COAG No. 72068718CA00001 Table Des Matières I

Home , Ambanja, Ambinanitelo, Ankatafa, Ankazoabo, Ankazoabo (district), Mananara Nord

COAG No. 72068718CA00001 Table des matières I. INTRODUCTION ...... 5 II. MAIN ACHIEVEMENTS DURING YEAR 1 ...... 9

II.1. IR 1: ENHANCED COORDINATION AMONG THE PUBLIC, NONPROFIT, AND COMMERCIAL SECTORS FOR RELIABLE SUPPLY AND DISTRIBUTION OF QUALITY HEALTH PRODUCTS ...... 9 II.2. IR2: STRENGTHENED CAPACITY OF THE GOM TO SUSTAINABLY PROVIDE QUALITY HEALTH PRODUCTS TO THE MALAGASY PEOPLE 17 II.3. IR 3: EXPANDED ENGAGEMENT OF THE COMMERCIAL HEALTH SECTOR TO SERVE NEW HEALTH PRODUCT MARKETS ACCORDING TO HEALTH NEEDS AND CONSUMER DEMAND ...... 31 II.4. IR 4: IMPROVED SUSTAINABILITY OF SOCIAL MARKETING TO DELIVER AFFORDABLE, ACCESSIBLE HEALTH PRODUCTS TO THE MALAGASY PEOPLE ...... 40 II.5. IR5: INCREASED DEMAND FOR AND USE OF HEALTH PRODUCTS AMONG THE MALAGASY PEOPLE ...... 46 II.6. CROSS‐CUTTING ACTIVITIES: MONITORING, EVALUATION, RESEARCH AND LEARNING ...... 56 1. Monitoring and Evaluation ...... 56 Research ...... 63 3. Knowledge Management ...... 64 II.7. CROSS‐CUTTING ACTIVITIES: GENDER AND SOCIAL INCLUSION ...... 65 II.8. SUCCESS STORIES ...... 66 III. ENVIRONMENTAL MITIGATION AND MONITORING REPORT ...... 67

III.1. GENERAL FINDINGS FOR PUBLIC SECTOR ...... 67 III.2. GENERAL FINDINGS FOR SOCIAL MARKETING ...... 68 IV. KEY CHALLENGES AND SOLUTIONS ...... 69 V. FINANCIAL SUMMARY ...... 70 ANNEXES ...... 71

ANNEX A ‐ PERFORMANCE MONITORING PLAN (PMP) ...... 72 ANNEX B – YEAR 1 WORKPLAN UPDATE ...... 98 ANNEX C ‐ ENVIRONMENTAL MITIGATION AND MONITORING REPORT ...... 121 ANNEX D ‐ SUCCESS STORIES (QUARTER 4) ...... 135 ANNEX E – STOCK INVENTORY AS OF SEPTEMBER (USAID AND PMI FUNDED) ...... 143 ANNEX F – STOCK STATUS BY END OF SEPTEMBER 2019 ...... 146 ANNEX G: SUMMARY OF MASS MEDIA SPOT AIRED DURING YEAR 1 ...... 149 ANNEX H: DESCRIPTIONS OF THE SEVEN QUALITY DIMENSIONS FOR THE RDQA ...... 151 ANNEX I: QUANTITY AND VALUE (USD) OF THE REDEPLOYMENT ...... 153

ACRONYMS ABM Accès Banque Madagascar ACM Aviation Civile de Madagascar ACT Artemisinin Combination Therapy ADDO Accredited Drug‐Dispensing Outlet A2F Access to Finance AMELP Activity Monitoring Evaluation and Learning Plan AMM Agence de Médicaments de Madagascar BOA Bank of Africa Madagascar CCM Country Coordinating Mechanism CDCL Continuous Distribution at Community Level CGL Comité de Gestion Logistique CHV Community Health Volunteer CHW Community Health Worker CSR Corporate Social Responsibility CSB Centre de Santé de Base CoAg Cooperative Agreement DCA Development Credit Authority DCoP Deputy Chief of Party DEPSI Direction des Etudes de la Planification et du Système d’Information DPEV Direction des Programmes Elargis de Vaccination DGI Direction Générale des Impôts DHIS‐2 District Health Information System ‐ 2 DPS Direction de la Promotion de la Santé DPLMT Direction de la Pharmacie, des Laboratoires et de la Médecine Traditionnelle DSFa Direction de la Sante Familiale DSSB Direction des Services de Santé de Base DEPSI Direction des Etudes, Planification et du Système d’Information EKAR Eglizy Katolika Romana EMMP Environmental Mitigation Monitoring Plan EU European Union FANOME Financement pour l’Approvisionnement Non‐stop en Médicaments FDA Food and Drug Administration Authority FEFO First Expiry – First Out FISA Fianakaviana Sambatra HPN Health Population and Nutrition HRD Health Regional Directorate MEL Monitoring, Evaluation and Learning FP Family Planning GAS Gestion des Approvisionnements et des Stocks GESI Gender Equality and Social Inclusion GF Global Fund GHSC‐PSM Global Health Supply Chain – Procurement and Supply Management GOM Government of Madagascar GYWG Gender and Youth Working Group

IMPACT Improving Market Partnerships and Access to Commodities Together IR Intermediate Result IPTp Intermittent Preventive Treatment during pregnancy ISM Integrated Social Marketing LLIN Long Lasting Insecticide‐treated Net RLA Regional Logistic Advisor LMIS Logistic Management Information System MCH Maternal and Child Health MDA Market Development Authority MENETP Ministère de l’Education Nationale et de l’Enseignement Technique et Professionnel MERL Monitoring Evaluation Research and Learning MOPH Ministry of Public Health MSME Micro Small Medium Enterprises MSH Management Sciences for Health MYS Ministry of Youth and Sport NMCP National Malaria Control Program NGO Non‐Governmental Organization ONP Ordre National des Pharmaciens de Madagascar PA Point d’Approvisionnement PAIS Plan d’Action d’Intégration des Intrants de santé PARC Point d’Approvisionnement Relais Communautaire PDPN Plan Directeur Pharmaceutique Nationale PMI President’s Malaria Initiative PMP Performance Monitoring Plan PPR Performance Plan and Report PPN Politique Pharmaceutique Nationale PSHP Private Sector Humanitarian Platform PSI/M Population Services International/Madagascar Pha‐G‐Dis Pharmacie de Gros de District Pha‐Ge‐Com Pharmacie à Gestion Communautaire RBM Roll Back Malaria RH Reproductive Health RDT Rapid Diagnostic Test SDSP Service de District de Santé Publique SILC Savings and Internal Lending Communities SBCC Social and Behavior Change Communication SHOPS Plus Sustaining Health Outcomes in the Private Sector Plus SoW Scope of Work SWOT Successes, Weaknesses, Opportunities, Threats SP Sulfadoxine Pyriméthamine SPD Superviseurs de Point de Distribution STTA Short‐term Technical Assistance TMA Total Market Approach TMI Total Market Initiative

ToR Terms of Reference ToT Training of Trainers TWG Technical Working Group UAV Unmanned Aerial Vehicle UCP Unité de coordination des Projets UHC Universal Health Coverage UNDP United Nations Development Program UNFPA United Nations Population Fund UTGL Unité Technique de Gestion Logistique USAID United States Agency for International Development VSLA Village Savings and Loan Association WASH Water, Sanitation and Hygiene WHO World Health Organization

I.INTRODUCTION

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

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

This report summarizes the activities carried out during Year 1 by the consortium partners. The Performance Monitoring Plan (PMP) figures and the workplan update are presented in Annex A and Annex B respectively. The narrative provides summary and updates on accomplishments, challenges, and solutions for Year 1.

Summary of Year 1 Achievements Eighty‐five activities were planned and approved by USAID for IMPACT Year 1. Graph 1 shows the final status of activities completion in Year 1.

Graph 1. Summary of the activities achieved vs activities planned for October 2018 – September 2019

100%

80% 73%

60%

40%

20% 14% 12%

1% 0% Completed Continued activities Replanned activities Cancelled activities

‐ Sixty‐two of the 85 activities (73%) planned during Year 1 were completely achieved. ‐ Twelve activities (14%) started during Year 1 but will continue in Year 2 ‐ Ten activities (12%) are rescheduled for Year 2.

One activity was cancelled. This activity is the feasibility study to use a third‐party vendor for the private sector data collection system that is not required and will be replaced by a mapping exercise. The initial purpose of a third‐party vendor was to routinely collect and analyze health market data, including market share (volume and value), for tracer health products in the three sectors (public, social marketing, and private for profit). A feasibility study was planned to evaluate barriers and motivation on collecting routine data within the private sector. Since there is already the TMA TWG on LMIS to manage all data collection issues with the aim to create a routine private sector system integrated into the public system, the feasibility study has been cancelled for the following reasons: ‐ An LMIS system for the private sector will be set up so a third‐party vendor will no longer be used as a LMIS routine data collection system. ‐ A mapping exercise, led by the TMA LMIS TWG, is being implemented in order to approach the pharmacies and drug shops that are randomly selected to participate in submitting the LMIS data. Useful information such as motivation and barriers to sharing LMIS data and agreements for sharing LMIS data will be collected.

Annex B includes details on which activities will continue in Year 2, which activities are rescheduled for Year 2, and the one cancelled activity.

Project Startup Activities At project startup, nine activities were planned. An update on the achievements of these activities is provided below.

 Finalization of the strategy with all IMPACT partners and key stakeholders through a collaborative process The IMPACT team closely engaged all relevant stakeholders (i.e., the public sector, commercial players, and nonprofit organizations) across the value chain through participative meetings to create a common understanding of current market constraints, a vision for a more equitable and sustainable future market, and the Government of Madagascar (GOM) ownership of a comprehensive strategy to get there.

During the project’s first month, all key stakeholders participated in a series of kick‐off meetings that explained to the actors from different sectors the project’s objectives and its structure. During this process, a strategy for the Total Market Approach (TMA) emerged (TMA champion identification, members of Technical Working Group ‐ TWG, etc.) and some keys activities for the GOM were added to the workplan, including support of events like World Malaria Day and radio broadcasts for malaria.

 Orientation Session An IMPACT orientation session was held during a two‐day workshop on January 22nd and 23rd. The purpose of this session was to create a common understanding of the project and build team spirit among the different members of the consortium.

‐ The first day of the workshop IMPACT was officially launched in the presence of 40 members of the IMPACT consortium, including PSI/M, PATH, MSH, Banyan Global, and Telma Foundation. The main goal of the first day was to ensure that all members of the consortium have a common understanding of the project according to the components set out in the Cooperative Agreement (CoAg) with USAID. ‐ On the second day, USAID/Madagascar’s staff joined the workshop. The thematic approaches and innovations were presented, including TMA, Market Development Approach (MDA), Total Cost Analysis/cost recovery pilot model, Development Credit Authority (DCA) private sector/supply‐side financing commitment, and last‐mile distribution solutions.

 Official Launch IMPACT was officially launched on April 15, 2019 at the SALAMA warehouse. The event was honored by the presence of the Minister of Public Health, HE Ambassador of USA, and the USAID Mission Director. The main objective of this event was to present IMPACT’s goals, objectives, targets, and approaches to the government, private sector, and various health stakeholders. 150 people from different sectors attended the ceremony, including the press.

 Key Personnel Recruitment/Setup ‐ Two of the five key personnel for IMPACT were in place at the beginning of the project, including the Finance Director and Monitoring Evaluation Research and Learning Director. ‐ The Deputy Chief of Party joined the team from mid‐October.

‐ The initial candidates recruited for Chief of Party and Senior Supply Chain Advisor resigned. New recruitments were launched to find qualified candidates and the new Chief of Party joined the team at the end of November 2018 and the Senior Supply Chain Advisor began on December 17th, 2018. ‐ IMPACT completed recruitment of all technical staff in March 2019.

 Elaboration of the IMPACT key documents ‐ The AMELP (Activity Monitoring Evaluation and Learning Plan) was created based on the template shared by USAID and approved in February 2019 while the PMP with the baseline (Performance Monitoring Plan) was approved in September 2019. ‐ EMMP (Environment Mitigation Monitoring Plan) was developed and approved in early January 2019. ‐ The Year 1 implementation plan and budget were submitted and approved in January 2019. ‐ The Branding and Marking Plan was submitted to USAID and the approval was received in February 2019.

 Strategic Planning Workshop Year 2 ‐ In order to prepare the IMPACT Year 2 workplan and budget, the team organized a retreat in Antananarivo from July 1st to 6th where national and international members from PSI, PATH, MSH, Banyan Global and Telma Fondation attended. ‐ During this event, USAID shared the operational planning FY2020 guidance based on developing country ownership through project activities and promoting leadership of Figure 1: Group photo of the team during the strategic planning workshop

the GoM, Universal Health Coverage, private sector engagement, Youth consideration, ensuring that DHIS2 is properly functional for reporting (Système d’Information Sanitaire ‐ SIS, Logistic Management Information System ‐ LMIS) at different levels, taking into consideration actions that would strengthen the country's capacity to prevent and respond to emergency, commitments in terms of additional resource mobilization and cost sharing, promoting collaboration with other USAID‐funded projects, empowering people, communities, and government leadership on their journey to self‐reliance and prosperity, and including annual and end‐ of‐project targets for each performance indicator. The Ministry Of Public Health (MOPH) 2020 workplan was collected and taken into consideration in the development of the IMPACT Year 2 workplan.

II. Main Achievements during Year 1

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

Sub‐IR 1.1 The total market for health products in Madagascar is understood and documented Conduct exhaustive desk review of TMI literature in Madagascar

Year 1 was spent laying the groundwork to better understand the total market for Family Planning (FP), malaria, and Maternal Neonatal and Child Health (MNCH) products. First, a desk review was conducted to better understand the existing information about the total market in Madagascar, including what had already been done and lessons learned, for the IMPACT team to build upon. The desk review covered all health areas that had information on a TMA or assessment, but focused particularly on malaria, FP, and MNCH. It enabled the IMPACT team to design the curriculum for the Champions’ training on TMA, and to understand the objective and the general content of the TMA roadmap.

Development of an overarching TMI roadmap for all three health areas (FP/RH, Malaria, and MCH)

The members of the TMA TWG (see TWG section) have identified the following priority issues: (i) the lack of communication around the national pharmaceutical policy, (ii) the availability and quality of data, and (iii) the application of regulatory texts.

To identify solutions for the three priority issues, a roadmap was developed, supported by an action plan detailing the specific joint actions to be taken towards the achievement of each solution. In addition, three subcommittees within the TMA TWG have been set up and have laid out all the possible actions to be taken to ensure proper implementation of the roadmap and its operational plan. The subcommittees will be coordinated and led by the MOPH director related to each respective topic. For example, the subcommittee in charge of the update and implementation of the Politique

Pharmaceutique National (PPN) and its Plan Figure 2: Subcommittee in discussion led by one TMA Champion during workshop Directeur Pharmaceutique National (PDPN) on September 24, 2019 will be led by DPLMT (Direction de la Pharmacie, des Laboratoires et de la Médecine Traditionnelle); the subcommittee in charge of the respect and application of regulatory texts governing health commodities will be led by AMM (Agence de Médicaments de Madagascar); and the subcommittee in charge of the continuous availability of logistical and statistical data will be led by DEPSI (Direction des Etudes, de la Planification et du Système d'Information). The activities, which are part of the roadmap and action plan, align with the priorities of each directorate within the MOPH, which fosters their ownership and engagement in the implementation.

Identify one priority health area among FP/RH, Malaria, and MCH and plan TMI market assessments for Year 1

It has been agreed with USAID that malaria is the priority health area chosen for Year 1. In addition, the desk review mentioned earlier laid the groundwork for the first market assessment for malaria.

Conduct TMI market assessment for the priority health area

In Quarter 2, IMPACT drafted data collection tools for the market assessment, created the study design, and oversaw the data collection process for the malaria market assessment, which is still underway (see further details in MERL section). Market assessments are considered as the second step in the TMA process because they provide information on the landscape of the priority health area. Thus, it was agreed with USAID that IMPACT will start assessing the landscape of six malaria products during Year 1. The malaria market assessment has four components such as the key informant interview, customer survey on willingness to pay, outlet survey and routine data collection which were conducted from Quarter 3 and preliminary findings were analyzed in Quarter 4. The results of the malaria market assessment will be presented in Quarter 1 of Year 2. IMPACT has collaborated with NMCP (National Malaria Control Program) through the Roll Back Malaria (RBM) to engage malaria stakeholders in the malaria market assessment and to set up a TMA extension of the RBM group involving the private sector.

Identify and train TMI Champions

In Quarter 3, the team began to work with key stakeholders on the market assessment and through this process champions for the TWG surfaced. In Quarter 4, the Total Market Approach Technical Working Group (TMA TWG) was established under the leadership and facilitation of three Champions from the MOPH, including the General Director for the Provision of Care (Directeur Général pour la Fourniture de Soins), the General Director for Preventive Medicine (Directeur Général de la Médecine Préventive), and the Director of the Drug Regulatory Authority of Madagascar (DAMM).

The three TMA Champions have proven to be highly motivated and highly capable in facilitating and leading the TMA TWG workshops. They were trained in the TMA concept in a one‐day session provided by IMPACT. Their leadership was invaluable in the development of the TMA roadmap and action plan.

Additional champions have emerged since this meeting through the joint leadership of each subcommittee by the private and public sector. IMPACT identified two potential Champions from the private sector who distinguished themselves by their active participation in discussions and their leadership in their respective groups. The two potential Champions will be confirmed and officially presented in Quarter 1 Year 2.

Figure 4: Two potential private sector TMA Champions facilitating Figure 5: DEPSI Director, a potential TMA Champion, presenting the subcommittee discussion on September 24, 2019 public sector information system on August 14, 2019

Under the initiative of the TMA Champion/General Director for the Provision of Care, and with IMPACT technical and financial support, 13 directors of University Hospitals (CHU‐Centre Hospitalier Universitaire) from 4 regions (Haute Matsiatra, Boeny, Atsinanana and Analamanga), and 6 staff from the Provision of Care Directorate were trained on TMA principles.

The health product management manual stipulated that Pha‐G‐Com’s managers and providers, CSB1, CSB2, authorized non‐profit NGOs and CHRD1 order health commodities at the Pha‐Ge‐Dis while CHRD2, CHRR, CHU and authorized non‐profit procured health commodities directly to SALAMA after receiving the validation by the program (NMCP for Malaria commodities) and approved by the Supply and Stock management committee. These products should be distributed freely following the TMA TWG principles. Otherwise, they could also procure from commercial wholesalers which are for sale. Currently, CHRD2, CHRR and CHU report directly to the NMCP and UTGL and IMPACT has no control whether these products are distributed free of charge or not. So, we expect to work with the NMCP and the GAS committee to monitor this situation by setting up a suitable tool.

They committed to ensure prompt and accurate data submission to DPLMT, to collaborate with DEPSI in order to establish an effective database management system on commodities sold at their pharmacies, and to work directly with pharmaceutical wholesalers while importing specific commodities that cannot be purchased by SALAMA. It is worth noting that this activity was not planned but was proposed by the Champion to help these hospitals in their supply chain management. In order to monitor the progress, IMPACT has planned to organize meetings with public hospitals to analyze routine data on key indicators such as stock‐out, LMIS issues, etc. for learning and adapting the use of DHIS2. This activity will be followed up in Year 2 in collaboration with UTGL, CGL and GAS committee to identify the barriers and challenges of commodity management in public hospitals are identified and to find corrective actions are implemented.

Establish and train multi‐sectoral (private, public, etc.) TWGs led by the TMI Champions

IMPACT has held three TMA TWG meetings with 68, 65, and 63 participants respectively. Those participants included the main actors in the health and health commodities sectors in Madagascar, including the public sector (from different ministries), the private sector (from various companies, pharmaceutical wholesalers, and drug shops), professional associations (learned societies, pharmacists and medical doctors), Non‐ Governmental Organizations (NGOs), and donors. The first meeting on July 16 aimed at training the participants on the principle of TMA, the importance of having a TWG dedicated to TMA, and the identification of key blockages of the availability and accessibility of health commodities. The second meeting on August 14 presented the context of the key blockages identified during the first meeting, and the members agreed that these blockages will be the points to be solved in relation to the TMA roadmap (see section on TMA roadmap above, p.9). The third meeting on September 24 was about the development of the operationalization plan for these three objectives (see section on TMA Roadmap, p.9). The mandate of the TMA TWG is thus to identify and agree on the issues impeding the availability and accessibility of quality health commodities in Madagascar, and to identify and agree upon solutions for those issues.

Figure 2: TMA TWG members at the second TMA workshop on August 14, 2019

Graph 2. Total Market Approach Technical Working Group Members

To express their willingness to be part of the TMA process and the implementation of the roadmap, TMA TWG members were asked to sign a voluntary letter of participation for the TMA process. IMPACT has received 61 signatures out of 196 participants. A strong engagement of the private sector in the TMA process through the presence of decision‐makers and executives during all three TMA workshops has been noted. Their participation was also significant through their decision to co‐lead each subcommittee with the MOPH. Although there were various members of the public sector, NGOs, and organizations present during the TMA TWG meetings, some of them did not sign the letter of participation but were represented in the signing process by their superiors and senior decision‐ makers. Five people from the European Union, Global Fund CCM (Country Coordinating Mechanism), FISA (Fianakaviana Sambatra), Direction Générale des Impôts, and EKAR Santé haven’t signed as they are not interested and didn’t come back to the second and third TMA TWG meetings

Graph 3. Percentage of Letters of Participation to the TMA process signed by sector

DONORS 58%

ASSOCIATIONS 59%

NGOs 70%

PRIVATE SECTOR 64%

PUBLIC SECTOR 62%

0% 20% 40% 60% 80% 100%

Signatures Participants

Initiation of the TMI operationalization plans for the priority health area

The development of the Malaria TMI roadmap was postponed to Year 2 because the market assessment results are not available yet. IMPACT has started working with the NMCP for the creation of the TMA Malaria Subcommittee under the Roll Back Malaria group. It was convened that the creation of this subcommittee

13 will take place in Quarter 1 of Year 2 and this subcommittee will oversee the development of the Malaria TMA roadmap based on the results of the malaria market assessment.

Sub‐IR 1.2: GOM leads TMI stakeholders to coordinate health product quantification and forecasting, procurement, and distribution according to market assessments and segmentation

During Year 1, IMPACT supported the Unité Technique de Gestion Logistique (UTGL) to coordinate the supply plan review of 2018 quantification plans and the quantification exercises for 2019.

Review and consolidate all existing forecasting exercises for all priority health areas (FP/RH, Malaria, and MCH)

Activities achieved in Year 1: ‐ Consolidated all 2018 quantification reports for malaria, MNCH, and FP products and contributed to the review of supply plans to analyze gaps and address all needs for public sector and community distribution channels. ‐ Advocated for President’s Malaria Initiative (PMI) to procure 1 million additional Rapid Diagnosis Tests (RDT) for malaria to cover the 2019 shortfall. These tests were delivered in Quarter 4, as reported under IR2. ‐ Advocated to USAID for an emergency procurement of FP commodities to complement UNFPA procurements for the public sector and to fill the 2019 shortfall. Quantities procured and delivered are reported under IR2.

Assist the GOM through UTGL in leading the annual system wide forecasting exercises as part of each TMI workshop.

Every year, the country is planning annual quantification to generate forecasting and supply plans and to use those plans to mobilize financial resources to procure commodities.

IMPACT provided technical and financial support to the UTGL to organize four (4) quantification workshops where 116 participants including the private sector were trained and capacitated on quantification methods and tools (QuantiMed and PipeLine) for generating multi‐year forecasting and supply plans for 2020‐ 2021 and 2022. The quantification plans for malaria, FP/RH and MNCH were validated by the “Comité de Gestion Logistique (CGL)” in July 2019 (table 1 shows attendance at the quantification workshops).

Table 1. Participants trained in quantification per sector

% participants/ Participants Male Female Total sector Public sector 39 52 91 78% Private sector (pharmacy wholesalers) 2 0 2 2% Partners (IMPACT, ACCESS, Mahefa Miaraka, SALAMA, Principal Recipients of Global Fund (PSI and UCP) 15 8 23 20% Total 56 60 116 % Gender 48% 52%

To improve the very low participation of private sector in Year 2 , IMPACT will pass through the PSHP health commission ‐ Subcommittee to explain the relevance of health commodities quantification , look after the adequacy of needs vs scarce available resources , on how to rationalize the stock and avoid wasting health commodities. In addition, we improve the collaboration between SALAMA and wholesalers in terms of ordering and health products availability on stock according to the national protocol against malaria. A specific session on quantification for private sector will be held in Year 2 and its determined quantity should be included to the public sector needs before the validation by the logistic management committee. Presented the forecasting and supply plan of malaria products to PMI during the Malaria Operational Plan, and to the Global Fund for financial resource mobilization. The Global Fund principal recipients (PSI and Unité de Coordination des Projets ‐ UCP) have submitted a proposal to Global Fund to reallocate funds to cover the gaps for malaria commodities.

Table 2. Commitments by PMI and Global Fund (end of September) to procure malaria commodities in 2020

Quantity to NMF2 Proposal for Needs procure per Global Fund Reallocation by Total % Products Covered by supply plans (not yet GF (not yet Commitments Achievements MOP 2019 for 2020 approved) approved) Artemisinin based combination therapy ‐ 1,853,975 100% 1,853,981 1,784,475 69,500 (ACTs) RAPID DIAGNOSIS 6,743,119 100% TEST, 1 KIT 10,849,500 2,290,235 1,852,622 10,885,976 ARTESUNATE

Injectable 60mg/vial, 298,812 100% 365,400 25,000 41,588 365,400 set ARTESUNATE 12,557 100% suppository, 1 suppo 18,500 5,943 18,500 Sulfadoxine 8,393,550 216% Pyrimethamine 3,891,250 1,500,000 6,893,550

133% Quinine tablets 178,300 236,261 236,261

404,500 100% Primaquin tablets 404,500 404,500

All the needs will be covered in 2020 if the proposal of reprogramming Global Fund NMF2 savings are allocated to the procurement of malaria commodities. Note that the quantities proposed to be reallocated by Global Fund NMF2 are still under the approval process by Global Fund Geneva.

After an annual quantification exercise, the forecasting and supply plans are generated for 3 years and used to mobilize funding for procurement. During the quantification exercise in 2018, SP forecasts for 2018, 2019, and 2020 were projected on demographic data of pregnant women who will attend ANC consultations and receive IPTp doses. The forecasting and supply plans generated were used to mobilize resources from Global Fund (2019‐2021) and PMI (2018 ‐ 2019) with a possibility of adjustment for each annual quantification exercise.

During the quantification exercise in 2019, the SP forecast for 2019‐2022 were reviewed and adjusted to the available data of IPTp uptake which is lower compared to 2018 projections. That is the reason why commitments are higher than needed. Currently, there is an ongoing request to reallocate Global Fund resources for SP to cover the gaps identified for other malaria commodities. Update on this action will be provided to PMI queuing the Quarter1 Y2 report.

For private sector, despite their participation during the 2019 quantification exercise, no accurate consumption data and distribution of malaria commodities throughout the private sector were available, so, the GAS Committee decided to not quantify the private sector needs in Year 1. The GAS Committee will plan to conduct an active data collection prior to the quantification exercise forecasted in April 2020 as well as using the ongoing total market assessment results.

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

Sub‐IR 2.1: Health commodities and pharmaceuticals are continuously available and accessible in the public sector 2.1.1 Central level

Emergency Distribution Plan of Family Planning (FP) Products The MOPH faced a long period of stock out of FP products in 2018. To address this issue, USAID through GHSM‐PSM procured FP products to be distributed by IMPACT.

IMPACT distributed the FP commodities through the Emergency Plan to Pha‐G‐Dis as shown below:

Table 3. Summary of the Family Planning commodities distributed to Pha‐G‐Dis by emergency plan in Q2 and Q3

Received from Distribution Delivered at Percent delivered Remaining Product Item USAID Plan by DSFa Pha‐G‐Dis from DSFa Plan balance Sayana Press (Vial) 301,600 301,600 301,600 100% 0 Depo‐Provera/ 398,122 950,320 558,958 552,198 98.79% Triclofem (Vial) + syringe Combination 3/ Microgynon 119,960 537,800 417,840 417,840 100% (Cycle)

The Triclofem and Microgynon remaining balances were stored at PSI’s warehouse and will be distributed based on DSFa’s new distribution plan scheduled in Quarter 2 of Year 2.

Ensuring no stockout in the public sector through a smooth transition from PSM‐FO to PSM‐NFO, and to PSM NFO to SALAMA. On December 25, 2018, IMPACT signed a Memorandum of Understanding (MoU) in order to determine roles and responsibilities with GHSC‐PSM Non‐Field Office for the management of USAID‐procured medicines and commodities. IMPACT also signed a long‐term agreement with SALAMA (for a duration of one year that is renewed every year) on July 11, 2019 for storage of USAID‐funded commodities upon arrival in Madagascar and distribution to Pha‐G‐Dis and hospitals.

Throughout Year 1, IMPACT achieved the following activities: ‐ Inventory of USAID commodities stock stored at SALAMA in December 2018 as part of the handover from PSM to IMPACT, ‐ Coordination of all USAID‐procured commodities delivered to SALAMA and PSI warehouses. Tables 3, 4, and 5 show quantities handed over by PSM and quantities delivered in country in 2019.

Table 4. Malaria commodities handed over by PSM to IMPACT and all quantities delivered in country in Year 1

Stock Handed Procurement Quantities Product over by PSM Planned in Delivered Comments 2019 at SALAMA Dec‐18 155,925 treatments were AS/AQ 6 – 13 years 100/270MG tablet – 2,125 320,000 475,925 procured in 2018 and Blister delivered in 2019 236,100 treatments were ASAQ 14 years and over 100/270mg 0 380,000 616,100 procured in 2018 and tablet– Blister delivered in 2019

Rapid diagnostic tests (RDTs) ‐ Kit 0 1,000,000 1,000,000

More quantities delivered to Sulfadoxine‐Pyrimethamine (SP) tablets, 499,950 1,700,000 1,806,900 accommodate packaging treatment (of 3 tablets) required

Artesunate Injectable 60mg/vial, set 3 152,000 152,000

Artesunate suppository, pack of 2 N/A 7,000 7,000 suppositories

Long‐lasting insecticide‐treated nets Shipment in transit, delivery N/A 1,000,000 0 (LLINs) for continuous distribution planned in November 2019

The quantities of Artemisinin Combination Therapy (ACT) delivered in 2019 were higher than procured. This is due to 2018 orders in the pipeline that were delivered in February 2019. LLINs already procured will be distributed in Year 2.

Table 5. MNCH Commodities handed over by PSM to IMPACT in Year 1

Product Stock handed over by PSM, December 2018 Gentamycin 10 Mg/ml, injectable, vial of 2ml (80ml) 128,400 Gentamycin 40 Mg/ml, injectable, vial of 2ml (20ml) 54,100 Sulfate de magnesium 50%, injectable, vial of 10 ml 40,970 Oxytocin 10U.I/ml, injectable, vial of 1ml 1,402,800

There was no new procurement.

Table 6. Family Planning commodities delivered in country in Year 1 and stored at PSI warehouses

Procurement Quantities % Product planned in Delivered at Comments Achievement 2019 PSI warehouse Depot (SC) Medroxyprogesterone Acetate 104 mg/0.65 mL, Pre‐Filled 518,400 518,400 100% Uniject Device, 1 Syringe [Pfizer] [Sayana Press] Levonorgestrel/Ethinyl Estradiol 150/30 mcg + Fe 75 mg, 28 748,400 748,400 100% Tablets/Cycle (SM), 1 Cycle [Bayer] [Combination 3] Levonorgestrel/Ethinyl Estradiol 150/30 mcg + Fe 75 mg, 28 907,920 907,920 100% Tablets/Cycle (PS), 1 Cycle [Bayer] [Microgynon ED Fe] Shipments of the Depot (IM) Medroxyprogesterone remaining 407,900 vials Acetate 150 mg/mL (1 mL) Vial, SR, 1 2,999,900 2,592,000 86% in transit, delivery Vial [PT Tunggal] [Triclofem] planned in November 2019 Shipments of 16,676 Etonogestrel 68 mg/Rod, 1 Rod implant in transit, 16,676 ‐ 0% Implant, 1 Each [Implanon NXT] delivery planned in November 2019 Shipments of 422,211 Levonorgestrel/Ethinyl Estradiol Cycles in transit, 150/30 mcg + Fe 75 mg, 28 442,122 ‐ 0% delivery planned in Tablets/Cycle (PS), 1 Cycle November 2019

Develop and support an emergency plan with SALAMA for the Distribution of Malaria products to avoid stock‐out and Support Quarterly distributions from Salama to Pha‐G‐Dis as well as storage and receipt of Malaria, FP and MCH commodities

During Year 1, IMPACT supported the national malaria program (PNLP) and the central GAS malaria committee members to:

‐ Collect and analyze logistics data (stock available, consumption and distribution, expiry date) and quarterly requisitions submitted by the 115 Pha‐G‐Dis to perform the resupplying of malaria and MNCH commodities at the district level. The malaria GAS committee created an excel tool to analyze data in order to develop and improve the distribution plan. ‐ Analyze stocks available at SALAMA and the district level (minimum and maximum levels of stocks required between 9 and 13 months at SALAMA) to detect risk of shortage, stock outs, and overstocks to apply corrective measures.

‐ Organize transportation of commodities to 115 Pha‐G‐Dis through the IMPACT – SALAMA agreement, either through routine distribution or, where needed, emergency transportation. Table 7 show quantities procured by USAID and distributed to districts in Year 1.

