Quarter 25 Report (October-December 2017) Page | 44 Figure 6: Monthly evolution of the number of uncomplicated and severe malaria cases, all ages in DCO HZ

Monthly evolution in the number of severe malaria cases Monthly evolution in the number of uncomplicated malaria cases

1800 12000

1600 10000

1400

1200 8000

1000 6000

800

4000 600

400 2000

200

0 0 JAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV DEC

Source : RMIS data 2015 2016 2017 Source : RMIS data 2015 2016 2017

ARM3 Quarter 25 Report (October-December 2017) Page | 45

Key results DCO

The malaria situation over the last three years shows the same trend in the DCO health zone with a slight offset of curves in the graph above. Thus, the quarterly indicator review is very important, because it states that epidemiological data should be monitored in real time in order to take the appropriate measures in a timely manner.

The level of execution of malaria activities was evaluated, and it was noted that the Health Zone Supervision team was unable to carry out all planned activities in the workplan due to the overlapping of other activities like the mass distribution campaign.

Key results Banikoara

The workshop highlighted reporting errors, inconsistencies between curative care registers, B5a and the PNLP1 data. In terms of malaria commodities management, poor use of LMIS tools was noted and the average monthly consumption was not updated; resulting in a stock-out of ACTs and an overstocks of RDTs. Also, the comparison of confirmed uncomplicated malaria and confirmed severe malaria from 2015 to 2017 revealed a resurgence of cases in 2017, specifically in May. Therefore, it was recommended to the Health Zone statistician to coach the HWs in maintaining better concordance of data and to regularly monitor the stock of commodities at the HFs level.

Key results of DDS Borgou

The overall performance of indicators decreased in some hospitals and health zones in 2017. The rate of use of health services declined, except in the HZ, which experienced an increase of 86% in 2017, where the reference and counter-reference systems run properly through regularly supervised CHWs who are followed-up by the local NGO SIAN SON.

Key results Malanville-Karimama

From 2014 to 2016, the number of malaria cases in Malanville increased from 21,325 in 2014 to 23,784 in 2016, while this number decreased from 12,625 in 2014 to 10,494 in 2016 in Karimama. The health zone should conduct weekly follow-up of the evolution of cases and reinforce case management.

Key results Bassila

According to available data, the number of uncomplicated malaria cases has decreased over the last 3 years.

ARM3 Quarter 25 Report (October-December 2017) Page | 46 Figure 7: Monthly evolution of the number of cases of confirmed uncomplicated malaria, all ages in the BASSILA HZ

8000

7000

6000

5000 of cases of 4000

3000

Nomber 2000

1000

0 JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NOV DEC

Source: RMIS data 2015 2016 2017

The 5 activities scheduled for the Q2 of 2017 were completely implemented and no stock-outs of malaria commodities were reported. However, the quality of the reports produced by HWs needs to be improved. In addition, the HZ team should coach and closely follow HFs in stock management.

Until December 2017, support the NMCP to provide weekly and monthly malaria data situational reports (SITREP) at 8 sentinel sites in Atacora where the IRS project was discontinued

Following the withdrawal of the IRS intervention in Atacora, a contingency plan was drawn up by the NMCP and malaria control partners in Benin. During this quarter, ARM3 supported the NMCP to collect weekly malaria data at the eight sentinel surveillance sites (Natitingou 1, Kotoponga, Perma, Toukountouna, Kouarfa, Tampégre, Boukoumbé Center and Manta) and two zonal hospitals (St Jean de Dieu de Tanguieta, HZ Kouande). Those data were collected to provide timely and rational databases for early detection of potential malaria outbreaks in areas where IRS has been withdrawn in order to respond rapidly. A total of 29 weekly situation reports were produced and shared with USAID during the reporting period.

During this follow-up, there was an upsurge of malaria cases after the withdrawal of AIRS. Measures have been taken to mitigate the effects of this recrudescence by organizing public‐awareness games called “radio reality” oriented towards malaria prevention and case management, organized in Boukoumbe, and Kouande Communities. Contracts were signed with public‐mobilizers to conduct a series of “information on malaria prevention and management” in their respective communities, initiating an early warning system for stock‐outs and over‐stock situations based on LMIS procedures (MIN‐MAX) and providing support on malaria commodities transportation. Following these activities, the trend has been reversed.

ARM3 Quarter 25 Report (October-December 2017) Page | 47 Figure 9: Evolution of malaria morbidity data in 8 sentinel HFs and two HZ hospitals through the Contingency plan in Atacor DDS

Weekly distribution of malaria (uncomplicated + severe ) all ages in the ten selected HFs 1200 1100 1000 900 800 700 600 500 Number of cases of Number 400 300 200 100

0

W1 W2 W3 W4 W5 W6 W7 W8 W9

W10 W11 W12 W13 W14 W15 W16 W17 W18 W19 W20 W21 W22 W23 W24 W25 W26 W27 W28 W29 W30 W31 W32 W33 W34 W35 W36 W37 W38 W39 W40 April May June July August September October November December

YEAR 2015 2016 2017

Figure 8: RMIS completeness in Benin from July 2011 to September 2017 disaggregated by public and private sectors

97.4 99.4 96.4 97.1 96.3 97.4 99.3 100 92.9 95.4 95.2 97.2 90.4 90.4 84.8 95.2 94.5 92.2 89.3 89 90 95.4 94.894.9 86.5 88.4 88.6 90.6 87.6 93.6 90.8 80 76.7 76.9 90.3 73.6 84 83.5 70 57 62.2 68.6 71.9 73.4 59.4 60 48.5 58.1 50 62.4 48.8 31.3 40 34.7

