MALARIA ELIMINATION PROJECT

Cambodia Malaria Elimination Project Quarterly Progress Report - Year 5, Quarter 1 October - December 2020

Submission Date: 29th January 2021

Contract Number: AID-442-C-17-00001 Contract Period: October 26, 2016 to October 25, 2021 COR: Rida Slot Alternate COR: Saad El-Din Hussein

Submitted by: Sharon Thangadurai, Chief of Party University of Research Co., LLC. #31, St 352, Sangkat Beugkengkang 1, Khan Chankamon, Email: [email protected]

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

I TABLE OF CONTENTS Acronyms...... iii

1. Introduction...... 1

2. Progress Toward achieving CMEP OBJECTIVES ...... 3 2.1 Objective 1: Develop a scalable, evidence-based elimination model in SPL OD and support its dissemination and replication for malaria elimination in Cambodia. ... 3 2.2 Objective 2: Support scale-up of high quality malaria control and prevention interventions in five to eight ODs, where gaps in coverage or quality exist...... 9 2.3 Objective 3: Strengthen national malaria surveillance systems and M&E appropriate for malaria elimination and control activities ...... 13 2.4 Objective 4: Build capacity of Ministry of Health (MoH) to manage, intensify, and sustain malaria control and elimination efforts particularly at the OD level ...... 15 Procurement ...... 18 Financial Management...... 18 Human Resource Management...... 19 3. CHALLENGES AND ACTIONS TAKEN OR PROPOSED...... 20

4. PLANS FOR NEXT QUARTER AND UPCOMING EVENTS...... 20 ANNEX 1 CSO FY21 Q1 RESULTS TABLES ...... 21 ANNEX 2 LABORATORY QUALITY ASSESSMENT/MICROSCOPY TRAINING TABLES ...... 24 ANNEX 3 – P.v. Radical Cure Treatment Status ...... 25

II ACRONYMS

ACT Artemisinin-based Combination Therapies AHEAD Action for Health Development (CSO in Cambodia) AOP Annual Operational Plan ASMQ Artesunate + Mefloquine ASTMH American Society of Tropical Medicine and Hygiene BCC Behavior change communication BKN Bakan BTB CHAI Clinton Health Access Initiative CMEP Cambodia Malaria Elimination Project CDC Centers for Disease Control and Prevention CNM Cambodia National Malaria Center COP Chief of Party COVID-19 2019 novel cornoavirus CSO Civil Society Organization DOT Directly-observed therapy EDAT Early Diagnosis and Treatment FY21 Fiscal year 2021 G6PD Glucose 6 Phosphate Dehydrogenase HC, HF Health Centre, Health Facility HH Household hsRDT Highly-Sensitive Rapid Diagnostic Tests IDQA Internal Data Quality Assessment IEC Information, Education and Communication IP Intensification Plan IP2 Intensification Plan 2 IPC Institute Pasteur in Cambodia ITN Insecticide-Treated Net KRK Krakor LLIN/LLIHN Long Lasting Insecticidal Net/Hammock Net M&E Monitoring and Evaluation MEAF Malaria Elimination Action Framework MIS Management Informationn System MMP Mobile and Migrant Populations MMW Mobile Malaria Worker MoH Ministry of Health MRS Maung Russey NTG National Treatment Guidelines OD/ODMS Operational Health District/OD Malaria Supervisor P.f. Plasmodium falciparum PHD/PMS Provincial Health Department/Provincial Malaria Supervisor PI Principal Investigator PFDA Partner For Development in Action (CSO in Cambodia) PKV Phnom Kravanh PLN Pailin PMI President’s Malaria Initiative PP Private Provider PPM Private Public Mix PQ Primaquine PSWGME Provincial Special Working Group Malaria Elimination P.v. Plasmodium vivax Q1 Quarter 1

III Q2 Quarter 2 QA Quality Assurance RDT Rapid Diagnostic Tests RH Referral Hopsital SBCC Social and Behavior Change Communication SPL Sampov Loun SPM Sampov Meas TMK Thmar Kaul UNOPS United Nations Office for Project Services URC University Research Co., LLC USAID United States Agency for International Development VMW Village Malaria Worker WHO World Health Organization

IV 1. INTRODUCTION The USAID|PMI Cambodia Malaria Elimination Project (CMEP), 2016-2021, was launched on October 26, 2016 to support the Cambodian National Center for Malaria Control, Parasitology and Entomology (CNM) to reduce malaria morbidity and mortality and contribute towards malaria elimination goals nationwide by 2025. To reach this goal, the project has set up four strategic objectives to: 1. Develop a scalable, evidence-based elimination model in Sampov Loun (SPL) operational district (OD) and support its dissemination and replication for malaria elimination in Cambodia. 2. Support scale-up of high-quality malaria control and prevention interventions in five to eight ODs, where gaps in coverage or quality exist. 3. Strengthen national malaria surveillance systems and monitoring and evaluation (M&E) appropriate for malaria elimination and control activities. 4. Build capacity of malaria program to manage, intensify, and sustain malaria control and elimination efforts particularly at the OD level. The Year 5 work plan and budget was approved well ahead on time and this enabled CMEP team to start implementing the activity from day 1 of Year 5. The major activity conducted was the development of the OD Annual Operational Plan (AOP) on 13th October 2020 which was attended and facilitated by the Provincial Health Departmarts (PHDs) and OD staff. The OD staff took leadership and ownership by leading the AOP development process with the CMEP team just providing guidance and advice. Due to the 28th November COVID-19 case community transmission in Phnom Penh, there was complete lockdown of the surrounding areas in Phnom Penh (Boeung Keng Kang 1) and this led to the CMEP team to teleworking for two weeks. The CMEP field activities were also affected and most of the activities where people of 20 or more would gather were suspended, and the AOP development exercise for the Kep, and Koh Kong provinces was postponed and then completed virtually. It was hard for the CMEP team to carry out the Plasmodium vivax (P.v.) radical cure quantitative training in Battambang (BTB), Pailin (PLN), , Kep, Kampot, and Koh Kong, but CMEP was able to successfully conduct the trainings due to special approval from the Provincial Director. Similarly, the mass campaign experienced the same challenges and thus the activity in Phnom Kravanh (PKV) was postponed but was completed once it resumed. One of the key activities held in Quarter 1 (Q1) was the surveillance meeting which was held to revise and update the surveillance manual incorporating the chapter on P.v. case investigation and refining the foci investigation protocol. Despite having some COVID-19 restrictons, the CMEP team was still able to complete most of the Q1 Year 5 activities. One of the major events in Q1 was the US Ambassador W. Patrick Murphy’s visit to CMEP project in Pailin province. He visited Kracharb Health Center (HC) and was welcomed by the Pailin PHD Director and CMEP Chief of Party (COP), Mr. Sharon Thangadurai, and their respective teams. The Ambassador met the HC Chief and the team, visited the Outpatient Department (OPD), laboratory unit, and requested to test himself for malaria. He then met with 13 Village Malaria Workers (VMWs) and learned about their work and appreciated them for their contribution to eliminating malaria. The Ambassador appreciated the work of CMEP and applauded the VMWs commitment to provide services to malaria patients. The Ambassador also visited the health education session conducted by CMEP sub-grantee, Action for Health Development (AHEAD), and witnessed the session provided to more than 10 migrant workers who gathered at the HC. The ambassador expressed his happiness and appreciation to all of the workers for their great efforts in the journey to eliminate malaria in Cambodia.