In year 1, SALAMA managed the contract well in terms of storage of commodities delivered by PSM, correctly organized stock inventory, and met the best storage practices at its warehouses. However, some areas of improvement are identified: ‐ Coordination and communication with other Ministry of Health Directions, specifically with the NMCP and DSFa, in terms of malaria and MNCH commodities management (preparing orders and managing shipment). IMPACT facilitated a meeting with SALAMA, UCP, NMCP, and IMPACT in December 2018 to address those weaknesses. Currently, in collaboration with SALAMA, they are ready to fully integrate the ordering system for malaria and FP commodities. ‐ Lack of participation and involvement in MOH supply chain strategic meetings such as the GAS committee, UTGL meetings, Plan d’Action d’Intégration des Intrants de Santé (PAIS), LMIS committee, TMA TWG, Regulatory reform. IMPACT has integrated the pharmacist from SALAMA into the annual quantification process and workshops in Year 1. In Year 2, SALAMA staff will facilitate sessions about stock management trainings organized both at central and community level. Once the new General Director is appointed, IMPACT will organize meetings with TMA champions and SALAMA in order to be much more involved in the different TMA committees. Currently, SALAMA is also part of the restricted committee to develop the PAIS. ‐ Delay on emergency transportation response to the districts related to malaria commodities. IMPACT will plan to introduce SALAMA to the PHSP / health committee in order to build strong coordination, collaboration, leverage resources, and benefit from private sector transporters’ expertise to improve essential commodities transportation to Pha‐G‐Dis.

Table 7. Distribution of malaria commodities in Year 1 from SALAMA to Pha‐G‐Dis

Targets for Total Distribution Quantity % Product in Year 1 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Distributed Achievements (PMP in Year 1 IMPACT) Distribution of PMI procured malaria commodities Artemisinin‐based combination therapy (ACT) 752,368 12,465 26,200 269,475 205,300 513,440 68% treatments (AS/AQ) Rapid diagnostic tests (RDTs) 2,990,915 249,075 0 0 0 249,075 8% Sulfadoxine‐pyrimethamine 1,369,711 0 305,850 185,550 262,300 753,700 55% (SP) tablets Distribution of GF procured malaria commodities Artemisinin‐based combination therapy (ACT) N/A 305,175 216,943 13,306 18,263 248,512 N/A treatments (AS/AQ) Rapid diagnostic tests (RDTs) N/A 852,225 588,425 898,950 981,975 2,469,350 N/A Sulfadoxine‐pyrimethamine N/A 67,830 0 100 0 0 N/A (SP) tablets Total PMI and GF

Artemisinin‐based combination therapy (ACT) N/A 317,640 243143 282781 223563 761,952 N/A treatments (AS/AQ) Rapid diagnostic tests (RDTs) N/A 1,101,300 588,425 898,950 981,975 2,718,425 N/A Sulfadoxine‐pyrimethamine N/A 67,830 305,850 185,650 262,300 753,700 N/A (SP) tablets

For PMI distribution: ‐ ACTs were delivered in March and May 2019 and distributed in Quarter 3 and 4. Since the target was defined for the entire year then only 68% were distributed. ‐ The RDT procured by PMI arrived in September and the target was set for the entire year which explained achievement of only 8%. ‐ In Year 1, there is less quantity of SP distributed due to unclear guidance on elimination and pre‐ elimination strategy. The distribution of Sulfadoxine‐ Pyrimethamine (SP) was not done according to plan due to low uptake of Intermittent Preventive Treatment in pregnancy (IPTp). The GAS committee alerted Roll Back Malaria members and PNLP on the low rate of resupply of SP by districts. The NMCP sent out a letter to regions and districts recalling the use of SP and plan to do SBCC activities to increase uptake of SP. The SBCC activities, including SMS, are jointly coordinated with NMCP, Mahefa Miaraka, ACCESS and all other stakeholders regrouped in the Roll Back Malaria. The GAS committee will continue to monitor distribution of SP to avoid any risk of expiration. The MOPH will be updated every Quarter on the progress of the SP uptake (to be prepared and presented by NMCP).

Note: The GAS committee manages all stocks procured by PMI and Global Fund and plans shipments of stock stored at SALAMA to Pha‐G‐Dis respecting the First Expiry‐First Out (FEFO) rule. More quantities of ACTs and RDTs have been distributed compared to the initial plan because Madagascar assumed that malaria cases will be reduced in 2019 as a result of many interventions implemented in previous years. However, the cases increased instead.

During this year, IMPACT supported the Direction de la Santé Familiale (DSFa) to plan distribution of MNCH procured medicines in 82 districts. IMPACT implemented the following activities:

‐ Provision of all required documentation to allow the Direction de l’Agence des Medicaments de Madagascar (DAMM) to approve the registration of Gentamicin and MgSO4 that were delivered in 2018. The registration was granted in May 2019 and medicines were delivered in Quarter 4 to the districts. ‐ Advocacy with UNFPA and DSFa to donate and transfer some quantity of Misoprostol to be distributed in USAID‐supported regions in Quarter 4. Misoprostol will be distributed in selected CSB (without a functional cold chain) and to CHVs. ‐ Coordination with SALAMA of distribution of commodities to selected 82 districts (60 USAID supported districts, 18 PARN‐ World bank districts, and 4 UNFPA supported districts). The districts were selected by the MNCH GAS Committee in Quarter 4. Table 8 show quantities distributed to 82 districts.

Table 8. Distribution of MNCH procured MNCH commodities from SALAMA to Pha‐G‐Dis

Distribution / Distribution / Total Product Quarter 3 Quarter 4 Distribution Oxytocin 10UI/ml, ampoule ‐ 192,740 192,740 Magnesium Sulfate, ampoule 30 13,240 13,270 Gentamicin 10mg/ml, vial of2ml 300 44,000 44,300 Gentamicin 40mg/ml, vial of 2ml 100 18,100 18,200 Misoprostol tablet, tablet ‐ ‐ 115,044* *: Distribution plans for Misoprostol tablet were sent to SALAMA in Quarter 4 Year 1. The Oxytocin is transported by SALAMA into the cold chain and integrated into vaccine district and health facility (CSB) cold chain to comply with storage conditions. At facility level, Oxytocin and vaccines are stored together. For the 894 facilities without cold chain, they are recommended to use Misoprostol tablets that do not need cold chain. By DPEV (Direction des Programmes Elargis de Vaccination) plan, all existing CSB will be equipped with fridges by December 2020.

Conduct in‐depth literature review of the existing public supply chain to generate recommendations for IMPACT

To support the MOPH in developing evidence‐based strategies to improve the supply chain, IMPACT completed a literature review of studies and evaluations related to the supply chain in Madagascar conducted between 2009‐2019. The literature review report documenting main recommendations will serve to inform development of strategic plans such as the PAIS for 2020‐ 2024. The report will be shared to USAID in Quarter 1 Year 2.

Assess GOM capacities and develop a capacity and training plan

A national training and capacity building plan have been developed and validated by the UTGL in April 2019. From the plan, IMPACT has trained district teams on stock management with an emphasis on estimating needs for timely and correct requisitions in the 13 USAID supported regions.

Assist DPLMT in establishing a roadmap towards a comprehensive LMIS.

Pha‐G‐Dis uses CHANNEL inventory management software, but its use has been challenging due to the complexity of the software and the lack of an initial Pha‐G‐Dis training for dispensers. IMPACT supported the national LMIS committee led by the Direction de la Pharmacie, des Laboratoires et de la Médecine Traditionnelle (DPLMT‐UTGL) to :

‐ Installed new version of channel software (light version updated in 2018 by GHSC‐PSM) in all Pha‐G‐ Dis to ease and facilitate the data entry and analysis. ‐ Developed an interim plan to actively collect LMIS data at districts to increase data availability and reporting. The active data collection was completed by DPLMT and IMPACT in 36 districts to collect LMIS data, specifically on stock available, distribution, and consumption of commodities. The data was used during the national quantification exercises.

‐ Conducted a selection/mapping of Pha-G-Dis that need laptop to do transaction and movements of stock in channel software to have accurate and timely report. Leveraging other resources available at UCP (Global Fund and PARN), IMPACT will officially provide 37 laptops in January 2020. All the 37 laptops will have Channel software already installed ‐ Provided internet connection to DPLMT to ensure quick upload of Channel data submitted by Pha-G- Dis ‐ Provided TA to the LMIS – UTGL subcommittee to analyze data from rapid data quality audits and take decisions to improve data reporting and use. ‐ Collected data through Channel and compare with services data reported through DHIS-2 to inform distribution plan on quarterly basis. ‐ Conducted an in-depth assessment of the existing LMIS. The report is being reviewed and edited internally before the dissemination planned in November 2019. Findings from this evaluation will be used to develop a 5-year strategic roadmap aiming to improving the LMIS in Year 2. ‐ Conducted several RDQA exercises to assess quality of the LMIS data. An action is being set up based on the RDQA results to ensure data quality (see details on RDQA results in MERL section)

Begin establishing the SCM quality improvement approach using the SPARS model

‐ IMPACT collected documents related to the SPARS model applied in Uganda and will conduct meetings with ACCESS to explore areas of coordination and implementation of quality improvement methodology and tools to adapt and apply at Pha‐G‐Dis and Pha‐Ge‐Com levels. In the meantime, RLAs conducted supervisions of Pha‐G‐Dis and Pha‐Ge‐Com on best practices of storage and stock management using supervision checklists to assess and identify issues and address the issues. The activity will continue in Year 2 and will consist of: 1) Finalize the approach and implementation plan, in collaboration with ACCESS to be developed in Quarter 2 Year 2. 2) Select one region to pilot SPARS. 3) conduct a training of trainers. 4) Conduct cascade trainings. 5) Track implementation and progress. 6) Assess the approach to inform the scaling up. This process will be done in Year 2 and if the pilot phase is conclusive then the scale up in other regions will be in Year 3.

Provision of initial training on supply planning to key public sector staff,

‐ In Year 1, staff in charge of supply chain at NMCP (3) and DSFa/ SMSR (2) have been coached and mentored on 1) Data analysis to develop distribution plans or redeployment at the Pha‐G‐Dis level 2) Stock status analysis to identify problems and find appropriate solutions to avoid stock outs at the central level, 3) Conduct a gap analysis of commodities in order to mobilize necessary financial resources to procure commodities.

Support the MOH in the revision of the forecast and supply planning through strengthening their capacity to use electronic tools, produce and utilize SCM reports

‐ This activity was completed and is already reported under activity Assist the GOM through UTGL in leading the annual system wide forecasting exercises as part of each TMI workshop (see above in IR1.2 section).

Activities related to R2.1.A15, R2.1.A16, R2.1 A17 and R2.1.A18 were completed and reported in previous sections in relation to the quantification and distribution sections under IR1.2 and IR2.1.

2.1.2. Regional/District Level

During Year 1, IMPACT recruited eleven (11) Regional Logistics Advisors (RLA), including the RLA supervisor, to strengthen capacity of regions and district teams on: 1) Stock inventory management. 2) Correct estimation of quantities for ordering/requisitions. 3) Analysis and use of logistics data (consumption, distribution, expiry dates, number of cases, etc.) for decision making. 5 RLA were on‐boarded in Quarter 2 and the other 6 RLA in Quarter 4. Two more RLA are being recruited and will be on‐boarded at the beginning of Year 2.

Provision of initial trainings to EMAR, EMAD and Stock managers at Pha‐G‐Dis and CHRD

IMPACT organized initial trainings on stock management, use of CHANNEL software, and data analysis to correctly estimate needs. A total of 309 stock managers (144 male and 165 female) from 104 Pha‐G‐Dis, 50

24 district hospitals, and 23 regional hospitals were trained from 10 USAID‐supported regions, 3 PARN regions, and 6 other regions with high prevalence of malaria, including: Alaotra Mangoro , Atsimo Atsinanana, Betsiboka, Ihorombe, Androy, and Anosy.

Table 9. Participants trained on stock management in 19 regions

Participants at the Trainings Men Female Total Participants % Participants/ Origin USAID 10‐ supported regions 86 103 189 62% PARN 3‐ regions 24 30 54 17% Other regions with high 34 32 66 21% prevalence rate of malaria (Alaotra Mangoro, Betsiboka, Anosy, Androy, Ihorombe, Atsimo Atsinanana) TOTAL 144 165 309 100% % gender 47% 53% 100%

Stock status analysis to inform decisions

‐ Support to 4 out of the 10 USAID‐supported regions to establish UTGL at the regional level and supported 26 out of the 60 districts to establish GAS committees. These forums aim to establish a coordination mechanism at regional and district levels to discuss stock status of commodities and other supply chain problems in order to find solutions together. Members of UTGL regional Committee are EMAR and technical and financial partners led by the Health Regional Directorate and members of the GAS District Committee are EMAD, Pha-G-Dis, and technical and financial partners led by the Medical Inspector. The Terms of Reference for the regional UTGL and district GAS committees were developed with IMPACT technical support. ‐ Organization of quarterly meetings in the 60 districts within the 10 USAID supported districts to analyze stock status and plan redeployment in case of overstock or resupplying (initiated by both central, regional, and district coordination committees (GAS and UTGL)). During Year 1, 43 districts organized a redeployment from district to district to correct shortages1, stock out2, and limit expiration.

Table 10. Quantities redistributed during the Year 1 with RLA’s support

Total Redistribution/ Redistribution/ Redistribution/ Product Quantities Quarter 2 Quarter 3 Quarter 4 Redistributed Rapid diagnostic tests (RDTs) 14,250 11,109 84,174 109,533

1 Shortage means that the available stock is under the minimum required level of 1 month (CSB) and 3 months (Pha-G-Dis) to cover the needs till the next routine resupply 2 Stock out means 0 stock available for a certain commodity

Total Redistribution/ Redistribution/ Redistribution/ Product Quantities Quarter 2 Quarter 3 Quarter 4 Redistributed ASAQ 2 – 11 months 25mg/67,5mg tablet, Blister of 3 tablets 10,780 7,350 22,788 40,918 ASAQ 1 – 5 years 50mg/135mg tablet Blister of 3 tablets 5,907 14,300 61,100 81,307 ASAQ 6 – 13 years 100/270MG tablet –Blister of 3 tablets 4,575 2,075 7,792 14,442 ASAQ 14 years and more 100/270mg tablet– Blister of 3 tablets 4,010 600 11,815 16,425 ARTESUNATE Injectable 60mg/vial, set 150 50 660 860 Sulfadoxine/Pyrimethamine 500/25 mg Tablets 22,500 5,400 30,973 58,873

Redeployment was coordinated by the SDSP with RLA’s technical support and under the Medical inspector approval. Sometimes, the NMCP was also involved to identify sites for redeployment. Deliveries were conducted by the SDSP (Service de District de Santé Publique) with IMPACT or ACCESS or other USAID/Global Fund projects technical and financial support. The RLA and the SDSP are using the “Bon de transfert” for the redeployment exercises copied from the template of essential commodities management manual. The standard operation procedure on redeployment of commodities will be officially included in the commodities management manual which is scheduled in 2020.

The redeployment details per district are presented in annex I.

On‐the‐job supervision

During FY19, the RLA conducted field supervision visits to 49 Pha‐G‐Dis and 57 Pha‐Ge‐Com to emphasize best storage practices and EMMP, installation and use of Channel to manage stock, and timely LMIS reporting to increase data visibility.

2.1.3. Community Level (CSB/Pha‐Ge‐Com)

The 3 USAID programs signed a MoU to define roles and responsibilities in relation to supply chain at all levels. IMPACT is supporting central and district levels, while ACCESS and Mahefa Miaraka will support the CSB and community level. The 3 projects meet on a monthly basis for regional/district levels and on a quarterly for the central level to discuss on issues and appropriate solutions to improve management of stock and thus, availability of commodities.

Explore with the MOPH distribution strategies from Pha‐G‐Dis to PhaGeCom and propose at least two scenarios to continue after the initial emergency contracting in close collaboration with ACCESS and Mahefa‐Miaraka

IMPACT collaborated with the other USAID implementing partners to:

‐ Support districts to define routes and estimate budgets for health commodities transportation from districts to CSB levels. The estimates were used to define costs of reimbursement of transportation included in the last mile distribution strategy validated by the MOPH and will be implemented from Q1 in Y2. ‐ Develop an implementation plan to address the last mile distribution strategy in collaboration with UCP‐ Global Fund. Transportations and storage management fees will be forfeited and reimbursed to CSB and Pha‐G‐Dis upon meeting some defined criteria (correct and timely ordering/resupply system, Correct and timely LMIS reporting and stocked according to the required minimum‐maximum levels)

From Quarter1 in Year 2, IMPACT will pay transportation cost for family planning and MNCH products to complement Global Fund that is paying for malaria.

Provide refresher training on stock management for malaria products in 100 priority communes identified by the NMCP and its partners

‐ Review of the training curriculum on stock management for CSBs and CHVs in collaboration with ACCESS, Mahefa Miaraka, DSFa, PNLP, DPLMT, DEPSI, and DDSB under the leadership of the Professional Training Service (SFP) of the MOPH. The new training curriculum is validated by the SFP and emphasizes the integration of community needs into CSB requisitions. ‐ Training of 90 Medical Doctor of CSB, Pha‐Ge‐Com Dispenser, and the head of management committee of Pha‐Ge‐Com from 2 districts in Analanjirofo region (Fenerive Est and Vavatenina) on public supply chain ordering system and how to quantify community level needs into their requisitions.

Development of budgeted roadmap for continuous LLIN distribution in 20 districts

The following startup activities were carried out in terms of LLIN continuous distribution at the community level (CDCL).

 Preliminary Activities: ‐ Identification and selection of targeted districts in collaboration with the NMCP. Twelve districts were identified: Port Bergé, Toamasina 2, Brickaville, Antanambao Manampotsy, Mahanoro, Mananjary, Manakara, Vohipeno, Farafangana, Vangaindrano, Bekily, Tuléar 2. The selection was led by the NMCP based on the following process: o Data analysis on fever, malaria case management, and entomological data in 39 districts with high malaria transmission districts, o Validation of the selection criteria taking into account the program priorities (high malaria positivity rate and high‐level transmission, included the IRS exit plan, recommended by the net durability study, proven pyrethroid resistance, and former continuous distribution districts). ‐ Review of the LLIN CDCL strategy that the finalization is in progress; ‐ Update training materials; ‐ Recruitment of technical advisors to ensure quality, monitoring of the activities such as logistics, distribution, and reporting at the community and district levels.

Table 11. List of targeted districts with selection criteria

Districts with Incidence Districts Districts Recommended Malaria High Former (cases for Included with Districts by Region District Positivity Transmission CD 1000 in IRS* Pyrethroid Net Durability Rate Level (>100 Districts inhabitants) Exit Plan Resistance Study cases)

Vatovavy Mananjary 33% 135 X X X Fitovinany Vatovavy Vohipeno 28% 133 X X X Fitovinany Atsinanana Brickaville 40% 140 X X Atsinanana Toamasina II 38% 117 X X Vatovavy Manakara 44% 125 X X Fitovinany Atsimo Farafangana 44% 285 X X X Atsinanana Atsimo Toliary II 35% 152 X X Andrefana Atsinanana Mahanoro 34% 120 X X Antanambao Atsinanana 23% 103 X X Manampotsy Atsimo Vangaindrano 65% 230 X X Atsinanana Sofia Port Bergé 55% 259 X X Androy Bekily 40% 171 X X *IRS: Indoor Residual Spraying

Table 12. Number of LLINs to be distributed per district

# LLIN Districts Population LLIN need household specification Manakara 588 482 130 774 134 450 White Vohipeno 190 846 42 410 43 600 White First Mananjary 491 594 109 243 112 300 White delivery Toamasina II 304 206 67 601 69 500 White Brickaville 266 823 59 294 60 950 White Toliary II 433 935 96 430 99 150 White Total 1 2 275 886 505 752 519 950 Farafangana 509 602 113 245 116 400 White Vangaindrano 491 726 109 272 112 350 White Mahanoro 374 892 83 309 85 650 White Second delivery Antanambao Manampotsy 78 846 17 521 18 000 White

Port Bergé 325 957 72 435 74 450 PBO Bekily 271 754 60 390 62 100 White Total 2 2 052 777 456 172 468 950 Total 1+2 4 328 663 961 924 988 900

 Monitoring and Evaluation: ‐ Review of the reporting tools and supervision manual; ‐ Validation of the reporting system based on the lessons learned.  SBCC on CDCL ‐ Strengthening collaboration with the School Health division of the Ministère de l’Education Nationale et de l’Enseignement Technique et Professionnel (MENETP), MOPH, and NMCP about the "Child‐ Community" approach in the targeted districts. MENETP agents actively participated in the development of CDCL strategy workshop and an MOU is under preparation (between MOPH/NMCP and MENETP);

SBCC tools (radio spots and posters) were updated including new messages on Pyrethroid‐PBO nets, waste management, and other messages on the use of LLINs.

LLIN storage at the central level

‐ Quantification of LLINs was completed using NetCalc software. The procurement process started from May 2019 due to long discussions on technical specifications of LLIN and agreed upon with the NMCP, PMI, RBM, and MOPH. ‐ Started procurement process with PSM for 1,000,000 LLIN including Polyester LLIN to distribute in 11 districts and new Piperonyl Butoxide (Pyrethroid‐PBO) LLINs that will be distributed in the district of Port Bergé ‐ Review and finalization of the logistics plan and management tools.

Conduct End‐Use Verification (EUV) surveys for Malaria, FP/RH, and MCH products.

IMPACT started planning the EUV and defined the sampling in the public sector (the private sector will be included after the TMA assessment). While preparing the data collection, IMPACT learned that the questionnaire and methodology of the EUV survey had been changed and validated by PMI Washington in March 2019. The GHSC‐PSM developed subsequent training materials and curriculum and uploaded the questionnaire in Survey CTO, which is a software to use for data collection through smartphones). IMPACT continued with preparations for the EUV survey:

‐ Training on the new methodology and questionnaires by PSM. IMPACT is still waiting for training curriculum and materials translated in French, guidance for sampling, and definition of PIRS to be shared by PSM. ‐ Advocacy to receive STTA from PSM to assist the first exercise. The STTA will be available early in January 2020. ‐ Establishment and orientation of the EUV survey committee members representing various directions of the Ministry of Health on the EUV guidance and selected the sampling methodology. ‐ Recruitment of 25 data collectors to conduct data collection ‐ Next steps will be: training of data collectors (January 2020), the pretest of the questionnaires to adapt to the Madagascar context (January 2020), data collection using Survey CTO (January 2020) , conducting the data analysis (February 2020), and disseminating EUV survey reports to USAID, PMI, PSM, and the Ministry of Health (March 2020).

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

‐ Meeting with DPMLT to discuss on how to support the public sector supply chain in terms of financial sustainability. From the meeting, DPLMT, DDSB, and IMPACT will 1) jointly coordinate a dissemination of the PSM and SHOPS Plus study on financial viability of FANOME recovery system and support the FANOME committee to implement recommendations suggested by the study. 2) support regions to conduct an audit of Pha‐G‐Dis and Pha‐Ge‐Com whenever necessary. 3) conduct a total cost analysis. 4) Support UTGL to conduct a qualitative study to identify key barriers and challenges around the contract management of Pha‐G‐Dis providers and Hospitals Pharmacies (concessionaires) ‐ Recruitment of a Short‐term Technical Assistance (STTA) to conduct a total cost analysis including all past studies regarding the “Financement pour l’Approvisionnement Non‐stop en Médicaments” (FANOME) recovery model assessment and SALAMA financial viability.

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

Sub‐IR 3.1: Commercial actors are incentivized to expand into new health product markets Through the Private Sector Humanitarian Platform (PSHP), IMPACT has sensitized the private and commercial sectors to commit and contribute in the development of the public health sector in Madagascar. Three pharmaceutical importers and wholesalers in Madagascar joined the PSHP in Year 1. They will contribute to health product transportation from central to regional/district levels and support on LMIS data collection through a TMA TWG LMIS sub‐committee by pharmacies, drug shops, and pharmaceutical wholesalers. The Public sector can benefit through this collaboration for emergency transportation of health products with affordable prices.

Present IMPACT to the PSHP

Table 13. PSHP members orientation on IMPACT project and MOPH UHC strategy at central level

General Number of Description Objectives assembly Participants  1st ordinary general assembly  Inform PSHP members on the held on January 10th at “Maison goal and objectives of IMPACT 22 Commune des Nations Unies”  Encourage PSHP members to

led by Telma Foundation and set‐up and initiate Corporate

Mrs. Violet Kakyomya, Resident Social Responsibility (CSR) and

Coordinator of the United the creation of shared value Nations System Ordinary  2nd ordinary general assembly  Identify solutions with health held on June 21st at “Maison commodities transportation Commune des Nations Unies” issues and on private sector led by Telma Foundation and LMIS data collection 23 the members of the PSHP office.  Review the PSHP statute including the health commission  Extraordinary General Assembly  Inform the private sector about held on May 15th at the MOPH, MOPH’s Universal Health Extraordinary led by Telma Foundation and Coverage (UHC) strategy 17 General Secretary of MOPH  Provide an update on the measles and plague outbreaks

Table 14. PSHP members orientation on IMPACT project at regional level

Regional presentation Date Participants PSHP Non‐PSHP Total members members Alaotra Mangoro* November 22nd 03 14 17 Atsinanana February 27th 0 21 21 DIANA March 15th 08 09 17 Atsimo Andrefana April 26th 05 15 20 Boeny May 24th 08 20 28 TOTAL 24 79 103 * While Alaotra Mangoro is not part of the 13 USAID-supported regions, it is among the 6 Rano-Wash intervention regions that are supported by PSHP.

During Year 1, IMPACT was presented in 5 regions. The goal was to explain the project objectives to the PSHP regional focal point in order to implement the regional activities specifically to strengthen LMIS data collection and submission among the private commercial sector (pharmacy wholesalers, pharmacies, and drug shops). In total, 103 participants attended these regional presentations composed by PSHP members, pharmacies, wholesalers, and representatives from the public sector.

Establish a formal partnership between the Platform and the MOPH

IMPACT and the MOPH signed a MoU to formalize the private sector commitment and engagement to the MOPH strategies and policies. The MOPH serves as the lead and mentor to PSHP members on providing technical support and sharing useful and relevant information at the MOPH. The communication and collaboration between the private sector and the MOPH were detailed and clarified inside the MOU (attached).

Expand the Platform by engaging new commercial active actors in health

Table 15. New active members joining the PSHP in Year 1

New Activities Expected action already discussed but no MOU signed yet Members COFARMA, Pharmaceutical importers and  Contribute on the review of current regulations (importation SOMAPHAR, wholesalers in Madagascar tax, health products registration, and distribution) SOPHARMAD  Actively participate in TWG and the PSHP Health Commission.  Commit to collect and submit LMIS data at their level to the DPLMT

Foundation Helps low income and  Partnership for the implementation of IMPACT activities in Aga Khan marginalized communities, in their intervention areas (make available health commodities in improving their overall quality the common intervention areas) of life (Education, Health, Agriculture, Microfinance)

New Activities Expected action already discussed but no MOU signed yet Members Fondation Works to improve life  Partnership for the implementation of IMPACT activities in Akbaraly conditions of the population their intervention areas (make available health commodities in focusing on women and the common intervention areas) children health Mirana Santé Sells Health materials  Participate regularly in TMA TWG and network to develop this / Education/ Training on activity. health  Provide flyers on health education to drug shops and pharmacies. Salama IOI Producers of Sur’Eau 150 ml  Expect the transfer of license of Sur’Eau to private sector for distribution  Salama IOI is willing to participate in the call of tender regarding license transfer of Sur’Eau 150ml to private sector.

Discussions with the new members for integrating the PSHP were continued based on their respective activities.

IMPACT has signed MOUs with the Vanille Durable de Bemanevika and Blue Ventures. Roles and responsibilities of each actor are detailed and included in the MOUs. Vanille Durable and Blue Ventures collaborate with IMPACT in the transportation of health commodities in their respective intervention areas which are difficult to access and in remote areas. These include the SAVA region for Vanille Durable and DIANA, BOENY, MELAKY, MENABE, and Atsimo Andrefana regions for Blue Ventures. They are able to transport products for free in remote areas with very difficult access, and are ready to help with the transportation for public sector products in case of emergency or outbreak.

Identify specific members of the PSHP to join the TWG created in IR 1.1 for the chosen priority health area and assign roles and responsibilities

Table 16. Participation/contribution of the PSHP members in the TMA TWG

TMA‐TWG sub committee PSHP Members TWG activities National Pharmaceutical Policy COFARMA, SOPHARMAD Participate in the review and (NPP) ‐ National Pharmaceutical improvement of the National Master Plan Pharmaceutical Policy (PPN) Texts and legislation for health Akbaraly Foundation, SAHAM Participate in the review and commodities Assurance, BNI improvement of the texts and legislations related to health commodities Logistics Management Information Mirana Santé, COFARMA, Ensure data collection and submission System (LMIS) SOMAPHAR, TELMA, to the DPLMT and respect quality standards of health commodities

In Year 1, IMPACT also provided financial and business expertise to support the following activities:

‐ The development of the framework and design of the market assessment questionnaire. The malaria market assessment survey has been carried out, and results will be disseminated in Year 2 Quarter 1.

‐ The design of a questionnaire to conduct the survey of drug shops and pharmacies in and around Toamasina to identify those which may want to partner with IMPACT for data reporting. Ten drug shops and 10 pharmacies signed a letter of agreement with IMPACT and agreed to provide data on a monthly basis. ‐ IMPACT goals, intermediate results, and geographic coverage were presented to PSHP regional members, as well as three drug shops, four pharmacists, and two representatives from the partner banks in the Atsimo Andrefana region.

The findings from all these Year 1 activities will be used to inform and support the implementation of the IMPACT work plan in Year 2.

Work with partner banks and SHOPS Plus platform to expand financing to health supply chain stakeholders through the DCA guarantees and adapted financial products During Year 1, the IMPACT project objectives were introduced to the two DCA partner banks, Accès Banque Madagascar (ABM) and Baobab Banque Madagascar (Baobab). The team helped the banks to understand private health commodities enterprises in general, and their financial needs specifically. In Quarter 2 and Quarter 3, the team held several meetings with the MOPH, represented by DPLMT and DAMM, to introduce IMPACT and to better understand roles and responsibilities of these two MOPH departments. Following these meetings, the IMPACT Team received list of registered drug shops per region. IMPACT met also with representatives of drug shops and pharmacy organizations, wholesalers, pharmacies, drug shops, Point d’Approvisionnement (PA)/ Point d’Approvisionnement Relais Communautaire (PARC) and Community Health Volunteers (CHV) in five regions: Diana, Atsinanana, Atsimo Andrefana, Analanjirofo, and Analamanga to understand and to learn more about their activities and their financial needs.

Findings:

‐ Wholesalers appear to receive favorable terms and conditions from most financial institutions. ‐ Urban pharmacies have access to term payments (30‐60 days) from wholesalers, and some are also able to access bank loans, although they would like to have additional credit. ‐ Smaller urban and peri‐urban pharmacies have limited options for financing, as wholesalers and financial institutions view them as having a higher degree of risk. ‐ Drug shops and rural pharmacies have minimal access to finance and are forced to pay for essential commodities in cash. This impacts their ability to expand and maintain adequate levels of essential commodities, resulting in stock‐outs. ‐ PAs/PARCs and CHVs have financial needs that are not directly linked to their volunteer health commodities supply activities, but rather to their family’s income‐generating activities (farming, transportation, managing a small shop or grocery, etc.).

During Year 1, the team supports technically PAs, PARCs, and CHVs to continue their health commodities supply activities. To understand the landscape of the businesses it was working with, the team conducted a survey of 925 PAs and PARCs to identify their financial needs and to begin developing tailored financial products with the partner banks. Findings included: ‐ Forty‐three percent of PAs/PARCs expressed interest in borrowing to buy a means of transportation. ‐ The level of financial literacy is very low for drug shops and PAs/PARCS. Only 28 percent have worked with banks or microfinance institutions.

‐ Geographical coverage of financial institutions is limited in the regions surveyed. ‐ Village Saving and Loan Associations (VSLAs) or Savings and Internal Lending Communities (SILCs) are the most common sources of funding and savings for PAs and PARCs. ‐ Under IMPACT, in Year 1, five non‐DCA loans (four women and one man) Under IMPACT, in Year 1, five non‐DCA loans (four women and one man) were disbursed by partner banks with 2 loans for Quarter 4. The loans totaled $20,245, representing 405 percent of the Year 1 target in value ($20,245/$5,000) and 500% percent of the target for number of loans (5/1). ‐ The 1st loan for $5,569 equivalent was disbursed by Baobab to a drug shop in Analanjirofo region for inventory. ‐ The 2nd loan for $3,898 was disbursed by Baobab to a PARC in Antsiranana to purchase a tuc‐tuc taxi in order to improve the PARC’s revenues and to deliver health commodities to PAs ‐ The 3rd loan for $4,640 was disbursed by Baobab to a drug shop in the Atsinanana region for the purchase of drug inventory. ‐ The 4th loan for $4,056 was disbursed by Accès Banque to drug shop in Sambava for the purchase of drug inventory. ‐ The 5th loan for $2,082 equivalent was disbursed by Baobab to a drug shop in Antananarivo for working capital.

Table 17. Loans to Private Health Commodities Supply Enterprises FY19

Loans Disbursed Q1 Q2 Q3 Q4 Total Y1 Number of loans 1 2 0 2 5 Value of loans (USD) $5,569 $8,538 0 $6,138 $20,245

Develop capacity building plans and training curriculum for DCA partner banks utilizing experience from SHOPS Plus In Year 1, the team developed a training curriculum for the DCA partner banks, focusing on market strategy for working with health commodities supply chain stakeholders. The curriculum was based on the results of the Private Sector Assessment conducted by SHOPS Plus in 2017, showing market size: MGA 150‐250 billion (about USD 40‐50 million) of pharmaceutical commodities sold per year in Madagascar, of which 91 percent come from the private sector. Training topics include: experience sharing in credit analysis, loan structuring, commercial strategies for working with health commodities supply chain stakeholders and regional market information (number of PAs/PARCs, drug shops and pharmacies).