Percentage 39.6 30 21.2 20 19.9 10

0

Apr-Jun Apr-Jun Apr-Jun Apr-Jun Apr-Jun

Jul-Sept Jul-Sept Jul-Sept Jul-Sept Jul-Sept

Oct-Dec Oct-Dec Oct-Dec Oct-Dec Oct-Dec

Jan-Mar Jan-Mar Jan-Mar Jan-Mar Jan-Mar

Apr-Jun*

Jul-Sept* Jul-Sept*

Oct-Dec* Jan-Mar* 2011 2012 2013 2014 2015 2016 2017

Source: RMIS data Public Private

The graph shows that the RMIS completeness rate in the public sector rose by 0.6% (from 88.4% to 89%) and by 1.3% (from 58.1% to 59.4%) in the private sector between April-June 2017 and July-September 2017. The new PNLP1 tools are now available in all health centers and an effort is being undertaken with the DPP and the PNLP to restart data entry after the latency period.

ARM3 Quarter 25 Report (October-December 2017) Page | 48

RESULTS: MOH Capacity to Collect, Manage and Use Malaria Health Information for Monitoring, Evaluation and Surveillance Improved

Y7 Indicator Baseline Target FY18 Q1 Results Source

RMIS results are 80.2% from April to June The national RMIS and 16) % of targeted facilities (953/1189) 2017 and July to sentinel surveillance reporting through the Routine July to September September 2017. sites are providing high Malaria Information System and 37.80% 2017 quality information on sentinel surveillance sites are Source : Data from April to a regular and timely providing complete information RMIS 79.1% June 2017 and July basis for decision- on a regular and timely basis for 2012 (915/1157) to September 2017 making decision-making April to June 2017 have not yet been

validated by the

NMCP and may change.

Technical and financial support provided for the therapeutic efficacy study to be implemented by the NMCP with the National Laboratory in two sentinel sites following the WHO protocol

Since January 2017, a therapeutic efficacy study (TES) by the NMCP has been ongoing with financial support from ARM3. Two sites were selected to conduct the study (Klouékanme HZ hospital and Djougou Health Center) and participants included children aged 0 to 59 months. This study aims to measure the clinical and parasitological efficacy of antimalarial treatment (artemether/lumefantrine) for children <5 with uncomplicated malaria, to determine the ratio of patients with early and late diagnosis of therapeutic failure versus adequate clinical and parasitological response. In addition, it aims to identify upsurge or new malaria cases monitored by quantitative Polymerase Chain Reaction (qPCR).

ARM3 continued to support the NMCP technically and financially to carry out the therapeutic efficacy study. From November 28th to December 2, 2017, a field follow-up visit was organized by two teams. One team was composed of two PNLP staff members and one ARM3 staff member, and it covered the Djougou () study site. The second team was composed of 3 PNLP staff members and it covered the Klouekanmey study site (Couffo Department).

Specific objectives of the follow-up visits were to validate all the study supports, classify thick and thin blood smears and Whatman papers for PCR by day of follow-up, provide feedback to the field research team, and bring all deliverables back to the NMCP for the next steps of the study.

Field activities were closed at the two study sites and the key results were that:  978 patients benefited from the first evaluation  235 patients were included in the study (eligible per the clinical and parasitological criteria)  235 patients received follow-up during 28 days on the following days: D0, D1, D2, D3, D7, D14, D21, D28 according the research protocol

ARM3 Quarter 25 Report (October-December 2017) Page | 49  13 patients had positive results according to their thick/thin smears slides at D28  222 patients had negative results between D2 and D3.

The Confetti (Whatman filter paper sample) were made at D0, D7, D14, D21 and D28, and will be sent to CDC Atlanta for PCR analysis. The PCR results will confirm whether the species was Plasmodium falciparum. The final report of the study will be shared by the NMCP with its partners, ARM3, the CDC, PMI, and with the decentralized level of the health pyramid during the next quarter (QR26).

Sub-result 3.3: Improve MOH Capacity in Commodities and Supply Chain Management

During this reporting period, ARM3 provided technical and financial support to the NMCP in their introduction of subsidized malaria commodities in the private sector, and in training private sector actors in Djougou / Copargo / Ouake health zone (DCO) on the logistic management information system (LMIS) and completion of management tools. Afterwards, the post-training supervision of the private HFs was done in CBGH, A / S and DCO HZs.

In addition, the post-training follow-up of the Medistock v6 software was carried out in Ouémé / Plateau, Mono / Couffo, Zou / Collines, Alibori and Donga. ARM3 provided technical support to the PNLP for the 2017 ILP consumption data validation workshop for 34 DRZs. Finally, ARM3 participated at the 10th Summit of the Global Health Supply Chain (GHSCS) 2017 in Ghana.

Technical assistance provided to the NMCP to pilot the process of integration of malaria commodities into the private sector through private clinics (procedures, ordering, management tools, supervision, reporting, quantification, etc.) and expand to other private sector actors

ARM3 Quarter 25 Report (October-December 2017) Page | 50

Photo 7: DCO Health zone private clinics participants at the introduction of subsidized malaria commodities into the private sector. Credit ARM3

On October 24, 2017, the workshop on the introduction of subsidized malaria commodities into the private sector was held at "Mozard" Hotel in Djougou. Forty-nine (49) health workers (25 women) from eighteen (18) private HFs, the Health Zone Supervision team and the NMCP departmental cell attended the workshop.