1 Figure 1. CMEP Summary of Activity Progress (Oct.-Dec. 2020)

CMEP conducted the following key activities in fiscal year 2021 (FY21) Q1: . 35,418 of suspected cases were tested with 212 positive cases confirmed and all cases received appropriate treatment according to the National Treatment Guidelines (NTG). . In the seven CMEP elimination ODs in Battambang, Pailin and Pursat provinces, there were zero Plasmodium falciparum (P.f.)/mixed cases in Q1. There was a total of 22 P.v. cases in FY21 Q1. 21/22 (95%) of the P.v. species cases were notified within 1 day, 21/22 (95%) were investigated within 3 days, and 21/22 (95%) responded to within 7 days. In the partial elimination ODs, PKV and Krakor (KRK), there were zero P.f./mix cases in FY21 Q1. . In Q1, 14 P.v. cases were identified in BTB and PLN provinces for P.v. radical cure treatment, of which 8 were tested for Glucose 6 Phosphate Dehydrogenase (G6PD) which found that 6 patients were normal and 2 were deficient. Six (6) of these normal patients received 14 days Primaquine (PQ) treatment, with no side effect or adverse reactions and the reamining 6 are explained in Annex 3. . CMEP response to the malaria cases in Pursat ODs in FY21 Q1 continued and included monitoring daily/weekly cases, intensifying services at all points of care, and continued setup and support of touchpoint/peer educator volunteers. Out of the 37 touch points/peer volunteers who performed as Mobile Malaria Workers (MMWs), regular mapping helped in identifying new hotspots and closing the exisiting ones that no longer qualified as hotspots. In Q1, there were 6 touch points volunteers and 9 peer educator volunteers in KRK, and 10 touch points volunteers and 12 peer educators in PKV. . During Q1, there was a mass distribution activity for long lasting insecticidal nest (LLINs) and long lasting insecticidal hammock nets (LLIHNs) in CMEP three ODs.In Mauung Russey (MRS) and Sampov Meas (SPM) OD a total of 23,830 ITNs were distributed. and for PKV, a total of 62,077 LLINs were distributed. . In the 7 elimination ODs, CMEP deployed 8,522 insecticide-treated nets (ITNs) as buffer stock to Health Facilities (HFs) and VMWs in Q1. Through VMW outreach activities, the total ITN distribution was 5,487 to local residents and 3,281 ITNs to farms. . In the 2 transitional ODs, 679 ITNs were deployed as buffer stock to HF and VMW levels, 2,366 ITNs were distributed to local residents and 483 ITNs to farms. . CMEP supported CNM technical units to conduct 36 planned supervision visits.

2 . In Q1, there were 253 malaria suspected patients referred from Private Providers (PPs) to public health facilities in the 7 elimination ODs. 183 private providers attended the PP meetings. In the 2 transitional ODs, 10 suspected patients were refered from PPs to public health facilities. None of the PP meetings took place in these 2 ODs. Figure 1 provides an infographic summary of CMEP progress in FY21 Q1. Progress against each performance indicator (PITT table) is presented in the file attached.

CMEP PITT FY21 Q1.xlsx 2. PROGRESS TOWARD ACHIEVING CMEP OBJECTIVES 2.1 Objective 1: Develop a scalable, evidence-based elimination model in SPL OD and support its dissemination and replication for malaria elimination in Cambodia. Task 2. Sustain universal long-lasting insecticidal net (LLIN) coverage: Mass distribution: There was a mass distribution activity in FY21 Q1 for the elimination ODs. A total of 23,830 ITNs (16,262 LLINs and 7,568 LLIHNs) were distributed as part of the mass campaign in MRS and SPM ODs. Ensure continuous distribution of LLINs: In line with the updated list of villages for ITN distribution, CMEP’s target for continuous LLIN distribution was 240 villages in the 7 elimination ODs [Act. 1.2.3]. In the elimination ODs, CMEP deployed 8,522 ITNs as buffer stock to HFs and VMWs in Q1 (14,610 planned). CMEP will further deploy ITNs in FY21 Quarter 2 (Q2) using USG purchased ITNs. CMEP distributed 5,487 ITNs (12,335 planned) to target populations during outreach and response activities [Act. 1.2.5] and another 3,281 ITNs (target = 407) were distributed to mobile and migrant populations (MMPs) at big farms and MMP locations (the increased actual for this activity was due to increased outreach work by Civil society Organizations in some of the elimination ODs) [Act. 1.2.5.a]. Q1 achieved versus target is lower due to the mass campaign in fiscal year 2020 Quarter 4 and revising the targets based on new CNM guidance of targeting villages with API >= 5. Net top up and malaria education to households: In the 7 elimination ODs, VMWs conducted 2,532 visits (target = 2,558) to households/farms for net use monitoring, net top-up and health education [Act. 1.2.6]. Visits to household (HH) members/farm workers included health education for malaria prevention/LLIN use. There were 6 monitoring and supervision visits conducted from CNM ITN Unit to elimination ODs in Q1 (target = 6) [Act. 1.2.7]. Task 3. Ensure Early Diagnosis and Treatment (EDAT) and follow up: In the 7 elimination ODs, CMEP activities covered 432 points of care in Q1. (107 public health facilities, 308 VMWs, and 17 MMWs) [Act. 1.2.1]. 18,286 of 18,286 (100%) suspected malaria cases received a parasitological test. 63.6% of individuals were tested by VMWs and 36.4% by HFs (this shows that VMWs are continuing to increase their share of testing over previous quarters). Out of all the individuals tested there were zero P.f./mixed cases and 22 P.v. cases were confirmed positive. All 22 P.v. cases were enrolled in the system and 20 of the cases have travel history information (see Figure 2 for a table of case classification and OD case distribution maps for Q1). Further analysis showed there were 17 cases (77%) imported from Pursat, 0 case (0%) from and 3 cases (14%) from other provinces in Cambodia. There were 2 local cases (L1) for Pv. identified in this quarter in the 7 elimination ODs. Figure 2. Map of case classification for 7 ODs and reported malaria cases by origin (Oct-Dec 2020)

3 Out of 22 positive malaria cases reported in FY21 Q1, 0 (0%) were P.f./mixed and 22 (100 %) were P.v. Figure 3 provides the cases breakdown for Q1 and the cases trend since April 2017. Figure 3. Number of confirmed malaria cases in 7 ODs per species in Jan. 2017-Dec. 2020 (source MIS/PMIS)

4 Due to zero P.f./mixed cases in Q1, it was not necessary to conduct any 28 day follow up [Act. 1.3.3]. Figure 4 summarizes the implementation of directly observed therapy (DOT) for confirmed cases in the 7 CMEP elimination ODs. Figure 4. Implementation of DOT in 7 ODs per species during FY21 Q1