Train and support DCA partner banks in credit analysis and loan structuring for health businesses ‐ During this fiscal year, the IMPACT team provided training, based on the curriculum described above, to 105 bank staff (57 women and 48 men) at partner banks’ branch offices in Antsiranana, Toliara, Fénerive Est, and Toamasina. ‐ Training sessions include coaching to bank loan officers: the IMPACT specialists accompany bank officers during client visits to PAs, PARCs, and drug shops introduced by IMPACT. This allows the loan officers to

practice the training received directly. Figure 6: Toliara: Baobab bank branch staff during IMPACT training in April 2019

Table 18. Number of Bank Staff Trained in FY19

Bank Staff Trained Q1 Q2 Q3 Q4 Total Y1 Number of bank staff trained NA 28 77 NA 105 Male NA 11 37 NA 48 Female NA 17 40 NA 57

Develop and adapt loan products, financial and risk mitigation tools for small and micro health enterprises in pharmaceutical sector

IMPACT team proposed the concepts for new pharma loan products to the two partners banks (ABM, Baobab). The banks validated these proposals, and during Year 2, the project will work with bank technical staff to develop the products and launch implementation. The proposed pharma loan products will mainly target rural and peri‐urban drug shops and pharmacies, helping to reduce stock outs.

Proposed products include:

(i) Inventory or Working Capital Financing through the value chain, leveraging sales information provided by wholesalers. (ii) Automated Invoice Collection by the bank on behalf of wholesalers. This product allows the bank to establish relationships with drug shops and wholesalers while providing a financial service.

These types of loan products exist in other countries, but the proposal to use them for the pharmaceutical sector in Madagascar is innovative. These new products could help drug shops located in remote areas to benefit from bank financial products and to increase their stock levels, in order to better serve rural populations.

Banyan Global’s Principal Associate for A2F conducted a mission to Madagascar from September 11 to 20, 2019. The specific objectives of the visit were to:

‐ Define the profile of target sectors; ‐ Assess unmet financing needs; ‐ Analyze the challenges associated with securing financing; ‐ Begin developing a financing product or risk‐sharing instrument in order to increase funding for IMPACT’s target sector.

During this mission, the team met with: ‐ The two DCA partner banks as well as with other banks (BNI Madagascar and Bank of Africa Madagascar (BOA) ‐ Non‐banking financial institutions (ARO, SONAPAR, SOLIDIS and PFIM project) ‐ Various pharmaceutical supply chain stakeholders.

The meeting topics ranged from discussing available financing products that could be leveraged for the target sectors, identifying interested partners for potential initiatives, evaluating available tools and data, etc. All these stakeholders expressed interest in participating in a financial mechanism dedicated to the health sector.

Overview of findings:

‐ Target sectors are broad with varying profiles, financing requirements, and levels of financial literacy. ‐ There is a lack of legal and regulatory enforcement. ‐ There is no credible association for drug shops that could serve as a representative stakeholder in product development. ‐ There are existing portfolio guarantees, such as the World Bank’s “Partial Portfolio Guarantee” which could be leveraged for this activity. ‐ The financial sector expressed interest in collaborating to develop a risk mitigation tool or financing mechanism targeting the pharmaceutical value chain. ‐ There is a local fund manager, SOLIDIS, with experience managing funds and guarantee instruments.

Develop and adapt a training and coaching curriculum to build the financial management capacity of health businesses that will borrow money through the DCA in collaboration with SHOPS Plus

Year 1 achievements for this activity include:

‐ Development of a training and coaching curriculum based on prior experience with the private health sector and on the needs, assessment conducted in Quarter 2. ‐ Conduct a pilot testing of initial modules focused on inventory management and financial bookkeeping for drug shops. The results of the pilot showed that there is a low level of financial literacy and a lack of regulatory knowledge, so basic information on regulatory compliance and drug usage should be added into the curriculum in Year 2, and the training material will be translated into Malagasy. ‐ Design of a Certified Peer Trainer program in Quarter 4 where training materials will be tested in Year 2.

The objective is to establish a capacity building program which can reach more drug shops, and which is not dependent on donor funding in the long term, in order to ensure the sustainability of this training beyond the end of the IMPACT program. ‐ This capacity building program of peer trainers will use existing local associations to supervise the drug shop training program under the MOPH umbrella. It will incorporate simple, inexpensive training materials, such as laminated cards, rather than PowerPoint presentations requiring electricity, computers and projectors. ‐ Participation of the A2F Specialist in the IMPACT study tour to Tanzania from August 24 to 31 to learn more about the Accredited Drug Dispensing Outlet (ADDO) program. Members of the delegation from the Ministry were impressed by the successful ADDO experience in Tanzania, and they plan to advocate the Ministry and private sector stakeholders to adapt and implement some parts of this program in Madagascar.

Provide training and coaching to strengthen the financial management skills of all borrowers through the DCA (e.g., drug shops, pharmacies, wholesalers, retailers) Activities achieved are: ‐ Conduct a pilot training in partnership with SOPHARMAD in Quarter 3. o Participants included 22 drug shops owners and managers (16 men, 6 women) in Fenerive‐Est from Analanjirofo region.

‐ Test of a positive self‐selection approach for the training. o This means the drug shop training was publicized through a local association, and participants needed to indicate their interest, instead of the IMPACT team specifically choosing participants. Because participants were self‐selected and had to pay the cost of transportation to the training venue and accommodations during the two‐day training, they were much more motivated and showed genuine interest in improving the business Figure7: The group of 22 drug shops owners and managers trained during the pilot session in Fenerive Est on May 2019 practices of their drug shops.

Sub‐IR 3.2: GOM facilitates the work of the commercial sector During Year 1 IMPACT: ‐ Initiated contacts and collaboration with the DAMM and engaged discussions to review the existing medicines registration processes with the aim of streamlining it. DAMM conducted a self‐evaluation using the WHO Global Benchmarking Tool (GBT). While waiting for the WHO report and scoring of the GBT, IMPACT recruited an international consultant to facilitate the development of a strategic plan based on the GBT results.

Next steps: 1) Discuss the GBT results and scoring with DAMM 2) Prepare a workshop to discuss results in a larger group and develop a strategic plan 3) Update/develop registration and inspection processes and SOPs.

Make an assessment of regulatory and policy barriers to the commercial sector’s involvement in the pharmaceutical supply chain

‐ IMPACT completed the literature review of 128 legal and regulatory documents in forms of laws, ministerial decrees, guidelines, and instructions related to pharmaceutical management in Madagascar that were signed between 1962 to 2019. 25% of the texts were deemed obsolete. The literature review was completed by discussing with key informants (Pharmacy Council, Association des grossistes et des dépots, Ministry of Health, DAMM, SALAMA). A preliminary report is available and will be finalized and disseminated in Quarter 2 Year 2 to guide the regulatory reform. ‐ A delegation of key stakeholders representatives participated to a one‐week study tour on the ADDO model implemented in Tanzania, in collaboration with MSH and the FDA (Food and Drug Administration Authority) Tanzania offices. The team led by the Secretary General of the Ministry of Public Health in Madagascar and composed of the DAMM, the pharmacist in‐charge of management of depots/drug shops within DPLMT, the President of the National Pharmacy Council, the President of Syndicat des Pharmaciens, and IMPACT representatives, learned from their peers in Tanzania on the set up of ADDO, pilot and scaling process and steps, challenges, and lessons learned to guide the implementation of the same system in Madagascar.

Organize advocacy meetings with the GOM for options to support the expansion of the commercial sector (e.g. tax exemption for health products dedicated to humanitarian activities)

‐ A workshop was held on May 9 to share best practices on the prequalification of suppliers used by donors (Global Fund, USAID, UNFPA, UNICEF, World Bank etc.) and SALAMA and the registration and importation processes used by DAMM and DPLMT. The goal of the workshop was to explore how to harmonize the quality assurance processes and to simplify the importation processes of essential medicines and supplies procured by donors to support the MOPH health programs. The meeting was jointly organized by IMPACT, H6+ group, DAMM and DPLMT, and confirmed by 75 participants representing the Ministry of Health, Ministry of Finance, Customs, UNICEF, WHO, USAID, and other stakeholders. ‐ A MOU between donors with the MOH has been drafted, which clearly defines the roles and responsibilities of each party in strengthening quality assurance of drugs and supplies imported by donors and stakeholders. The MOU will be finalized and signed in Year 2. ‐ On May 17, IMPACT has supported the MOH led workshop to finalize and validate the updated List of Essential Medicines and supplies. This will serve as a basis for the Ministry of Finance to approve tax exemptions, which will lead to increased financial accessibility of essential drugs and medical supplies. The list was approved by the Minister of Health and is ready to be disseminated and used.

Support the GOM to develop an action plan to implement the Stratégie Nationale de Lutte contre la Contrefaçon et le Marché Illicite de Médicaments with an emphasis on malaria, Family Planning and MCH products

IMPACT initiated contact with the President of the National Committee in charge of fighting illicit drugs to revitalize the Committee to implement activities. The steps identified were: ‐ Upon availability of the Prime Minister, who hosts the Committee, meet to discuss the way forward to restructuring the Committee (membership, equipment and furniture, legal texts, action plans, budget). ‐ Plan a mid‐term review of the existing strategic plan and adjust next plans according to funding and realistic objectives to be attained. ‐ Support DPLMT to sensitize depots on existing regulations in order improve licensing processes. The Prime Minister has not been available in Year 1 and this activity is replanned for Year 2. IMPACT will engage the Prime Minister through advocacy by the Minister of Health.

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

Sub‐IR 4.1.1: Socially marketed products are continuously available at convenient and accessible locations Addressing stock out of commodities (transition from SHOPS Plus to IMPACT)

‐ In Quarter 1, a field visit with USAID, ACCESS, Mahefa Miaraka, MCSP, and PSI took place in the Menabe region from November 26 to November 30 to better understand all health services funded by USAID through IMPACT and ACCESS. Additionally, Mahefa‐Miaraka shared their experiences with the new USAID‐funded projects namely ACCESS and IMPACT. After the visit, USAID suggested the organization of monthly meetings at the regional and district levels between IMPACT and ACCESS. Distribution at the community level was deemed to be satisfactory despite stockouts in Pneumox and ORS/Zinc. ‐ IMPACT distributed 216 thermometers (71 in Diana, 94 in Atsimo Andrefana, and 51 in Menabe) to control temperature of where stocks are stored at the PARC and PA levels. ‐ The IMPACT social marketing distribution began in January 2019 with a smooth transition from the SHOPS Plus Project. A six‐month emergency plan for public sector and community FP products was developed with USAID to avoid stock outs and distributed to the Pha‐G‐Dis and PARC in 13 IMPACT‐ supported regions. In addition to the emergency plan, IMPACT developed and implemented a social marketing procurement plan of FP commodities in Year 1 (see further explanation in IR2.1 on emergency distribution). ‐ The MCH product procurement was launched in November 2018 and arrived as follow:

Table 19. Summary of the MNCH products delivery

MNCH product Quantity Expected date for arrival Real arrival date 58,600 strips June (first delivery) Pneumox April 112,340 strips July (second delivery) Arofoitra or Chlorhexidine 50,000 tubes April July ORS 240,000 sachets April August Zinc Sulfate 12,000 strips April September

‐ Through a request from Mahefa Miaraka, IMPACT delivered 30,845 pregnancy tests to 3,026 Mahefa Miaraka Community Health Volunteers (CHVs) working with 195 CSB in seven districts of the Sofia region in March 2019 as a start‐up quantity while the distribution to PA in these districts began in April 2019. Mahefa Miaraka had chosen Sofia region as a pilot for pregnancy test training and distribution. Furthermore, based on the estimated need for pregnancy tests provided by Mahefa Miaraka, the available stock of 200,000 pregnancy tests procured by USAID may not be sufficient to cover 7 regions so this quantity was supposed to be for the Sofia region only. A procurement of 200,000 Pregnancy Tests was already launched in 2019 for a delivery in 2020. There is an additional 400,000 Pregnancy Tests approved by USAID to procure. Those quantities will cover the 13 regions. ‐ From March to June 2019, IMPACT trained 925 PA and PARC (859 PA: 505 females and 354 males; and 66 PARC: 51 females and 18 males) through 53 training sessions in the 10 regions of IMPACT and 3 PARN regions. Training modules were focused on (i) information about IMPACT; (ii) importance of the product availability; (iii) method to calculate the average monthly consumption; (iv) situation of regular users; (v) distribution for health products; (vi) use of management tools, storage, waste, and expired product management, and (vi) sharing of some success practices and stories. A manual including the topics listed above was produced and distributed to the PA and PARC as a guide.

All the PA and PARC trained were pre‐tested and post‐tested on their knowledge using a questionnaire and an average score is summarized below.

Table 20. Summary of findings from the training

Attendance rate of the PA & PARC 96.84% Average score during Pre‐test (10/20) 86.41% Average score during Post‐Test (10/20) 97.82% PA who gained scoring points 82.43%

The PAs and PARCs who received the training were followed up after one month during the monthly supervision by the Superviseurs de Point de Distribution (SPD) who continuously strengthen their capacity during formative supervision.

‐ IMPACT offers a range of socially marketed FP/RH and MNCH products to support the national programs. Table 21 shows the Quarter 2 to Quarter 4 distribution of these products against annual targets. Since the distribution transitioned from SHOPS Plus at the end of Quarter 1, the annual targets and achievements are from Quarter 2 to Quarter 4.

Table 21. Distribution of FP commodities in Quarter 2 to 4 against Year 1 targets at PARC level (from PSI to PARC)

Products Year 1 Achievement Year 1 Quarter 2 Quarter 3 Quarter 4 Cumulative (%) Oral Contraceptives 1,232,057 1,382,159 112.2% (cycles) 286,692 577,726 517,741 Triclofem injectable 1,052,396 926,044 88% contraceptive (doses) 268,760 285,453 371,831 Sayana Press injectable 338,825 41,598 130,016 49,403 221,017 65.2% contraceptive (doses) Yes With You condoms 269,100 103,500 119,700 45,900 269,100 100% 518,823 (community

Protector Plus condoms and 868,896 167.5% 86,928 89,472 692,496 commercial channels)

‐ Oral Contraceptive (Microgynon and Combination 3): In Year 1, the distribution of oral contraceptives began during the second week of January. The distribution of oral contraceptives doubled in Quarter 3 compared to Quarter 2 as Mahefa Miaraka updated the number of regular users per CHV at the end of April. ‐ Triclofem: Data on regular users from Diana and Sava were only available from July 2019 that is why the quantity distributed during quarter 4 has increased. ‐ Sayana Press Injectable Contraceptive: The quantity of Sayana Press being restocked by PARCs tripled in Quarter 3 compared to Quarter 2 after the arrival of the product in March 2019 due to lower central‐level stock available during Quarter 2. The difference between the Year 1 planned vs Year 1 achieved (cumulative) is due to the FY 2018 database where the public sector was experiencing a long period of stock‐out of FP products and the social marketing sector was solicited to fill the gap. Some CSB procured products at the PA level, which is why sales at the PA level were higher in 2018. However, from Quarter 2, the quantity distributed was updated and only based on the number of regular users. ‐ Yes With You Male Condom: Through the commercial channel, IMPACT distributed 269,100 Yes With You male condoms which matched with the Year 1 target. ‐ Protector Plus Male Condom: IMPACT distributed 868,896 units of Protector Plus male condoms through the community and commercial channels vs 518,823 planned for Year 1 because Protector Plus was newly re‐introduced into the commercial sector in the 13 regions of Madagascar and the commercial distribution pipeline restocked the products in Quarter 4.

Table 22. Distribution of MNCH commodities from Quarter 2 to Quarter 4 against Year 1 targets at PARC level

Year 1 % of Target Year 1 Products Quarter 2 Quarter 3 Quarter 4 Achievement Achieved Target (Q2+Q3+Q4) (Q2+Q3+ Q4) Diarrhea Treatment ‐1 2,140 530 2,873 ‐ Kits (ORS/Zinc) 203 Sur'Eau Pilina 3,515,320 660,400 868,440 770,840 2,299,680 65.4% Sur'Eau 150 ml bottle 337,862 143,840 153,884 46,871 344,595 102% Pneumox pneumonia treatment kits 53,309 ‐ 102,404 192.1% 102,404 (boxes) Arofoitra 7,373 ‐ 16,109 16,109 254.8% (Chlorhexidine) 1 The target was not defined because when IMPACT set the PMP targets, the DTK (Diarrhea Treatment Kits) were not available and IMPACT still doesn’t have the confirmation of the order or the expected date of the product arrival.

‐ ORS/Zinc: In Year 1, IMPACT only distributed the remaining stock of diarrhea treatment kits (2,873 kits) from SHOPS Plus. ‐ IMPACT has received 240,000 ORS on August 23rd and 12,000 blisters of Zinc Sulfate on September 12th. These quantities will be distributed in Quarter 1 of Year 2. ‐ Sur'Eau Pilina: The quantity distributed has decreased (2,299,680) compared to the Year 1 planned (3,515,320) because the distribution only started in January 2019 and new communities not covered during the Mikolo project still needed to be sensitized on the use of Sûr’Eau Pilina between the end of the Mikolo project and the beginning of ACCESS (Mikolo did not cover all the communities while ACCESS plans a total coverage). Also, this year there was not a long rainy season, which might reduce the number of diarrhea cases (61,773 diarrhea cases treated in 2018 versus 24,202 diarrhea cases treated in 2019; Source ACCESS and Mahefa‐Miaraka, January to October). ‐ Sûr’Eau 150 ml: In Year 1, IMPACT distributed 344,595 bottles of Sûr’Eau 150 ml instead of 337,862 previously planned.

In Year 1, Sûr’Eau Pilina and Sûr’Eau 150 ml distributed purified 519,368,180 liters of water.

‐ Pneumox: After a long stock out, IMPACT received 58,600 blisters of Pneumox by air in mid‐June 2019 and 112,340 blisters by sea in mid‐July 2019. During quarter 4, 102,404 blisters of Pneumox were sent and distributed by the PARCs. ‐ Arofoitra: Arofoitra (Chlorhexidine) also experienced a long period of stock out. IMPACT has received 50,000 tubes in July and distributed 16,109 tubes in Quarter 4.

Sub‐IR 4.1.2: Innovative last mile distribution ventures

PSI conducted a feasibility study on the use of drones to transport PSI products in remote and hard‐to‐reach areas. The objective of this study is to identify the types of UAV transportation conditions for social marketing products and conform with regulatory limits.

Findings show three appropriate categories of drones:

‐ Fixed‐wing or hybrid drones capable of carrying a payload of at least 1.3kg (minimum quantity) over a distance of 100km.

‐ Fixed‐wing or hybrid drones capable of carrying a payload of at least 2kg over a distance of 50km.

‐ Hybrid drones, helicopters, or multirotor capable of carrying a payload of at least 2kg over a distance of 25km.

This feasibility study also enabled the draft of a plan for the pilot phase of the project in 8 hard‐to‐reach areas from October to November and establish an estimated global cost of its implementation (more details are available in the report shared with this annual report).

IMPACT has initiated a pilot on using a drone to address stock out as part of the last mile distribution strategy. This is designed to transport FP, MNCH, malaria, and other health products and medical supplies in case of emergency and outbreaks.

One Unmanned Aerial Vehicle (UAV), will be deployed from a base in Maroantsetra to serve 92 PA located in difficult‐to‐reach areas experiencing stock out covering 6 districts (Befandriana Avaratra, Antalaha, Andapa, Mananara, Mandritsara, and Maroantsetra) in Analanjirofo, Sava, and Sofia regions.

PAs who have GSM coverage will receive detailed messages on the deliveries from the operational unit managing the drone over the phone. The contract with Aerial Metric, the UAV provider, was signed at the end of Quarter 4. IMPACT expects to use three drones and expand the targeted areas from Year 2 after receiving USAID approval based on the evaluation of the pilot.

The map below shows the PA that will benefit this new mean of transportation in the 3 regions.

Figure 8: PA that will benefit this new mean of transportation

The following are the activities completed in Year 1 using the drone for last mile distribution

‐ Procedures and tests: Aerial Metric and IMPACT held a workshop in September to develop a plan to respect the procedures and regulations from ACM (Aviation Civile de Madagascar) for flight tests. Aerial Metric collected the necessary information for the flight test such as GPS coordinates from the departure point to the release point with the consideration of obstacles (mountains, lakes, etc.), and created an itinerary from takeoff point to PA. o Tested the capacity of the drone to do a vertical take‐off at one point o Tested the products release on the take‐off points with a stationary flight

‐ Preparation: Several preparatory activities were necessary before the first drone flight, including: collection of geographical data of the PA and GSM networks; recruitment of “Superviseurs de Points de Distribution” for Drone (SPD Drone) to supervise and follow up activities related to the distribution to the PAs; training of the SPD; simulation of products packaging for the delivery (container (capsule) has 12.5x12.5x6 cm dimension).

‐ Sensitization: IMPACT conducted courtesy visits to authorities of the MOH, regions, Fokontany, and communes in order to inform them and to involve them in the drone delivery project. Radio spots were developed to inform the population about the activity and posters were displayed at commune, fokontany, and PA levels. In collaboration with local authorities, SPD has organized social mobilization at fokontany and communes in Ambodimanga, Rantabe, Manambolo, Madiotsifafana, Ambinanitelo, Marerano, Voloina, Ankofa, Ankofa Be in order to prevent fear, threats, and misunderstandings about the project. Sensitization of other communes will be carried out progressively. Local authorities and the population in the concerned villages have expressed their interest and intention to help the project.

Portfolio Analysis

The product portfolio analysis and the Cost of Goods Sold (COGS) analysis are ongoing. Information about existing health products in pharmacies and from different studies were collected and available. A mapping and positioning of the social marketing products in the market will be obtained from the analysis results. The portfolio analysis and the COGs final reports are expected in Quarter 1 of Year 2.

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

Innovative Demand Creation and Product Promotion Campaigns

In Year 1, the communication activities carried out to increase demand creation included:

‐ All 13 USAID‐supported regions were reached through the communication channel using radio broadcasts; ‐ Distribution of Sur’Eau Pilina posters in 60 districts/communes and Protector Plus posters in 78 districts/communes, through IMPACT supported regions; ‐ Social mobilization at the community level was designed and conducted to increase the local population awareness of the health products. Ten communication teams composed of an animator and a driver using mobile sound system promoted Sur’Eau Pilina and Protector Plus in collaboration with the CHVs.

Table 23. Summary of the communication activities on demand creation

Products Quarter 2 Quarter 3 Quarter 4 Total Year 1 Sur’Eau Pilina 2,147 760 4,420 7,327 Number of Radio Protector Plus NA 3,200 NA 3,200 Spots Aired Family planning NA NA 1,550 1,550 Total 2,147 3,960 5,970 12,077 IMPACT Posters Sur’Eau Pilina 36,000 NA NA 36,000 printed and Protector Plus NA 1,000 NA 1,000 distributed Total 36,000 1,000 NA 37,000 Sales on Sur’Eau 94,760 218,320 436,520 749,600 Pilina Social mobilization at Sales on community level NA NA 8,277 8,277 Protector Plus Total sales 94,760 218,320 444,797 757,877

Table 23 shows that: ‐ In the 13 USAID‐supported regions, 12,077 radio spots were broadcasted to increase demand for health products and 1,550 spots related to FP to support the celebration of World Contraception Day. ‐ In Year 1, 37,000 Posters about IMPACT were printed and distributed

IMPACT worked closely with ACCESS and Mahefa Miaraka to promote health products during Year 1. While IMPACT ensured availability of health commodities, ACCESS and Mahefa Miaraka addressed social behavior change of target groups in their respective geographical areas. In Quarter 4, coordination meetings between the 3 USAID‐funded projects have been initiated. The objective of these coordination meetings are to share information and activities of each partner and coordinate communication campaigns. Mahefa Miaraka included a session during the review with the CHVs to promote Arofoitra including its usage guidelines.

Demand Creation Subcommittee of the TMA TWG A demand creation subcommittee of the TMA TWG was set up and led by the Health Promotion Directorate (Direction de la Promotion de la Santé ‐ DPS) of the MOPH, including all TMA stakeholders. Its main objectives is to increase demand and coordinate and share communication activities on health commodities to public, private, commercial, profit and nonprofit sectors. A training session focused on the methodology to be used to develop communication plans and tools for the first workshop was organized on September 30, 2019 at Havana Hotel.

National Malaria Control Program Communication Plan IMPACT participated in the development and validation of the National Malaria Control Program Communication Plan 2019‐2022 led by the NMCP in Quarter 2. The goal of this plan is to get at least 80% of the population to adopt behaviors conducive to the prevention and management of malaria.

In addition, IMPACT contributed to the following activities:

‐ Technical and financial support to the national strategy “Ecole Ami du Paludisme” by providing job aids and sanitation equipment through the national school contest organized during World Malaria Day in Quarter 3; ‐ Broadcasting of TV and radio spots related to:  Rapid Diagnostic Tests (RDT): only test performed at health facility would confirm whether the patient with fever has malaria or not;  Intermittent Preventive Treatment (IPTp);  Long‐Lasting Insecticide‐treated Nets (LLIN) for all family members. ‐ From July 17th to August 18th and after the LLINs mass distribution conducted in 2018, IMPACT broadcasted 1,980 radio spots on net care in 13 districts of the 10 USAID‐supported regions.

Mobile Technology to Increase Demand Creation Since May 2019, IMPACT has supported the “910” hotline, which provides information on FP, MNCH, malaria and other health topics. The “910” hotline is also used to encourage people to call if they need further information related to malaria, FP, and MNCH health products. In all IMPACT SBCC materials and tools (posters, radio spots, and TV spots) 910 hotline is referred as an information source. During Quarter 4, calls received have increased up to 137% compared to Quarter 3 (2 months for Quarter 3 vs 3 months for Quarter 4). The most significant increase was on FP, malaria, and MNCH. The “910” hotline became an essential tool for the population to have information on health. The calls received related to general information, questions on prevention and treatment, and to report suspected cases of diseases. The “910” hotline is also used as a tool to monitor suspected cases of epidemics, such as malaria, plague, and measles. The detailed report on “910” calls received was submitted daily to the MOPH.

Table 24. Summary of number of hotline calls received by health areas

Quarter 3 Quarter 4 Q4/Q3 (May‐June1) Total N % N % N % % Hotline calls received on 10,475 21% 35,271 29% 45,746 27% 237% Malaria (% of total) Hotline calls received on Family Planning (% of 299 1% 4,943 4% 5,242 3% 1,553% total) Hotline calls received on Maternal, Child Health (% of 4,553 9% 12,813 11% 17,366 10% 181% total) Hotline calls received on other health domains2 (% of 35,607 70% 67,822 56% 103,429 60% 90% total)

Total hotline calls received 50,934 100% 120,849 100% 171,783 100% 137%

1: IMPACT started taking the lead from May 2The other diseases are related to plague, measles, headache, stomach pain, etc.

SMS Broadcast SMS is one of the communication channels that was used to reach the population based on segmentation criteria such as geographic area and sex, using a database of telephone companies

In collaboration with the MOPH, IMPACT conducted three SMS campaigns with one message per health area (see table 25). Messages were created by NMCP (for malaria) and DSFa (for FP) and validated by DPS.

Table 25. Summary of SMS sent to population

Health Messages Target Network Number of People Period Area Reached Q3 Q4

Malaria Use of RDT "Ny fitiliana na test eny Women and Telma ‐ 1,821,382 X amin'ny Tobimpahasalamana irery ihany men in the 10 Orange no manamarina fa tena voan'ny USAID‐ tazomoka ianao na tsia"; and translated supported in English it means: "Only the diagnostic regions test to be performed at the health facility will confirm whether you have malaria or not. "

Malaria TPI “Mandehana misafo raha vao tsy Women and Telma – 2,497,456 X miverina ny fadimbolanao ahazoana ny men in the 10 Orange fanafody SP miaro @ vokadratsin'ny USAID‐

tazomoka @ reny sy zaza. Antsoy supported maimaimpoana 910” “If you don’t have regions your menstrual cycle go to a health facility for a prenatal consultation where you can receive IPTp that protects you and your baby against malaria. Call 910 for free.”

FP FP “Handrindra fiainam‐pianakaviana Women and Telma – 3,632 ,167 X ianao? Tongava misafidy izany eny men in the 13 Orange amin’ny tobimpahasalamana na USAID‐ mpanentana ara‐pahasalamana, antsoy supported Airtel maimaimpoana ny 910” “You want to do regions FP? Come and choose a method in a health center or with a CHV. Call 910 for free”.

In Quarter 4, targeted SMS were also sent to PA and CHV to inform on the availability of MNCH health products and to encourage them to resupply their stock of commodities.

Table 26. Summary of targeted SMS on availability of health product

Health Messages Target Number of SMS Product Received by Recipient Pneumox, “Salama e, efa tonga eny @ PARC mahazatra anao ny Arofoitra AROFOITRA sy ny PNEUMOX. Efa mahalala izany koa ireo AC PA 510 namantsika” “Hi, PNEUMOX and AROFOITRA are available at your usual PARC. Our CHW are also already aware.” “Salama e, efa tonga ao @ PA mahazatra anao ny AROFOITRA sy ny PNEUMOX. Tongava malaky!” “Hi, PNEUMOX and CHV 3,591 AROFOITRA are available at your usual PA. Come quickly!”

The Communication Plan Targeting Youth

‐ In Year 1, IMPACT developed a strategy to target youth. This strategy is a peer education approach in collaboration with ACCESS, Mahefa Miaraka, Ministry of Youth and Sports (MYS), and other NGOs. Young people will be selected based on agreed criteria (leader and good example in their community, volunteer of local association, etc.) and will benefit from training on leadership, prioritized health areas commodities, and sensitization to have good health behaviors, such as prompt care seeking to health facilities or CHVs and using FP products to avoid early pregnancy. IMPACT will also develop job aids and SBCC materials to raise peer educator’s awareness according to the training and messages that they have received. The implementation of communication plan targeting Youth will be in Year 2.

Telma Foundation will also contribute to this initiative through its program called “Informatique pour tous” (“Computing for All”). The purpose of the “Informatique pour tous” program is to integrate the use of new technologies, such as networks and computers, to educate the Malagasy youth who are unable to afford these technologies. Through the Youth Strategy, Telma Foundation will provide computer, Internet connection, and trainings to the members of the youth association of ACCESS, Mahefa Miaraka, Ministry of Youths and Sports (MYS), and other NGOs to ensure sustainability and efficient collaboration with the youth association.

The following activities have been conducted during Year 1: ‐ Collaboration with ACCESS and Mahefa Miaraka based on their “Youth Champions Approach” where IMPACT has integrated the use of health commodities in their respective program. ‐ Meetings with the MYS to support youth centers ‐ In Quarter 4, a MOU was signed with Blue Venture. Blue Venture is a program that aims to improve access to health services and commodities for people who are living in the Coast and who have a project to protect their ecosystems. Through the MOU, Blue Venture agreed to integrate its youth members in particular through the strategy targeting youth (explained above). Blue Venture youth members will receive capacity building on leadership, sensitization to have good health behaviors, and use health commodities. ‐ With the MYS, IMPACT participated on the roll‐out of the International Youth Day on August 12th in Antananarivo. This year, the theme was “Une jeunesse instruite, garant du succès de la nation” “An educated youth, guaranteeing the success of the nation”. 3,000 young people attended the event and

IMPACT provided 120 drinking cups and 100 tee‐shirts for those who participated in the different animations.

Figure 9: Celebration of the International Youth Day Figure 10: Young people participating in the animations

Other communication Activities In addition, IMPACT provided technical and financial support to different activities organized by the GOM and other partners:

 Measles Outbreak Campaign During the three measles vaccination campaigns held respectively from January 14th to 18th, February 18th to 25th, and from March 25th to April 5th, IMPACT supported: ‐ Transport of vaccines, medical supplies, management tools and SBCC materials from Antananarivo to 80 out of 114 districts nationwide. ‐ Broadcast of 160 TV spots and 720 radio spots. ‐ Procurement of 13,456 medical kits (11,700 standard kits, 1,279 pediatric kits, and 477 adult kits).

 Support victims of a landslide On January 21st, IMPACT donated 400 bottles of Sur’Eau 150ml, 80 tee‐shirts, 80 drinking cups, and 15 water containers to 80 victims of a landslide in the Fokontany of Tsimialonjafy – Antananarivo.

 World Malaria Day

Supporting the roll‐out of the annual World Malaria Day on April 26th in Ambanja. The event was led the Minister of Health. The week of mother and child health was launched at the same time as the World Malaria Day event. IMPACT held a booth to present the project and its products.

 World Water Day On March 22nd, World Water Day was celebrated in the Commune of Masindray in Antananarivo under the lead of the Ministry of Water, Energy, and Hydrocarbons. This year, the theme was: “Qui qu’il soit, où qu’il soit, il a besoin d’eau” (“Whoever she/he is, wherever she/he is, she/he needs water”). IMPACT donated: ‐ 300 drinking cups and 50 pens to reward those who participated in the quiz during the sensitization. ‐ two containers of treated water with Sur’Eau Pilina.

In addition, IMPACT participated in community mobilization at the event through the communication team. This was an opportunity for IMPACT to promote Sur’Eau Pilina and increase demand.

Figure 11: Community who were present at the World Water day Figure 12: Container of water treated with Sur’Eau Pilina at the World Water Day

 World Health Day World Health Day was celebrated on April 12th in Antananarivo. This year, the theme was: «Tolotra fahasalamana ho an’ny daholobe, ho fanatsarana ny fahasalamam‐bahoaka» translated in English: “Universal Health Coverage, for public health improvement.” IMPACT participated in the: ‐ Broadcast of 20 TV spots and 90 radio spots on the event. ‐ Donation of 500 drinking cups to reward the winners of the quiz.