The objectives of these workshops were to:  Brief the private sector on malaria case management according to the national protocol  Share the procurement mechanism for subsidized malaria commodities and the private sector sale pricing defined by the NMCP  Define the eligibility criteria to access subsidized malaria commodities  Explain the methodology to quantify needs, as well as the reporting and supervision system  Define next steps, including the training and the and post-training follow-up timeline

Next steps  Quarterly meetings to be held with private HFs joining the process, and the HZ team to monitor the progress  Train private HF actors on supply chain management, logistic management information system (LMIS) and the completion of management tools

ARM3 Quarter 25 Report (October-December 2017) Page | 51 In collaboration with the NMCP, train private sector HWs on MOH supply chain guidelines, standards and tools (LMIS, MEDISTOCK, etc.), used to manage malaria commodities

Photo 8: Private clinics HWs participating at the training session on subsidized malaria commodities supply chain and LMIS tools in DCO. Credit ARM3

From October 25 to 27, 2017, ARM3 provided technical and financial support to the NMCP to organize a training session for private sector HWs on subsidized malaria commodities supply chain, LMIS and on management tools in Djougou. Forty-nine (49) HWs (25 women) from eighteen (18) private health facilities, HZs team and the NMCP departmental cell attended the session.

The main objectives of this workshop were to train HWs on national case management guidelines and malaria commodities supply chain, on LMIS procedures, as well as on how to properly use the LMIS tools (stock sheets, REMECOM, purchase order forms).

Results of the pre- and post-tests are presented below.

ARM3 Quarter 25 Report (October-December 2017) Page | 52 Figure 10: Pre-test and post-test scores for private sector LMIS training in DCO HZ (out of 20)

20 18 15.4 16 14 12 10 8

6 Average Score Average 4 2 0.9 0 Pre-test Post-test

The results of the pre- and post-tests show that the average score increased by 14.5 (from 0.9 to 15.4 out of 20). This demonstrates that participants acquired a better understanding and knowledge of the introduction of the subsidized malaria commodities approach and process in the private sector.

The next steps: • Quantification of needs which will be integrated into the DRZs order • Plan a supervision to monitor the measure the acquired competencies and capabilities of HWs

Supported the NMCP’s post-training supervisory visits to private sector health facilities to oversee supply management and provide on-site coaching

Photo 9: From the left to the right, Dr. Jocelyn ACAKPO, ARM3 Malaria Officer, Ms. D'Almeida ABIBI, midwife on the private clinic of L'ESPOIR in Djougou and Dr. Lionel SOGBOSSI, NMCP departmental cell checking the availability of malaria officer in the pharmacy of HF in Djougou. Credit: ARM3

ARM3 Quarter 25 Report (October-December 2017) Page | 53

ARM3 conducted a post-training supervision and coaching of private health facilities enrolled in the introduction of subsidized malaria commodities process in CBGH, A/S and DCO HZs. This supervision was carried out by three teams led by the Health Zone medical Coordinator, the medical officer of the communes and the DNSP departmental cell. Those teams were supported by the NMCP departmental cell, DRZ and ARM3.

The main objectives of the supervision were to:  assess the implementation of the process by private HWs  ensure the availability of malaria commodities and management tools in the enrolled HFs  check if the HWS respect the malaria case management national guidelines and the pricing conditions defined by the NMCP and on how HWs have filled the management tools

The main results are summarized in the table below.

Table 11: Summary of the post-training supervision results in CBGH, A/S and DCO HZs

% private % private HFs HFs having # of having complied private # of % private # private produced with the % private HFs HFs private HFs supplied HZS HFs their national respected enrolled HFs malaria supervised monthly guidelines the pricing in the trained commodities order for malaria conditions process report case management

CBGH 25 25 24 67% 100% 100% (16/16) 94% (16/24) (16/16) (15/16) A/S 62 42 28 64% 83% 100% 83% (18/28) (15/18) (18/18) (15/18) DCO 18 18 18 61% 45% 73% 73% (11/18) (5/11) (8/11) (8/11) Average 64% 76% 91% 83%

An average of 64% of the private HFs supplied malaria commodities. Respectively, 76% of HFs, 91% and 83% of private HFs produced their monthly order reports, complied with the malaria case management national guidelines and respected the pricing conditions of the commodities. Supervision teams provided advice to HWs on how to improve their results, specifically on how to produce the order reports on time.

ARM3 Quarter 25 Report (October-December 2017) Page | 54 Figure 11: Percentage of private HFs with availability of management tools and correctly filling-out management tools the day of the visit in DCO HZ

90% 80% 80% 80% 70% 60% 56% 50% 50% 40% 33% 28% 30% 20% 10% 0% Stock cards REMECOM Monthly Order Report

Availability of management tools Good filling of management tools

The supervision team in DCO recommended improving the timely preparation of the order report.