In FY21 Q1, zero patients were hospitalized for second line treatment in the 7 elimination ODs [Act. 1.3.6]. CMEP provided case management training during Year 4 where it was emphasized to administer single low dose primaquine. This was also done during refresher training and regular visits to VMWs and HFs. Since there were no P.f. cases, no Single Low Dose Primaquine was administered. CNM Pharmacy, Lab and Diagnosis and Treatment units completed 10 supervision visits in the elimination ODs (7 planned) during FY21 Q1 [Act. 1.3.10]. Task 4. Malaria case reporting, investigation, and response In 7 ODs, in Q1, 21 out of 22 cases (95%) were notified within 1 day via the SMS Day-0 mHealth system, 21 cases (95%) were investigated within 3 days, and for 21 (95%) the response was provided within 7 days

5 [Act.1.4.1-1.4.3]. All HFs/VMWs followed the established 1-3-7 surveillance practice. For response within 7 days, 1 cases out of the 22 cases (5%) were not responded due to patient unavailability at home. [Act.1.4.1-1.4.3]. Task 5. Strengthen case management, reporting, and response to all malaria cases in the private sector CMEP proposed and received approval from PMI for PPs not to test or treat as per the PRAKAS in 2018, thus the previous indicator has been removed from this quarter but the referral and supervision indicator is still being tracked and reported. In Q1, there were 253 malaria suspected patients referred from PPs to public health facilities in the elimination ODs and 94.8% of PPs (183/193) attended the PP meetings [Act. 1.5.3]. PPs who were absent from quarterly meetings were either busy with other tasks or did not consider the meetings relevant as they realize PPs are no longer able to test or treat, lack of motivation among the PPs are also seen as one of the major factors. 6 monthly supervision visits were also conducted to provide technical feedback on referrals and to improve SBCC initiatives. 44 PP visits were accomplished during supervision visits in Q1 [Act. 1.5.4]. 4 supervision visits (target = 5) from CNM’s Private Public Mix (PPM) unit were conducted in Q1 [Act. 1.5.5]. Task 6: Build capacity and strengthen systems to manage elimination activities Supporting VMW monthly meetings: Monthly meetings continued in Q1 to support capacity building of VMWs. Meetings were held during the fourth week of October, November, and December. In Q1 for the 7 ODs, in total, 1,084 VMWs attended meetings versus 975 planned [Act 1.6.1]. The increase was due to the reason that in some HF’s, 2 VMWs from the same village participated as well [Act 1.6.2]. Integrated supervision from ODs to HFs: 102 supervision visits were conducted to 107 HFs in the 7 elimination ODs using the CNM checklist (target = 104) [Act. 1.6.3]. Data verification on total tests, total confirmed cases and total treated cases was performed during the visits. Stock monitoring: CMEP continued to provide monthly rapid diagnostic tests (RDT) and artemisinin-based combination therapies (ACT), Artesunate + Melfoquine (ASMQ), stock status reports to CNM and all partners including United Nations Office for Project Services (UNOPS) and updates from all HFs in the 7 elimination target ODs. Overall, stocks of tests and drugs in CMEP areas was secured for the period of October-December 2020; there was no stockout and the few places that did identify any potential stockout were immediately fixed. There was no reallocation of drugs between elimination ODs during Q1. CMEP staff also visited key HCs, reviewed/monitored the stock levels and verified the consumption against the allocation. Visit to selected VMW’s from CNM VMW Unit: There were 2 visits from CNM VMW Unit conducted in elimination ODs in Q1 [Act. 1.6.6]. District Special Working Group for Malaria Elimination: 7 meetings were conducted in Q1 in the elimination ODs (target = 8) Due to COVID-19 situation, one of the districts (Bakan) decided to do conduct the meeting in Q2. These meetings enabled participants to recieve updated information on the potential gaps, tested cases, frequency of testing, etc. Provincial Special Working Group for Malaria Elimination (PSWGME) There were 2 PSWGME meetings in Q1 (planned = 1) [Act. 1.6.8]. During PSWGME meetings, there was discussions around tourists visiting mountainous areas and not following COVID-19 protocol. It was also mentioned that more rigorous action needs to be taken by the ministry of environment in tracking forest goers/MMPs who may not follow any COVID-19 guidelines. Task 7. Social and Behavior Change Communication (SBCC) for malaria elimination In the 7 elimination ODs, 18,286 individuals tested for malaria received interpersonal

6 communication for malaria education (target= 13,023), and was over target mainly due to VMWs/HFs increasing their number of tests and increased Civil Society Organization (CSO) activity [Act. 1.7.1]. In addition to malaria patients, malaria messages have been provided to 30,127 people from high-risk groups during case response activities within the village and farms [Act. 1.7.2]. CNM Health Education Unit made 4 visits in Q1 in the elimination ODs (planned = 5) [Act. 1.7.3]. Task 8. Support civil society organizations (CSO) to complement malaria elimination activities: In FY21 Q1, AHEAD was able to carry out activities succesfully in all of its 5 ODs and was able to work well with CMEP, OD teams, HCs, community level persons, OD staff, VMWs/MMWs and contact point staff. AHEAD also worked with local authorities and volunteers to identify hot spot areas, map MMP locations and identify suspected malaria patients for referring to VMWs/MMWs or HFs for testing and treatment. To ensure the effectiveness of referral cases reaching the delivery points, AHEAD staff and contact points carried out extensive follow ups through phone calls or face to face meetings (respectful of COVID-19 guidelines) with the relevant persons, in spite of COVID-19 restrictions and the flooding situation. AHEAD regularly followed up on the malaria situation in there respective ODs, and met the OD/PHD counterparts to discuss progress, challenges and ways forward. Considering the ongoing COVID-19 challenges, AHEAD was able to carry out their activities as usual and the majority of the activities were implemented as per the quarter plans. Most of the targets were achieved and some over achieved; for example MMPs reached by campaigns (1,250 target versus 1,511 result), ITNs distribution to MMPs (1,110 target versus 1,228 result) and referring suspected malaria patients (189 target versus 261 result). Please see the results comparing target and actuals in Annex 1, Table 1. In Q1, Partner for Development in Action (PFDA) continued to implement its activities in its 2 elimination ODs in , Bakan (BKN) and SPM. PFDA was able to continued working collaboratively with SPM and BKN OD counterparts, CMEP OD teams, HF staff, VMWs, local authorities and contact points to implement the assigned tasks to support the malaria elimination in the two ODs. Despite the COVID-19 restrictions and flooding, PFDA was able to implement the activities as planned. PFDA successfully organized 10 health education campaigns in the two ODs which reached 291 MMPs and high risk residents, and also distributed 326 ITNs to MMPs and local residents in the remote target areas. PFDA engaged local authorities and village volunteers to map 10 hot spots. PFDA’s contact points were able to identify 47 suspected malaria patients who were referred to VMWs/MMWs and HFs for testing and treatment (100% of referred patients reached the points of care as required). PFDA has continued to meet with OD/PHDs to share its activity implementation and progress. In Q1, most of the targets were achieved. Results are provided in Annex 1, Table 2. CMEP team provided capacity building, technical support, supervision and monitoring vists to both CSOs. Quarterly meetings were held to discuss the progress (planned versus achieved), challenges, lessons learned and finding solutions to address gaps. The quarterly meeting was held on 12th and 14th January as it was postponed due to COVID-19 restrictions. CMEP team suggested that the CSO needs to have clear targets and maps to plot new identified hotspots and target locations. They were also advised to target MMPs based on actual numbers for ITN coverage. Task 9. Conduct operational research in the context of malaria elimination In FY 2020 Quarter 4, the final technical report of the study on performance of highly sensitive Rapid Diagnostic Tests (‘hsRDTs’) was finalized and submitted to the Cambodia National