 Private Sector Exhibition Fair On August 2ndand 3rd, 2019, SHOPS Plus organized a private sector exhibition at Hotel Carlton‐Antananarivo. Thirty exhibitors from healthcare services, banks, NGOs, medical associations, and pharmaceutical wholesalers were present. The objectives of this event were to create a dynamic partnership between health stakeholders, exchange experiences, lessons learned, and improve visibilities. In collaboration with PSHP, IMPACT presented a booth displaying social marketing and malaria commodities. It was an opportunity to present IMPACT goals and objectives to visitors and to recruit new members for the health commission of the PSHP. After the event MIRANA Santé, a new actor, was interested to IMPACT’s TMAand joined the PSHP. MIRANA Santé is working on the following: purchase, importation, wholesaler and retail sale of health commodities, rental of maintenance equipment and home care, medical devices as well as therapeutic education and patient counselling.

Figure 13: IMPACT booth Figure 14: Presentation of IMPACT activities to the official visitors lead by the General Secretary of MOPH  Vaccination campaign ‐ Famerenana ny Andron’ny Vaksiny (FAV) Polio 15 – “Vaccination Mass Campaign” The vaccination campaign was held from August 12th to 15th, and IMPACT provided financial support to the MOPH to transport vaccines from 30 districts to 696 CSBs in Atsimo Andrefana, Atsinanana, DIANA, Melaky, SAVA regions where 1,041,971 children under 59 months benefitted. IMPACT shared with ACCESS and Mahefa-Miaraka the total cost of the financial support to the vaccination campaign, including the transportation, the supervision, and daily allowances of the vaccinators and communicators.

 World Pharmacist Day On August 25th and 26th in Antananarivo, the Pharmacist National Order, the Association of Pharmacists of Madagascar, and the MOPH celebrated the World Pharmacists Day. The theme of this year was "Des médicaments sûrs et efficaces pour tous" ‐ “Safe and effective drugs for all.” ‐ IMPACT and the PSHP held a booth where IMPACT’s goals and objectives were presented, including social marketing, FP, malaria, and MNCH health products. This was an opportunity for the IMPACT team to share experiences, lessons learned, and explain to the visitors the new and innovative approaches undertaken through the project. Participation to such event will increase IMPACT visibility and then encourage

partnerships with private sector either through PSHP or direct collaboration with Figure 15: Presentation of IMPACT activities to the official visitors lead IMPACT/MOPH. Five meetings with by the DGFS pharmaceutical wholesalers were obtained with NAJMI, IMEX Pharma, Interpharma, DICOPROPHAGI and PharmaEk. Discussions have begun for their integration into the PSHP expected in Quarter 1 of Year 2. ‐ The concept of “Creating Shared Value” was shared to the audience composed by pharmaceutical professionals and students.

 World Contraception Day World Contraception Day was celebrated on September 26th in Antananarivo. The theme this year was “La planification familiale c'est ma vie, c'est ma responsabilité" “Family planning is my life, it’s my responsibility."

IMPACT supported the MOPH by:

‐ Creating the design for the printed media (posters, invitations, banners) ‐ Broadcasting 1,550 radio spots on FP ‐ Providing goodies to reward the winners of the quiz animation ‐ Holding a booth displaying IMPACT products.

Figure 16: Figure: IMPACT booth tour

Communication Working Group The USAID Development and Communication Outreach department has organized a quarterly sharing communication activities session with its partners. Different topics and tips were discussed, including success story checklists, story collection guidance, photo and video release forms, USAID and State Department policies and strategies and their impact on communications. The IMPACT SBCC team attended all sessions held in Year 1.

 6th Annual meeting of Malaria SBCC Working Group The 6th annual meeting of the SBCC working group was organized from September 10th to 12th in Maputo, Mozambique to share experiences and best practices, take part in skills‐building, and develop work plans for the upcoming years. IMPACT attended this annual meeting with the teams from MOPH (NMCP, DPS), USAID PMI Madagascar, ACCESS, and Vector Link.

IMPACT was selected to present a poster whose theme is the role and importance of advocacy on the LLINs mass distribution conducted in 2018. Figure 17: Figure: Presentation of the poster

During this high‐level meeting, one of the priorities of the working group in 2020 will to develop malaria SBC strategies in stratified settings according to malaria transmission zones. NMCP will be the lead for Madagascar starting in Year 2.

This meeting enabled to discover the concept of Human Center Design that will be used for the journey mapping study scheduled in year 2.

By integrating the platform Springboard as a member of the SBCC working group, IMPACT will participate to the online sharing of experiences on malaria SBCC and will receive the latest information on the fight against malaria.

II.6. Cross‐Cutting Activities: Monitoring, Evaluation, Research and Learning

1. Monitoring and Evaluation Formative supervision/active data collection

In Year 1, 14 formative supervisions were organized to supervise 55 Pha‐G‐Dis in order to strengthen LMIS data submission identified as having LMIS data issues: they had not sent their LMIS data and/or they needed assistance with LMIS issues. The formative supervision was led by DPLMT with the participation of IMPACT, DEPSI, EMAR, EMAD, and other MOPH departments (NMCP, DSFa). During the supervision visits, the teams were actively collected the LMIS data. Supervision teams were composed by one person from DPLMT, DEPSI, or IMPACT, one person from DSFa or NMCP, and one person from EMAR or EMAD. The objectives of the supervision are focused on (i) identifying and solving LMIS issues if possible, (ii) collecting LMIS data and sending a copy to the DPLMT.

In Year 1, IMPACT set a target of 64% for the submission of LMIS data. Six regions show good performance with the target largely exceeded: Amoron’i Mania 73%, Atsimo Andrefana 70%, Atsinanana 82%, Boeny 71%, Sava 69%, and Sofia 83%. Formative supervision main findings include: For the regions highlighted in red (see table 28 below), the predominant issues on low reporting rates are: lack of functional IT equipment, no qualified CHANNEL personnel, and lack of personnel to report data. Additional issues are poor Internet connection, power cuts, and use of the old version of CHANNEL software by health information system managers. All those issues were addressed during visits and were discussed within the LMIS committee. An action plan was set‐up per district and implemented in Quarter 1 of Year 2 to address all issues cited above. A mapping of Pha‐G‐Dis with functional computer used for stock management and LMIS data reporting was conducted. Contribution of partners is presented in table 27 below. Distribution of the 37 computers is scheduled from Quarter 1 in Year 2.

Table 27. Availability of computer in USAID‐supported regions

Number Pha‐G‐Dis without computer 43 Contribution of UCP 6 Contribution of IMPACT 37

Regions that do not submit completed reports are Analanjirofo and Melaky, with emphasis on MNCH missing report (as explained below).

Table 28. Year 1 Average Reporting Rate per Region (source CHANNEL for Pha‐G‐Dis)

Number of Districts District Average Average Completion REGION per Region Supervised Reporting Rate1 Rate1

MELAKY 5 4 33% 28% ANALANJIROFO 6 5 36% 31% VAKINAKARATRA 7 5 50% 37% MENABE 5 4 52% 37% DIANA 5 4 55% 42% HAUTE MATSIATRA 7 2 58% 49% VATOVAVY FITOVINANY 6 4 58% 52% SAVA 4 4 69% 55% ATSIMO ANDREFANA 9 6 70% 61% BOENY 6 3 71% 59% AMORON I MANIA 4 3 73% 61% ATSINANANA 7 5 82% 62% SOFIA 7 6 83% 61% TOTAL 78 55 62% 50% ‐ 1: 11 months from October 2018 to September 2019 ‐ In red the regions that did not meet the Year 1 target of a reporting rate of 64% and completion rate of 35% as defined in the PMP

Graph 4 presents the evolution of the overall reporting rate in Year 1:

‐ For malaria and FP, the reporting rates have increased from 24% in October 2018 to 62% in September 2019 with some rates between February 2019 and August 2019 exceeding the Year 1 target of 64%. From June 2019, the reporting rates decreased and submission of data was delayed due to the staff workload and lack of Internet connection. Also, some Pha‐G‐Dis did not respect the deadline (27th of each month for the month‐1 LMIS report) so data was received slowly in the CHANNEL central system. ‐ For MNCH, the reporting rate was under 45% because the Pha‐G‐Dis did not submit data when no products were distributed or registered in the stock monitoring, so no reports were submitted. This issue was dealt with during the visit and communicated to other Pha‐G‐Dis during the next formative supervision (especially in Quarter 4).

Graph 4. Overall progress on reporting rates in Year 1

Table 29. Year 1 Average Reporting Rate per Region (source DHIS2 for CSB)

Average Average REGION Reporting Rate Timeliness Rate Target: 33% Target: 28% AMORON’ I MANIA 92,5% 42,6% ANALANJIROFO 97,1% 58,0% ATSIMO ANDREFANA 94,8% 65,7% ATSINANANA 95,6% 65,7% BOENY 96,8% 64,0% DIANA 99,8% 61,2% HAUTE MATSIATRA 91,3% 52,7% MELAKY 92,3% 49,0% MENABE 97,2% 52,4% SAVA 98,7% 51,6% SOFIA 95,9% 80,1% VAKINANKARATRA 89,2% 55,8% VATOVAVY FITOVINANY 87,8% 47,7% Average 90.0% 70.0%

In Year 1, IMPACT set the target of 33% for the submission of LMIS data from Pha‐Ge‐Com to Pha‐G‐ Dis/DEPSI (central level). The result of on average reporting rate was 90% which is almost three times higher than the target. All USAID implementing partners (Measure Evaluation, ACCESS, IMPACT, Mahefa‐Miaraka, etc.) participated to strengthen supervision of DHIS2 with DEPSI. During the supervision, it was recommended to prioritize data entry in DHIS2 before GESIS, and the data entry responsible received refresher training on DHIS2 use to increase reporting rate. The PMP targets for the remaining years will be updated in order to follow the results obtained in Year 1.

For both CHANNEL (Pha‐G‐Dis) and DHIS2 (CSB/Pha‐Ge‐Com), the data entry happens at district level. There is a significant difference on reporting rate between Pha‐G‐Dis (CHANNEL) 62% versus CSB/Pha‐Ge‐Com (DHIS2) 90%. For CSB/Pha‐Ge‐Com, there was big supervision with participation of all partners as stated above. For CHANNEL, the following reasons could explain the low performance on reporting rate comparing to DHIS2:

‐ The reporting rate went down at 24% after the end of PSM (September 2018). IMPACT started from Quarter 2. ‐ The short‐term corrective action started from the end of Quarter 2: i) active data collection, ii) formative supervision: training on CHANNEL and LMIS tools such as stock card, purchase order etc. ‐ The five LRA starting LMIS support from Quarter 2.

The definitive LMIS solution at Pha‐G‐Dis will be known and will be implemented in Year 2.

Routine Data Quality Assessment (RDQA)

RDQA activities were conducted in Quarter 3 and Quarter 4 with participation of DPLMT, DEPSI, DFSa, NMCP, EMAR, and EMAD in 7 regions within 23 Pha‐G‐Dis, 29 Pha‐G‐Com, 10 PARCs and 17 PAs. The tool used for the RDQA exercise was adapted from the Measure Evaluation RDQA tool to fit the LMIS context in Madagascar. The objective of the RDQA was to check the performance system through the seven quality dimensions: availability, completeness, timeliness, integrity, confidentiality, precision, and accuracy (See Annex H for a detailed description of the 7 dimensions). For Pha‐G‐Dis, the overall data quality score was 82% (calculation method shown in the footnote of the tables 30 below). The challenges among Pha‐G‐Dis included: ‐ 79% Timeliness score: data is not available or not submitted on time as described in the Pha‐G‐Dis manual. ‐ 62% Accuracy score: data from stock monitoring sheets do not match with data in the CHANNEL system.

For Pha‐Ge‐Com, the overall data quality score was 77%. The challenges among Pha‐Ge‐Com included: ‐ 76% Availability score: data and its supporting documentation are not available. ‐ 66% Integrity score: the tool was not protected from unauthorized changes or manipulation especially for the stock monitoring sheet. ‐ 77% Accuracy score: data from the stock monitoring sheets do not match with data in the CHANNEL system.

For PARC and PA, the overall data quality score was 92% which means that data submitted are of good quality. The accuracy dimension (79%) has been challenged because data from the stock monitoring sheets don’t match those found in DHIS2.

Recommendations from the RDQA were communicated to the concerned structures (Pha‐G‐Dis, Pha‐Ge‐ Com, PARC, PA) at the end of each visit.

The LMIS committee led by DPLMT organizes a meeting every quarter or after formative supervision and RDQA exercises to discuss data quality issues. Following the RDQA in Quarter 4, the LMIS committee will meet in Quarter 1 of Year 2 to develop an action plan on the recommendations of the RDQA. The committee

59 will monitor the implementation of RDQA recommendations using a small questionnaire (based on the list of RDQA issues) to assess and follow‐up the implementation of the recommendations. During the quarterly meeting, the LMIS committee will analyze the barriers to the implementation of the recommendations.

Table 30. Summary of the RDQA findings for the public sector

PHA‐G‐Dis (N=21) Pha‐Ge‐Com (N=29) Storage level Quarter 3 Quarter 4 FY2019 Quarter3 Quarter4 FY2019 Atsimo Vakina Atsimo Vakinak VV7V Atsinanana Boeny Analanjirofo VV7V Atsinanana Boeny Analanjir Regions Andrefana karatra Total Andrefana aratra Total (n=3) (n=3) (n=3) (n=3) (n=6) (n=6) (n=3) ofo (n=3) (n=4) (n=5) (n=7) (n=4) Data Quality

Parameter Availability 100% 96% 83% 58% 100% 83% 87% 50% 86% 50% 83% 97% 88% 76%

Completeness 67% 95% 67% 100% 95% 85% 85% 100% 86% 50% 83% 86% 88% 82%

Timeliness 27% 100% 67% 89% 100% 92% 79% 100% 73% 67% 80% 83% 91% 82%

Integrity 100% 54% 100% 75% 92% 90% 85% 100% 83% 0% 67% 83% 63% 66%

Confidentiality 100% 89% 67% 100% 75% 95% 88% 100% 96% 50% 100% 89% 75% 85%

Precision 100% 98% 58% 100% 93% 100% 92% 100% 99% 50% 100% 86% 88% 87%

Accuracy 79% 80% 40% 32% 68% 75% 62% 87% 100% 50% 64% 87% 78% 77%

Summary Overall Data 82% 87% 69% 79% 88% 89% 82% 91% 89% 45% 82% 89% 75% 79% Verification Score1 System Assessment 92% 92% 68% 83% 69% 81% 81% 82% 90% 50% 67% 74% 80% 74% Score2 Overall Data 87% 90% 68% 81% 79% 85% 82% 87% 89% 48% 74% 84% 78% 77% Quality Score3

Table 31. Summary of the RDQA findings for social marketing PARC and PA

PARC (N=10) PA (N=17) Storage level Quarter3 Quarter4 FY2019 Quarter3 Quarter4 FY2019 Atsimo Atsimo Atsinanana Analanjirofo Vakinakaratra VV7V Atsinanana Analanjiro Vakinakaratra Region VV7V (n=2) Andrefana Total Andrefana Total (n=2) (n=3) (n=1) (n=4) (n=4) fo (n=3) (n=4) (n=2) (n=2) Data Quality

Parameter Availability 100% 100% 100% 100% 100% 100% 100% 77% 100% 100% 100% 95% Completeness 100% 100% 100% 100% 100% 100% 100% 82% 92% 100% 100% 95% Timeliness 100% 100% 75% 92% 100% 93% 100% 65% 56% 100% 100% 84% Integrity 100% 100% 63% 100% 100% 93% 100% 80% 50% 100% 100% 86% Confidentiality 100% 100% 100% 88% 100% 98% 100% 93% 100% 100% 100% 99% Precision 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Accuracy 97% 98% 67% 65% 71% 80% 91% 89% 68% 74% 74% 79% Summary Overall Data 100% 100% 86% 92% 96% 95% 92% 90% 81% 97% 96% 91% Verification Score1 System Assessment 91% 87% 87% 85% 100% 90% 87% 91% 89% 90% 99% 91% Score2 Overall Data Quality 95% 92% 87% 90% 98% 92% 92% 90% 85% 94% 97% 92% Score3 ‐ 1: Average score on the seven quality dimensions (availability, completeness, timeliness, integrity, confidentiality, precision, accuracy) ‐ 2: Qualitative assessment of the strengths and weaknesses of the functional areas of the data management and reporting system. A series of questions are used to calculate the average score based on the responses ‐ 3: Average score on “Overall Data Verification Score” and “System Assessment Score” Legend Score 90% and above 80% ‐ 89% Below 80%

LMIS Evaluation

‐ In Year 1, IMPACT conducted a LMIS evaluation in order to find appropriate solutions to improve LMIS performance. The LMIS evaluation protocol using qualitative and quantitative approaches and routine data analysis to evaluate the public, nonprofit, and commercial sectors was developed and approved by DPLMT, DEPSI, Measure Evaluation, USAID, and the HERA agency. The objective of the LMIS evaluation is to identify the strengths and weaknesses of the existing LMIS system performance with the aim of proposing long‐term and sustainable solutions to improve performance. The local agency ATW was recruited through an open bid to conduct the evaluation. ‐ The data analysis took more time than expected and the final report will not be available by the end of Year 1. The first draft of the report was received, and feedback was provided by the IMPACT internal team. A workshop will be organized by the end of November 2019 to create the short and long‐term LMIS roadmap.

Research

IMPACT conducted a study titled “Assess the capacity of Government of Madagascar's (GOM) to supervise private sector.” This study was done by the IMPACT research team.

Main results are: ‐ The MOPH accepted to provide oversight of the private sector if the pharmacies and drug shops apply and respect the drug regulations (outlets legally authorized, products with AMM) and the recommendations (stock condition, hygiene, etc.) provided by the MOPH. ‐ Lack of human resources and qualified personnel, material and financial issues at MOPH level, insecurity and the prevalence of illegal sales in the informal sector.

1. The following are activities completed through this study:

‐ The dissemination of the study was held on July 9, 2019 led by the General Secretary of the MOPH. ‐ A second meeting was organized on September 9th to develop a detailed action plan with pharmacies and drugs shops that the DAMM and DPLMT will ensure the follow‐up based on the research findings and IMPACT will provide technical and financial support. Specifically, in Year 2 with DPLMT leadership, IMPACT will support on the sensitization of drugs shops on the following aspects:  Session on regulation of drug shops  Creation of drug shops regional association in order to facilitate communication  Set up of LMIS system

2. IMPACT recruited two local agencies, ATW and CAPSULE, to implement four data collection to feed information and data needed for the market assessment design on malaria commodities. The following are the status of each research activity:

- Key informant interviews (implemented by CAPSULE) to identify key players in the fight against malaria and to collect the views of key stakeholders, such as government, donors, implementing partners, the private sector, and supply chain players to understand the in‐country malaria landscape with an emphasis on the priority products. The draft of the report was received, and feedback was provided to the agency in order to respond to the specific need of the market assessment design. The final report

will be submitted by CAPSULE during the first week of October 2019. Dissemination is scheduled in November along with the market assessment design. - Outlet survey (implemented by ATW): was designed to measure the availability of malaria priority products and to estimate the volume and value among all potential outlets. The data collection was completed. The dashboard was received and sent back to the agency for edits based on IMPACT’s recommendation on data analysis and cleaning. The agency is still working on data analysis that will be completed during the second week of October. Dissemination is scheduled in November. - Collecting routine data (implemented by ATW) is part of the market assessment that is focused on market volume, market value, market share, and analysis on forecasts versus procurement. The dashboard has been received and sent to PATH for the design of the market assessment. Results will be included in the dissemination scheduled in November. - A household survey (implemented by ATW): was mainly designed to measure the willingness to pay for the primary target group related to the following malaria products: LLIN, ACT, and RDT (including cost of consultation). Data collection was not completed in Quarter 4 Year 1 because of difficulties during the study implementation (resignation of interviewers causing multiple trainings to be required and insecurity issues that led to substitution of some enumeration areas). The first draft of the dashboard will be received in mid‐October. Dissemination is scheduled in November along with the market assessment design.

3. Knowledge Management

During Year 1, IMPACT developed a Knowledge Management Plan and created key dissemination tools in order to share project’s successes, results, and lessons learned to internal and external audiences.

‐ Intranet: One of the tools created is the Intranet platform to facilitate internal communication. The Intranet was developed under Office 365 and ensures that:  All IMPACT files are available, such as key documents (AMELP, EMMP, Branding and Marking, annual workplans), reports (USAID quarterly reports, study reports, etc.), national strategic documents on malaria/FP/MNCH, tools and templates produced and used to implement IMPACT activities.  IMPACT staff are informed on the latest events, news, and project success stories.  Dashboards on data reporting, stock out, and other indicators are available and updated on a monthly basis using PowerBi, which is a component of Office 365. IMPACT can exchange comments and discuss performance for continuous improvement using PowerBi’s forum.  All IMPACT central, field staff and headquarters staff from each consortium partner have access to the Intranet platform.

‐ IMPACT Website: In line with its knowledge management plan, IMPACT developed a Website to increase visibility and understanding of the project to external audiences. Mainly, the Website provides:  Information on the project’s objectives, progress, achievements, innovations, successes, and lessons learned at national and international level.  Information on social marketing products and best health practices.

Prior to the online official upload, IMPACT will share the Website link with USAID for approval. This is scheduled in Quarter 1 Year 2.

II.7. Cross‐Cutting Activities: Gender and Social Inclusion

Gender equality and social inclusion (GESI) is a cross‐cutting component led by Banyan Global in collaboration with the IMPACT program team. The IMPACT GESI team includes one national Gender Advisor and one International Gender Specialist who work together to ensure that gender equality and social inclusion interventions are integrated throughout the IMPACT program. IMPACT’s approach to gender equality and social inclusion is guided by the GESI analysis and action plan that was developed during Year 1 of the program. On an annual basis, IMPACT will revisit the GESI action plan, using internal and external consultation to set priorities and strategies based on the progress of the program.

Key accomplishments in FY19 include: ‐ Conducted a GESI analysis study and developed a GESI action plan for the IMPACT program in line with USAID’s ADS 205 – Integrating Gender Equality and Female Empowerment in USAID’s Program Cycle. The study aimed to identify key gender advances, constraints, and opportunities as well as issues related to social inclusion and women’s economic empowerment within the health commodities sector. A field‐ based study was conducted in Antananarivo, Antsiranana (Diana region), and Tuléar (Atsimo Andrefana region) through key informant interviews with stakeholders at all levels of the public, private, and commercial health commodity supply chains, as well as through focus group discussions with 18 men, 21 women, and 2 youth from urban and rural areas in Diego and Tulear. ‐ Developed and conducted a one‐day gender equality and social inclusion training for 22 IMPACT program staff (11 men and 11 women). The objective of the training was to provide a foundation for understanding GESI in the context of the health commodity supply chain, and to support staff to serve as gender champions. A pre‐training survey informed the design of the training, and results indicated that staff initially had limited knowledge or experience integrating gender into development programs. ‐ Hosted a dissemination workshop to share the key findings from the GESI analysis and to validate the GESI action plan with IMPACT program stakeholders from the public, private and commercial health sectors. Following the workshop, the full report, PowerPoint, and a briefer summarizing key findings and recommendations was put on a flash drive and distributed to all IMPACT partners. ‐ Developed a 10‐page briefer of the GESI analysis and action plan to increase dissemination and uptake of key findings and recommendations. ‐ Contributed to gender mainstreaming within IMPACT program activities in the following ways: o Reviewing and refining Business Health Survey Tools to ensure gender equality and social inclusion considerations) o Analyzing gender data on commercial sector stakeholders including ownership and management of drug shops (based on pilot training held in Analanjirofo Fenerive Est from May 21‐22) o Advocating for Malagasy language training curriculum considering the low literacy and education level of participants to ensure social inclusion o Disseminating key findings and advocating for GESI integration into commercial sector training design o Working with the IMPACT team to develop a gender‐integrated action plan by facilitating the IMPACT program staff retreat July 1‐5, 2019 and an external GESI workshop with implementing partners on July 18, 2019 o Participating as a member of the Gender and Youth Working Group (GYWG) for USAID implementing partners with cross‐cutting gender components (CRS, ADRA, Mahefa Miaraka, and ACCESS), as well as the Gender Madagascar Platform initiated by the Ministry of Population that leads all gender‐based initiatives in the country

o Participating in the workshop organized by the USAID‐funded ACCESS program May 8‐9, 2019 to introduce, promote and coordinate a Village Savings and Loan (VSLA) approach within the health sector o Collaborating with the General Director and the Gender Mainstreaming Director of the Ministry of Population to strengthen awareness on gender issues in the health commodities supply chain based on gender analysis findings and discuss about GESI action plan.

II.8. Success Stories

During Year 1, IMPACT developed seven Success Stories to illustrate its activities. Stories are summarized below:

1. Enhancing the role of the private and commercial health sectors through accessing to subsidized malaria commodities (Cf. Quarterly report 2) 2. Madagascar Measles Outbreak: Rapid delivery of vaccines has helped control the epidemic (Cf. Quarterly report 2) 3. Using Innovative Approaches to Provide Business and Financial Training to Drug Shops (Cf. Quarterly report 3) 4. How IMPACT and AQUALMA work together to deliver health products on time in the rural Besalampy District (Cf. Quarterly report 3) 5. Redeployment of Malaria Commodities in Sofia Districts helping to save 4 Districts from Stock‐Out (Cf. Quarterly report 3) 6. Quantification exercise: how IMPACT supported the Ministry of Health in conducting the activity and how it impacts on commodity availability (See Annex D) 7. Vavatenina District: leadership of management team helps Improve Health Commodity Management at District Pharmacy (See Annex D)

III. Environmental Mitigation and Monitoring Report

To respond to the EMMP, supervision checklists were created and tested. Each outlet type (SALAMA, Pha‐G‐ Dis, CSB/Pha‐Ge‐Com, PSI warehouse, PARC, PA) has a specific supervision checklist:

III.1. General findings for public sector

‐ 52% of CSB/Pha‐Ge‐Com visited have infrastructure for handwashing, soap, and equipment for cleaning and disinfection of area if accidental spillage occurs. 70% of them had medical equipment for infection prevention (safety box, sharp container, gloves, garbage for disposal). ‐ Storage: o 42% of Pha‐Ge‐Com visited respected all 5 criteria of proper storage. 70% of them stored the expired and damaged commodities in a separate area. o 59% of Pha‐G‐Dis visited respected more than 4 storage conditions among the 7 criteria required. o Only 9% of Pha‐G‐Dis and 6% of Pha‐Ge‐Com visited had controlled room temperature. ‐ Training: o 42% of Pha‐Ge‐Com supervised were trained in proper storage, use, and disposal of commodities. o 100 % SALAMA staff, 73% of Pha‐G‐Dis providers, and 36% of Pha‐Ge‐Com providers supervised were trained on management of expired and surplus commodities. o 100% SALAMA staff, 73% of Pha‐G‐Dis and 45% of Pha‐Ge‐Com providers supervised in Year 1 were trained in distribution of commodities. ‐ 29% of Pha‐G‐Dis and only 12% of Pha‐Ge‐Com assessed have SBCC materials for storage conditions.

Challenges identified included: ‐ Number of staff trained in commodities management and distribution is higher for Pha‐G‐Dis than for CSB. ‐ Regarding storage in CSB, the distance between walls and commodities on shelves was the major issue affecting proper storage. ‐ Regarding risk management, the majority of Pha‐G‐Dis and Pha‐Ge‐Com store their commodities in dry and ventilated, high areas and in a robust building, protected from humidity and direct sunlight. But just a few of them use thermometer to control room temperature. ‐ Communication tools are missing in most Pha‐Ge‐Com and Pha‐G‐Dis.

Recommendations: ‐ Plan regular follow‐up visits to CSB and Pha‐Ge‐Com that did not respect the five quality requirements on proper storage. IMPACT will collaborate with ACCESS district staff for permanent follow up. ‐ Support Pha‐G‐Dis and CSB providers to draft request letters for rehabilitation to DPLMT and Direction des Services de Santé de Base (DSSB) for Pha‐G‐Dis and CSB with infrastructure failures (warehouse, handwashing infrastructure). ‐ Plan training sessions from central level to health facilities with UCP before implementing last mile distribution strategies. Training will include management of health commodities including expired and overstocked drugs and storage. ‐ Continue to support the EMAD to set‐up District GAS committee in 78 districts and support them to conduct monthly stock analysis and to prepare quarterly orders with real need quantities. Continue providing on‐the‐job training and refresher trainings on distribution management in Year 2.

Design and produce job aids and communication tools for commodities storage to be distributed to Pha‐G‐Dis and Pha‐Ge‐Com providers from Quarter 1 in Year 2.

III.2. General findings for social marketing

Sixty‐six PARCs (100%), 859 PA (100%), and 13/15 warehouses were supervised. PA and PARC were supervised on a quarterly basis and the PSI warehouses was supervised semi‐annually‐.

Following are good practices observed: ‐ 85% of warehouses (11 out of 13) met the required criteria in terms of health commodities and LLINs storage ‐ All PAs and PARCs received regular training and supervision on distribution management and expiry products management. During the SPD supervision visit at PARC and PA, they redeployed the products with expiry date less than 6 months to other PARC and PA or CSB. To ensure consumption before the expiry date, the PA and PARC keep their average consumption for 3 months.

However, some challenges are identified: ‐ A number of expired products were stored at PSI’s central warehouse in Antananarivo, and with PAs and PARCs. This number is particularly high for PSI central warehouse in Antananarivo (118,275 units). ‐ Less than 50% of warehouses met the quality transport criteria and storage (dry and ventilated place to avoid humidity and high temperature/heat, high area to avoid flood, robust warehouse to prevent cyclone or landslide, deterioration, temperature controlled) related to climate risk management (flood, cyclone, landslide, humidity, and increased temperatures).

Recommendations:

‐ Send the expired products to CSB that will manage the destruction as per the national guideline. ‐ Maintain the high storage quality by performing regular supervisions (at least once per year). ‐ Include two non‐visited warehouses during Year 2 supervisions. ‐ Include in the training curriculum the management of expired products and commodities storage to all warehouse agents (regional assistant, stock keeper) and distribution teams through formative supervision and technical workshops. ‐ Train all new warehouse agents in terms of expired products management, transportation, and storage. ‐ Perform a risk analysis regarding the climate risk management unmet quality criteria.

IV. KEY CHALLENGES AND SOLUTIONS

N° Key Challenges Solutions 1 Absence of a sustainable structure or mechanism to Create a training structure with local associations deliver training to health commodities supply chain and set up certified peer trainers’ program. actors, especially drug shops 2 Mobilization of the private sector to attend Limit meetings and workshops to half day maximum meetings or workshops is difficult due to time in order to ensure that private actors will attend. constraints of the actors. 3 Data collection and submission among private IMPACT should develop a win‐win approach to commercial actors (pharmaceutical wholesalers, convince commercial actors. pharmacies, and drug shops). Those outlets request IMPACT will act through TMA TWG to recommend immediate benefits by submitting their LMIS data. commercial sectors to submit their LMIS data on time.

V. FINANCIAL SUMMARY

Table 32. Reporting period: October 2018 to September 2019

Estimated remaining Actual Expenditures Description Y1 Budget Obligated Amount Funds as of Through Y1 Sept 2019 Malaria 2,340,671.35 3,134,500.00 1,535,933.73 1,598,566.27 MCH 2,428,007.95 2,872,795.00 1,717,814.65 1,154,980.35 FP/RH 2,369,438.96 3,079,520.00 1,651,319.58 1,428,200.42 TOTAL 7,138,118.26 9,086,815.00 4,905,067.96 4,181,747.04

ANNEXES

ANNEX A ‐ Performance Monitoring Plan (PMP)

Note: ‐ PMI Quarterly report is attached in an Excel File sent with this Annual Performance Report ‐ HPN Quarterly report is available on DHIS2 website https://data.mis‐psimada.org/

USAID IRs and Reporting Measure Achievement Target Year Indicator Baseline Achievement (%)/Explanations Sub‐Irs to of Unit Year 1 1 Intermediate Outcomes/Outputs Short‐term Outcomes PMP SO1 Disability‐adjusted life years (DALY) averted IMPACT Total public sector 22 045 253 358 1 051 865 24% 69% ‐ Emergency distribution. DSFa request was lower than the products received from FP 0 108 521 157 741 USAID. All the DSFa request was delivered in Year 1. Public sector 16% ‐ 2019 distribution was very low. ACTs MALARIA 22 045 144 837 894 124 were delivered in March and May 2019 and distributed in Quarter 3 and 4 DALY coefficients are not available for the MCH N/A N/A N/A MNCH products Total private for nonprofit sector 598 737 219 491 220 429 99,6% Number FP 251 683 175 004 196 516 89% ‐ and 100 414, emergency distribution Private for nonprofit sector This is only for LLIN product with no MALARIA 275 601 0 0 distribution foreseen in Year 1 MCH 71 453 44 487 23 913 186% Total commercial sector 69 288 N/A N/A

‐ No LMIS data available yet for commercial FP N/A N/A N/A sector. Commercial sector ‐ The LMIS data collection system will be implemented through TMA TWG process MALARIA 69 288 0 N/A planned from Quarter 1 Year 2. MCH N/A N/A N/A SO2 PPR Couple Year Protection (CYP) in USG supported 560 247 629 698 787 512 80% (IR 2.9) USAID programs 69% ‐ Emergency distribution. DSFa request Number was lower than the products received from Public sector N/A 241 306 351 003 USAID. All the DSFa request was delivered in Year 1. Private for nonprofit sector 560 247 388 392 436 508 89,0%

‐ No LMIS data available yet for commercial sector. Commercial sector N/A N/A N/A ‐ The LMIS data collection system will be implemented through TMA TWG process planned from Quarter 1 Year 2. IR1: Enhanced coordination among public, non‐profit, and commercial sectors for supply and distribution of health products IR1.1. The total market for health products in Madagascar is understood and documented Number of companies with CSR (Corporate PMP Social Responsibility) action plans developed IR1.1.1 1 2 2 100% IMPACT and implemented to increase the provision of WASH or health services Number Developed 1 2 2 Action Plan 100% Implemented 1 2 2 250% reached: 12 entities trained including 10 having signed the letter of participation to implement the TMA. The actual number Number of companies / commercial actors and has increased compared to the planned PMP private sectors associations trained and IR1.1.2 Number 0 10 4 number because of the participation of the IMPACT implementing the TMA (Total Market PHSP members and the invitation of many Approach) companies and private sector associations which exceeded the expectation of attendance The data collection (household survey on willingness to pay and outlet survey) to feed PMP Number of market assessments conducted by the malaria market assessment deign was IR1.1.3 Number 1 0 1 IMPACT health areas delayed then this document was not completed in Year 1. The market assessment design will be presented in Quarter 1 Year 2.