Photo 10: From the left to the right, Mr. Roger SAMADI, nurse and Ms. Isabelle BOKOSSA, midwife at the PENIEL HF, Ms. Nadine AGOSSA GLELE, HZ Immunizations Head, and Awase RADJI Supply Chain Coordinator (ARM3) during the supervision of the private HFs at Abomey- Calavi Soava HZ. Credit: ARM3

ARM3 Quarter 25 Report (October-December 2017) Page | 55 Figure 12: Percentage of private HFs with availability of management tools and correctly filling out of management tools the day of visit to CBGH and AS HZs 100% 100% 100% 100% 94% 88% 90% 80%

70% 63% 60% 57% 50% 38% 38% 39% 40% 33% 29% 30% 20% 10% 0% ZS CBGH ZS AS ZS CBGH ZS AS Availability of management tools Good filling of management tools

Stock cards REMECOM Monthly Order Report

Compared with the results of the first supervision, we noted a significant improvement in the management tool’s availability, which rose from 21% to 38% in CBGH and 10% to 29% in AS .

Figure 13: Percentage of private HFs with ACTs and RDTs available the day of visit in CBGH, AS and DCO HZs

60% 50% 50% 39% 40% 33% 33% 29% 28% 30% 25% 21% 21% 21% 21% 21% 21% 22% 20% 17%

10%

0% AL 6 AL 12 AL 18 AL 24 TDR CBGH AS DCO

The percentage of private HFs with ACTs and RDTs available the day of the visit was low in the three HZs, as some of them had not yet supplied malaria commodities because they noted that the ACTs available at DRZs would expire soon. To mitigate this situation, a needs assessment was done on-site by the private HF managers and the supervision team, and purchase orders were developed and sent to the HZs for immediate processing.

ARM3 Quarter 25 Report (October-December 2017) Page | 56 Compared with the first supervision in CBGH and AS HZs, there is an improvement in terms of the availability of malaria commodities, as it rose from 17% to 21% for AL 6, 17% to 29% for AL 12, 13% to 21% for AL 18, and 38% to 50% for AL 24 respectively. Availability of RDTs rose only slightly, from 29% to 33%.

Supported the NMCP to conduct a post-training follow-up on the use of updated Medistock v6 and its maintenance in 34 DRZs

Photo 11: From the left to the right, Mr. Adamou OROU YAGUI, warehouse keeper in Banikoara DRZ and Mr. Lamidi OLAYE, Banikoara DRZ entering the monthly order reports from the health facilities in the Medistock v6 software. Credit: ARM3

From November 20 to 24, 2017, ARM3 organized a post-training follow-up of the new version of Medistock v6 in DCO, Banikoara, LA5, ADD6, KTL7, PAS8, 3A9, PAK10, COZO11 and DAGLA12 health zones.

The objectives of this post-training follow-up were to:

5 Lokossa Athieme 6 Aplahoue Dogbo Djakotey 7 Klouekanmey Lalo 8 Porto-Novo Aguegue Seme-Kpodji 9 Adjara Avrankou Akpro-Misserete 10 Pobe Adja-Ouere Ketou 11 Cove Zagnanado Ouinhi 12 Dassa Glazoue

ARM3 Quarter 25 Report (October-December 2017) Page | 57  Assess the availability, use and functionality of Medistock v6  Check data entry rates of the monthly reports at the DRZ level for the third quarter of 2017  Perform software maintenance at DRZs visited

The results obtained are illustrated through the graphs and comments below.

Figure 14: Medistock v6 status at HZ level

Medistock v6 status at the 34 HZs level 120% 100% 100% 100% 80% 80%

60%

40%

20%

0% Available Functional In use

Medistock v6 software is available and functional in the 10 DRZs visited. It is only used at eight (8) out of ten (10) supervised DRZs, however, due to the non-control of rules required by the new version such as:

 Respect for promptness in chronology of consecutive monthly entries of data  Concordance between the logistics data and the consecutive reports transmitted by HFs

These principles guaranteeing the quality of data are not followed by the two concerned DRZs when they complete data entry. These findings have already been shared with the IT Consultant and will be fixed soon by sitting with the DRZ managers and providing technical assistance to them.

ARM3 Quarter 25 Report (October-December 2017) Page | 58 Figure 15: LMIS complete reports submitted and percentage of the consumption data captured through Medistock v6 by department for Q3 2017

LMIS completeness and percentage of consumption data captured in Medistock v6 for Q3 2017 (July-Sept 2017) at the 10 HZs visited

100% 87% 88% 88% 90% 83% 82% 80% 75% 74% 69% 69% 70% 62% 60% 50% 40% 30% 20% 10% 0% Oueme/Plateau Mono/Couffo Zou/Collines Alibori Donga

LMIS completeness rate Medistock v6 consumption data rate

After reviewing the completion and reporting rates through Medistock v6, Zou-Collines had the lowest completion rate of 74%, compared to Alibori which had 88%. For data entry, the percentage was 62% in Alibori and 88% for Zou-Collines, respectively.

Participate in the semi-annual validation (field visit of 15 days) and consolidation (3 days) of malaria commodities data consumption

The semi-annual validation of malaria commodities data consumption workshop took place from December 5 to 9, 2017 in the south and from December 12 to 16, 2017 in the north. The activity was organized by the NMCP and funded by the GFATM. Ninety-six (96) participants (11 women) from thirty- four HZs including Medical Doctor Coordinators, GDRZs, Statisticians, CAME, the NMCP and ARM3 attended the workshop.