7 Ethics Committee for Health Research and the Centers for Disease Control and Prevention (CDC) Institutional Review Board. The final dissemination virtual meeting was held on 11th December 2020, presentation of the hsRDT study (final report) was provided. The meeting was chaired by CNM deputy director and Principal Investigator (PI) of the study, and was attended by 9 participants from CNM, USAID/PMI/CDC, Institute Pasteur in Cambodia (IPC) and CMEP. Dr. Benoit, from IPC who is also the Co-PI for the study, went through presentation highlighting the study design, purpose, methods, study sites, results and the conclusion/recommendations. The participants asked questions regarding the usefulness of the hsRDT tool, the assumptions and to understand CNM position for future diagnostic tools. It was clearly concluded that given the study report CNM will continue using the conventional RDT while the country is moving towards malaria elimination. The report is available for future references. Task 10. Refine existing malaria elimination tools, Standard Operating Procedures, and guidelines P.v. elimination has been initiated along with comprehensive malaria case management, including P.v. radical treatment scale up for countrywide implementation since late 2020. For elimination surveillance, while the response and management of P.f. foci with the introduction of targeted drug asministration and intermittent preventive treatment for forest goers has been added in the surveillance manual. P.v. case investigation and classification has been discussed and enabled the introduction of an investigation form piloted in CMEP elimination ODs. CMEP, along with other partners, has been extensively and actively involved in the entire process in revising and updating the surveillance manual. CMEP provided technical inputs and examples from field experiences to feed into the revision process. The surveillance manual finalization is in process and pending approval. Task 11. Expanded 5 ODs CMEPs approach to the 5 elimination ODs largely comprises of technical assistance on 1-3-7 approach, case based surveillance and quality service delivery. The three Technical Officers, regularly attended provincial and OD meetings to provided malaria health functionary timely support and advise on areas of improvement. In addition, PP team monitoring visits also complemented in assessing gaps and providing feedback for further improvement. The Technical Officers conduct daily and weekly case tracking from both HF and VMW, and assisting 1-3-7 activities for every P.f./mix malaria case. In Q1, there were in total 6,161 cases tested and 35 confirmed malaria cases in the three provinces (4 P.f. and 31 P.v.). Among these, Kampot tested 3,852 and confirmed 25 in which there were 21 P.v. and 4 P.f. (1 L1, 1 L2 and 2 L4); Kep tested 266 and confirmed 2 (both P.v.); and Koh Kong tested 2,043 and confirmed 8 cases (all P.v.). With the 1 L1 case identified in Kampot, CMEP staff from Phnom Penh and Technical Officer from Kampot joined and supported the PHD/OD team to conduct foci-investigation (from 16 – 18 Nov. 2020), for the P.f. L1 case at Mot Pearm Village under the cathchment area of Snam PramPi Health Center. The result was classified as R0V01. The Technical Officer at attended all three District Malaria Elimination Committee meetings in October, November and December in addition to supporting 2 P.f. case investigations at Monorom and Chey Ta Svay Village under Koh Sla HC, Chhouk OD.

1 Level of active foci demonstrates by scoring of Receptivity (R) linked to malaria vector and Vulnerability (V) linked to population movement and malaria case. Score of R & V ranges from 0-10: - R0 scores ≤ 6, R1 scores > 6 & V0 scores ≤ 6 , V1 scores > 6

8 Summary of P.v. Radical Cure progress in Q1 Up to the end of Q1, 14 P.v. cases were identified in CMEP BTB and PLN OD areas for P.v. radical cure treatment (3 were female and 1 was underweight). In Q1, 8 of the 14 were tested for G6PD, of which 6 resulted in a normal status of G6PD, 2 were deficient and zero invalid. All 6 of the G6PD normal patients were then enrolled and received 14 days PQ treatment, 6 of these cases have completed 14 days treatment and follow up. Annex 3 provides the detailed summary of P.v. radical cure results in Battambang and Pailin ODs for FY21 Q1. As per CNM guidance, the quantitative P.v. radical cure training was conducted in all CMEP provinces and in the 3 coastal provinces. The CMEP team was identified as technical trainers who solely were responsible to conduct the training for CMEP provinces and to Kep. Kampot, and Koh Kong Provinces. The participants for this training were mainly from selected HFs from all provinces. The training covered the use of SD Biosensor G6PD tests to detect G6PD status of P.v. patients before providing them with PQ for 14 days (including the follow ups on day 3, day 7 and after 14 days). A total of 210 PHD/OD/HF staff were trained from Battambang, Pursat, Pailin, Koh Kong, Kampot, Kep and Kompong Som provinces. 2.2 Objective 2: Support scale-up of high quality malaria control and prevention interventions in five to eight ODs, where gaps in coverage or quality exist Task 2. Ensure universal coverage with LLINs Mass distribution: There was mass distribution activity in FY21 Q1 for the transitional ODs. A total of 62,077 LLINs were distributed as part of the mass campaign in PKV ODs. The LLIHNs (45,264) were not distributed due to unavailablility and it is envisaged to be available by May 2021. However, it would be a challenge to distribute the LLIHNs as the project will begin to the phase out plan. Continuous LLIN distribution and top up monitoring: CMEP continued to deploy ITNs to villages. 679 (15%) ITNs were deployed as buffer stock at the HC and VMW level (4,400 planned). During Q1, CMEP distributed 2,366 ITNs (62% of 3,800 planned) to target populations during outreach and response activities from October to December [Act. 2.2.5]. MMWs distributed zero ITNs at big farms and MMP locations in Q1 (against 160 targeted) [ Act. 2.2.6]. Overall, the lower figures for deployment and distribution in Q1 was due to the significantly large number of distributed ITNs as part of the mass distribution event and target revision based on new CNM guidance of targeting villages with API >= 5. VMWs conducted outreach visits to households and farms to monitor ITN distribution along with providing SBCC activities and EDAT services when required. 1,363 visits were accomplished against 474 planned [Act. 2.2.7]. 8,356 malaria education sessions were provided for interpersonal communication [Act. 2.2.8]. Task 3. Ensure EDAT and follow up Provide ongoing support in malaria diagnosis and treatment: CMEP activities covered 276 Point of Care in Q1 for its 2 transitional ODs (19 HFs, 182 VMWs and 42 MMWs) [Act. 2.3.1]. In the 2 transitional ODs, 17,119 individuals were tested, 190 were confirmed with malaria and all of these cases (100%) were treated in Q1 (Figure 5 shows the confirmed malaria cases from 2018 to 2020). Among the 190 confirmed cases, 0 cases (0%) were P.f./mixed and 190 cases (100%) were P.v. In Q1, there were no severe malaria cases in the transitional ODs [Act. 2.3.4].