‐ Malaria market assessment will use four sources : key informant interview, outlet survey, household survey, and routine data ‐ There was a delay in the implementation of Malaria 1 0 1 the household survey with data collection will be completed in the first week of October ‐ Market assessment design will be presented in Quarter 1 of Year 2. FP 0 N/A N/A MCH 0 N/A N/A We have initiated the creation of the malaria PMP Number of TMI workshops with public, IR1.1.4 Number 0 0 1 subcommittee and it will be effective from IMPACT nonprofit, and commercial stakeholders Quarter 1 of Year 2 128% reached: Active participation of PMP Percentage of female participants in GOM‐led women in the TMA TWG. We have exceeded IR1.1.5 Percent 0 51 40 IMPACT TMI TWG our gender parity objective of 50% of women in the TMA TWG. 125% reached: we have 12 individuals in leadership positions from the public sector PMP Percentage of GOM‐led TMI TWG leadership IR1.1.6 Percent 0 50 40 including 6 women. We have reached our IMPACT positions held by women gender parity objective of 50% of women in leadership position 290% reached: we have a total of 98 unique participants for TMA TWG meetings, a PMP Number of people trained in TMA 101 during refresher on TMA 101 is done at the IR1.1.7 Number 0 116 40 IMPACT workshops (not unique trainees) beginning of each meeting, and 18 additional people trained in a workshop involving public hospital Directors. 75% reached: Three champions were trained. A Champion for Malaria has PMP Number of TMI Champions/people, trained in IR1.1.8 Number 0 3 4 emerged and has been involved in the last IMPACT TMA & stewardship skills (not unique trainees). TMA TWG meeting but her training will be done in Quarter 1 of Year 2.

300% reached: TMA has caught the attention of the different actors and they GOM‐led TMI TWG (Technical Working Group) have agreed that there are some important PMP meets at least four times a year as a forum for IR1.1.9 Number 0 3 1 issues to be addressed in the health sector IMPACT consultations and roundtables between public, in Madagascar. They have been interested non‐profit, and commercial stakeholders and eager to work together to find solutions (3 meetings during Quarter 4) IR1.2. GOM leads TMI stakeholders to coordinate health product quantification and forecasting, procurement, and distribution according to market assessments and segmentation Percentage of difference between forecasts IR1.2.1 PMP previously made for a year and the actual N/A N/A N/A (IR 2.3.2) USAID consumption (national level) Implantable The results are based on UNFPA FP products 0,44 76 10,00 Contraceptives distributed through SALAMA for public Injectable Hormonal sector. Contraceptives (Depo 4 38 10,00 provera) For Depo‐Provera, there was a period of Injectable Hormonal stock out that led to low consumption which Contraceptives N/A N/A 10,00 was increased after the emergency (Sayanna Press) distribution of Triclofem. Intra Uterine Devices 38 69 18,67 Oral Hormonal Sayanna Press was not in the RMA then the FP Contraceptive. 64 30 36,00 data is not yet available for Year 1. This product is already in the new RMA then will Microgynon Percent be available for Year 2 Public sector ‐ Only 1,400 out of 2,600 CSB were trained to perform Implant contraceptive method that Oral Hormonal 60 34 33,33 led to low consumption. Same trend for IUD Contraceptive. Microlut with only 400 out of 2,600 CSB were trained to perform this method that reduced its consumption.

ACT New born 7 49 10,00 In year 1, consumption of malaria commodities is different compared to ACT Infant 112 25 50,00 Malaria forecasts due to assumptions used during ACT Adolescents 50 41 50,00 quantification exercise. The country planned ACT Adult 42 36 50,00 for a reduction of malaria cases following

Rapid Diagnostic Test the LLIN mass campaign in 2018. To improve 82 18 50,00 (RDT) accuracy of the quantification, Sulfadoxine‐ The GAS malaria Committee improved the 230 1 50,00 pyrimethamine (SP) process of quantification by collecting consumption data and calculating quantities of commodities necessary for all planned and new strategies to be implemented by NMCP and RBM members that may impact consumption of malaria priority products (ACT, RDT, SP, Injectable Artesunate) such as 1) active detection of malaria in case of upsurge of malaria cases 2) Home case management coupled with recruitment and training of CHVs 4) Refresher training of health care providers 5) Pre and elimination zone, and 6) Case management of key Injectable Artesunate 62 N/A 50,00 populations, etc.

Specifically, the consumption of RDT has been increased as any case of fever should be tested with RDTs according to the national protocol and from October to April, hot and rainy season where there is an upsurge of malaria cases as the NMCP has introduced active detection approach. Injectable Artesunate was not in the RMA then the data is not yet available for Year 1. This product is already in the new RMA then will be available for Year 2. Oxytocin (10 IU 8,9 N/A N/A Injection) Magnesium Sulfate N/A for year 1: No distribution plan in Year MCH 6 N/A N/A (500mg Inj) 1. Gentamicin (20mg inj) 7,5 N/A N/A Gentamicin (80mg inj) 0,6 N/A N/A OC Community 4,00 N/A 10,00 ‐ The analysis on forecast versus consumption is a new indicator for the social Private for nonprofit sector FP Injectable (Depo‐ Percent Provera/TRICLOFEM) 10,00 N/A 10,00 marketing sector. Community ‐ The variable on sales from PA to CHV (a

FP Condom Protector proxy of use/consumption) was included in 46,00 N/A 24,00 Plus (Community) the system from June 2019. ‐ Analysis cannot be done for the entire year FP Youth Condom Yes 53,00 N/A 28,67 then we prefer to not calculate this indicator (Commercial) for Year 1. Sayana Press 16,00 N/A 10,00 ORS/Zinc DTK 34,00 N/A 16,00 (Community) Sur Eau 150 ml 22,00 N/A 10,00 Commercial Sur Eau Pilina (67mg 67,00 N/A 38,00 tablet) (Community) MCH Arofoitra (CHX 7,1%) 73,00 N/A 42,00 (Community) Pneumox (amoxycilline) 18,00 N/A 10,00 (Community) Pregnancy Test N/A N/A N/A (Community) ACT N/A N/A N/A Malaria SP N/A N/A N/A RDT N/A N/A N/A Oral contraceptive N/A N/A N/A ‐ No LMIS data available yet for commercial Injectable FP N/A N/A N/A sector. contraceptive Commercial sector Percent ‐ The LMIS data collection system will be Condom N/A N/A N/A implemented through TMA TWG process Oxytocin (5 IU Injection) N/A N/A N/A planned from Quarter 1 Year 2. Magnesium Sulfate N/A N/A N/A MCH (500mg Inj) Gentamincin (20mg inj) N/A N/A N/A Gentamicin (80mg inj) N/A N/A N/A IR2: Strengthened capacity of the GOM to sustainably provide quality health products to the Malagasy people IR2.1. Health commodities and pharmaceuticals are continuously accessible and available in the public sector IR2.1.1 PMP Average stockout rate at service delivery points (IR2.4.1 Percent N/A N/A N/A USAID (SDP) of tracer essential drugs (MCH, malaria) IR3.1.3)

‐ In January 2019, the country encountered a ACT New born 11,50 17 10 shortage of all formulations of ACTs at the central level. ACT arrived on March and May and then distributed to Pha‐G‐Dis in Quarter ACT Infant 11,50 10 10 3 and Quarter 4. ‐ At district level, commodities were available and SDSP teams with RLA support ACT Adolescents 11,50 13 10 organized redeployment of malaria commodities to deal with this shortage and correct stock imbalances at peripheral level. ACT Adult 15,40 17 10 ‐ Since the indicator is calculated using the average of stock out rate over the last 12 Rapid Diagnostic Test months then the period with stock out 4,20 8 10 (RDT) reduced the chance of reaching the target of 10%. Sulfadoxine‐ ‐ In Quarter 2, 3 and 4, IMPACT organized 12,00 18 10 pyrimethamine (SP) trainings/refresher trainings of Pha‐G‐Dis and EMAD teams to strengthen their Malaria capacity to better estimate and calculate PhaGDi Public sector Percent their needs for resupply. Districts began to s establish GAS Committee that will contribute to effective and continuous availability of the products. ‐ In Year 1, SP was not distributed as anticipated due to lack of clear guidance on elimination and pre elimination strategy. This situation is clarified by the NMCP in Injectable Artesunate 35,00 30 18 September with an official note sent to districts. ‐ For artesunate injectable, the product was delivered at the end of Quarter 1 and distributed to Pha‐G‐Dis during Quarter 2. This impacted the achievements since the indicator is calculated using the average stock out rate over the last 12 months then the period with stock out reduced the chance of reaching the target of 18%. Oxytocin (10 IU ‐ These commodities are also available in the MCH 47,00 25 42 Injection) FANOME program

Magnesium Sulfate ‐ The products purchased by USAID are 100,00 35 90 (500mg Inj) already available at PHA‐G‐DIS level. Gentamicin (20mg inj) 100,00 36 90 Gentamicin (80mg inj) 88,00 36 79 ACT New born 6,00 19 27 ‐ With the RLA support, District GAS ACT Infant 4,50 13 27 Committee were established. ‐ Stock status was analyzed and decisions ACT Adolescents 6,00 15 27 made to organize redistribution to ensure ACT Adult 7,20 17 27 availability of the products. Rapid Diagnostic Test 6,60 12 27 (RDT) In Year 1, the SP was delivered in country and available end of Quarter 1. The SP was distributed to Pha‐G‐Dis in Quarter 2 and Pha‐G‐Dis to CSB in Quarter 3. This impacted the achievements rate since the indicator is calculated using the average of stock out rate over the last 12 months and the period with stock out reduced the chance of Malaria Sulfadoxine‐ 16,60 39 27 reaching the target of 27%. pyrimethamine (SP)

The IPTp strategy was not clear to all Pha‐Ge‐ districts as some districts were considered in Com elimination and pre‐elimination zones. The NMCP is doing sensitization and disseminating notes to clearly indicate districts on the use of SP. ‐ The Injectable Artesunate does not appear in DHIS2 ‐ There is stock out data in CHANNEL which Injectable Artesunate 84,50 N/A 27 is not complete ‐ This commodity is already in the updated RMA. Oxytocin (10 IU In Year 1, the MNCH commodities purchased 52,10 75 52 Injection) by USAID were delivered in Quarter 1 and Magnesium Sulfate not distributed due to the delay of the 66,60 76 67 MCH (500mg Inj) registration process that was completed in Gentamincin (20mg inj) 77,60 47 78 Quarter 2. Then the commodities were sent to Pha‐G‐Dis in July and August, and Gentamicin (80mg inj) 81,00 72 81 distributed to CSB in September. The

consumption data will only be available in Year 2. Targets are set up for an entire year then the calculation is based on the average of 12 months. Achievements were very low due to availability of commodities at district level only in Quarter 2 and distribution to CSB in Quarter 4. ORS/Zinc DTK ORS arrived in mid‐August and Zinc in mid‐ 0,00 62 5 (Community) September. Sur Eau Pilina (67mg 0,00 3 5 tablet) (Community) Arofoitra (CHX 7,1%) Product received in July and distributed in 7,00 77 5 PARC MCH (Community) Quarter 4 Pneumox (amoxycilline) Product arrived in mid‐June and distributed 3,00 62 5 (Community) in Quarter 4 Stock out rate is calculated based on the Pregnancy Test 100,00 5 5 pilot distribution in SOFIA agreed with (Community) Mahefa Miaraka Private for nonprofit sector Percent ORS/Zinc DTK ORS arrived in mid‐August and Zinc in mid‐ 3,00 43 5 (Community) September. Sur Eau Pilina (67mg 0,00 1 5 tablet) (Community) Arofoitra (CHX 7,1%) Product received in July and distributed in 93,00 80 5 PA MCH (Community) Quarter 4 Pneumox (amoxycilline) Product arrived in mid‐June and distributed 32,00 61 5 (Community) in Quarter 4 Stock out rate is calculated based on the Pregnancy Test 100,00 10 5 pilot distribution in SOFIA agreed with (Community) Mahefa Miaraka. Average stockout rate of contraceptive IR2.1.2(HL7.1.3 PPRUSAID commodities at Service Delivery Points by Percent N/A N/A N/A ) family planning methods Implantable Hormonal ‐ USAID did not supply the public sector then 14 32 14,0 Contraceptives the stock out rates presented for family Public sector PhaGDis Injectable Hormonal Percent planning are not for USAID products but Contraceptives (Depo 48 29 48 based on UNFPA distribution. provera)

Injectable Hormonal ‐ Stock out rate of Implantable hormonal is Contraceptives 43 28 43 two times higher than the defined target at (Sayanna Press) Pha‐G‐Dis level as to‐date, few CSB were Intrauterine Devices 38 35 38 trained (only 400 out of 2600 on Oral Hormonal intrauterine devices and 1400 out of 2600 Contraceptive. 19 26 19 on Implant method) , so, no concerned Microgynon methods were ordered at Pha‐Ge‐Dis and implicitly Pha‐Ge‐dis don’t also order at Oral Hormonal 38 37 38 SALAMA level Contraceptive. Microlut ‐ During Year 1, the public sector Implantable Hormonal encountered stockout of Microgynon as the 29 5 29 Contraceptives emergency distribution of Combination 3 Injectable Hormonal (Microgynon) started from Quarter 2, Contraceptives (Depo 15 3 15 explaning high stock out rate of oral provera) contraceptives at Pha‐G‐Dis level. Injectable Hormonal Contraceptives N/A N/A 50 ‐ Stock out rate at Pha‐Ge‐Com is better (Sayanna Press) than the targets which are underestimated. Intrauterine Devices 52 5 52 The method to calculate the denominator is revised as follow: either 1) the CSB has had Oral Hormonal the method in stock at any time in the past Contraceptive. 18 5 18 12 consecutive months (prior to the month Microgynon when the indicator is reported), OR, 2) the PhaGeCo CSB has issued the method to clients at any m time in the past 12 months, OR 3) the CSB has ordered the method at any time in the past 12 months. ‐ The PMP will be revised based on the Year 1 results.

Oral Hormonal 33 14 33 ‐IMPACT follows the stockout indicator to Contraceptive. Microlut improve the supply chain management since IMPACT is supposed to capacitate the public sector.

For Pha‐Ge‐Com: ‐ The Sayanna Press does not appear in DHIS2 ‐ The stock out calculation is from CHANNEL.

‐ This commodity is already in the updated RMA. Oral Contraceptive 0 2 5 (Community) Injectable (Community) 0 2 5 PARC FP Condom Protector 0 2 5 Plus (Community) Sayana Press 0 3 5 Stockout rate for all FP products is under the Private for nonprofit sector Percent benchmark of 5% which is a good result to Oral Contraceptive 1 2 5 be maintained. (Community) Injectable (Community) 1 1 5 PA FP Condom Protector 7 1 5 Plus (Community) Sayana Press 2 3 5 Percent of targeted PhaGDis in the 13 supported regions with at least 5 points improvement in PMP N/A for year 1: No distribution plan in Year 1 IR2.1.3 composite SPARS scores over baseline or Percent 0,0 0 0 IMPACT (see narrative section on IR2.1). previous year (or reach 90% of the composite score). IR2.1.5 Number of artemisinin‐based combination PPR (IR 2.4.2 or HL therapy (ACT) treatments purchased with 106 000 1 092 050 700 000 156% USAID 3.1‐1) United States Government (USG) funds

ACT New born 0 0 No procurement plan in the MOP since this formulation is procured by the Global Fund

ACT Infant 106 000 0 0 No procurement plan in the MOP since this formulation is procured by the Global Fund Number 149%. PMI started procurement of additional ACT to anticipate the closure of By weight ACT Adolescents 0 475 925 320 000 PSM in country and using the FY18 reprogramming funds. The ACT arrived in country in 2019 162% PMI started procurement of additional ACT to anticipate the closure of PSM in ACT Adult 616 125 380 000 country and using the FY18 reprogramming funds The ACT arrived in country in 2019

IR2.1.6 Number of malaria rapid diagnostic tests (RDTs) PPR (IR 2.4.3 or HL purchased with United States Government Number 1 000 000 1 000 000 1 000 000 100%. USAID 3.1‐2) (USG) funds

. The 1,700,000 doses of SP were delivered in country but purchased in FY 18. PMP need IR2.1.7 PMP Number of sulfadoxine‐pyrimethamine (SP) 1 700 Number 0 900 000 to be corrected to 900,000 tablets (300,000 (IR 2.4.4) USAID tablets purchased with USG funds 000 doses) in FY 18 reprogramming. Achievement is 100%

IR2.1.8 Number of insecticides treated nets (ITNs) PPR (IR 2.4.5 or HL purchased with United States Government Number 4 650 000 1 000 000 1 000 000 100% USAID 3.2‐1) (USG) funds Mass campaign Number 4 650 000 0 0 No distribution planned in Year 1 Distribution Type 100% ‐ The purchase in Year 1, delivery in Continuous distribution Number 0 1 000 000 1 000 000 November and December Quarter 1 Year 2. Number of artemisinin‐based combination IR2.1.9 PMP therapy (ACT) treatments purchased by other Number 0 0 0 (IR 2.4.6) USAID partners that were distributed with USG funds 68% ‐ ACTs were delivered in March and Number of ACT treatments purchased in any IR2.1.10 PMP May 2019 and distributed in Quarter 3 and 4 fiscal year with USG funds that were distributed Number 78 150 513 440 752 368 (IR 2.4.7) USAID that impacted the achievements as targets in this reported fiscal year are set for an entire year.

8% ‐ RDTs ordered were delivered in Number of RDTs purchased in any fiscal year IR2.1.11 PMP September 2019 that impacted the with USG funds that were distributed in this Number 945 675 249 075 2 990 915 (IR 2.4.8) USAID achievements as targets are set for an entire reported fiscal year year. IR2.1.12 PMP Number of ITNs purchased by other partners N/A N/A N/A (IR 2.4.9) USAID that were distributed with USG funds Number No distribution planned in Year 1 Donors Global Fund (GF) 271 149 0 0 No distribution planned in Year 1 Number of ITNs purchased in any fiscal year IR2.1.13 PMP with USG funds that were distributed in this 6 745 000 0 (IR 2.4.10) USAID reported fiscal year Number Campaigns 6 745 000 0 0 No distribution planned in Year 1 Through distribution type Continuous distribution 0 0 0 No distribution planned in Year 1

55% ‐ there is less quantity of SP distributed in Year 1 due to unclear guidance on Number of SP tablets purchased in any fiscal elimination and pre‐elimination strategy. IR2.1.14 PMP year with USG funds that were distributed in Number 0 753 700 1 369 711 The NMCP disseminated a note to (IR 2.4.11) USAID this reported fiscal year emphasize on the use of SP. IMPACT is also supporting SBCC messages to sensitize women to take SP in ANC services. Percentage of USG supported districts that IR2.1.15 PMP This is the average completeness rate submit timely and complete reports through Percent N/A N/A N/A (IR 3.1.3) USAID obtained across the 12 reporting periods LMIS 95% ‐ Formative supervision combined with Reports submitted 34,0 61 64 active data collection provided good results on LMIS reporting rates 193 % ‐ Formative supervision combined Reports submitted on time 20,0 58 30 with active data collection provided good results on LMIS reporting rates 86%‐ Some data elements are not completed by the data entry example Pha‐G‐Dis To DPLMT Reports that are complete 26,0 31 35 stockout, or value "zero" instead of empty. Formative supervision and RDQA are conducted to improve data quality on LMIS 60%‐ Some data elements are not completed by the data entry example Reports that are complete and 18,0 18 30 stockout, or value "zero" instead of empty. submitted on time Public sector Percent Formative supervision and RDQA are conducted to improve data quality on LMIS 272% ‐ All USAID implementing partners participated to strengthen supervision of DHIS2. During the supervision, it was Reports submitted 23,0 90 33 recommended to prioritize data entry in DHIS2 before GESIS, and the data entry responsible received refresher training on Pha‐Ge‐Com to DHIS2 use to increase reporting rate. PhaGDis 251% ‐ All USAID implementing partners participated to strengthen supervision of Reports submitted on time 18,0 70 28 DHIS2 to increase reporting rate and on time. 316% ‐ All USAID implementing partners Reports that are complete 21,0 88 31 participated to strengthen supervision of

DHIS2 to increase completeness of the report submitted 276% ‐ All USAID implementing partners Reports that are complete and participated to strengthen supervision of 15,0 69 25 submitted on time DHIS2 to increase completeness and promptness. Reports submitted 94 98 100 98% Data from PARC Reports submitted on time 94 98 100 98% submitted to central server (DHIS2) by the Reports that are complete 94 98 100 98% Reports that are complete and Private for SPD 94 98 100 98% submitted on time nonprofit Percent Reports submitted 98 98 100 98% sector Data from PA Reports submitted on time 98 98 100 98% submitted to central server (DHIS2) by the Reports that are complete 98 98 100 98% Reports that are complete and SPD 98 98 100 98% submitted on time PMP Number/Percentage of required supply plans IR2.1.16 N/A 3 6 66% IMPACT submitted to GHSC‐PSM during the quarter. Malaria NA 2 2 100% FP/RH NA 1 2 50% 0%‐ In year 1, quantification was completed Number in June and validated in July by the Comité de Gestion logistique. The supply plan was not done as there is no clear mechanism of MCH NA 0 2 procurement in place. IMPACT supported DSFa to establish a GAS committee in September 2019 to organize future supply planning sessions. IR2.2. The public‐sector supply chain achieves financial sustainability PMP Percent of product that is unusable due to IR2.2.1 Percent 0 IMPACT expiry or damage Expiry SALAMA Percent 0,00 0 1,00 Damaged The country managed well the stock available in country and avoided unusable Expiry PhaGDis Percent 5,00 3,2 5,00 stock. Damaged

Expiry PhaGeCom Percent 4,00 2,7 5,00 Damaged IR2.2.3 PMP Percent of medicines from vertical programs 64 100 64 (IR 3.3.3) USAID integrated into SALAMA distribution system ACT 100 100 100 Rapid Diagnostic Tests Malaria commodities are 100% integrated in 100 100 100 (RDT) SALAMA distribution system and managed in MALARIA Sulfadoxine‐ a common basket with the Global Fund 100 100 100 pyrimethamine (SP) procured commodities. Injectable Artesunate 100 100 100 Implantable Hormonal 0 0 0 Contraceptives Injectable 0 0 0 FP\RH Contraceptive IUD 0 0 0 Oral Contraceptive Percent 0 0 0 SALAMA Oxytocin (10 IU 100 100 100 Injection) Magnesium Sulfate 100 100 100 (500mg Inj) MCH commodities are 100% integrated in Gentamincin inj 100 100 100 SALAMA distribution system ORS/Zinc DTK 0 0 0 MCH (Community) Arofoitra (CHX 7,1%) 0 0 0 (Community) Conversion startup of PA to Pha‐Ge‐Com and Pneumox (amoxycilline) PARC to Pha‐G‐Dis will start in Year 2 0 0 0 (Community) Pregnancy Test 0 0 0 (Community) Percent of total product procurement PMP conducted through integrated public‐sector IR2.2.4 0 0 0 IMPACT supply chain system (including USAID‐funded commodities) Percent ACT New born 0 0 0 PUBLIC MALARIA ACT Infant 0 0 0

ACT Adolescents 0 0 0 ACT Adult 0 0 0 Rapid Diagnostic Tests 0 0 0 (RDT) Sulfadoxine‐ 0 0 0 pyrimethamine (SP) Injectable Artesunate 0 0 0 Other male condoms 0 0 0 Yes condom 0 0 0 Oral contraceptive 0 0 0 Procurement of MCH commodities will be Injectable Hormonal fully integrated through public sector supply FP\RH 0 0 0 Contraceptives chain sector in Year 2 Implantable Hormonal 0 0 0 Contraceptives Intrauterine Devices 0 0 0 Oxytocin (10 IU 0 0 0 Injection) Magnesium Sulfate 0 0 0 MCH (500mg Inj) Gentamincin (20mg inj) 0 0 0 Gentamicin (80mg inj) 0 0 0 Number of individuals trained in logistics, IR2.2.5 PMP supply chain, forecasting, registration, N/A N/A N/A (IR 3.3.4) USAID regulatory activities, and budgeting Logistic 830 399 460 87% ‐ This result is justified by the increase of the number of people to train compared to the forecast due to the turnover of the staff specifically in Analanjirofo region. In Number addition, the training curriculum need to be revised to include the calculation of malaria Supply Chain 830 399 460 commodities requisition both at the CSB and CHVs level. The training curriculum will be validated early in Year 2, and then trainings of CSB will be followed.

In total:

 Zero People trained at central level in logistics and supply chain as central level was trained through the previous project PSM  309 people trained at district level (144 Men, 165 Women)  90 People trained at CSB level (45 Men, 45 Women) 117% ‐ Newly recruited pharmacists at Quatification and Forecasting 25 35 30 hospitals were trained in quantification, in addition to central GAS committee members Registration 0 N/A 0 Regulatory 0 N/A 0 Budgeting 0 N/A 0 IR2.2.6 PPR Number of universal Health Coverage (UHC) Number 1 1 1 100% (HL 1) USAID areas supported by USG investment IR3: Expanded engagement of the commercial health sector to serve new health product markets, according to health needs and consumer demand IR3.1. Commercial actors are incentivized to expand into new health product markets Number of new private sector companies PMP participating in public health coordinating IR3.1.1 0 5 5 100% IMPACT bodies, such as Private Sector Humanitarian Platform (PSHP) NGO Number 0 1 1 100% Bank, Insurance, other sector 0 2 2 100% Type of sector Commercial: Pharmaceutical 150% ‐ Three importers wholesalers joined 0 3 2 wholesaler, Pharmacy, Drugs Shop the PSHP

250% ‐ Good collaboration with all stakeholders, IMPACT project gets notoriety among private sector PMP Number of loans (in general) disbursed to IR3.1.2 Number 0 5 2 For the first year of the activity, it was IMPACT businesses (excluding service providers) difficult to project potential loan uptake. PMP targets will be revised based on the Year 1 figures.

405% ‐ Good collaboration with all stakeholders, IMPACT project gets notoriety among private sector. PMP Value of loans (in general) disbursed to 5 IR3.1.3 USD 0 20 245 For the first year of the activity, it was IMPACT businesses (excluding service providers) 000 difficult to project potential loan uptake. PMP targets will be revised based on the Year 1 figures. 147% ‐ Good dynamic drug shop PMP Number of people trained in business association's leader, many drug shop IR3.1.4 Number 0 22 15 IMPACT and financial management owners responded to IMPACT invitation Percent of female and youth PMP participation in project‐assisted private TRIGGER : IR3.1.5 Percent N/A 27 135% IMPACT health commodity businesses, and in 20% leadership positions PMP Percent of market share for commercial IR3.1.6 N/A N/A N/A IMPACT sector for specific health products ACT N/A N/A N/A Malaria SP N/A N/A N/A ‐ No LMIS data available yet for commercial sector. RDT Percent N/A N/A N/A ‐ The LMIS data collection system will Oral contraceptive N/A N/A N/A be implemented through TMA TWG Injectable FP N/A N/A N/A process planned from Quarter 1 Year contraceptive 2. Condom N/A N/A N/A IR3.2. GOM facilitates the work of the commercial sector Percent of targeted GOM (Direction de la Pharmacie, des Laboratoires et de la PMP IR3.2.1 Médecine Traditionnelle and DAMM) Percent 0 0 0 IMPACT staff trained in improved regulatory processes PMP Percent of existing drug shops that IR3.2.2 Percent 0 0 0 IMPACT achieve accreditation in pilot area PMP Percent of TWG meetings attended by IR3.2.3 Percent NA 100 80 125% IMPACT commercial actors

Number of laws/decree/ministerial order, policies, or regulatory frameworks drafted, amended (including IR3.2.4 PMP reglementation), approved, or 0 0 0 (IR 4.1.1) USAID implemented with project support that expand access to or availability of health products or services Drafted, Amended 0 0 0 Malaria Approved Number 0 0 0 Implemented 0 0 0 Drafted, Amended 0 0 0 FP Approved 0 0 0 Implemented 0 0 0 Drafted, Amended 0 0 0 MCH Approved 0 0 0 Implemented 0 0 0 Percentage of USG supported districts PMP IR3.2.5 that submit timely and complete reports N/A N/A N/A IMPACT through LMIS Reports submitted N/A N/A N/A Reports submitted on time N/A N/A N/A Pharmacy to IMPACT server Reports that are complete N/A N/A N/A ‐ No LMIS data available yet for Reports that are complete and commercial sector. N/A N/A N/A submitted on time ‐ The LMIS data collection system will Commercial sector Percent Reports submitted N/A N/A N/A be implemented through TMA TWG Reports submitted on time N/A N/A N/A process planned from Quarter 1 Year Drug Shops to 2. IMPACT server Reports that are complete N/A N/A N/A Reports that are complete and N/A N/A N/A submitted on time IR4: Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy people IR4.1. Socially marketed products are continuously available at convenient and accessible locations PMP Percent of PAs/PARCs that are converted IR4.1.1 Percent 0 0 0 IMPACT into PhaGeCom/PhaGDis

PA to PhaGeCom 0 0 0

PARC to PhaGDis 0 0 0

PMP Number of socially marketed products IR4.1.2 IMPACT distributed 1 564 1 382 OC Community 1 232 057 112% 517 159 Injectable (Depo‐ 1 336 926 Provera/TRICLOFEM) 1 052 396 88% 376 044 Community FP Condom Protector Plus 868 FP 410 304 518 823 167% (Community) 896 FP Youth Condom Yes 1 304 269 269 100 100% (Commercial) 250 100 65% ‐ Products arrived in March. The 221 Sayana Press 430 254 338 825 products had been ordered in Quarter 017 1 Year 1. 2 Distribution started in Quarter 4 upon ORS/Zinc DTK (Community) 57 190 0 873 product arrival Number 1 171 344 Sur Eau 150 ml Commercial 337 862 102% 405 595 65% ‐ The quantity distributed has decreased (2,299,680) compared to the Year 1 target (3,515,320) because the distribution has only started in January 2019. In addition, some MCH communities need to be sensitized in Sur Eau Pilina (67mg tablet) 3 829 2 299 3 515 320 order to increase demand. (Community) 660 680

In 2019, the period of rainy season was reduced and has decreased diarrheal disease threat perception and the use of preventive method accordingly. Arofoitra (CHX 7,1%) 16 22 120 7 373 255% (Community) 109

Pneumox (amoxycilline) 102 155 270 53 309 192% (Community) 404 48 57 Pregnancy Test (Community) 0 85% 645 091 PMP Number of products sold at 100% cost IR4.1.3 2 2 2 100% IMPACT recovery or greater Condom Yes Strawberry 1 1 1 100% Condom Yes Banana 0 0 0 FP Condom Yes Vanilla 0 0 0 Number Protector Plus 0 0 0 Sur Eau 150 ml Commercial 1 1 1 100% Sur'Eau Pilina 0 0 0 MCH Arofoitra (CHX 7,1%) 0 0 0 Pneumox (amoxycilline) 0 0 0 IR4.2. GOM facilitates the work of the commercial sector Product sustainability plan developed, PMP IR4.2.1 updated, and implemented for socially N/A 0 1 IMPACT marketed products (by product) Injectable hormonal N/A 0 0 contraceptives (Confiance) Oral hormonal contraceptives N/A 0 0 (Microgynon) FP The product sustainability plan was Condom (Yes and Protector N/A 0 1 updated but not yet implemented (it Plus) Number is reported in Year 2) Sayana Press N/A 0 0 ORS/Zinc DTK (Community) N/A 0 0 Sur Eau 150 ml Commercial N/A 0 0 Sur Eau Pilina (67mg tablet) MCH N/A 0 0 (Community) Arofoitra (CHX 7,1%) N/A 0 0 Pneumox (amoxycilline) N/A 0 0 PMP Costing analysis of selected socially 1 (Yes IR4.2.2 Number 1 1 100% IMPACT marketed products conducted condom) IR5: Increased demand for and use of health products among the Malagasy people/Output/Activity

PMP Market size increased for specific health IR5.1 N/A N/A N/A IMPACT products in term of percentage Injectable N/A N/A TBD contraceptive FP Oral contraceptives N/A N/A TBD YES N/A N/A TBD Protector Plus N/A N/A TBD Rapid Diagnostic Tests for malaria N/A N/A TBD (RDT) MALARIA Sulfadoxine‐ N/A N/A TBD Pyrimethamine (SP) Percent ITN N/A N/A TBD Awaiting market assessment, results Amoxicillin (or were not available in Year 1. N/A N/A TBD Pneumox) Oral Rehydration Therapy (with or without zinc) (or N/A N/A TBD MCH Hydrazinc / Viasur in time) Sur'Eau 150 ml N/A N/A TBD Sur'Eau Pilina N/A N/A TBD Chlorhexidine (ou N/A N/A TBD Arofoitra) PMP Percentage of target group who know TBD (Q4 IR5.2 N/A N/A IMPACT where to get a specific health product Year 1) FP Product (Injectable TBD (Q4 N/A N/A contraceptive or Year 1) Female Oral contraceptive) FP Condom (Yes or TBD (Q4 N/A N/A Protector Plus) Year 1) Condom (Yes or TBD (Q4 Male N/A N/A Awaiting findings from surveys that Protector Plus) Percent Year 1) were not available in Year 1