The purpose of this workshop was to:

 Analyze and validate the data collected and reported, including the quality control and accuracy of data and the HFs monthly order reports submitted through the MEDISTOCK v6 software  Compile the data of malaria commodities consumption from January to November 2017 from the 34 DRZ  Share experiences and good practices between GRDZs  State recommendations regarding difficulties and constraints encountered

ARM3 Quarter 25 Report (October-December 2017) Page | 59 Figure 16: Accuracy rate of malaria commodities consumption data from 34 DRZs, in 2017 97% 96% 100% 94% 93% 94% 92% 91%92% 91% 90% 86% 86% 87% 90% 83% 85% 84% 83% 84% 80% 79% 79% 80% 73% 69%71% 70% 60% 50% 40% 30%

Accuracyrate 20% 10% 0% AL 6 AL 12 AL 18 AL 24 SP RDT

Q1 2017 (Jan-March) Q2 2017 (Apr-June) Q3 2017 (July-Sept) Average

It is important to note that IPTp has the lowest accuracy rate because it does not always appear in REMECOM in some health facilities.

At the end of the workshop, the malaria commodities data consumption rates were compiled by HZ and department from January to November 2017 according to the template developed by the NMCP.

Table 12: Recommendations following this semi-annual malaria commodities data consumption

Recommendations Responsible Parties Deadlines Plan supervision and coaching for Recurrently from January 1 decentralized staff to ensure data MCZS 2018 quality Integrate LMIS data into DHIS2 to 2 ensure timely and complete data DPP and NMCP March 31, 2018 tracking Make internet connection available at 4 MCZS et CAR March 31, 2018 the DRZ office Communicate to the NMCP the 5 potential number of active CHWs for MCZS December 22, 2017 2018 in each health zone

ARM3 Quarter 25 Report (October-December 2017) Page | 60 Participation in the 10th Summit of the Global Health Supply Chain (GHSCS) 2017 in Ghana

Photo 12: Participants at the 10th Summit of the Global Health Supply Chain (GHSCS) 2017 in Ghana. Credit: ARM3

The 10th Global Health Supply Chain Summit (GHSCS) was held in Accra, Ghana from November 14 to 17, 2017 and was attended by Dr. Adjibabi, the head of the NMCP pharmacy and pharmaco-vigilance (SPPV) service, Dr. Alexis Tchevoede, the NMCP national coordinator, Mr. Ricardo Missihoun, the USAID Benin Commodity & Logistics Specialist and ARM3’s SCM Manager, and Dr. Gbaguidi.

The theme of this summit was “Linking to the future of Global Health Supply Chain Management through enhancing the role of the private sector, technology enablement, and workforce development and empowerment.”

The delegation from Benin presented results, lessons learned, best practices and challenges experienced in-country during the introduction of subsidized malaria commodities to the private sector assessment piloted in CBGH, A/S, Djougou and Natitingou HZs. This was presented through an abstract entitled “Enhancing the role of the private health sector through accessing to subsidized malaria commodities for accelerating the reduction of Malaria Morbidity and Mortality: game changer in Benin’s supply chain system.”

This innovate approach was highly appreciated by the participants. The Nigerian delegation invited those from Benin to join the upcoming supply chain workshop in .

ARM3 Quarter 25 Report (October-December 2017) Page | 61 RESULTS: MOH Capacity in Commodities and Supply Chain Management (SCM) Improved Indicators Baseline FY18 FY18 Q1 Results Source Target

The national malaria 71% commodity supply chain is functioning with a 17) # of quarterly and Source Logistics Management annual reports generated LMIS reports Information System 100% by the LMIS per year LMIS (LMIS) providing (34/34) (PY5/Q4) quarterly and annual reports RMIS results are from April to June 80.66% 2017 and July to 18) % of government HFs 85% of PMI-supported (880/1091) September 2017. with ACTs available for 100% health facilities report July to September treatment of Source no stock outs of 2017 Data from April to uncomplicated malaria EUV malaria commodities in June 2017 and July to the last three months 76.5% September 2017 have (PY5/Q2) (801/1047) not yet been

April to June 2017 validated by the NMCP and may change. ce63) # of monthly 100% ARM3 Program N/A FY6 Target : 8 N/A supervision held activities report

Program management

Field Office  Participated in the USAID-Benin Biannual Partner meeting held on October 5, 2017

 Developed the ARM3 Annual performance report for Year 6 -The ARM3 Annual performance report was sent to USAID on December 4, 2017

 Participated in the RBM meeting on October 11, 2017 at the NMCP office

 Finalized and submitted the revised ARM3 Year 7 workplan budget and narrative to USAID on November 21, 2017

 Prepared for the field visit in Benin by the Director of the MCDI International division to held January 15 to 19, 2017

 Participated in the 66th Annual meeting of ASTMH in Baltimore, Maryland, USA - The COP participated in the 66th annual meeting of American Society of Tropical Medicine and Hygiene (ASTMH) in Baltimore from November 5 to 10, 2017 with a 5-member delegation from the NMCP (Dr. Alexis Tchevoede, the National NMCP coordinator, Dr. Cherifatou Adjibabi, head

ARM3 Quarter 25 Report (October-December 2017) Page | 62 of the SPPV, Dr. Filemon Tokpannou, Head of the vector control, Dr. Bella Hounkpe, Head of the M&E and Mr. Boniface Denakpo, Head of the BCC partnership). The COP assisted the NMCP team in preparing and presenting the two posters they had developed (see Annex 3). He also had the opportunity to meet and discuss new, innovative approaches, new research/studies and results, best practices and lessons learned from malaria interventions with delegations from other countries.

 Office closing for the end of year 2017 - The ARM3 office in Cotonou was closed from December 22, 2017 to January 3, 2017. It is important to note that some ARM3 technical staff (i.e. Supply Chain, Monitoring evaluation, Case management) continued to support the NMCP on planned activities during the period.