9 Figure 5. Confirmed malaria cases in 2 transitional ODs (January 2018 to December 2020)

Table 1 provides a breakdown of the confirmed malaria cases by species in the 2 transitional ODs (see Figure 6). Table 1. Breakdown of confirmed malaria cases by species in 2 ODs

OD Name Species Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Pf 380 242 196 157 128 67 54 77 39 33 28 29 99 37 20 34 6 7 3 0 1 0 1 3 2 5 4 0 0 0 Kravanh Pv 928 853 740 669 644 545 517 415 365 323 331 320 480 290 222 252 170 135 93 71 54 37 44 52 74 49 34 25 27 14 Mix 26 7 18 11 15 10 11 6 2 4 4 8 4 1 3 1 2 1 1 0 0 0 0 0 0 0 0 0 0 0 Pf 73 81 47 47 48 26 25 16 9 8 9 19 46 15 6 3 7 6 3 1 0 0 1 0 76 54 38 25 27 14 Krakor Pv 246 308 205 231 216 165 195 137 120 130 119 144 218 132 108 165 109 91 77 69 60 50 44 53 0 0 0 0 0 0 Mix 11 7 4 3 2 2 4 1 0 0 4 3 1 2 1 1 0 0 0 1 0 0 0 0 53 65 42 52 46 26 Figure 6. Monthly malaria cases in Kravanh and Krakor ODs

Outreach activities: Amongst all confirmed P.v. malaria cases, 66 (34.7%) were in PKV, and 124 (65.3%) were in KRK ODs. Although there were some changes in the number of cases as compared to the last two quarters,the general areas of concern remain the same, with most of the cases being notifed from villages nearing the forest. For example one village named Kbal Teahen reported 22 P.v. cases and Bam Nak reported 6 cases in Q1 both from Cheutom HC, Krakor OD. Since KRK and PKV were not part of case investigation, the newly introduced case based surveillance from January 2021 will help in identifying the case history of these cases in the future. Forest interventions The forest interventions have been managed along with an intensification plan (IP) introduced by CNM. The current intensification plan, ‘IP2’, focuses on pro-actively increasing malaria service coverage for forest workers in PKV and KRK ODs where malarial transmission is concerning due to population movement into the forest areas. In FY21 Q1, 35 MMWs were available for implementing IP2 in PKV OD (20 MMWs) and in KRK OD (15

10 MMWs). 7 MMWs were removed from 42 MMWs in FY20 Quarter 4 due to almost zero malaria cases in their assigned locations. The MMWs (designated as either ‘touch points’ or ‘peer volunteers’) have been regularly monitored. MMWs conduct malaria testing for forest workers and goers, providing treatment for confirmed cases, providing health education via interpersonal communication, and distributing treated nets and SBCC materials. The MMWs regularly joined monthly meetings with VMWs (under the same catchment areas of relevant HFs). Results showed that, from October to December 2020, the 35 MMWs conducted 312 site visits and interacted with forest goers and tested suspected malaria patients. Of the 4,260 suspected patients, 30 tested were P.v. positive (Test Positivity Rate: 0.70%) and all 30 patients received treatment as per NTGs. 881 LLIHNs were distributed and 3,775 health education sessions were conducted. Also, 99 forest packs and 847 bottles of repellents were distributed to forest goers. P.f. elimination has been implemented in the 2 ODs of PKV and KRK since April 2020. The MMWs have also been engaged for additional works such as timely notifying every detected cases to the relevant HF, applying 3 days DOT for all P.f./mix patients as well as assisting in reactive case detection, foci investigation and management. During this reporting period (Oct.- Dec. 2020), there were no P.f./Mix cases detected in the 2 ODs. Capacity building on P.v. radical cure: In Q1, the case management training (P.v. radical cure and quantititve G6PD testing) was conducted for PKV and KRK in November 2020. Kick-off meeting for P.v. radical cure country scale up: A 1-day meeting was organized over 3 days in Phnom Penh in Oct. 2020 by CNM with financial support from Global Fund and PMI to launch the P.v. radical treatment to be implemented countrywide from the beginning of 2021. Participants included PHD and Provinical Malaria Supervisor (PMS), OD & OD Malaria Supervisor (ODMS) staff, selected HFs piloting P.v. radical treatment from 4 provinces, Provincial hospitals, National hospitals, Ministroy of Health (MoH), department of defense, MOI, CMS, DDF of MOH and Non-Governmental Organization partners. Training on P.v. radical treatment and acute hemolytic anaemia (AHA) managamant for provincial hospital staff: 1-day training was held in Phnom Penh on 9th Oct. 2020 for 25 provincial hospital staff. The trainers were from CNM, CMEP and World Health Organization (WHO). The agenda included: (i) management of referred suspected treatment failure; (ii) management of severe malaria cases, (iii) management of AHA; and (iv) management of drug adverse events using DDF ADR form. Training of Trainers training on P.v. radical treatment: In Oct. 2020, training on P.v. radical treatment was conducted for 30 participants. CNM staff, selected PMS and senior staff from provincial hospitals, including CMEP team, Clinton Health Access Initiative (CHAI), Malaria Consortium, Armed Forces Research Intitute of Medical Sciences and UNOPS staff attended the Training of Trainers training. The CMEP team were key facilitators along with the CNM lead person. P.v. radical treatment training to HF staff in Pursat and Battambang: 3-day training was held in Pursat PHD on 4th, 5th, and 6th Nov. 2020 and BTB in on 10th, 11th, and 12th Nov. 2020 for a total of 131 trainees from selected HCs, Referral Hospital (RHs), Provincial Hospitals, ODs and PHDs of Battambang and Pursat provinces along with CMEP OD Team Leaders and HFCs from the 2 provinces Pv radical treatment training to HF staff for 4 provinces: Three-day training was held in Koh Kong PHD from 24th to 26th November 2020, 68 trainees attended the training from selected HCs, RHs, Provincial Hospitals, ODs and PHDs of Kep, Kampot, Koh Kong and Preah