FP Product (Injectable TBD (Q4 N/A N/A contraceptive or Year 1) Rural Oral contraceptive) Condom (Yes or TBD (Q4 N/A N/A Protector Plus) Year 1) FP Product (Injectable TBD (Q4 N/A N/A contraceptive or Year 1) Urban Oral contraceptive) Condom (Yes or TBD (Q4 N/A N/A Protector Plus) Year 1) Sulfadoxine‐ TBD (Q4 N/A N/A Pyrimethamine (SP) Year 1) Rural TBD (Q4 Bednet N/A N/A Year 1) Malaria Sulfadoxine‐ TBD (Q4 N/A N/A Pyrimethamine (SP) Year 1) Urban TBD (Q4 Bednet N/A N/A Year 1) Oral Rehydration Therapy (with or TBD (Q4 without zinc) (or N/A N/A Year 1) Rural Hydrazinc / Viasur in time) TBD (Q4 Sur'Eau Pilina N/A N/A Year 1) MCH Oral Rehydration Therapy (with or TBD (Q4 without zinc) (or N/A N/A Year 1) Urban Hydrazinc / Viasur in time) TBD (Q4 Sur'Eau 150 ml N/A N/A Year 1)

Percentage of target group who PMPIMPA TBD (Q4 IR5.3 perceived a specific health product to be N/A N/A CT Year 1) relevant FP Product (Injectable TBD (Q4 N/A N/A contraceptive or Year 1) Female Oral contraceptive) Condom (Yes or TBD (Q4 N/A N/A Protector Plus) Year 1) Condom (Yes or TBD (Q4 Male N/A N/A Protector Plus) Year 1) FP Product (Injectable TBD (Q4 FP N/A N/A contraceptive or Year 1) Rural Oral contraceptive) Condom (Yes or TBD (Q4 N/A N/A Protector Plus) Year 1) FP Product (Injectable TBD (Q4 N/A N/A contraceptive or Year 1) Urban Oral contraceptive) Condom (Yes or TBD (Q4 N/A N/A Protector Plus) Year 1) Sulfadoxine‐ TBD (Q4 N/A N/A Pyrimethamine (SP) Year 1) Rural TBD (Q4 Bednet N/A N/A Year 1) Malaria Sulfadoxine‐ TBD (Q4 N/A N/A Pyrimethamine (SP) Year 1) Urban TBD (Q4 Bednet N/A N/A Year 1) Oral Rehydration Therapy (with or TBD (Q4 MCH Rural without zinc) (or N/A N/A Year 1) Hydrazinc / Viasur in Awaiting findings from surveys that time) Percent were not available in Year 1

TBD (Q4 Sur'Eau Pilina N/A N/A Year 1) Oral Rehydration Therapy (with or TBD (Q4 without zinc) (or N/A N/A Year 1) Urban Hydrazinc / Viasur in time) TBD (Q4 Sur'Eau 150 ml N/A N/A Year 1) PMP 15 14 IR.5.4 Number of mass media spots aired 628 112% IMPACT 622 000 2 2 MALARIA 0 128% Number 555 000 4 4 Health area FP 0 119% 750 000 8 8 MCH 628 104% 317 000 80% ‐ The first members who joined the Demand Creation Subcommittee Number of GOM and commercial sector were composed of 8 people from PMP employees trained in developing a IR5.5 Number N/A 10 public sector (DPS, AMM and DPLMT). IMPACT national demand generation strategy 8 The private sector and NGOs will be during TMI meetings encouraged to join the committee in Year 2. National Product Promotion PMP IR5.6 Communication Plan developed and Number 0 1 (Malaria) 100% IMPACT 1 implemented

ANNEX B – Year 1 Workplan Update

Year 1 Activities & Outputs Progress Code Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Comments Project start up activities Finalization of the strategy x with all IMPACT partners and key stakeholders Completed through a collaborative D1 process Submit Year 1 Annual x Implementation Plan and Completed D2 Budget D3 Submit MEL Plan x Completed Submit branding and x Completed D4 marking plan Submit environmental x assessment, ensuring Completed D5 environmental compliance All five IMPACT Key x Completed D6 Personnel are in place Internal launch for x Completed D7 partners and USAID Official IMPACT External x Completed D8 Launch Ensuring no stockout in x x x the community through a Completed smooth transition from D9 SHOPS Plus to IMPACT Intermediate Result 1. Enhanced coordination among the public, nonprofit, and commercial sectors for reliable supply and distribution of quality health products

Intermediate Result 1. Enhanced coordination among the public, nonprofit, and commercial sectors for reliable supply and distribution of quality health products 1.1: The total market for health products in Madagascar is understood and documented Conduct exhaustive desk x x x review of TMI literature in Madagascar for all three

R1.1 health areas (FP/RH, Completed A1 Malaria, and MCH) resulting in one

encompassing summary of the work done to date x First draft of TMA roadmap action plan Development of an developed on September 24, 2019. R1.1 overarching TMI roadmap Continued x x Finalization of the roadmap document and A2 for all three health areas activity operationalization scheduled in Quarter 1 (FP/RH, Malaria, and MCH) of Year 2. Identify one priority health area among FP/RH, R1.1 Malaria, and MCH and Completed A3 plan TMI market assessments for Year 1 x x x x Step 1: 100% ‐ Framework of the market assessment submitted Conduct TMI market Step 2: 100% ‐ Design and implementation assessment for the priority R1.1 Continued of the assessment health area and x x x x x A4 activity Step 3: 20% ‐ Results analysis and incorporate into TMI documentation starting in Quarter 4 of roadmap Year 1 and presentation of final document in Quarter 1 of Year 2

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Identify and train TMI 3 TMA Champions identified and trained Champions for the chosen on TMA 101 health area at the MOPH R1.1 (to be identified with the X X Completed A5 General Secretary of the MOPH – SG Santé – who will appoint people); Establish and train multi‐ The first TMI TWG meeting held on July, 16 sectoral (private, public, etc.) TWGs led by the TMI Champions for the chosen health area. The TMI R1.1 Champions will assist the X X Completed A6 TWG in conducting TMI workshops according to the TMI roadmap and produce a more detailed TMI roadmap and draft operationalization plan Conduct one exchange trip Due to the schedules of the Champions and in a country that has difficulty in finding a date suitable to all already operationalized a Champions, this trip has been postponed TMI for the TMI to Quarter 1 of Year 2, which may also Champions to identify best enable IMPACT to have all Champions R1.1 Replanned practices, key X available, including the newly emerging A7 in Year 2 performance indicators, ones, so that they all have the same level and tools in TMI and of knowledge on TMA. incorporate them into the TMI operationalization plan

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The operational plan of the overarching TMI roadmap is developed. The Initiation of the TMI R1.1 operational plan for the Malaria TMI operationalization plans X X X Completed A8 roadmap is replanned for Year 2 as waiting for the priority health area for results from the malaria market assessment. Through the IMPACT Success story reported: TMI TWG meeting knowledge management on July 16, and on August 14 platform and R1.1 dissemination meetings, X X X X X Completed A9 ensure that TMI results are known to all key stakeholders 1.2: GOM leads TMI stakeholders to coordinate health product forecasting according to market assessments and segmentation Review and consolidate all x x x x existing forecasting R1.1 exercises for all priority Completed A10 health areas (FP/RH, Malaria, MCH) with collaboration from UTGL Consolidate forecasting for Malaria products (RDT, R1.1 ACT, SP, LLIN) with GAS X X X X X Completed A11 subcommittee under the leadership of UTGL Assess existing in‐country All members of UTGL have been trained on GOM forecasting capacity forecasting and supply plan concept, R1.1 and provide trainings as X X X Completed methodologies and tools (Quantimed and A12 needed including Pipeline). 100% of targeted people are Quantimed trained.

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4 sessions of quantification exercises (out of 4) have been completed, representing Assist the GOM in leading 100% of completion. Quantification R1.1 the annual system wide X X X X X Completed exercises for malaria, Family planning and A13 forecasting exercises as Reproductive Health, and MNCH were part of each TMI workshop completed and will be validated by the CGL end of June. Intermediate Result 2: Strengthened capacity of the GOM to sustainably provide quality health products to the Malagasy people 2.1: Health commodities and pharmaceuticals are continuously available and accessible in the public sector 2.1.1 Central Level Ensuring no stockout in x x x the public sector through a smooth transition from PSM‐FO to PSM‐NFO R2.1 (quantification exercises Completed A1 for IMPACT, signature of an MOU between PSI and PSM‐NFO, signature of a contract with SALAMA, etc.) Develop an emergency x x x R2.1 plan for the distribution of Completed A2 priority FP/RH products (OCS, injectables) Develop and support an emergency plan with R2.1 SALAMA for the X Completed A3 Distribution of Malaria products to avoid stock‐ out

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R2.1 Support Quarterly X X X X X Completed This is a continuous activity conducted A4 distributions from each quarter. SALAMA to Pha‐G‐Dis as well as storage and receipt of Malaria, FP and MCH commodities R2.1 Support the distribution of X Distribution of the 1st distribution plan of A5 emergency FP/RH TRICLOFEM to Pha‐G‐Dis ‐ 100% products in the public Reception from DSFa of the 2nd Continued sector and report on the distribution plan of Triclofem ‐ Distribution activity number of emergency 95% products distributed in the public sector and via CHVs R2.1 Conduct in‐depth A local consultant has been recruited to A6 literature review of the conduct the literature review of the public existing public supply supply chain. The consultant compiled all chain resulting in a past studies and evaluations on supply summary of past chain for the past 10 years (since 2009), recommendations and the identify recommendations, assess current Continued current situation, which X X X X status with actions implemented so far, activity will help generate conduct interviews with key authorities. recommendations for The literature review is completed, and IMPACT (e.g. staff skills report is being edited to be disseminated lacking, use of data for in Quarter 1 Year 2. LMIS, last mile distribution etc.) R2.1 Assess existing supply Same activity as R1.1 A12 A7 planning capacity of the 100% of targeted audience have been X X X Completed GOM staff at all levels of assessed and trained with assessment the supply chain completed

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R2.1 Develop a training and During Q3, staff at region and districts have A8 capacity building plan for been trained on estimating correctly their key MOPH divisions needs (DPLMT, UTGL, DAMM) at X Completed all levels of the supply chain as needed with collaboration of key donors involved in HSS R2.1 Conduct an in‐depth The STTA will support the development of A9 SWOT analysis of the the LMIS roadmap in September. Data current LMIS and develop collection is completed, and the consultant an LMIS/supply planning is supporting data analysis. A first draft of strengthening roadmap the report has been shared by ATW agency but needs to be reviewed according to the Consultant inputs. It is expected that first draft ready to be disseminated to USAID and DPLMT will be ready by mid of October. Next activities: 1) Finalize the evaluation report and disseminate the Continued X X X X report 2) Use the evaluation findings to activity develop a road map to strengthen the LMIS in Madagascar This activity is delayed for the following reasons: ‐ Inclusion of private sector and social marketing sector prolonged the review process of tools and results ‐ Several iterations of the report ‐ Translation of qualitative data from Malagasy to French

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IMPACT collected documents related to the SPARS model applied to Uganda. IMPACT conducted meetings with ACCESS to explore areas of coordinating implementation of SPARS to apply at Pha‐G‐Dis level with ACCESS tool and methodology that will be used at CSB/PhaGeCom levels. While this activity has Begin establishing the not moved so far, the RLA conducted R2.1 SCM quality improvement Continued X X X supervisions of Pha‐G‐Dis and PhaGeCom on A10 approach using the SPARS activity best practices of storage and stock model management using the EMMP checklist to improve quality of services provided. Next steps: 1) Finalize approach with ACCESS 2) select pilot zone 3) conduct a training of trainers 4) Conduct cascades trainings 5) Track implementation and progress 6) Evaluate to inform the scaling up. Provision of initial Same activity as R1.1 A12; All members of training on supply UTGL have been trained on forecasting and planning to key public supply plan concept, methodologies and tools sector staff, on‐the‐job (Quantimed and Pipeline). R2.1 capacity building (regular X X X X X Completed A11 reporting, supply plans, stock status, distribution plans, Pipeline, financial management), and ongoing mentoring Support the MOPH in the Same activity as R1.1 A13. 100% Completion R2.1 revision of the forecast X X X Completed A12 and supply plan through strengthening their

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capacity to use electronic tools and produce and utilize SCM reports R2.1 Development of 12 Districts. Strategy drafted A13 budgeted roadmap for X X X X Completed continuous LLIN distribution in 20 districts R2.1 LLIN storage at the Replanned Replanned in Year 2 X X X A14 central level in Year 2 Develop a budgeted 100% of the plan is completed. national distribution plan R2.1 for SALAMA for 10 X X X X X Completed A15 regions for all products and only FP for 3 PARN Regions Develop a budgeted Completed Same activity as R2.1 A4. 100% Completed R2.1 national distribution plan X X X X X A16 with SALAMA for malaria products Develop a budgeted Completed The GAS Committee finalized forecasting and national procurement supply plan for malaria products including R2.1 plan for Malaria contribution of all partners. The plans were X X X X X A17 commodities including presented to PMI and to CGL for validation and the contribution of all use for resources mobilization. partners Develop a budgeted Completed Completed national procurement R2.1 plan for USAID through X X X X X A18 PSM‐NFO for the 13 regions using input from all donors

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IMPACT started planning of EUV and define sampling in public sector (the private sector will be included after the TMA assessment). While preparing to data collection, IMPACT learned that questionnaire and methodology of the EUV survey have been changed and validated by PMI Washington in March 2019. In August, IMPACT received PSM training on Conduct End‐Use the new methodology and questionnaires. R2.1 Verification (EUV) surveys Continued X X IMPACT is still waiting training curriculum to be A19 for Malaria, FP/RH, and activity shared by PSM. Next steps : 1) Discuss with MCH products various directions of the Ministry of Health to appoint the EUV survey committee 2) Select sample and organize logistics for field data collection 3) recruit data collectors 4) Train data collectors 5) conduct data collection using Survey CTO 6) Conduct data analysis 7) Disseminate EUV survey report to USAID, PMI, PSM and Ministry of Health 2.1.2 Regional/District Level R2.1 Provision of initial X X X X X The RLA (Regional Advisors in Logistics) A20 training on supply completed initial trainings to Pha‐G‐Dis and planning to key public CHRD in districts of Menabe, Atsimo Andrefana sector staff and on‐the‐ and Diana to orient and reinforce capacity job capacity building building of Pha‐G‐Dis and CHRD staff in stock based on the needs from Completed inventory management and use of Channel the assessment (e.g. software. The trainings were an opportunity to warehousing, supply share Terms of Reference and sensitize regions plans, stock status, use of and districts teams to set up GAS committees LMIS, distribution plans, that will serve as a forum to discuss and take IT support for electronic

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reporting, financial appropriate solutions for supply chain management) improvement. Provide refresher training Orientation Channel is combined with R2.1 on CHANNEL software at R.2.1.A.20. X X X X X Completed A21 district level for malaria

products data collection Explore an emergency x x x x IMPACT supported emergency transportation transportation to respond to situation of stock outs or in case R2.1 mechanism from Central x x x Completed of upsurge of malaria. Re distributions at A22 to Pha‐G‐Dis and from regional level were organized in close Pha‐G‐Dis to Pha‐Ge‐Com supervision by our RLA. 2.1.3 Commune Level Explore with the MOPH distribution strategies from Pha‐G‐Dis to Pha‐ Ge‐Com and propose at R2.1 least two scenarios to X X X X X Completed A23 continue after the initial emergency contracting in close collaboration with ACCESS and Mahefa‐ Miaraka IMPACT collaborated with ACCESS to support Provide refresher training the curriculum review for trainings of CSB and on stock management for CHV to ensure that community needs are R2.1 malaria products in 100 Continued integrated in CSB requisitions. The Curriculum X X X X X A24 priority communes activity and training modules are translated into identified by the PNLP Malagasy to facilitate trainings and and its partners understanding of trainees. The training material was pre tested in Analanjirofo (47 CSB

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of Vavatenina and Fenerive Est districts) by IMPACT to adapt final version of the curriculum. Currently, the material is finalized and waiting final validation of the Service de Formation Professionnelle of the Ministry of Health. The curriculum process was conducted by a committee formed of representatives of the Ministry of Health (PNLP, DPLMT, DSFa, DSSB, SFP) and partners (IMPACT, ACCESS, Mahefa Miaraka). Remaining activity is to train additional 53 CSB to complete all districts of Analanjirofo. Intermediate Result 3: Expanded engagement of the commercial health sector to serve new health product markets according to health needs and consumer demand 3.1 Commercial actors are incentivized to expand into new health product markets R3.1 Present IMPACT to the Continuous activity X X X X X X Completed A1 PSHP 100% of field visits completed at regional level Establish a formal MOU signed R3.1 partnership between the X X Completed A2 Platform and the MOPH 7 new members joined the PSHP: Three Expand the Platform by R3.1 wholesalers SOMAPHARD and COFARMA, engaging new commercial X X X X X Completed A3 Akbaraly Foundation and Aga Khan actors active in health Foundation, Salama and Mirana santé. Identify specific members Specific members identified: SOMAPHARD, of the PSHP to join the COFARMA, Akbaraly Foundation, Aga Khan R3.1 TWG created in IR 1.1 for Foundation, Salama, Mirana santé, Saham X X Completed A4 the chosen priority health Assurance, BNI, Telma area and assign roles and responsibilities

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Provide PSI with quarterly Specific members support IMPACT team in reports on the elaborating report from TWG workshops. R3.1 achievements of the X X Completed A5 specific PSHP members of the TWG in order to track progress Work with partner banks Continuous activity. Team has identified and SHOPS Plus platform financial products for pharmacies and drug to expand financing to shops with bank team based on their needs health supply chain from mapping exercise in Tamatave. The team stakeholders through the notes that few health supply chain actors work DCA guarantees and with banks or microfinance institutions due to adapted financial institutions limited geographical coverage and products the actors' lack of knowledge of the institutions services and offers. VSLAs or SILCs R3.1 savings and credit groups are used for most X X X X X Completed A6 financing needs. Grouped loans and new financial products for wholesalers and pharmacies or drug shops are conducted with partner banks (loans for transportation means acquisition for PA/PARC, village council with ABM, etc.). New financial products (pharmaloan) have been proposed and validated by the partner banks. These new products will be proposed to dépôts and pharmacies during Year 2. Develop capacity building 100% Done ‐ Training is based on how to plans and training finance health businesses in the supply chain R3.1 curricula for DCA partner X Completed and how to approach them to better serve A7 banks utilizing experience their needs. from SHOPS Plus

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100% ‐ 105 bank staff (57 women and 48 men) from ABM and Baobab branches in Tanà, Train and support DCA Diego, Toliara, Tamatave, and Fenerive Est partner banks in credit were trained in credit analysis and loan R3.1 analysis and loan X X X X X Completed structuring for health businesses. Training A8 structuring for health session are also an opportunity to show to the businesses bank the potential market of borrowers in this sector (drug shops, PAs and PARCs, pharmacies) in each region. This activity started in Q4 Finances expert had come to explore the Develop and adapt loan possibilities of setting up a mechanism to products and financial finance private sector actors in Health sector R3.1 and risk mitigation tools Continued and met local stakeholders from Sept 11 to 20. X X X A9 for small and micro activity To be done in Y2: ‐ further studies about the health enterprises in actors needs in the supply chain (third‐party pharmaceutical sector drug shops and wholesalers) and elaborate several options of financing mechanisms to be submitted to USAID before implementation. 100% ‐ A pilot test was conducted to train 22 Develop and adapt a drug shops in Fenerive Est on May 21‐22 with training and coaching the participation of SOPHARMAD, which curriculum to build the accepted, on a cost share basis to finance the financial management training up to 30%. Based on the results of this R3.1 capacity of health X X X X X Completed pilot, the training materials are being revised, A10 businesses that will and a Certified Peer Trainer program is being borrow money through conceptualized. The training material for drug the DCA through shops will be used during the sensitization collaboration with SHOPS campaign with DPLMT during first and second Plus months of Year 2 while the material adapted

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for the Peer Trainer program is to be finalized in Q1 FY20.

Provide training and 100% ‐ Training of drug shops in Analanjirofo coaching to strengthen on 21‐22 May completed the financial R3.1 management skills of all X X X X X Completed A11 borrowers through the DCA (e.g., Dépôts, pharmacies, wholesalers, retailers) 3.2: GOM facilitates the work of the commercial sector Assess GOM's interest x x R3.2 and capacity for oversight Completed A1 of the private sector The initial purpose of a third‐party vendor was to routinely collect and analyze health market data including market share (volume and value) for tracer health products in the three sectors (public, social marketing, and private for profit). A feasibility study was planned to Conduct feasibility study evaluate barriers and motivation on collecting on using a third‐party routine data within private sector. Since there R3.2 is already the TMA TWG on LMIS to manage all vendor for the data Cancelled A2 data collection issues with the aim to create a collection system of the routine private sector system integrated to the private sector public system, the feasibility study has been cancelled for the following reasons:

‐ First, an LMIS system for private sector will be set up then a third‐party vendor will no longer be used as a LMIS data collection routine system.

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‐ Second, a mapping exercise is being implemented led by the TMA LMIS TWG in order to approach the pharmacies and drug shops that are randomly selected to participate to the LMIS data. Useful information such as motivation and barriers on LMIS data sharing, and agreement for sharing LMIS data will be collected . During FY 1, IMPACT engaged discussions with DAMM on the registration process. DAMM conducted a self‐evaluation using the Global Benchmarking tool (GBT) of WHO. While waiting WHO report and scoring of the GBT, Review and assess the IMPACT recruited an international consultant R3.2 DAMM drug registration Continued to facilitate the development of a strategic X X X A3 processes with the aim of activity plan based on the GBT results. streamlining them Next steps: 1) Discuss with DAMM on the GBT results and scoring 2) Prepare a workshop to discuss results in a larger group and led to development of strategic plan 3) Update/develop registration and inspection process and SOPs Make an assessment of The report is being finalized and will be ready regulatory and policy for dissemination. barriers to the R3.2 commercial sector’s X X X X X X Completed A4 involvement in the pharmaceutical supply chain

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Organize advocacy IMPACT facilitated a meeting on quality meetings with the GOM assurance and registration of commodities for options to support the imported by donors. The meeting was expansion of the organized May 9 with 75 persons invited commercial sector (e.g. representing Ministry of Health, Ministry of R3.2 tax exemption for health Finance, Customs, UNICEF, WHO, USAID, and X X X X X Completed A5 products dedicated to other stakeholders. The meeting was jointly humanitarian activities) prepared by IMPACT, H6+ group, DAMM and DPLMT. As an immediate next step, IMPACT facilitated the validation workshop of the National List of Essential medicines and Commodities on May 17. IMPACT initiated contacts with the President of the National Committee in charge of fighting Support the GOM to illicit drugs to revitalize this committee to develop an action plan to implement activities. Next steps: 1) Upon implement the Stratégie availability of the Prime Minister who host the Nationale de Lutte contre Committee, meet to discuss on the way R3.2 la Contrefaçon et le Continued forward to restructuring the Committee A6 Marché Illicite de activity (membership, equipment and furniture, legal Médicaments with an texts, action plans, budget). 2) Plan a mid‐term emphasis on malaria, review of the existing strategic plan and adjust Family Planning and MCH next plans according to funding and realistic products objectives to attain 3) Implement activities. This is rescheduled for Year 2.

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Intermediate Result 4. Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy people 4.1.1: Socially marketed products are continuously available at convenient and accessible locations Distribution of socially Reception of 12 000 blisters of ZINC marketed products across Reception of 1 234 000 doses of DEPROVERA 10 regions for all Preparation of distribution of Kit SRO/ZINC and products and only FP for DEPOPROVERA R4.1 3 PARN Regions trough Continued X X X X X A1 PSI PARC (Point activity d'Approvisionnement Relais Communautaire) and PA (Point d’Approvisionnement) Elaborate a plan with x x x R4.1 USAID to avoid stock‐outs Completed A2 during the transition from SHOPS Plus to IMPACT Elaborate a procurement x x x x R4.1 plan for socially marketed x x x x x Completed A3 products for Year 1 Replanned in Year 2 Conduct a pilot study on Since this activity relates to the private sector, the use of vouchers for IMPACT decided to read the market specific segments to assessment results first to confirm the need for R4.1 Replanned target subsidy and X X a pilot study on the use of vouchers for specific A4 in Year 2 incentivize remote segments to target subsidies and incentivize businesses (e.g., Dépôts, remote businesses. Results of the market small retailers) (see IR5) assessment is postponed.

4.1.2 Innovative last mile distribution ventures

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Conduct a feasibility x A report is available and shared along with the R4.1 study on the use of revised annual report Completed A5 drones for last mile medicine delivery Design a drone‐based Specification on weight and volume per flight R4.1 pilot for emergency defined, possibility of upgrading volume X X X X X X Completed A6 transportation of health according to IMPACT's need products 2 villages identified for the test flight Conduct the pilot for the First test flight: September 16th was effective R4.1 delivery of health Continued and successful X X X X A7 products to communities activity using drones 4.2: Socially marketed products achieve cost recovery at an affordable price for consumers Analyze Cost of Goods Sold (COGS) and propose options for the R4.2 optimization of financial X X X Completed A1 sustainability for the current socially marketed products portfolio This activity depends on products portfolio. The collection of information related to the products portfolio analysis was conducted in Explore licensing of some Quarter 3 and the portfolio analysis was socially marketed brands conducted in Quarter 4 of Year 1. In depth R4.2 Replanned to local manufacturers X analysis was done which took more time than A2 to Year 2 pending the results of the initially expected. IMPACT sent the report to COGS analysis PSI Washington for review before dissemination with USAID local mission. All of these processes took more time than anticipated.

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Pilot the introduction of a Depends on products portfolio analysis low‐cost socially R4.2 marketed products in the Replanned

A3 public sector pending the to Year 2 results of the COGS analysis Explore brand extension Depends on products portfolio analysis R4.2 of Yes condoms pending Replanned X X X X A4 the results of the COGS to Year 2 analysis Develop a marketing plan Replanned to Year 2 for different pregnancy Awaiting FP market assessment design tests at different price expected in Year 2. points and different R4.2 Replanned packaging based on TMA X X A5 to Year 2 assessment of the total market for pregnancy tests done under SHOPS Plus Intermediate Result 5. Increased demand for and use of health products among the Malagasy people 5.1: The market demonstrates sufficient and sustained demand for health products Implement a dynamic and Communication campaign for Sur’Eau Pilina R5.1 innovative demand and Protector plus X X X X X Completed A1 creation and product promotion campaigns Set up one demand Meeting with DPS, AMM and DPLMT was held creation subcommittee of to set up the demand creation subcommittee R5.1 the TMI TWG (in X X X Completed of the TMI TWG. A2 coordination with the SBCC national committee

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and including the commercial sector) Develop a comprehensive Communication plan developed for Sur'Eau communication plan for Pilina , Protector Plus Arofoitra and ORS Zinc. R5.1 all project years and a X X X X X X Completed A3 detailed budgeted communication plan for YEAR 1 Co‐develop, with the Depends on a segmentation research and demand creation journey mapping that is scheduled in Year 2 R5.1 Replanned subcommittee, audience X X A4 in Year 2 archetypes, and adapt our segmentation Develop a Implementation of national communication communication plan on plan on Malaria R5.1 health products at the Participation in international days and events X X X Completed A5 national level with the demand creation subcommittee Implement a Development of transfer plan to ACCESS for communication plan 910 targeting youth and continue to leverage the R5.1 use of new technology for X X X X X Completed A6 interactive product promotion efforts based on ACCESS and Mahefa Miaraka Develop and conduct a 3 rounds of SMS Broadcast completed R5.1 pilot of a strategy using X X X X X X Completed A7 mobile technology such

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as SMS to increase SMS targeting PARC and CHW were sent to demand creation prevent them on the availability of health commodities. Cross‐Cutting: Gender and Social Inclusion The Gender Analysis was completed as Conduct gender analysis planned. Final study report integrating PSI and and develop gender USAID comments was submitted to USAID in CC1 integration strategy, X Completed July and shared to all IMPACT partners ensuring ADS 205 involved in the gender analysis launch compliance workshop. Initial training was completed in March 2019. Conduct initial and The internal dissemination of the GESI analysis follow‐up gender and and Action Plan workshop was done during the CC2 X Completed social inclusion training IMPACT staff retreat July 1‐5, 2019. The next with IMPACT project staff follow‐up training session will be conducted at least 12 months following the initial training. Hold pause‐and‐reflect This activity should be conducted every 6 learning sessions related Replanned months, with the first session following the CC3 X to gender and social in Year 2 dissemination of the Gender Action Plan, inclusion which was held in July 2019 (see CC4 below).

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ANNEX C ‐ Environmental Mitigation and Monitoring Report

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Summary number of the outlets visited

Number of outlets visited during Year Number of Total number of Type of Outlet 1 outlets visited at Outlets Q2 Q3 Q4 least once Public Sector SALAMA/Central Warehousing 1 0 0 1 6 Pha‐G‐Dis 8 14 12 34 78 Pha‐Ge‐Com 8 11 14 33 1,734 Social Marketing PSI Warehouse 4 9 7 13 15 PARC 14 66 64 66 66 PA 188 859 817 859 859

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ACTIVITY MONITORING INDICATORS FINDINGS RECOMMENDATIONS and COMMENTS

1. Capacity building through technical workshops and training to enhance coordination and distribution of quality health products. 1.1.1. Training of CSB (Centre de Number of CSB providers trained Male Female Total ‐ 42% (14/33) of Pha‐Ge‐Com supervised in Year Santé de Base) providers on proper (disaggregated by sex) 1 were trained in proper storage, use, and 0 14 14 storage, use, and disposal of disposal of commodities. The people trained commodities. Training support may [33 CSB /Pha‐Ge‐Com visited] are 100% female. include communication materials Number of CSB not respecting ‐ The training curriculum needs to be revised to and packaging (Job Aids) proper storage, use, and disposal Number of CSB not respecting proper storage and disposal of include the calculation of requisition of malaria of commodities during spot‐ commodities commodities at the CSB level to include the checks Proper Storage including: needs of CHVs. The training curriculum will be ‐ stored on pallets or shelves validated in Year 2, and then trainings of CSB ‐ stored at least 30 cm away from walls and other piles can continue to achieve 100% of the target. ‐ stored in a functional refrigerator ‐ 42% (14/33) of Pha‐Ge‐Com visited in Year 1 ‐ protected from direct sunlight respected all 5 criteria of proper storage. The ‐ storage rooms dry and adequately ventilated criteria on distance between walls and commodities on shelves was the big issue on proper storage.

Two actions will be taken in Quarter 1 Year 2: ‐ Apply recommendation on five quality norms to the other Pha‐Ge‐Com. A note with the summary of the recommendations will be drafted with the CSB providers and will be shared to the DSSB (Direction des Services de Santé de Base). ‐ In collaboration with ACCESS, the RLA will Proper Disposal of Commodities: organize follow‐up visits of CSB and Pha‐Ge‐ ‐ expired or damaged stored in a separate location Com that did not respect the five quality requirements on proper storage, use, and Proper Storage 14 disposal of commodities. Medium 6

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Improper Storage 8 ‐ 70% (23/33) of Pha‐Ge‐Com visited in Year 1 stored the expired and damaged commodities Proper Disposal of in a separate location. 23 Commodities ‐ During the supervision, for the 30% non‐ Medium 0 compliant Pha‐Ge‐Com, the RLA worked Improper Disposal of together with the Pha‐Ge‐Com to rearrange the 6 Commodities location and transferred the expired and [33 CSB /Pha‐Ge‐Com visited] damaged commodities to the specified location. ‐ A communication tool on expired and damaged commodities management is being created and will be distributed to the Pha‐Ge‐Com.

1.1.2. Provide supervision of CSB Number of CSB with the Infrastructure and non‐medical equipment for infection ‐ 52% (17/33) of CSBs visited in Year 1 had providers by using a Rapid equipment (chlorinated water, prevention should include: infrastructure for handwashing with non‐ Monitoring Tool to assess tissues for cleaning, etc.) ‐ handwashing device with a bucket to catch water medical equipment for infection prevention infrastructure and equipment for required to clean and disinfect ‐ soap for washing hands (soap, tissues for cleaning, and chlorinated handwashing, infection prevention the area in case of accidental ‐ tissues for cleaning water). (decontamination and containers spillage ‐ chlorinated water ‐ For the 48% non‐compliant CSB, IMPACT, with for infectious waste), waste cans, ACCESS district‐based staff, will support the CSB safety boxes, etc. 17 CSB were equipped with non‐medical equipment for infection to formulate a request letter to the Direction prevention out of the 33 CSB/Pha‐Ge‐Com visited. des Services de Santé de Base (DSSB) for the installation of hand washing stations and for the [33 CSB /Pha‐Ge‐Com visited] other non‐medical equipment. 1.1.3. Provide CSB providers with: Number of CSB providers Medical equipment for infection prevention should include: ‐ 70% (23/33) of CSB visited in Year 1 had medical garbage cans & gloves for ordinary equipped ‐ Safety boxes equipment for infection prevention (safety box, waste; sharps containers and ‐ Sharps containers sharp container, gloves, garbage for disposal). gloves; handwashing device with a ‐ Gloves ‐ It was recommended to the CSB providers to bucket to catch handwashing water ‐ Garbage disposal include in each commodity order to Pha‐G‐Dis the medical equipment 23 CSB equipped with medical equipment for infection prevention out of the 33 CSB/Pha‐Ge‐Com visited.

[33 CSB /Pha‐Ge‐Com visited]

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2. Social Marketing, Education, & Social Behavior Change Communication (SBCC).