Home Office At the end of September 2017, Home Office backstopping for ARM3 changed due to MCDI’s re-structuring of program management operations. Dr. Pablo Aguilar left the position, and Dr. Luis Tam (Director, International Division) took over that role, with the support of Ms. Jamie Mullaney (Assistant Project Officer). Dr. Pharath Lim, Ms. Megan Perry and Dr. Luis Benavente also provide Home Office-based technical assistance to the field team. Mr. Moussa Dambo remained as MCDI’s financial officer assigned to the project at the Home Office.

The Home Office backstopping team worked alongside the field team, supporting them in technical, contractual and financial matters. Weekly calls were held to identify and address issues of mutual interest, followed by more specific consultations.

MCDI provided logistical and technical support to the five-person NMCP delegation that was sponsored by USAID to attend the 66th annual meeting of the American Society of Tropical Medicine and Hygiene (ASTMH) in Baltimore, USA from November 5 to 10, 2017. The Home Office team played a significant role in the preparation of the presentations made by the ARM3 field team and the Benin NMCP at the ASTMH annual meeting (see Annex 3 for the ARM3 posters that were presented).

Major Activities Planned for Next Quarter (Year 7, January–March 2018)

Result 1: Strengthen the effectiveness of the national malaria prevention interventions Sub-result 1.1a: SBCC Activities conducted in support of prevention and case management interventions  Technical assistance provided to the NMCP to integrate the revised SBCC strategy in the National BCC Plan in collaboration with the GFATM and the CRS CATCH project Sub-result 1.1b: Increase coverage of intermittent preventive treatment during pregnancy (IPTp) per new national norms  In coordination with the NMCP, participate at a post training follow-up of the 1,500 health providers trained in Year 6 under GFATM funding (Only ARM3 case management staff participation)

ARM3 Quarter 25 Report (October-December 2017) Page | 63 Sub‐result 1.1c: Increase universal access and utilization of LLIN  Technical and financial assistance provided to the NMCP to develop and implement the baseline and evaluation protocols and conduct the LLIN Result 2: Improve and implement malaria Diagnosis and Treatment Activities in support of the National Malaria Strategy Sub-result 2.1: Improve diagnostic capacity and use of diagnostic testing  With the NMCP, participate as national supervisor member at 1 OTSS supervision of microscopists in 118 laboratories using the NMCP's integrated supervision forms (ARM3 Diagnostic Manager will accompany supervisory visits in key regions). Sub-result 2.2.: Improve Case Management of Uncomplicated and Severe Malaria  Provided technical assistance and oversight to the IRSP in the development of the training plan, which began in Year 6, and to the NMCP in its validation including payment of remaining balance and the establishment of a roadmap to implement recommendations  Technical and financial assistance to the NMCP to organize a validation session at national level of the injectable and rectal artesunate (IA/RA) documents developed with the support of ARM3 (trainings materials: manual of participants, facilitator guide, supervision and M&E tools)  Technical and financial provided to train 15 trainers for 5 days (trainers pool) for the introduction of IA and RA in HFs  Technical and financial support to the NMCP to train 30 HWs for 5 days on the introduction of IA/RA, M&E and supervision tools including SOPs from targeted 15 hospital (2 people per hospital : maternity and pediatric wards) Sub-result 2.3: Improve integrated Community Case Management (iCCM)  Technical and financial assistance provided to the DNSP, DPP and departmental levels to conduct one (1) data quality audit through a representative sample of CHW's and HFs in 10 HZs Provide technical and financial assistance to the DNSP, DPP and departmental levels to conduct two data quality audits through a representative sample of CHW's and HFs in 10 HZs  In collaboration with the DNSP and NMCP jointly supervised CHWs in 10 HZs through monthly field visits of 2-3 days, using the supervision framework (checklist) to assess testing by RDTs, use of ACTs and data quality control Result 3: The National Health System's Capacity to Deliver and Manage Quality Malaria Treatment and Control Investigations Strengthened

Sub-result 3.1: Enhance the NMCP's Technical Capacity to Plan, Design, Manage, and Coordinate a Comprehensive Malaria Control Program  Participate in the NMCP’s existing working groups. All four TWGs (Supply Chain Management, M&E, BCC, Case Management) meet on a quarterly basis to discuss solutions to key challenges for malaria implementation  Techncial and financial support to the WHO, National Council against AIDS, Tuberculosis and Malaria (CNLSTP) and the NMCP to conduct a workshop to discuss HMIS roadmap for malaria