11 Sihanouk provinces. CMEP staff participated as trainers and participants along with other CNM and other partners. CNM supervision: In FY21 Q1 there was no planned supervision visits from the CNM pharmacy and lab units to the transitional ODs[Act. 2.3.10]. Task 4. Strengthen case management and reporting in the private sector: Private Providers: Due to the COVID-19 situation and priorities related to ITN mass distribution, the PP quarterly meetings in the 2 transitional ODs have been postponed to January 2021 (target = 2). In Q1, there were 15 malaria suspected patients referred from PPs to public health facilities in the transitional ODs (target = 115) [Act. 2.4.3]. Supervision visits: During Q1, there was 1 supervision visits to PPs by CNM PPM Unit [Act. 2.4.5]. Task 5. Build capacity and strengthen systems to manage malaria control activities: CMEP Support to VMWs/MMWs: In total, 638 (321 in KRK and 317 in PKV) VMWs/MMWs (target 470) attended monthly meetings from Oct. to Dec. 2020 (136 %) [Act 2.5.1]. During these meetings, VMWs reported information on malaria cases; received RDTs/ACTs from health center staff; and, received on the job training for case management, SBCC, case registration/reporting, and ITN monitoring/top-up reports. VMWs also shared challenges which included difficulties with DOT completion among MMPs and forest-related workers, poor road conditions, long distances to travel and some demands of topping up ITNs among the residents [Act 2.5.2]. Integrated supervision from OD to HFs [Act. 2.5.3]: 17 (81%) of supervisory visits were accomplished during Q1 (target = 21). Due to COVID restrictions and changing priorities, 4 visits could not be completed. Build capacity and strengthen systems to manage malaria commodities: CMEP provided support in stock monitoring and management to the two target ODs during Q1. CMEP used the Management Information System (MIS) to validate report and assess gaps and inform relevant authorities on stock status [Act. 2.5.4-2.5.5]. ACT distribution (all 9 ODs) ACT and/or RDT stock status were reported for 9 ODs in Q1. Table 2 provides a summary of ACT and RDT stock monitoring in all CMEP ODs. Table 2. FY21 Q1 ACT and RDT stock monitoring in all ODs Operational # of HFs ACT RDT District monitored Potential Stock Out Potential Stock Out SPL 33 0 0 6 0 BTB 87 3 0 10 0 PKV 24 0 0 3 0 KRK 27 0 0 0 0 TMK 57 0 0 4 0 MRS 42 1 0 0 0 PLN 21 0 0 7 0 BKN 33 1 0 6 0 SPM 39 0 0 5 0 Total 363 5 0 41 0 The potential stockouts were anticipated during the quarter to face complete stockouts of ACTs and RDTs. However, due to the stock monitoring at HFs and OD level the team were able to manage reallocating drugs to potential stock out facilities. Thus this helped in avoiding

12 complete stockouts. Visits to selected VMWs from CNM VMW Unit: In Q1, there were 2 supervision visits by the VMW unit in the transitional ODs (planned=2) [Act. 2.5.6]. Provincial Special Working Group for Malaria Elimination [Act. 2.5.7]: The PSWGME was already conducted [Act. 2.5.8]. Task 6. Strengthen behavioral change communication (BCC) interventions for intensified malaria control Interpersonal Communication to tested malaria cases and high-risk groups: In Q1, 17,119 (target 15,500) suspected malaria patients were tested and received IPC through VMWs, MMWs and HCs [Act. 2.6.1]. In addition to malaria patients, malaria messages were provided to 4,994 people from high risk groups, including 1,234 MMPs who received messages from 16 peer educators and 21 touch points (target = 1,950) [Act. 2.6.2]. Task 7. Support civil society and community-based organizations to implement Provide support to selected CSO partners and Implement sub-grant activities [Act. 2.7.2]: PfDA in Q1 has been quite active and engaged in implementing the activities as per plan. The mapped sites in PfDA location showed considerable progress in reaching out to the MMPs in remote locations forest areas and in farms. PfDA maintained good relationship with the ODMS and the OD/HF staff to ensure their activities were well coordinated and complemented. They participated in provincial and OD meetings and continued providing information on their work and challenges. Close coordination with VMWs/MMWs and contact points helped in organizing health education campaigns and screening high risk populations. With the COVID situation worsening in Q1, PfDA were still able to organise 36 health educational campaigns and reached out to 862 MMPs including forest goers/workers and distributed 736 ITNs to MMPs. PfDA staff collaborated and worked closely with local authorities and volunteers to map 36 MMPs settlements/locations and identified 644 suspected malaria patients who were referred to VMWs/MMWs and HFs. All of the referred patients reached the malaria service providers. PfDA on a regular basis keeps engaging with the PKV and KRK OD countertparts regarding project activities implementation and regularly meets them to shares results and challenges and finding solutions to immediately address any issues. The detailed targets versus results for key activities implemented in the two ODs are provided in Annex 1, Table 3. Task 8. Operational research- CMEP FY21 Q1 Operational Research activity is covered under Objective 1. 2.3 Objective 3: Strengthen national malaria surveillance systems and M&E appropriate for malaria elimination and control activities Task 1. Refine and harmonize M&E reporting forms and support consistent use by public and private healthcare providers Work with CNM and partners to harmonize M&E reporting forms: As part of updating the surveillance manual, discussions and deliberations happened to add P.v. case indicators in the MIS system and also refining and harmonizing M&E forms incorporating P.v. case investigation along with P.f. case investigation, CMEP has been providing continuous support and input to CNM in revisiting the M&E forms. As an initiative, the new P.v. case investigation form is being piloted in CMEP locations [ Act. 3.1.1]. Support consistent use of the harmonized forms by providers: CMEP in Q1 supported and emphasized use of case base surveillance forms with HFs and VMWs. During monitoring visits, CMEP staff ensured to check and verify the existence of different forms used by HF

13 staff. Wherever forms were not available, CMEP staff made sure to provide said forms. The gaps identified during monitoring visits highlighted issues around case and history being properly documented and case classification required for capacity building. CMEP staff conducted spot checks and ad hoc vists to ensure the correct usage and documentation of required forms [Act. 3.1.2]. Overall, during Q1, 92.3% of providers submitted surveillance data on time (100% from HFs and 84.7% from VMWs). Figure 7 provides submission percentages since FY 2019 Q1. Figure 7. Percentage of HFs, VMWs/MMWs in target transitional ODs submitting surveillance data on time per national guidelines (since FY 2019 Quarter 4)

Task 2. Provide technical assistance on data management and use Conduct Internal Data Quality Assessment (IDQA) at OD and selected HFs by ODMS/PMS and CMEP [Act. 3.2.2]: The CMEP FY20 IDQA was conducted in FY21 Q1 at one elimination and one transitional OD (SPM and PKV ODs). Manual and information system indicator data sources were checked/verified The findings were good overall for the 4 CMEP indicators selected for the exercise. The IDQA report was submitted to USAID on 30th December 2020. Provide Technical Assistance to CNM on village-based stratification and facilitate use of stratification tools [Act. 3.2.3]: Analysis of villages with high cases were regularly informed to CNM during the planning meeting and making plans for mass distribution. CMEP on an ongoing basis during CNM meetings provided village information based on ‘no risk,’ ‘low,’‘medium,’ ‘risk,’ ‘high,’and ‘highest.’ Provide Technical Assistance to CNM on data visualization and outbreak module development for MIS CMEP on a regular basis have been supporting HFs to prepare and showcase case data through visual maps (data visualization). In addition CMEP team has provided Kep, Kampot and Koh Kong HFs with the capacity to develop data visualization maps. The OD quarterly bulletin is also one of the means to highlight the OD malaria cases and trends in case reduction [Act. 3.2.4]. CNM supervision [Act. 3.2.5]: During Q1, several visits were conducted by CNM technical units to CMEP target areas, and overall, 92% of the planned visits were achieved. Table 3 summarizes these visits. The 3 visits not undertaken were due to COVID restrictions. Table 3. Summary of CNM Technical Unit visits in FY21 Q1 Q1 Planned Q1 Actual Percentage ITN unit 6 6 100% Pharmacy unit 5 5 100% Laboratory unit 5 5 100% PPM unit 4 5 125% VMW unit 4 4 100% Health Education Unit 5 4 80% M&E unit 5 5 100% Epidemiology unit 5 2 40%