2.1.1 Include messages on proper Number of communication Message on disposal of Sur’Eau bottles was inserted in the poster The messages on proper storage and disposal of storage, use and disposal of materials or radio spots or TV of Sur’Eau and the same for Protector Plus with message on commodities were: commodities in the communication with instructions on proper disposal displayed on the packaging ‐ Included in the radio spots for Protector Plus campaigns using various CHANNELs storage, use, and disposal of ‐ Included on the Poster of Sur’Eau and Protector such as mass‐media. Messages will commodities by end‐users 3,200 radio spots for Protector Plus on disposal of used condoms Plus. be tested with a diverse audience broadcasted and packaging were broadcasted in 13 USAID‐supported regions (differences in sex, age, literacy within 37 districts. Poster was used to covered 78 USAID‐supported Net care and repair were included in the LLIN radio level, and socio‐economic status). Percent of target group who know districts. spots. and those who adopt the Details of the activities will be behavior (all people interviewed 1,980 radio spots broadcasted on LLIN care and repair in 10 USAID‐ Indicators measuring proper disposal of commodities included in the communication plan. and among those who know the supported regions within 13 districts and old LLINs among target groups are inserted in the instruction on proper storage, use household surveys questionnaires that are currently and disposal of commodities) being conducted by ACCESS and Mahefa Miaraka. respect the proper disposal of Data will be available in Quarter 1 of Year 2. commodities and the old LLINs 3. Storage, management, distribution, transportation and disposal of public health commodities and equipment 3.1.1. Include in training curriculum Number of PSI central warehouse, Nonprofit sector Nonprofit Sector how to properly manage expired PARC, PA and public sector Type Male Female Total ‐ 18 PSI warehouse staffs were trained on expired (properly logged), obsolete or (SALAMA/central warehousing, Warehouse 13 5 18 and surplus products management. Only 2 surplus commodities for PSI central Pha‐G‐Dis, Pha‐Ge‐Com and CSB) PARC 18 51 69 warehouses did not receive training. Some warehouse, PARC, PA and public persons trained (disaggregated by PA 354 505 859 warehouses and PARC had more than one person sector (SALAMA/central sex) trained. warehousing, Pha‐G‐Dis, Pha‐Ge‐ [13 warehouses visited] ‐ All the 66 PARC and 859 PA were also trained on Com and CSB). A disposal plan will be [66 PARC visited] expired and surplus products management. created and will be available for the [859 PA visited] ‐ The plan would be to train field staff from Quarter trainees following the national 1 Year 2. guidelines. Curriculum will be adapted to different literacy or Public Sector education levels to ensure effective Public sector (Training on expired and surplus commodities) ‐ SALAMA central warehouse staff were trained on understanding Type Male Female Total management of expired and surplus commodities. SALAMA 1 0 1

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Pha‐G‐Dis 6 19 25 ‐ In 34 Pha‐G‐Dis supervised for Year 1, 73% Pha‐Ge‐ (25/34), were trained on management of expired 0 12 12 Com/CSB and surplus commodities. ‐ In 33 Pha‐Ge‐Com supervised for Year 1, 36% [1 SALAMA visited] (12/33) were trained on management of expired [34 Pha‐G‐Dis visited] and surplus commodities. [33 CSB /Pha‐Ge‐Com visited] ‐ The RLA will participate in the training of commodity management scheduled in Year 2 that ACCESS is conducting for Pha‐Ge‐Com and CSB.

3.1.2. Regularly check expiry date of Number of expired, obsolete, and Nonprofit Sector Nonprofit Sector commodities during monthly visit of surplus products at PSI central Products Expired Surplus Obsolete ‐ The 118,275 identified expired products were PSI central warehouse, PARC, PA, warehouse, PARC, PA, and public Warehouse 118 275 0 0 incinerated by ADONIS in July. The report of the and public sector (SALAMA/central sector (SALAMA and central PARC 0 180 499 incineration is available. warehousing, Pha‐G‐Dis, Pha‐Ge‐ warehousing, Pha‐G‐Dis, Pha‐Ge‐ PA 39 7,176 7,806 ‐ The PAs with 39 expired products were Com and CSB). Com and CSB) [13 warehouses visited] recommended to send the expired products to the [66 PARC visited] nearest CSB for incineration. “If there are expired products in the [859 PA visited] warehouse, the supervisor will take appropriate action to rectify the Public Sector Public Sector practice" Products Expired Surplus Obsolete ‐ Expired and surplus commodities were detected SALAMA 0 0 0 in Pha‐G‐Dis supervised.

Pha‐G‐Dis 21,316 49,772 0 ‐ Since Quarter 3, IMPACT Malaria GAS committee CSB/Pha‐Ge‐ redeployed surplus commodities (See IR.2 191 0 0 Com narrative section). ‐ The RLA provided recommendations on the [1 SALAMA visited] destruction of the expired commodities according [34 Pha‐G‐Dis visited] to the national guideline. [33 CSB /Pha‐Ge‐Com visited]

Objective for Year 2: Every quarter, it was recommended to the GAS committee to conduct a stock analysis of each district with RLA support. The objective of this exercise is to

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redeploy surplus commodities before sending quarterly orders to SALAMA. 3.1.3. Provide guidelines and Number of PSI central warehouse, Nonprofit Sector Nonprofit Sector appropriate communication tools on PARC, PA and public sector Warehouse 10 ‐ 10 warehouses had the appropriate guidelines on storage conditions for each product (SALAMA/central warehousing, PARC 56 storage conditions during visit. by following standard guidelines for Pha‐G‐Dis, Pha‐Ge‐Com and CSB) PA 740 ‐ In Quarter 1 Year 2, the 5 non‐compliant proper storage and distribution of that have guidelines and [13 Warehouses visited] warehouses will be equipped with communication health commodities for PSI central communication tools [66 PARC visited] tools and guideline on storage condition and on warehouse, PARC, PA and public [859 PA visited] transportation of commodities. sector (SALAMA/central warehousing, Pha‐G‐Dis, Pha‐Ge‐ Public Sector Public Sector Com and CSB) ‐ SALAMA is equipped with communication tools. SALAMA 1 ‐ 29% (10/34) of Pha‐G‐Dis and 12% (4/33) of Pha‐ Pha‐G‐Dis 10 Ge‐Com visited in Year 1 had communication tools CSB/Pha‐Ge‐Com 4 in their storage rooms. [1 SALAMA visited] ‐ RLAs duplicated and shared guidelines to Pha‐G‐ [34 Pha‐G‐Dis visited] Dis during supervision in Year 1. [33 CSB /Pha‐Ge‐Com visited] ‐ The missing guidelines and communication tools will be part of the primary focus on EMMP activity for Quarter 1 Year 2. 3.1.4. Follow and share WHO Number of reports on expired Among the Pha‐Ge‐Com and Pha‐G‐Dis visited in Year 1, no report ‐ The RLA recommended the Pha‐Ge‐Com and Pha‐ guidelines for Safe Disposal of pharmaceutical waste and plastic on destruction of expired and damaged commodities was available G‐Dis to always document all related activities on unwanted pharmaceuticals and medical delivered to CSB/SSD for because there was no destruction activity conducted. destruction of commodities. enhance collaboration with MOH: incinerating ‐ Collect and deliver expired pharmaceutical waste and plastic medical supply at Supply Points and warehouses and deliver them to the CSB/SSD for incinerating according to the National Medical Waste Management Policy issued in 2014

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3.1.5. Distribution of safety boxes to Non stock‐out rate of safety box Non stock‐out rate of safety box at CSB: ‐ For the 48% that were stocked out of safety boxes, be used by the CHV and CSB at all PA at PA and CSB 51.5% [17 CSB/Pha‐Ge‐Com among the 33 CSB/Pha‐Ge‐Com the RLA recommended the CSB/Pha‐Ge‐Com to and CSB visited] include safety boxes in the next commodity order.

3.1.6. Submit to Malaria SBCC Number of SBCC communication No SBCC communication materials produced for continuous ‐ Printing and distribution of the communication working group all LLIN materials produced, including all distribution. The creation of the communication tools is still tools is scheduled in Year 2 during the continuous communication and training materials produced by other ongoing. distribution activity. materials in line with the malaria partners. With the lead of the national communication plan (2018‐ MOH, IMPACT will organize a 2022) to align with the malaria meeting with other partners to national strategic plan (NSP 2018‐ collect SBCC communication 2022): job aids, training curricula, materials produced. scope of work, and radio messages to ensure proper disposal of LLIN bags is addressed.

4. Storage and distribution of LLIN 4.1.1.1. Use pre‐approved WHOPES Percent of LLINs tested for Post‐campaign 2018 Net durability study on DawaPlus® 2.0 The bioassay analysis (one of the three components brands of LLINs to ensure the quality bioassay and that are above the of the Net durability study) of the DawaPlus 2.0 net and efficacy of the LLINs purchased, WHO threshold (knock down LLIN brand Bekily Farafangana Maintirano conducted in August 2018 in three districts (Bekily, that they contain effective >95% and mortality >80%) No. of LLIN tested 30 30 22 Mainitrano, and Farafangana) after one month of pyrethroid levels. KD (%) 66.7 65.6 66.4 use by the households targeted during the LLIN Average mortality mass campaign distribution provided the following 84.0 84.5 84.9 rate (%) results: ‐ The average knocks down was 66% which is KD: Knock Down under the WHO threshold of 95% for the three

districts studied.

‐ The average mortality rate was 84% which is

above the WHO threshold of 80%.

Pre‐campaign 2018 A bioassay test conducted upon arrival of the LLINs DawaPlus® PermaNet® LLIN brand in Madagascar showed that: 2.0 2.0 No. of LLIN tested 30 30

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KD (%) 79.3 71.2 ‐ The knock down was 79% for DawaPlus 2.0 LLIN Average mortality rate (%) 86.4 83.9 brand and 71% for Permanet 2.0 brand which are under the WHO threshold of 95%. ‐ The mortality rate was 86% and 84% for DawaPlus 2.0 and Permanet 2.0 respectively which are above the WHO threshold of 80%.

The final report for the net durability study will be available in 2021 after the implementation of the 36 months. These first results will be used as evidence for the upcoming LLIN procurement of the mass campaign distribution scheduled in 2021.

4.2.1.1. Store LLINs in wooden Number of PSI warehouses and ‐ IMPACT will continue to check every quarter to pallets, dry, ventilated, and secure field storage areas that meet 11 warehouses met the storage quality of being dry, secure, and maintain high storage quality. areas to prevent theft or storage quality (dry, ventilated, ventilated among the 13 warehouses visited. unauthorized access. and secure) 4.2.1.2 Post guard or use barred Number of PSI warehouses and Post guard Barred window ‐ All visited warehouse were post‐guarded. windows as needed field storage areas with post 13 11 ‐ For Quarter 1 of Year 2, the objective is to visit guard or barred windows [13 warehouses visited] the remaining 2 warehouses.

4.2.1.3. Post visible warning signs on Number of PSI warehouses and 5 PSI warehouses and field storage areas were equipped with ‐ Printed warning signs were sent to 14 doors and windows in local language field storage areas equipped with warning signs among the 13 warehouses visited. warehouses. to alert people that pesticide warning signs ‐ Continue to visit the remaining 2 warehouses in products are stored inside Quarter 1 of Year 2 to install and check the installation of warning signs for non‐compliant warehouses.

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4.2.1.4. Do not store LLINs with food, Number of SBCC materials The net durability conducted after one month of the mass campaign ‐ The net durability was conducted within only 3 feed, or potable water supplies created and distributed showing in 2018 provided that 77% of households surveyed stored food in districts with distribution of DawaPlus 2.0. that LLINs need to be stored far the room where they slept. ‐ Results on this indicator with large sample will be from food, potable water obtained (proper storage/place of LLIN not with food or potable water) from a household surveys Percent of storage that do not questionnaire that are currently being conducted meet the criteria for storage (not by ACCESS and Mahefa Miaraka. Data will be with food or potable water) available in Quarter 1 of Year 2.

4.2.2.1. Ensure provision of gloves Number of workers equipped For the continuous distribution of LLINs in 2020, the training ‐ Stakeholder training activities will begin in and instruction on their use with gloves and the instruction of documents are revised and finalized with the NMCP. November and December 2019. their use (disaggregated by sex)

4.2.2.2. Provide worker training on Number of workers trained on For the continuous distribution of LLINs in 2020, the training ‐ Stakeholder training activities will begin in the proper handling and display of proper handling and display of documents are revised and finalized with the NMCP. November and December 2019 LLINs. The training materials will LLINs (disaggregated by sex) ‐ Indicators on knowledge of malaria prevention include messages related to malaria and proper use of LLIN among target groups are prevention and proper use of LLINs Percent of target group who know inserted in the household surveys questionnaires using mass‐media and interpersonal malaria prevention and proper that are currently being conducted by ACCESS communication (by Mahefa‐Miaraka use of LLIN and Mahefa Miaraka. Data will be available in and ACCESS) Quarter 1 of Year 2. 4.3.1.1. Ensure that SBCC materials Percent of LLINs properly washed Data from surveys is not yet available. ‐ The net durability study conducted 12 months and outreach activities are and maintained after the 2018 campaign will be available Quarter coordinated with net distribution 1 of Year 2 and is the appropriate tool to provide activities during campaigns, and the information on net care (washing and repair). include guidelines on how to ‐ Indicators on net washing can be also calculated properly wash and maintain LLINs from the household surveys questionnaires that (e.g., discourage disposal of wash are currently being conducted by ACCESS and water in sensitive ecosystems, Mahefa Miaraka. Data will be available in Quarter discourage washing and rinsing 1 of Year 2. LLINs in bodies of water)

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4.4.1.1. Ensure that SBCC messages Number of campaign distributors For the continuous distribution of LLINs in 2020, the training ‐ Stakeholder training activities will begin in inform campaign distributors and and community leaders trained documents are revised and finalized with the NMCP. November and December 2019 local communities about the on potential harm (disaggregated potential harm to human health and by sex) the environment if bags and baling materials are reused and are in line with the malaria national communication plan (2018‐2022) 4.4.1.2. Support the NMCP in the Communication tools (job aids, No communication tools produced for continuous distribution. The ‐ All communication tools will be used in the development of the national malaria pamphlets.) created and creation of the communication tools is still ongoing. continuous distribution with mention on how to communication plan 2018‐2022) distributed on how to handle and handle and dispose bags and baling materials which will provide guidance, best dispose bags and baling materials (communication tools will include details of the practices for handling and disposing (communication tools will include disposal plan) of bags and baling materials. details of the disposal plan) Messages need to be adapted for literacy or education levels. Number of campaign distributors No training conducted yet. and community leaders trained ‐ Training activities will begin in November and on how to handle and dispose December 2019 bags and baling materials (disaggregated by sex) 4.4.1.3. Encourage the MOH and the Minutes on decision of bulk No results reported yet on this activity. ‐ This activity will be reported in Quarter 2 of Year RBM (Roll Back Malaria) committee packaging during RBM meeting 2. to procure LLINs with bulk packaging. The project will Waste management plan coordinate with NMCP to create a developed waste management plan. 4.5.1.1. If there is evidence of misuse Solution developed and ‐ Based on net durability study conducted one month after the ‐ Issues will be addressed by NMCP with support of LLINs (from surveys such as implemented to address the issue mass campaign distribution, it was noted that there was low from IMPACT and will be monitored during the Malaria Indicator Survey, Net on misuse. coverage on SBCC, low LLIN coverage, and soap powder was implementation of the continuous distribution durability study), assess the extent being used to wash the LLINs, which was not recommended. activity. of misuse and collaborate with The RBM committee recommended that Bekily and different ministries (Ministries of Farafangana need to be included in continuous distribution. health, environment, agriculture) to ‐ RBM meeting minute are available to confirm this decision.

131 develop locally relevant solutions, and proceed with implementation.

4.6.1.1. Ensure that the disposal of Burial report stated the No results reported yet on this activity. ‐ The tool to record landfill of LLIN is developed LLINs comply with the WHOPES & consideration of the following and validated with NMCP. NMCP guidelines. If LLINs and criteria: controlled access, soil ‐ Burial of LLIN and packaging which is part of packaging are collected, the option with low permeability, away from continuous community distribution activity, will for disposal will be high‐ residences, at least 100m away start in January 2020 then related report will be temperature incineration. If this is from any wells and surface water available from Quarter 2 year 2. not possible, the other option will be sources and at 1.5m above the burial, away from water sources. water table

Incineration3 report stating temperature of the incineration 5. Climate Risk Management 5.1.1.1. The storage and On inspection, the storage and Number of warehouse/public sector meeting the criteria of storage transportation of the commodities transportation meet the following and transportation of products: and LLIN should be : criteria: Standard Storage: ‐ away from humidity, direct 1. dry and ventilated place to ‐ SS1: Dry and Ventilated sunlight avoid humidity and high ‐ SS2: High area ‐ protected from high temperature/heat ‐ SS3: Robust building temperature/heat 2. High area to avoid flood ‐ SS4: Temperature Controlled ‐ in a high area to avoid damaged 3. Robust warehouse to or deterioration by flood, prevent cyclone or landslide Standard temperature conditions: ‐ stored in a robust building deterioration ‐ ST5: Away from moisture and humidity (made with burnt brick, cement or 4. temperature controlled ‐ ST6: Avoid heat modern materials) to avoid ‐ ST7: Avoid direct sunlight deterioration of the warehouse by cyclone and landslide, Nonprofit sector Nonprofit Sector

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‐ in area with temperature Storage ‐ 11 warehouses met at least one of the 4 criteria controlled, including transportation Warehouse PARC PA of storage quality. from central warehouse to the Pha‐ SS1 11 64 815 ‐ 8 warehouses met the criteria on “High to avoid G‐Dis , Pha‐Ge‐Com, and to the LLIN SS2 8 0 0 flood.” distribution sites SS3 13 0 0 ‐ A risk evaluation will be conducted in Quarter 1 SS4 12 0 0 Year 2 among the 5 warehouses that did not Total 11 0 0 meet the SS2 criteria. A plan will be proposed for Transportation sites with higher risk. ST5 7 44 583 ‐ Less than 50% of warehouses meet the quality transport criteria. ST6 7 44 584 ‐ For Quarter 1 Year 2, continue the formative ST7 7 41 582 supervision for the workers involved in Total 7 44 583 transportation (distribution team, warehouse [13 Warehouses visited] teams, and drivers). [66 PARC visited]

[859 PA visited]

Public sector Public Sector Storage ‐ Only 9% of Pha‐G‐Dis and 6% of Pha‐Ge‐Com Pha‐Ge‐ SALAMA Pha‐G‐Dis visited had controlled room temperature. Com/CSB ‐ IMPACT will support the SDSP to send a request SS1 1 29 31 letter to DPLMT for the procurement of SS2 1 33 33 thermometers for storage room. SS3 1 34 33 ‐ 59% (20/34) of Pha‐G‐Dis and 67% (22/33) Pha‐ SS4 1 3 2 Ge‐Com visited in Year 1 respected more than 4 SS5 1 33 33 storage conditions among the 7 criteria required. SS6 1 34 33 ‐ Transportation of commodities from Central to SS7 1 33 33 Pha‐G‐Dis and from Pha‐G‐Dis to Pha‐Ge‐Com Total 1 20 22 respected the three criteria for transportation: Transportation 100% (34/34) for Pha‐G‐Dis and (33/33) Pha‐Ge‐ ST5 1 33 33 Com respectively. ST6 1 34 33 ST7 1 33 33 Total 1 34 33

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[1 SALAMA visited] [34 Pha‐G‐Dis visited] [33 CSB /Pha‐Ge‐Com visited] 5.1.1.2. Organizing capacity building Number persons from PSI central Nonprofit sector Nonprofit Sector through technical workshops and warehouse, PARC, PA and public Male Female Total ‐ All PARC and PA were trained on distribution training to enhance coordination sector (SALAMA/central Warehouse 10 2 12 management. and distribution of quality health warehousing, Pha‐G‐Dis, Pha‐Ge‐ PARC 50 22 66 ‐ 12 warehouse staff received training on products: among PSI central Com and CSB), and the PA 361 815 859 distribution management, which represents 50% warehouse, PARC, PA and public responsible for sending [13 Warehouses visited] of the total staff working in the 15 warehouses. sector (SALAMA/central commodities and LLINs trained [66 PARC visited] ‐ In Quarter 1 Year 2, the objective is to expand warehousing, Pha‐G‐Dis, Pha‐Ge‐ (disaggregated by sex) [859 PA visited] training to all PSI warehouse agents (regional Com and CSB), and those assistants, stock keepers). responsible for sending commodities and LLINs. Public sector Public Sector Male Female Total Regarding distribution management (order, SALAMA 1 0 1 shipment, etc.) of commodities, Pha‐G‐Dis 6 19 25 ‐ SALAMA staff were trained. Pha‐Ge‐ ‐ 73% (25/34) of Pha‐G‐Dis providers and 45% 0 15 15 Com/ CSB (15/33) of Pha‐Ge‐Com providers supervised in Year 1 were trained.

[1 SALAMA visited] On job training and refresher training on distribution [34 Pha‐G‐Dis visited] management will continue in Year 2. [33 CSB /Pha‐Ge‐Com visited] 5.1.2.1 Include messages to end‐ Number of communication No communication materials to address CRM issue were Communication tools will be developed with the TMA users to address improper storage of materials or radio spots or TV developed. sub‐committee on communication and demand commodities and LLIN linked to with instructions on proper creation in year 2. climate risk management (CRM: storage, of commodities and LLIN flood, cyclone, landslide, to avoid CRM issue. evapotranspiration, humidity, and increased temperatures) in the Percent of target group who know No data available yet from the survey Indicators measuring knowledge on proper storage communication campaigns using and respect the proper storage of of LLINs is inserted in the household surveys mass‐media. commodities and LLINs to address questionnaires that are currently being conducted by CRM issue ACCESS and Mahefa Miaraka. Data will be available in Quarter 1 of Year 2.

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ANNEX D ‐ Success Stories (Quarter 4)

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Enhancing the role of the private and commercial health sectors through accessing to subsidized malaria commodities: game changer in Madagascar’s supply chain system

In Madagascar, the public supply chain for health products is fragmented, commercial supply chain options are under‐utilized, and the social marketing supply chain is limited in its reach. Providing support to the GOM (DPLMT) to deliver and increase the use of quality health products at scale, IMPACT sets a diverse supply of priority health products across sectors, which entails sufficient number of delivery points, and diverse products at different price points that grow the market in terms of volume and value. As important players in the supply and distribution of health products across the country, the private and commercial sectors have an invaluable asset and in order to expand their commitment, the IMPACT project through the Private Sector Humanitarian Platform (PHSP) led by TELMA Foundation has been integrated SOPHARMAD and SOMAPHAR, two General Assembly of the PSHP pharmaceutical wholesalers, leaders in the import and distribution of drugs in Madagascar. However, an action plan aims to sustainably increase access to priority health products will be developed and implemented. The PHSP is a platform open to all private actors, which allows its members to explore new markets, access funding, and integrate technical working groups that IMPACT will create to advance initiatives based on the creating shared value and corporate social responsibility.

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Madagascar Measles Outbreak: Rapid delivery of vaccines has helped control the epidemic The Ministry of Public Health declared a measles outbreak in Madagascar in September 2018. At the end of March 2019, a total of 118,088 measles cases were reported with nearly 1,714 cases resulting in death, including 1,115 laboratory confirmed cases. Measles is a highly contagious viral disease and its complications can cause death in people with weakened immune systems. 70% of measles cases are children and adolescents aged 1 to 14 years.

In March 2019, 13,456 medical kits (standard, pediatric, and adult) were delivered to 74 health districts in 14 hard‐to‐reach areas. Three vaccination campaigns were conducted in 114 health districts and IMPACT supported the Direction du Programme Elargi de Vaccination (DPEV) in delivering 500 m3 of vaccines, medical supplies, management tools, and SBCC materials to 66 health districts.

“Due to delicate logistical challenges to keep vaccines between 2°C and 8 °C, especially in Loading of vaccines and kits at the Airport remote areas, we have to deliver vaccine Crédit Photo : MAF Madagascar containers within 72 hours,” said Tovohery Ramarolahy Tony, a Ministry of Public Health conveyor.

“Transporting these health products is very challenging as we face the rainy season, the bad road conditions, should maintain the good condition of the product, and respect the delivery time fixed for 72 hours,” explained Mr Fenohery Benjamina Razafindratafika, a transporter. For some very remote health districts, IMPACT used Mission Aviation Fellowship (MAF) to transport vaccines on time. To date, IMPACT has contributed $165,885 to the transportation of vaccines and medical kits and the vaccination campaigns have enabled 7,300,000 children to be immunized against measles in 114 health districts. At the beginning of the epidemic, the case fatality rate was 0.8%, but has decreased to 0.06% in March (Source: Weekly epidemiological report on measles from the MOPH) The close collaboration between the Ministry of Public Health and its partners made it possible to control the measles epidemic.

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Redeployment of Malaria Commodities Saves 4 Sofia Districts from Stock‐Out

In May, the District Pharmacy of Soalala (Pha‐G‐Dis) in the Boeny region was overstocked with anti‐malarial products (34 months of stock for ACT 2‐11 months, 22 months of stock for ACT 1‐5 years old, and 14 months of stock for RDTs) while districts in neighboring regions (Port Bergé, Analalava, Antsohihy and Mitsinjo) were in stockout of ACT 2‐11 months, ACT 1‐5 years old and RDT .

After an inventory analysis and field visits, the IMPACT team, in collaboration with USAID ACCESS, initiated the redeployment of products from the Soalala district to the Sofia region to supply the districts of Port Bergé,

Analalava, and Antsohihy. At the same time and under IMPACT Staff coordination, the same District also redeployed commodities to Mitsinjo District. In total, 7,200 doses of ACT 2‐ 11 months, 1,800 doses of ACT 1‐5 years, and 1,500 RDTs were transported by boat from Soalala to the districts.

These inter‐regional and inter‐district redeployments helped to avoid stock‐outs in the four districts of the Sofia region and to avoid the destruction of overstocked drugs equivalent to USD 2,193 in the Soalala district. Redeployment of Malaria Commodities During their supervision visit, IMPACT also provided on‐the‐job training to the responsible of the malaria program in Soalala on the correct calculation of their commodity needs, inventory management, and good storage practices. IMPACT is conducting supervision visits each semester in hard to reach districts like Soalala to follow up on progress. In practice, EMAR or EMAD mainly conduct supervision and training activities and the IMPACT team brings support in organization and preparation of didactic materials for training and result restitution.

The malaria program manager in Soalala said, "We have been able to avoid the destruction of these overstocked drugs at home. In addition, the team trained us on the basics of quantification of health products. We are currently able to quantify our needs to avoid overstocks."

"We are truly grateful to the IMPACT team and partners because with this redeployment, the stockout problem has been resolved and the needs of health facilities can be met," said the district pharmacy manager of Port Bergé.

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IMPACT and Aqualma work together to deliver health products on time in the Besalampy rural District

The district of Besalampy in the Melaky region is one of most inaccessible districts in Madagascar. Depending on the amount of rainfall, the road opens only 3 to 4 months during the year. For years, supplying health products to this district has been a challenge.

To ensure the continuous availability of family planning and maternal, newborn, and child health products, IMPACT collaborated with Aqualma, a shrimp farming and fishing company known for its humanitarian convictions. The IMPACT field team solicited collaboration of Aqualma to transport community health products to Besalampy.

Through this partnership, Aqualma transports community health products free of charge by boat or plane in the record time of 24 hours by air and 48 hours by sea so that the Point d’Approvisionnement Relais Communautaire (PARC), the 9 Points d’Approvisionnement (PA), and the 161 Community Health Volunteers (CHV) in this district be regularly supplied. In the district of Besalampy, 594 women regularly use Oral

Contraceptives and 4,040 use injectable contraceptives. The boat KEA DELFINI of the Aqualma Company which ensures the transport of products.

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Using Innovative Approaches to Provide Business and Financial Training to Drug Shops

IMPACT conducted its first financial business strengthening training for drug shops on May 21st and 22nd in Fénerive Est. The training was led by IMPACT’s Access to Finance (A2F) team, and included the owners and managers, including six women, of 22 drug shops in the Analanjirofo region.

In 2019, PSI conducted a drug shops survey to identify training needs. Findings of this survey showed that bookkeeping and inventory management are the main areas in which drug shops most urgently need training. The A2F team tailored the training to meet those needs.

This pilot training was the first of its kind in the Participants doing group exercise on bookkeeping private health supply chain sector, offering not only new training topics, but also a new approach to participant selection. The A2F team used positive self‐ selection for participant selection. Under this approach, the regional drug shop association publicized the training event, and participants had to indicate their interest in attending, rather than IMPACT spending time and resources to mobilize participants. In addition to pro‐actively attending the training, participants were also required to pay their own transportation and accommodation costs for this two‐day training and IMPACT provided only meals and training materials. The training participants therefore invested in their own capacity building, which indicates that they are more likely to be motivated to apply what they learned to the daily operations of their drug shops.

Given that the managers and owners of 22 drug shops were willing to cover the costs to attend the training, the evidence suggests that this participant selection approach was effective in attracting participants that have a genuine interest in improving their business practices.

The A2F team also partnered with a pharmaceutical wholesaler, SOPHARMAD, for the stock management portion of the training to build participants’ knowledge of the drugs they sell. Training participants greatly appreciated SOPHARMAD’s attendance because it enabled them to better understand the drugs that they sell and to learn about new drugs. SOPHARMAD also offered drug shops participating in the training a special discount on pharmaceutical products and a reduction of transportation costs. SOPHARMAD benefitted from this training as well because it introduced them new potential drug shop clients.

The training was a success and appreciated by the participants. One participant, Pauline, a drug shop owner based in Sainte Marie explained, “I have been working in this sector for more than 25 years, and this is my first time receiving a management and financial training. It was practical and simple.”

This pilot training has created high interest in future trainings integrating participant self‐selection and capacity building for drug shops. The IMPACT A2F team ensured that participants walked away satisfied and motivated to improve their business practices.

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Vavatenina District: Management team Leadership Helps Improve Health Inputs Management at District Wholesale Pharmacy

The District of Vavatenina is one of six districts constituting the region of Analanjirofo. The District Pharmacy (Pha‐G‐Dis) of Vavatenina supplies 23 health facilities (CSB), one District Hospital Pharmacy Unit (CHRD 1) and the private dispensary called SALFA.

For more than a year, due to lack of computer equipment and electrical infrastructure, the district has been unable to record its reports on health products consumption and to transmit orders on time to the central level for resupply. As a result, the Pha‐G‐Dis could not obtain adequate supplies and meet the drug needs of the health Figure 23: IMPACT Logistic Regional Advisor and the responsible of stock facilities it serves. In addition, it made it difficult to management of the district pharmacy of Vavatenina trace the drugs that the pharmacy was managing.

In July 2019, the IMPACT project team conducted a field visit to Vavatenina to identify the problem and support the district. During the visit, the IMPACT team took an inventory of commodities and sensitized the management team, including the Medical Inspector on the importance of using the “Channel” Software management tool to facilitate health commodity management, namely to send consumption reports, forecast needs, and transmit orders. Convinced of the importance of this tool, the Medical Inspector mobilized his team to install an electrical connection in the Pha‐G‐Dis. He has also made a computer available to install the Channel Software to record all logistics data. In addition, he designated a dedicated person to manage the logistics management information system. Vavatenina's Pha‐G‐Dis has started using the Channel Software and has been sending reports to the central level since August. Thanks to the use of this software, they are better equipped to trace health products and find the issues identified during the inventory.

"Prior to this initiative, the Channel software was not even installed on our computer and no data was recorded and reported. The use of this software helps us to better manage our stocks and to send our data in time to anticipate stockouts. We were convinced of the importance of the good management of health products, especially after the on‐the‐job training conducted by IMPACT, " said Dr RAFALIMANANARISOA Elson Jedekia, Medical Inspector of Vavatenina.

The Channel Software automates order tracking and allows reports and orders to be sent to central warehouses. With more streamlined and faster reporting, central warehouse teams are better able to supply the district.

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Projecting commodity needs to avoid Health Commodity Stock Outs

Quantification is a crucial step of health commodity supply chain. It is an exercise consisting of accurately determining the supply requirements of a country for a given period. This exercise is very important because it minimizes the risk of too low or too high estimates, leading to stock outs, shortages, or costly losses due to the expiry of drugs. In order to ensure the availability of medicines and health products for the fight against malaria, Family Planning, Reproductive Health and Maternal, Neonatal and Infant Health, and other essential medicines, the IMPACT Project has strengthened the capacity of the Ministry of Public Health staff and its partners in quantification. 116 people from the various departments of the Ministry of Health, technical and financial partners, representatives of private sector wholesalers, pharmacists from reference hospitals,

Figure 24: Participants during forecasting exercise SALAMA central medical store and l'Unité d'approvisionnement en Solutés Massifs (UASM) benefited from training. Participants learned about quantification concepts, methods and principles and were trained in the use of forecasting tools (Quantimed), monitoring and supply planning (Pipeline).

Under the leadership of the Ministry of Health, four workshops were organized from April to June 2019, including one for a training of trainers in quantification and three others to define forecasts and supply plans for the period from 2019 to 2021. Supply plans and procurement defined the needs of the public and the social marketing sectors and were used to mobilize the necessary resources from financial partners. IMPACT supported the Ministry of Health in all stages of quantification exercises, from selection of participants, collection of data for the quantification exercise, preparation meetings until the elaboration of quantification final report.

Thanks to this initiative, the supply plans were validated in July by the National Logistics Management Committee (CGL) and helped mobilize the necessary funds and proceed to the purchase of medicines and health products which the country needs for the next three years.