ARM3 Quarter 25 Report (October-December 2017) Page | 64 data, including potential added uses of DHIS2, how to use DHIS2 for data validation workshops, production of malaria bulletins, technical assistance gaps  Technical and financial support provided to the WHO , CNLSTP and the NMCP to finalize and implement the HMIS roadmap , desired products and use routine malaria data in Benin  Technical assistance to the NMCP’s existing working groups. All four TWGs (Supply Chain Management, M&E, BCC, Case Management) meet on a quarterly basis to discuss solutions to key challenges for malaria implementation  Technical and financial support to Borgou , Alibori, Atacora and Donga DDS to support their action plans and to improve their leadership and management through Malaria Officer Sub-result 3.2: Improve MOH Capacity to Collect, Manage, and Use Malaria Health Information for Monitoring, Evaluation, and Surveillance  Participate in the validation of RMIS data at national level (Only ARM3 team participation)  One (01) quarterly follow-up RDQAs conducted in high lethality rate HZs including HZs in the border with and Burkina Faso  Technical and financial assistance provided to selected health zones to organize Quarterly Malaria Indicators Review Workshop for decision-making, using scorecards and dashboard (private sector will be included)  Technical and financial support provided for the therapeutic efficacy study to be implemented by the NMCP with the National Laboratory in two sentinel sites following the WHO protocol. CDC will also provide technical assistance Sub-result 3.3: Improve MOH Capacity in Commodities and Supply Chain Management  Technical and financial assistance provided for the preparation of the Annual Quantification Workshop for malaria commodities conducted with the NMCP Provide technical assistance to the NMCP to conduct monthly 100% LMIS supervision to new HZs  Technical assistance provided to the NMCP to continue to support the introduction of public sector malaria supplies into the private sector (procedures, ordering, management tools, supervision, reporting, quantification, etc.)  In collaboration with the NMCP, trained private sector HWs in MOH supply chain guidelines, standards, and tools used to manage malaria commodities (LMIS, MEDISTOCK,etc) including the Plateforme du secteur privé pour la santé (PSSP)  Supported the NMCP’s post training supervisory visits to private sector health facilities to oversee supply management and provide 1 onsite coaching  Technical assistance provided to the NMCP to continue the monitoring of the Common Basket performance and availability of stocks in public HFs in 34 HZ  Technical and financial assistance provided to the NMCP to conduct a lessons learned workshop to assess access of private sector to public malaria supplies, as well as the implementation of the Common Basket after one year

ARM3 Quarter 25 Report (October-December 2017) Page | 65 Assessment of Behavior Change Communication (BCC) intervention conducted in Benin

Boniface Denakpo1, Saka I. Amossou1, Bella Hounkpe1, Adrien Hessavi1, Mariam Oke Sopoh1, Gilbert Andrianandrasana2, Jeanne Togbenou2, Michelle Kouletio3, Peter Thomas3, Fortune Dagnon4, Pablo Aguilar4, Christopher Schwabe4 , Désiré Ekué Amegnikou5

Results Background Benin is a malaria endemic country. Prevention and case • Survey results showed that: management interventions require behavior change at the • 65.9% of women in the Intervention Group were reported exposure to malaria awareness messages compared to 52.3% in the individual and social levels, including the use of bednets (ITNs) Control Group (p <0.05) and the uptake of intermittent presumptive treatment (IPTp) • 92.8% of the Intervention Group knew what to prevent malaria compared to 84.1% in the Control Group (p <0.05) services delivered through routine antenatal care. • 90% of their children <5 and 86.7% of women in the Intervention Group slept under an ITN the previous night, compared to 81.8% of the children and 76% of the women in the Control group (p <0.01) From 2012 to 2014, the Accelerating the Reduction of Malaria • The level of LLIN used by pregnant women in the intervention group was higher compared to the control group (86.7% against Mortality and Morbidity (ARM3) project delivered a malaria 76% (p <0.05)) Behavior Change Communications (BCC) intervention • The maternal registers showed that 66.2% of women who had a live birth during the past two years received two or more doses targeting 28 of the 34 health zones. A study was conducted of IPTp during ANC visits, versus 42.4% win the Control Group (p <0.01) with the National Malaria Control Program (NMCP) in May Table1 : Comparison Women exposure indicators between the intervention and the Control group (data related period: April-June 2014) 2015 to assess differences in attitudes and practices of women Intervention Group Control Group with children under five and health care providers between the INDICATORS (Ouémé-Plateau) (Mono-Couffo) P-value N=296 N=232 intervention and non-intervention HZs. *p<.0.05 **p<0.01 EXPOSURE % / Confidence Intervals % / Confidence Intervals ***p<0.001

% of women (pregnant/non-pregnant) with children under 5 who 65.9 52.6 0,001925 ** remember having heard or seen a message on malaria whatsoever (60.4 – 71.3) (46.1 – 59.1)

Methods % of women (pregnant/non-pregnant) with children under 5 who 32.4 13.8 0,000001*** remember having heard/seen a message about malaria through radio (27.1 – 37.8) (9.3 – 18.3) • A comparative retrospective study between 296 women 15-

% of women (pregnant/non-pregnant) with children under 5 that 79.7 53.9 49 aged randomly selected through 8 public health facilities 0,00000*** recognize at least one of the images of flyers on malaria awareness (75.1 – 84.3) (47.4 – 60.3) in 2 Health Zones out of 5 in the Health District (intervention % of women (pregnant/non-pregnant) with children under 5 who 34.5 9.1 0,00000*** group where ARM3's BCC activities were implemented over participated in social mobilization on malaria / mosquito/SP/ACT (29.0 – 39.9) (5.3 – 12.8)

a 12-month period) and 232 women 15-49 aged randomly Figure 1. Social mobilization activity in Oueme-plateau (Area of Chart 2 : Comparison of ITN use among pregnant women and children under-five intervention) and IPTp Uptake during ANC visits between the 2 groups of the study area 2015) selected through 8 public health facilities in 2 Health Zones 100% 94.0% out of 4 in the Health District with no ARM3 BCC activity as 89.4% 90% 79.1% 82.1% 80% the control group. 70% • A total of 528 women (321 pregnant and 207 mothers of 60% 50% children <5) were interviewed using Roll Back Malaria BCC 40% 31.7% 30% 23.3% instruments and maternal registers were reviewed in all 16 20% 10% participating health centers. 0% • Both groups shared similar socio-economic characteristics. Proportion of pregnant Proportion of children Proportion of pregnant women who slept under an under five who slept under women had received the • Associations among variables were tested at the 5% ITN the previous night in ITN the previous night in two doses of sulfadoxine- intervention areas intervention areas pyrimethamine (SP) under threshold using the ANOVA F-test. direct observation