14 Entomology 0 0 Total 39 36 Task 3. Support further development and implementation of electronic data reporting and use platform: CMEP along with the CNM M&E team has regularly monitored malaria cases through regular visits and validating the data (HF versus CNM MIS). Recently, CMEP has requested the CNM M&E team to visit Pursat more frequently, learning that the system in Pursat is quite weak both in terms of capturing data and reporting. CNM MIS team have conducted several visits in the last quarter to Pursat and have made suggestions and corrective actions. The challenges exist more with VMWs and HFs with mobile phones and tablets. Many have been reported to be broken and non functioning. VMWs are using their personal phones as a stop gap arrangement until further procurements are done. CMEP is working closely with CNM to have specifications to procure mobile phones and tablets for all 6 provinces. Task 4. Strengthen capacity to conduct entomologic monitoring Conduct entomology training for OD and PHD staff [Act. 3.4.1.]: This activity ended in Year 4. However, CMEP is supporting the CNM entomology unit to undertake foci investigation. 2.4 Objective 4: Build capacity of Ministry of Health (MoH) to manage, intensify, and sustain malaria control and elimination efforts particularly at the OD level Task 1. Develop and implement a plan to strengthen technical and management capacity at National, PHD and OD levels2 OD AOP development [Act. 4.1.4.]: All the ODs have developed the AOP in Q1 and it has been approved and duly signed. The AOPs have been submitted to COR. Internal Competency Assessment course for malaria microscopists [Act. 4.1.7]: In Q1, there was no plans for conducting Internal Competency Assessment course. CMEP is in conversation with CNM to identify referral labs in 6 provinces to restart conducting the course. Laboratory quality assurance [Act. 4.1.8]: During FY21 Q1, the CMEP laboratory supervision monitoring continued as planned in BTB and PLN ODs (Annex 2 for reference). Provide on the job training and mentoring by CNM units [Act. 4.1.9]: During supervision visits conducted by CNM, mentoring and supportive supervision and on the job trainings are regularly being provided. More emphasis wwas given on testing all fever cases and followups. Stock management was one of the concerns raised during CNM visits and CNM unit has provided regular on the job training during supervision visits. E-Payment [Act. 4.1.10]: The e-payment system is being implemented in all ODs except TMK because there are no VMWs in this OD. Task 2. Support CNM and MoH to develop and maintain a system for on-going technical and management capacity development Provide feedback to HFs/OD/PHD by CNM technical units during supervisions [Act. 4.2.1]: In spite of the COVID situation, 36 supervision visits were conducted by CNM teams. During these visits, CNM visits ODs, HFs and PHDs and highlights issues that need immediate interventions but has also appreciated the work done in malaria case reduction. The issue of VMW working in low/low-risk villages were also highlighted as part of the integration phase. CMEP Central Progress Review [Act 4.2.2]. CMEP team held the program review meeting of all staff in October 2020 where all OD teams presented their performances and highlighted

2 Activities 4.1.1-4.1.3 are not applicable to the reporting period

15 gaps which were proposed to be addressed in Year 5. Additionally, Kep, Kampot and Koh Kong provinces also provided an update on their progress. The Year 5 Central Progress Review meeting will be conducted in March 2021. Task 3: Improve malaria policies and guidelines [Act. 4.3.1]: CMEP technical team has been regularly joining meetings with CNM, WHO, CHAI and others to review training tools for P.v. radical cure and planning for scale up from pilot to countrywide implemntation along with shifting G6PD testing from qualitative by RDT to quantitative by SD Biosensor. The implementation of P.v. radical treatment will begin in early 2021. The training to targeted selective HFs had been already conducted during Oct. to Nov. 2020. The CMEP team has also joined in series of technical meeting of surveillance working group to review/revise the surveillance manual for malaria elimination attempting to align with Malaria Elimination Action Framework (MEAF) 2 (2021-2025). The manual is in process of finalization. Training of Trainers training on updated surveillance is planned in early February 2021, and will be provided to sub-national levels in May/June 2021. CNM SBCC strategy development [Act. 4.3.1]: In Q1, CMEP joined SBCC technical working group meeting with CNM and IPs in Dec. to discuss the formative study on Forest Goers Behaviors in malaria prevention and seeking care services and to review existing information, education and Communication (IEC)/BCC materials for future programing. CMEP SBCC ‘SWOT’ analysis of the existing IEC/BCC materials were prepared and shared with CNM. Project Management CMEP Sub-grantee quarterly meeting: On 1st October 2020, at Battambang PHD, CMEP met with its 2 sub-grantees (PFDA and AHEAD). Project progress, issues and challenges, lessons learned and next action plans were presented. Other key discussion covered were emphasizing that the sub-grant activities should always complement malaria services provided by points of contact and whereever needed should seek help and support from all points of contact. The subgrantees were informed about the Year 5 workplan approval and that they should plan their activities in line with the workplan and ensure preparing in advance action plans for phase out and exit. Workshop on Drugs Management for Malaria Program at OD level: Workshop was conducted in on 1st /2nd Oct. 2020. The objective was to equip Store Keepers with the knowledge on how to calculate MoS, AMC, and how to place requests (regular, additional and emergency requests). The workshop was funded by Global Fund and attended by CMEP. CNM-PHD-CMEP Directors’ meeting “Review and Forward thinking”: On 22nd October 2020, all key functionaries from CNM, 6 PHD Directors from Koh Kong, Kampot, Kep, Pailin, Pursat and Battambang, and CMEP team met to review the CMEP project and share learnings on CMEP’s elimination work in BTB and PLN, Year 5 strategic priorities, Mid Term Review findings, and CMEP’s exit and sustainability plan. Three PHDs Directors shared successes and achievements from their provinces to help the Kep, Kampot and Koh Kong Provinces learn on the 1-3-7 approach. CNM functionaries shared and discussed the National Program 5-year plan and its link to MEAF 2 and providing guidance and advice to CMEP on the follow on project. CMEP staff annual meeting on 26th and 27th October to review Year 4 Program performance and Year 5 work plan: The 2-day meeting involved all CMEP staff and the all staff meeting was held to review project progress, discuss targets and gaps, challenges, lessons learned and plan for Year 5 priority activities. Session and presentations were provided on MEAF 2, MTR, and training conducted on work place harassment, human trafficking, human