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ANNEX E – Stock inventory as of September (USAID and PMI funded)

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Malaria commodities SALAMA

Commodity Batch PERIOD QUANTITY Unit SULFADOXINE‐PYRIMETHAMINE 500‐25MG ‐ CP ‐ BTE/150 9E55 1‐April‐22 6,000 B/150 Tablet SULFADOXINE‐PYRIMETHAMINE 500‐25MG ‐ CP ‐ BTE/150 SP180801 1‐August‐21 2,113 B/150 Tablet SULFADOXINE‐PYRIMETHAMINE 500‐25MG ‐ CP ‐ BTE/150 SP180802 1‐ August‐21 8,028 B/150 Tablet SULFADOXINE‐PYRIMETHAMINE 500‐25MG ‐ CP ‐ BTE/150 SP180803 1‐ August‐21 7,928 B/150 Tablet SULFADOXINE‐PYRIMETHAMINE 500‐25MG ‐ CP ‐ BTE/150 SP180804 1‐ August‐21 6,994 B/150 Tablet 4,659,450 Tablets ASAQ ADOLESCENT(ENFANT) 100/270MG ‐ CP ‐ B/25*3 8MA610 1‐December‐20 2,894 B/25 Tablet ASAQ ADOLESCENT(ENFANT) 100/270MG ‐ CP ‐ B/25*3 CYZ658178 1‐November‐20 3,121 B/25 Tablet ASAQ ADOLESCENT(ENFANT) 100/270MG ‐ CP ‐ B/25*3 CYZ658179 1‐November‐20 3,798 B/25 Tablet 245,325 Dose ASAQ ADULTE 100/270MG ‐ CP ‐ B/25*6 8MA602 1‐December‐20 2,320 B/25 Tablet ASAQ ADULTE 100/270MG ‐ CP ‐ B/25*6 8MA603 1‐December‐20 3,345 B/25 Tablet ASAQ ADULTE 100/270MG ‐ CP ‐ B/25*6 CYZ728181 1‐November‐20 482 B/25 Tablet ASAQ ADULTE 100/270MG ‐ CP ‐ B/25*6 CYZ728182 1‐November‐20 3,186 B/25 Tablet ASAQ ADULTE 100/270MG ‐ CP ‐ B/25*6 CYZ728183 1‐November‐20 3,208 B/25 Tablet ASAQ ADULTE 100/270MG ‐ CP ‐ B/25*6 CYZ728184 1‐November‐20 1,373 B/25 Tablet 347,850 Dose TEST DE DIAGNOSTIC RAPIDE DU PALUDISME ‐ BTE/25 MR19E65 1‐October‐21 21,740 B/25 Kit TEST DE DIAGNOSTIC RAPIDE DU PALUDISME ‐ BTE/25 MR19E66 1‐October‐21 18,243 B/25 Kit 999,575 Kit ARTESUNATE 60 MG‐INJ‐BTE/ 1 ZA1180411 1‐March21 63,891 Vial 63,891 Vial

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MNCH commodities

Commodity Batch PERIOD QUANTITY GENTAMICINE 10MG/ML INJ ‐ AMP 2ML ‐ (20MG) ‐ BTE/100 8EB01206 1‐May‐21 52,200 GENTAMICINE 10MG/ML INJ ‐ AMP 2ML ‐ (20MG) ‐ BTE/100 8EB02272 1‐June‐21 32,000 84,200 Vial GENTAMICINE 40MG/ML INJ ‐ AMP 2ML ‐ (80MG) BTE/100 QD2180201 1‐February‐21 14,900 GENTAMICINE 40MG/ML INJ ‐ AMP 2ML ‐ (80MG) BTE/100 QD6171111 1‐November‐20 21,000 35,900 Vial MAGNESIUM SULFATE 50% INJ.AMP.10ML ‐ BTE/10 0094649 1‐February‐21 167,200 MAGNESIUM SULFATE 50% INJ.AMP.10ML ‐ BTE/10 2218MG‐A/4 1‐May‐21 109,800 1‐May‐21 277,000 Vial OXYTOCINE 10UI/ML INJ. AMP. 1ML ‐ B/10 80274 1‐May‐21 12,386 OXYTOCINE 10UI/ML INJ. AMP. 1ML ‐ B/10 80462 1‐June‐21 75,180 OXYTOCINE 10UI/ML INJ. AMP. 1ML ‐ B/10 80463 1‐June‐21 33,440 121,006 Vial

FP commodities Will be discussed with DSFa and will be reported in Year 2.

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ANNEX F – Stock status by end of September 2019

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STOCK STATUS OF MALARIA COMMODITIES AT CENTRAL LEVEL: SALAMA,

Stock Month of Planned shipments in available at AMD PRODUCT Stock stock status the period of October SALAMA, end (quantification) available to December 2019 of September New PMI order of 57 ASAQ 2 – 11 months 25mg/67,5mg 600 blisters with 95,700 12,958 7.39 Under Stock tablet, Blister of 3 tablets Estimated arrival date of March 2020 New PMI order of ASAQ 1 – 5 years 50mg/135mg tablet 933 400 blisters with 209,725 32,258 6.50 Under Stock Blister of 3 tablets Estimated arrival date of December 2019 New PMI order of 305 ASAQ 6 – 13 years 100/270MG tablet – 325 blisters with 296,600 27,692 10.71 Normal Blister of 3 tablets Estimated arrival date of March 2020 New PMI order of ASAQ 14 years and more 100/270mg 488 150 blisters with 376,750 32,392 11.63 Normal tablet– Blister of 3 tablets estimated arrival date of March 2020 Global Fund Shipment of 10,000 suppos ARTESUNATE suppository, 1 suppo 0 1,167 0.00 planned to arrive in December 2019 New order of 25 000 Vials with estimated ARTESUNATE Injectable 60mg/vial, set 117,227 9,981 11.75 Normal arrival date of December 2019 Global Fund Shipment of 1,816,056 Kits planned to arrive in December 2019. RAPID DIAGNOSIS TEST, 1 KIT 2,914,500 322,700 9.03 Normal New PMI order of 2 290 325 tests with estimated arrival date of January 2020 The NMCP has disseminated clear guidance on use of SP to boost its consumption. IMPACT is collaborating with NMCP, ACCESS and Sulfadoxine/Pyrimethamine 500/25 mg MAHEFA‐MIARAKA to 11,003,550 225,275 48.84 Overstock Tablets increase communication and sensitization on IPTp. The GAS committee will continue monitoring of expiry dates to avoid any loss.

STOCK STATUS OF MNCH COMMODITIES AT CENTRAL LEVEL: SALAMA

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stock available Month of at PRODUCT AMD* stock Situation Recommended actions SALAMA, available end of Sept Close monitoring on consumption and Under Gentamycin 10 Mg/ml, 84,200 33,722 2.50 mobilize resources for a new Stock injectable, vial of 2ml (80ml) procurement This product will be used in Year 2,

35,900 2,134 16.82 there is no risk of expiry (expiry date is Gentamycin 40 Mg/ml, Overstock injectable, vial of 2ml (20ml) February 2021) This product will be used in Year 2,

27,700 1,423 19.47 there is no risk of expiry (expiry date is Sulfate de magnesium 50%, Overstock injectable, vial of 10 ml May 2021) Request to USAID to distribute the Oxytocin natiowide (all districts) even 112,600 1,280 87.94 Oxytocin 10U.I/ml, Overstock out of USAID supported zones. Expiry date is June 2021 injectable, ampoule of 1ml all quantities have been transported to Pha‐G‐Dis. Close monitor distribution at Misoprostol Tablets Pack of 4 28,761 2,876 10.00 Normal CSB and Community level. There is a need to confirm with UNFPA for a next donation

148

ANNEX G: Summary of mass media spot aired during Year 1

149

Health Area Product Activities Quarter 1 Quarter 2 Quarter 3 Quarter 4 Total Number NA 2,147 760 4,420 7,327 Sur'Eau Radio Spot Number NA 5 5 10 10 Pilina Number NA 16 16 28 28 MNCH Radio Spot Number 504 216 NA NA 720 Measles Radio TV Number 124 36 NA NA 160 World Radio Spot Number NA NA 90 NA 90 Health Day Radio TV Number NA NA 20 NA 20 Number NA NA 3,200 NA 3,200 Protector Radio spot Number NA NA 12 NA 12 Plus Number NA NA 37 NA 37 FP Number NA NA NA 1,550 1,550 FP Radio Spot Number NA NA NA 13 13 Number NA NA NA 29 29 Number NA NA NA 1,980 1,980 LLIN radio spot Number NA NA NA 10 10 Number NA NA NA 13 13 Number NA NA 180 NA 180 IPTp TV spot Number NA NA 12 NA 12 Number NA NA 12 NA 12 Malaria Number NA NA 135 NA 135 RDT TV spot Number NA NA 9 NA 9 Number NA NA 4 NA 4 Number NA NA 260 NA 260 Gag Radio Gag Radio Number NA NA 10 NA 10 of 6mn Spot Number NA NA 7 NA 7

150

ANNEX H: Descriptions of the seven quality dimensions for the RDQA

151

Data Quality Parameter Descriptions The extent to which data and its supporting documentation are available. Review availability of the indicator source documents for the selected reporting period. 1‐ Availability Source documents depends on the indicator but will often refer to client intake forms, registers, cards redeemed vouchers, etc. Specify the name of the documents reviewed.

Complete means that the document contained all the required entries of the indicator as appropriate. 2‐Completeness Review completeness of the indicator source documents for the selected reporting period.

The degree to which the data correctly reflects what they were intended to measure. 3‐Accuracy It is also known as validity. Accurate data correctly measure actual events, cases, units, etc.

The extent to which data is up‐to‐date (current) and is made available on time. Review the timeliness of documents received from the site for the selected reporting 4‐Timeliness period. Reports can either be summary reports or reports of aggregated data that is submitted to the next reporting level e.g. regional or district level.

The extent to which data is protected from unauthorized changes or manipulation. 5‐Integrity Review the source document for any indication of unauthorized (accidental or deliberate) insertion, modification or destruction of data.

6‐Confidentiality The extent to which information or data is protected and kept secure.

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

152

ANNEX I: Quantity and value (Usd) of the redeployment

153

Departure Destination Cost Unit Value Cost of price of Product to be Quantity (doses/ of the Region Departure District Region Destination District transportation the deployed Vial Inj/kits) products (USD) product (USD) (USD) MELAKY AMBATOMAINTY ACT 2‐11 mois 1 800 MELAKY ANTSALOVA 8,33 0,11 198,0 MELAKY AMBATOMAINTY ACT 2‐11 mois 2 400 MELAKY MAINTIRANO 11,11 0,11 264,0 MELAKY MORAFENOBE ACT 1 à 5 ans 4 800 MELAKY AMBATOMAINTY 0,00 0,20 940,8 MELAKY MORAFENOBE ACT 1 à 5 ans 7 800 MELAKY ANTSALOVA 0,00 0,20 1528,8 MELAKY AMBATOMAINTY ACT 2‐11 mois 1 875 MELAKY MAINTIRANO 0,00 0,11 206,3 MELAKY AMBATOMAINTY ACT 2‐11 mois 9 000 MELAKY TANA 27,78 0,11 990,0 MELAKY MORAFENOBE ACT 2‐11 mois 900 MELAKY MAINTIRANO 0,00 0,11 99,0 MELAKY MORAFENOBE ACT 1 à 5 ans 3 400 MELAKY MAINTIRANO 0,00 0,20 666,4 MELAKY MORAFENOBE ACT 6 à 13 ans 2 375 MELAKY MAINTIRANO 0,00 0,29 679,3 MELAKY MORAFENOBE ACT 14 ans et + 1 375 MELAKY MAINTIRANO 0,00 0,72 988,6 MELAKY MORAFENOBE ACT 1 à 5 ans 1 200 MELAKY MAINTIRANO 0,00 0,20 235,2 MELAKY AMBATOMAINTY ACT 1 à 5 ans 3 600 MELAKY MAINTIRANO 0,00 0,20 705,6 BOENY SOALALA ACT 2‐11 mois 3 600 BOENY DRSP BOENY 29,17 0,11 396,0 BOENY SOALALA ACT 2‐11 mois 1 200 BOENY DRSP BOENY 0,00 0,11 132,0 BOENY DRSP BOENY ACT 2‐11 mois 600 SOFIA MAMPIKOMY 0,00 0,11 66,0 SOFIA PORT BERGE ACT 6 à 13 ans 600 SOFIA MAMPIKOMY 0,00 0,29 171,6 BOENY DRSP BOENY ACT 2‐11 mois 600 SOFIA PORT BERGE 0,00 0,11 66,0 SOFIA PORT BERGE ACT 1 à 5 ans 600 SOFIA BEALANANA 0,00 0,20 117,6 BOENY DRSP BOENY ACT 2‐11 mois 1 200 SOFIA ANTSOHIHY 0,00 0,11 132,0 BOENY DRSP BOENY ACT 2‐11 mois 600 SOFIA BEALANANA 0,00 0,11 66,0 SOFIA MAMPIKOMY Artésunate 60mg inj 100 SOFIA PORT BERGE 0,00 SOFIA MAMPIKOMY SP 6 000 SOFIA PORT BERGE 0,00 0,13 780,0 BOENY DRSP BOENY ACT 1 à 5 ans 1 200 SOFIA ANTSOHIHY 0,00 0,20 235,2 SOFIA DRSP BOENY ACT 2‐11 mois 600 SOFIA BEFANDRINA NORD 0,00 0,11 66,0

154

Departure Destination Cost Unit Value Cost of price of Product to be Quantity (doses/ of the Region Departure District Region Destination District transportation the deployed Vial Inj/kits) products (USD) product (USD) (USD) SOFIA PORT BERGE ACT 1 à 5 ans 2 400 SOFIA BEFANDRINA NORD 0,00 0,20 470,4 SOFIA MAMPIKOMY Artésunate 60mg inj 100 SOFIA BEFANDRINA NORD 0,00 SOFIA MAMPIKOMY SP 5 400 SOFIA MANDRITSARA 0,00 0,13 702,0 SOFIA PORT BERGE ACT 6 à 13 ans 600 SOFIA ANALALAVA 0,00 0,29 171,6 SOFIA Befandrina nord RDT 2 250 SOFIA Mampikomy 0,00 0,31 697,5 SOFIA Mandritsara ACT 2‐11 mois 600 SOFIA Bealalana 0,00 0,11 66,0 SOFIA Port Berge ACT 1 à 5 ans 450 SOFIA Mandritsara 0,00 0,20 88,2 SOFIA Port Berge RDT 3 000 SOFIA Mampikomy 0,00 0,31 930,0 SOFIA Mampikomy ACT 14 ans et + 600 SOFIA Mandritsara 0,00 0,72 431,4 SOFIA Soalala ACT 2‐11 mois 600 SOFIA Antsohihy 0,00 0,11 66,0 SOFIA Soalala ACT 2‐11 mois 600 SOFIA Port Berge 0,00 0,11 66,0 BOENY Soalala ACT 2‐11 mois 1 200 SOFIA Analalava 0,00 0,11 132,0 BOENY Marovoay ACT 2‐11 mois 550 BOENY Mitsinjo 0,00 0,11 60,5 SOFIA Port Berge ACT 1 à 5 ans 150 BOENY Majunga I 0,00 0,20 29,4 SOFIA Port Berge ACT 1 à 5 ans 1 800 BOENY Marovoay 0,00 0,20 352,8 SOFIA Mampikomy ACT 6 à 13 ans 500 BOENY Marovoay 0,00 0,29 143,0 SOFIA Mampikomy SP 5 400 BOENY Marovoay 0,00 0,13 702,0 BOENY Soalala ACT 2‐11 mois 1 200 BOENY Mitsinjo 0,00 0,11 132,0 BOENY Soalala ACT 1 à 5 ans 600 BOENY Mitsinjo 0,00 0,20 117,6 BOENY Soalala RDT 1 500 BOENY Mitsinjo 0,00 0,31 465,0 BOENY Majunga I ACT 2‐11 mois 425 BETSIBOKA Maevatanana 0,00 0,11 46,8 SOFIA Port Berge ACT 1 à 5 ans 525 BETSIBOKA Maevatanana 0,00 0,20 102,9 BETSIBOKA KANDREHO ACT 1 à 5 ans 3 000 BETSIBOKA Maevatanana 57,22 0,20 588,0 DIANA AMBILOBE ACT 6 à 13 ans 300 DIANA AMBANJA 0,00 0,29 85,8

155

Departure Destination Cost Unit Value Cost of price of Product to be Quantity (doses/ of the Region Departure District Region Destination District transportation the deployed Vial Inj/kits) products (USD) product (USD) (USD) DIANA AMBILOBE ACT 14 ans et + 400 DIANA AMBANJA 0,00 0,72 287,6 DIANA AMBILOBE ACT 6 à 13 ans 300 DIANA NOSY‐BE 0,00 0,29 85,8 DIANA AMBILOBE ACT 14 ans et + 400 DIANA NOSY‐BE 0,00 0,72 287,6 DIANA Ankatafa AMBANJA ACT 2‐11 mois 13 DIANA Pha‐G‐Dis AMBANJA 0,00 0,11 1,4 DIANA Ankatafa AMBANJA ACT 6 à 13 ans 53 DIANA Pha‐G‐Dis AMBANJA 0,00 0,29 15,2 DIANA Ankatafa AMBANJA ACT 14 ans et + 15 DIANA Pha‐G‐Dis AMBANJA 0,00 0,72 10,8 DIANA Ankatafa AMBANJA RDT 24 DIANA Pha‐G‐Dis AMBANJA 0,00 0,31 7,4 DIANA Ankatafa AMBANJA Artésunate 60mg inj 10 DIANA Pha‐G‐Dis AMBANJA 0,00 DIANA Ankatafa AMBANJA SP 273 DIANA Pha‐G‐Dis AMBANJA 0,00 0,13 35,5 DIANA AMBILOBE ACT 6 à 13 ans 25 DIANA DIEGO II 0,00 0,29 7,2 DIANA AMBILOBE ACT 14 ans et + 25 DIANA DIEGO I 0,00 0,72 18,0 DIANA AMBILOBE ACT 14 ans et + 25 DIANA DIEGO II 0,00 0,72 18,0 DIANA AMBILOBE SP 150 DIANA DIEGO I 0,00 0,13 19,5 DIANA AMBILOBE SP 150 DIANA DIEGO II 0,00 0,13 19,5 DIANA DIEGO I RDT 50 DIANA NOSY‐BE 2,78 0,31 15,5 SAVA ANDAPA ACT 2‐11 mois 200 SAVA ANTALAHA 0,00 0,11 22,0 SAVA ANDAPA Artésunate 60mg inj 50 SAVA SAMBAVA 0,00 SAVA ANTALAHA RDT 1 500 SAVA ANDAPA 0,00 0,31 465,0 Vatovavy Fitovinany Ifanadiana ACT 2‐11 mois 525 Vatovavy Fitovinany MANANJARY 102,31 0,11 57,8 Vatovavy Fitovinany Ifanadiana ACT 2‐11 mois 900 Vatovavy Fitovinany NOSY VARIKA 0,00 0,11 99,0 Vatovavy Fitovinany Ifanadiana ACT 2‐11 mois 6 630 Vatovavy Fitovinany MANAKARA 72,56 0,11 729,3 Vatovavy Fitovinany Ikongo ACT 6 à 13 ans 1 275 Vatovavy Fitovinany MANANJARY 0,00 0,29 364,7 Vatovavy Fitovinany Ikongo ACT 14 ans et + 1 150 Vatovavy Fitovinany MANANJARY 0,00 0,72 826,9 Vatovavy Fitovinany Ikongo ACT 6 à 13 ans 1 425 Vatovavy Fitovinany NOSY VARIKA 9,72 0,29 407,6

156

Departure Destination Cost Unit Value Cost of price of Product to be Quantity (doses/ of the Region Departure District Region Destination District transportation the deployed Vial Inj/kits) products (USD) product (USD) (USD) Vatovavy Fitovinany Ikongo ACT 14 ans et + 1 375 Vatovavy Fitovinany NOSY VARIKA 0,00 0,72 988,6 Vatovavy Fitovinany ikongo ACT 6 à 13 ans 1 175 Vatovavy Fitovinany NOSY VARIKA 6,94 0,29 336,1 Vatovavy Fitovinany ikongo ACT 14 ans et + 687 Vatovavy Fitovinany NOSY VARIKA 0,00 0,72 494,0 Vatovavy Fitovinany ikongo ACT 14 ans et + 798 Vatovavy Fitovinany MANANJARY 100,89 0,72 573,8 Vatovavy Fitovinany Manakara SP 9 462 Vatovavy Fitovinany IFANADIANA 0,00 0,13 1230,1 Vatovavy Fitovinany Manakara ACT 1 à 5 ans 1 743 Vatovavy Fitovinany IKONGO 0,00 0,20 341,6 Vatovavy Fitovinany Manakara RDT 6 825 Vatovavy Fitovinany MANANJARY 0,00 0,31 2115,8 Vatovavy Fitovinany Manakara ACT 1 à 5 ans 714 Vatovavy Fitovinany NOSY VARIKA 8,33 0,20 139,9 Vatovavy Fitovinany Manakara SP 7 938 Vatovavy Fitovinany NOSY VARIKA 0,00 0,13 1031,9 Vatovavy Fitovinany Manakara RDT 6 675 Vatovavy Fitovinany NOSY VARIKA 0,00 0,31 2069,3 Vatovavy Fitovinany Manakara SP 5 100 Vatovavy Fitovinany VOHIPENO 69,72 0,13 663,0 Vatovavy Fitovinany Iafanadiana ACT 6 à 13 ans 1 500 Vatovavy Fitovinany Nosy Varika 239,22 0,29 429,0 Vatovavy Fitovinany Iafanadiana ACT 14 ans et + 1 000 Vatovavy Fitovinany Nosy Varika 0,00 0,72 719,0 Atsimo Atsinanana vondrozo RDT 750 Vatovavy Fitovinany Mananjary 0,00 0,31 232,5 Atsimo Atsinanana vondrozo RDT 3 750 Vatovavy Fitovinany Nosy Varika 0,00 0,31 1162,5 Atsimo Atsinanana vondrozo RDT 4 500 Vatovavy Fitovinany Ifanadiana 0,00 0,31 1395,0 Haute Mahatsiatra Ambohimahasoa ACT 1 à 5 ans 1 200 Vatovavy Fitovinany IFANADIANA 55,56 0,20 235,2 Haute Mahatsiatra Ambohimahasoa ACT 1 à 5 ans 1 200 Vatovavy Fitovinany IKONGO 5,56 0,20 235,2 Haute Mahatsiatra Ambohimahasoa ACT 1 à 5 ans 1 200 Vatovavy Fitovinany MANANJARY 0,00 0,20 235,2 Haute Mahatsiatra Ambohimahasoa ACT 1 à 5 ans 2 400 Vatovavy Fitovinany NOSY VARIKA 9,72 0,20 470,4 Haute Mahatsiatra Ambohimahasoa ACT 1 à 5 ans 4 200 Vatovavy Fitovinany MANAKARA 117,78 0,20 823,2 Haute Mahatsiatra Ambohimahasoa ACT 1 à 5 ans 1 800 Vatovavy Fitovinany VOHIPENO 45,33 0,20 352,8 Haute Mahatsiatra Ambohimahasoa RDT 1 500 Vatovavy Fitovinany IFANADIANA 0,00 0,31 465,0 Haute Mahatsiatra Ambohimahasoa RDT 1 500 Vatovavy Fitovinany IKONGO 0,00 0,31 465,0

157

Departure Destination Cost Unit Value Cost of price of Product to be Quantity (doses/ of the Region Departure District Region Destination District transportation the deployed Vial Inj/kits) products (USD) product (USD) (USD) Haute Mahatsiatra Ambohimahasoa RDT 1 500 Vatovavy Fitovinany MANANJARY 0,00 0,31 465,0 Haute Mahatsiatra Ambohimahasoa RDT 1 500 Vatovavy Fitovinany NOSY VARIKA 0,00 0,31 465,0 Haute Mahatsiatra Ambohimahasoa RDT 3 000 Vatovavy Fitovinany MANAKARA 0,00 0,31 930,0 Haute Mahatsiatra Ambohimahasoa RDT 1 500 Vatovavy Fitovinany VOHIPENO 0,00 0,31 465,0 Haute Mahatsiatra Ambohimahasoa ACT 2‐11 mois 500 Vatovavy Fitovinany IKONGO 47,22 0,11 55,0 Haute Mahatsiatra Ambohimahasoa ACT 1 à 5 ans 6 300 Vatovavy Fitovinany IKONGO 0,00 0,20 1234,8 Haute Mahatsiatra Ambohimahasoa RDT 7 450 Vatovavy Fitovinany IKONGO 0,00 0,31 2309,5 Haute Mahatsiatra Ambohimahasoa Artésunate 60mg inj 50 Vatovavy Fitovinany IKONGO 0,00 Haute Mahatsiatra Ambohimahasoa ACT 1 à 5 ans 1 200 Vatovavy Fitovinany IFANADIANA 0,00 0,20 235,2 Atsimo Andrefana PNLP ACT 6 à 13 ans 1 300 Ihorombe Ihosy 146,22 0,29 371,8 Atsimo Andrefana PNLP ACT 14 ans et + 900 Ihorombe Ihosy 0,00 0,72 647,1 Atsimo Andrefana Ankazoabo RDT 3 300 Ihorombe Iakora 0,00 0,31 1023,0 Amoron'i Mania Ambositra ACT 1 à 5 ans 1 000 Ihorombe IHOSY 80,41 0,20 196,0 Amoron'i Mania Ambositra SP 10 000 Ihorombe IHOSY 0,00 0,13 1300,0 Amoron'i Mania Ambositra Artésunate 60mg inj 400 Ihorombe IHOSY 0,00 Atsimo Andrefana Ankazoabo RDT 11 490 Anosy Betroka 103,01 0,31 3561,9 IHOROMBE Ihosy RDT 8 100 ANOSY BETROKA 8,33 0,31 2511,0 Atsimo Andrefana Ankazoabo ACT 2‐11 mois 1 600 Atsimo Andrefana Betioky 95,93 0,11 176,0 Atsimo Andrefana Ankazoabo ACT 14 ans et + 2 250 Atsimo Andrefana Betioky 0,00 0,72 1617,8 Atsimo Andrefana Ankazoabo ACT 6 à 13 ans 500 Atsimo Andrefana Ampanihy 74,68 0,29 143,0 Atsimo Andrefana Ankazoabo ACT 14 ans et + 1 500 Atsimo Andrefana Ampanihy 0,00 0,72 1078,5 Atsimo Andrefana Ankazoabo RDT 8 250 Atsimo Andrefana Ampanihy 0,00 0,31 2557,5 Atsimo Andrefana PNLP ACT 6 à 13 ans 239 Atsimo Andrefana Sakaraha 73,26 0,29 68,4 Atsimo Andrefana PNLP ACT 1 à 5 ans 2 000 Atsimo Andrefana Sakaraha 0,00 0,20 392,0

158

Departure Destination Cost Unit Value Cost of price of Product to be Quantity (doses/ of the Region Departure District Region Destination District transportation the deployed Vial Inj/kits) products (USD) product (USD) (USD) Atsimo Andrefana PNLP ACT 14 ans et + 175 Atsimo Andrefana Sakaraha 0,00 0,72 125,8 Atsimo Andrefana Ankazoabo ACT 14 ans et + 2 250 Atsimo Andrefana Sakaraha 0,00 0,72 1617,8 Atsimo Andrefana Ankazoabo SP 7 000 Atsimo Andrefana Sakaraha 0,00 0,13 910,0 Atsimo Andrefana Ankazoabo RDT 11 550 Atsimo Andrefana Sakaraha 0,00 0,31 3580,5 Atsimo Andrefana Ankazoabo ACT 2‐11 mois 549 Atsimo Andrefana Toliara II 92,39 0,11 60,4 Atsimo Andrefana Ankazoabo ACT 14 ans et + 624 Atsimo Andrefana Toliara II 0,00 0,72 448,7 Atsimo Andrefana Ankazoabo SP 1 000 Atsimo Andrefana Toliara II 0,00 0,13 130,0 Atsimo Andrefana Ankazoabo RDT 10 560 Atsimo Andrefana Toliara II 0,00 0,31 3273,6 Atsimo Andrefana Ankazoabo SP 1 000 Atsimo Andrefana Toliara I 0,00 0,13 130,0 Atsimo Andrefana Ankazoabo ACT 2‐11 mois 66 Atsimo Andrefana Toliara I 0,00 0,11 7,3 Atsimo Andrefana Ankazoabo ACT 14 ans et + 126 Atsimo Andrefana Toliara I 0,00 0,72 90,6 Atsimo Andrefana Ankazoabo ACT 2‐11 mois 285 Atsimo Andrefana Morombe 92,39 0,11 31,4 Atsimo Andrefana Ankazoabo ACT 14 ans et + 750 Atsimo Andrefana Benenitra 0,00 0,72 539,3 Haute Mahatsihatra Ambohimahasoa RDT 10 500 Haute Mahatsihatra Ambalavao 0,00 0,31 3255,0 Atsinanana Vatomandry ACT 2‐11 mois 75 Atsinanana Brickaville 0,00 0,11 8,3 Atsinanana Vatomandry ACT 2‐11 mois 75 Atsinanana Toamasina II 0,00 0,11 8,3 Atsinanana Vatomandry ACT 1 à 5 ans 525 Atsinanana Toamasina II 0,00 0,20 102,9 Atsinanana Vatomandry ACT 6 à 13 ans 200 Atsinanana Toamasina II 0,00 0,29 57,2 Atsinanana Vatomandry Artésunate 60mg inj 100 Atsinanana CHU Morafeno Toamasina I 0,00 Analamanga Ankazobe ACT 2‐11 mois 600 Atsinanana Mahanoro 0,00 0,11 66,0 Analamanga Ankazobe ACT 2‐11 mois 400 Atsinanana Brickaville 0,00 0,11 44,0 Analanjirofo Maroantsetra ACT 2‐11 mois 650 Atsinanana Mahanoro 2,78 0,11 71,5 Analanjirofo Maroantsetra ACT 2‐11 mois 125 Atsinanana Toamasina II 0,00 0,11 13,8 Analanjirofo Maroantsetra ACT 2‐11 mois 1 000 Atsinanana Brickaville 5,56 0,11 110,0

159

Departure Destination Cost Unit Value Cost of price of Product to be Quantity (doses/ of the Region Departure District Region Destination District transportation the deployed Vial Inj/kits) products (USD) product (USD) (USD) Analanjirofo Maroantsetra ACT 1 à 5 ans 900 Atsinanana Toamasina II 0,00 0,20 176,4 Analanjirofo Maroantsetra ACT 1 à 5 ans 75 Atsinanana Toamasina I 0,00 0,20 14,7 Analanjirofo Maroantsetra ACT 1 à 5 ans 1 025 Atsinanana Mahanoro 8,33 0,20 200,9 Atsinanana Vatomandry ACT 1 à 5 ans 3 600 Atsinanana Antanambao Manampontsy 20,83 0,20 705,6 Atsinanana Vohibinany ACT 1 à 5 ans 3 600 Atsinanana Marolambo 18,06 0,20 705,6 Atsinanana Vohibinany ACT 6 à 13 ans 1 000 Atsinanana Mahanoro 8,33 0,29 286,0 Atsinanana Vatomandry ACT 6 à 13 ans 300 Atsinanana Ambatondrazaka 5,56 0,29 85,8 Atsinanana Toamasina I Artésunate 60mg inj 50 Atsinanana Vohibinany 0,00 Atsinanana Brickaville ACT 1 à 5 ans 2 600 Atsinanana Toamasina II 0,00 0,20 509,6 Atsinanana Vatomandry ACT 1 à 5 ans 3 000 Atsinanana Antanambao Manampontsy 0,00 0,20 588,0 Atsinanana Vatomandry ACT 1 à 5 ans 2 000 Atsinanana Mahanoro 0,00 0,20 392,0 Atsinanana Vatomandry ACT 1 à 5 ans 3 000 Atsinanana Marolambo 39,44 0,20 588,0 Alaotra Mangoro Moramanga ACT 2‐11 mois 400 Alaotra Mangoro Anosibe An'ala 1,94 0,11 44,0 Analanjirofo Maroantsetra ACT 2‐11 mois 300 Alaotra Mangoro Ambatondrazaka 0,00 0,11 33,0 Analanjirofo Maroantsetra ACT 2‐11 mois 350 Alaotra Mangoro Anosibe An'Ala 2,78 0,11 38,5 Atsinanana Vohibinany ACT 1 à 5 ans 2 700 Alaotra Mangoro Ambatondrazaka 16,67 0,20 529,2 Analamanga DLP RDT 7 500 Analanjirofo Fénérive Est 0,00 0,31 2325,0 Analanjirofo Maroantsetra ACT 2‐11 mois 125 Analanjirofo Fénérive Est 0,00 0,11 13,8 Analanjirofo Maroantsetra ACT 2‐11 mois 500 Analanjirofo Mananara Nord 0,00 0,11 55,0 Analanjirofo Maroantsetra ACT 2‐11 mois 50 Analanjirofo Nosy Boraha (Sainte Marie) 0,00 0,11 5,5 Analanjirofo Maroantsetra ACT 2‐11 mois 250 Analanjirofo Soanierana Ivongo 0,00 0,11 27,5 Analanjirofo Maroantsetra ACT 1 à 5 ans 1 100 Analanjirofo Fenerive‐Est 0,00 0,20 215,6 Analanjirofo Maroantsetra ACT 1 à 5 ans 100 Analanjirofo Nosy Boraha (Sainte Marie) 0,00 0,20 19,6 Analanjirofo Maroantsetra ACT 1 à 5 ans 600 Analanjirofo Soanierana Ivongo 0,00 0,20 117,6

160

Departure Destination Cost Unit Value Cost of price of Product to be Quantity (doses/ of the Region Departure District Region Destination District transportation the deployed Vial Inj/kits) products (USD) product (USD) (USD) Analanjirofo Mananara Nord ACT 6 à 13 ans 325 Analanjirofo Maroantsetra 0,00 0,29 93,0 Analanjirofo Mananara Nord ACT 6 à 13 ans 450 Analanjirofo Soanierana Ivongo 0,00 0,29 128,7 TOTAL 81766,1

161