Intervention group Control group

Conclusions • BCC activities had a positive effect in improving behaviors related to the prevention of malaria in pregnant women and children <5. • Despite design limitations, BCC assessments can be useful in discerning exposure to and practice of key malaria practices. Future studies should be planned pre-intervention and include a baseline in intervention and control areas. • While malaria control practices are generally good, populations exposed to ARM3's intervention had more exposure to malaria messages, social mobilization and higher ITN and IPTp utilization levels.

Contact Affiliations Acknowledgements Boniface Denakpo 1. NMCP/MOH, Benin This poster was made possible through support provided by U.S. Benin’s National Malaria Control Program 2. USAID/PMI, Benin Agency for International Development (USAID), West Africa Mission, Email: [email protected] 3. ARM3/MCDI, Benin Benin Office, US President’s Malaria Initiative (PMI). The authors’ Phone: (229)21333930 4. Medical Care Development International (MCDI), United States views expressed in this publication do not necessarily reflect the 5. MCDI Benin National Consultant views of the United States Agency for International Development, the United States Centers for Disease Control and Prevention, or the United States Government. Reduced malaria commodity stock-outs at health facility level through monthly supervision in Benin Adjibabi Cherifatou1, Alexis Thevoede1, Ricardo Missihoun2, Michelle Kouletio2, Fortune Dagnon2, Angelique Gbaguidi3, Gilbert Andrianandrasana3, Maria Arias-Coscarón4, Christopher Schwabe4, Pablo Aguilar4

Background Results To improve the availability of malaria commodities and • The average percentage of HFs visited monthly during pilot period was 98.75% and 95.62% in PKN and CBGH respectively. reduce health facility (HF) stock-outs, this pilot tested • The percentage of HFs where health workers knew how to correctly fill out an LMIS report increased by 63% for CBGH and the concept of “100% supervision” facilitated frequent, 74% for PKN. supervision of supply chain management at all HFs in • The degree of discordance in quantity of ACT prescribed compared to the consumption quantity decreased by 74% in CBGH targeted Health Zones (HZ). The approach aimed to and 55% in PKN. • The percentage of HFs that experienced Artemether/Lumefantrine (AL) stock-out (first line anti-malarial) the day of the visit for, improve management efficiency through monthly declined from approximately 35% in July to 12% in September 2015 in CBGH and from 41% in April to 24.5% in September physical stock inspection and logistics management 2015 in PKN. information system (LMIS) data validation by a local

Quality Improvement Team (QIT). 110% 93% Methods 90% 73% • The “100% supervision” was tested over a six month 70% 59%

period (April-September 2015) in two HZs: Parakou- 50% CBGH 33% N'Dali (PKN) and Come-Bopa-Houeyogbo-Grand Popo 13% 30% 21% PN 15% 18% (CBGH), covering all 20 and 48 HFs respectively. HZs 19% 10% 4% 7% -2% were purposively sampled base d on average and low -10% Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 LMIS performance. Chart 1 : Discordance in quantity of ACT prescribed compared to the reported consumption quantity, April – September 2015

• The QIT collected information, assessed compliance with

the LMIS parameters and determined the completeness 100% 100% 100% 96% 93% 93% 92% 96% 95% and timeliness of the reports transmission, consistency, 90% 90% 81% 83% 83% 80% 80% accuracy and the quality of data. 69% 70% ilities 70% • Limitation - some indicators were only assessed for a 65%

Fac

60% 60% three month period due to the availability of data. 50% 50%

40% Health 40% Percentage 30% 30%

% of 20% 21% 20% 17%

10% 8% 11% 10% 9% 4% 7% 5% 0% 0% 0% 0% 0% 0% Apr-15 May-15 June-15 July-15 Aug-15 sept-15 CBGH PN

Apr-15 May-15 June-15 July-15 Aug-15 sept-15 CBGH PN

Fig 2: Timeliness of LMIS reports submitted by CBGH and PKN, Fig 3 : % of Health Facilities experienced Stock out the day of the visit, April- Sept 2015 April – Sept 2015

Conclusions

The improvement in the supply chain metrics and indicators achieved through the 100% supervision, as part of the effort to strengthen the local level is evident: reduced stock-outs, more reliable commodity data, local problem solving and resource mobilization. Linking prescription and drug administration data is key to quality control. The approach is planned for geographic scale-up and the addition of other key non-malaria commodities. Fig 1. Mr. Daniel Agodou, HZ Warehouse Manager during a 100% supervision visit

Contact Affiliations Acknowledgements Adjibabi Cherifatou This poster was made possible through support provided by U.S. Agency for 1. NMCP/MOH, Benin National Malaria Control Program International Development (USAID), West Africa Mission, Benin Office, US 2. USAID/PMI, Benin Email: '[email protected]' President’s Malaria Initiative (PMI). The authors’ views expressed in this 3. ARM3/MCDI, Benin Phone: (00229)97891235 publication do not necessarily reflect the views of the United States Agency for 4. Medical Care Development International (MCDI), United International Development, the United States Centers for Disease Control and States) Prevention, or the United States Government.