16 resources and conflict of interest, corruption, and fraud. The staff recieved an orientation on the phased out plan and were asked to prepare OD action plans for the exit phase. Meetings with USAID (including Contracting Officer’s Representative and PMI-USAID): US Ambassador visit to Pailin on 19th Oct. 2020: The US Ambassador visited CMEP project in Pailin province, visited Kracharb HC and was joined by the Pailin PHD Director and CMEP COP. He met with 13 VMWs and applauded their commitment to provide services to malaria patients. The Ambassador also visited a health education session conducted by AHEAD. ‘Last Mile’ meeting between PMI-CMEP on 15th Dec.: The meeting was attended by USAID/PMI staff and CMEP COP. The meeting discussion covered the consideration pf potential scope, need for last mile activities, to have collective agreements with CNM and PHDs, and to plan and propose action for Pursat province. The proposal submitted by CNM on entomology surveillance was discussed and it was felt by all that this activity was not part of Year 5 workplan and the need to conduct entomology surveillance was not seen as a priority given the drastic case reduction in PKV. COP virtual call with Dr. Saad on 15th on ITNs– COP and Dr. Saad discussed the current status of mass campaign and the continuous distribution targets and roll out plans. It was informed to CMEP that based on CNM proposal, PSM went ahead and ordered 265,000 LLINs which probably arrive somewhere around May 2020. The COP expressed the need of LLINs and LLIHNs for continuous distribution as all the nets stocked has been used for mass campaign and the stocks are empty. CMEP and CNM Meeting: (including virtual meetings) CNM meeting to monitor supply management: On 10th Dec., CMEP team joined the virtual meeting with CNM, UNOPS, etc. and the following information was provided on the stock status: Current stock at CMS has ASMQ 100+200 mg (expiry date Nov. 2021), has RDT, (expiry date Apr. 2022), PQ 15mg is now out of stock at CNM and there are no plans to procure more. Next shipment: ASMQ 100+200 mg already arrived to CMS, G6PD analyzer + Control Kits already arrived CMS, and RDT Test already arrived CMS. Annual Malaria Conference Planning – 10th December – A call was held with COP/CNM to discuss the annual malaria conference planning and support (Feb. 2021). Three possible scenarios were discussed for the event: a) approx. 40 people to meet in Phnom Penh or at MoH; b) approx. 70 persons to join, in Phnom Penh or at MoH and planned for 1 day; and c) the usual conference with the presence of the Minister, MoH, CNM, donors, IPs, PHDs/ODs, and selected HFs for approx. around 250 persons (venue shall be in Siem Reap planned for a 2 day conference). The final decision is yet to be made. MIS meeting at CNM on 22nd Dec. – The meeting was chaired by CNM Deputy Director and facilitated by Chief of CNM technical bureau and the CNM Data Manager. The discussion was mainly around updating the applications in the MIS for HFs staff and VMWs to enter data of P.v. radical treatment and conducting monitoring of tablets and smart phones. CMEP plans to procure tablets and mobile phones for VMWs and HFs for CMEP 6 provinces. Meetings with CNM and Other Partners Surveillance working group meetings at CNM: A series of surveillance working group meetings was held in Q1 and CMEP team joined the Surveillance working group meetings to update and revise the surveillance guidelines to align with MEAF 2. The meeting covered various sections which comprised of P.v. investigations, foci investigation/response so as to simplify tools, the vulnerability and receptivity components of the questionnaire were simplified, and updates on malaria elimination progress. Examples and lesson learnt from

17 CMEP P.v. case investigation work, foci management and responses mentioned the upgrading of the MIS by adding information on foci were some additional topics discussed. The surveillance manual after incorporating all of the above is yet to be approved. Launching workshop on Last Mile malaria elimination in Cambodia on 3rd November in Kg Speu: CMEP COP, PMI, CNM and other key stakeholders attended the launch in Kampong Speu provincial governmental hall which included the Health Minister and the Provincial Governor. The presentation provided the overall approach of the last mile intervention. Virtual meeting of the CNM SBCC working group on 22nd Dec. – The virtual meeting, chaired by CNM and attended by partners included: (i) Promoting Healthy Behaviour Formative Study of Population Services International on Forest Goers Behaviors in malaria prevention and seeking care services and (ii) review of existing IEC/BCC materials for future actions (the study results will be shared later). Meeting with IPC/Partners: Meetings with IPC and other partners – Meetings were held with IPC to discuss/finalise the hsRDT reports. CMEP team met IPC staff to review and finalise the data and some sections in the report to officially present and submit to PMI and to the ethical committee. The final presentation was virtually held 9th Dec. It was attended by CNM, PMI, CMEP and partners. American Society of Tropical Medicine and Hygiene (ASTMH) meetings - ASTMH Virtual meeting 2020: On 16th November COP/Senior Technical Advisor attended the 2020 virtual ASTMH meeting making two presentations on CMEP’s work in elimination and Pursat case reduction. CMEP’s work was very much appreciated by people from other Asian countries. Procurement In FY21 Q1: The tablets and mobile phones for VMWs and HFs are in the process to be procured. CMEP is discussing with UNOPS to identify suppliers. However, CMEP will be following its own procurement policy to procure tablets and mobile phones. Ideally, the procurement is planned to be executed in Q2. Financial Management During FY21 Q1, CMEP spent approximately 77% of its budgeted amount (see Table 4 for a summary of planned versus actual expenses during FY21 Q1 with explanations). The major reason for the lower spending of 23 % was due to lower fringe benefits, indirect costs and sub- grants. During FY21 Q2, CMEP will continue to maintain the program activity expenditure.

Table 4. CMEP planned vs. actual expenses in FY21 Q1

18 Human Resource Management During FY21 Q1, CMEP had 69 staff on board. All vacant positions were filled in Q1, The 4 new staffs who joined in FY21 Q1 were the mHealth Specialist, M&E Officer in Phnom Penh,and two OD Data Assistants in Krakor and Sampov Meas OD. The challenges of staff retention will continue as the project is in the last year of its implementation and staff are potentially finding long term options. CMEP on an ongoing basis is doing quick recruitment to fill positions as they become vacant. RESOLVING CHALLENGES FROM FY20 QUARTER 4 The efforts made to implement P.v. radical cure training were somewhat delayed due to the COVID crisis and also late arrival of the quantative G6PD tests, and in addition the hospital assessment by CNM was not completed for all provinces. However, with the support from WHO and CMEP, CNM was able to have the kick off meeting followed by the Training of Trainers in October, therafter the P.v. training was held for all CMEP locations with CMEP faciliators in 6 provinces, which was very much appreciated by the CNM leadership. The planned IP2 implementation was slowed down due to COVID restriction and the MMWs did not counduct outreach activity given the issues of corona spread with migrants entering into Cambodia from Thailand. CMEP team worked very closely with provincial directors and ensure the movement of migrants are tracked and all entry points to the forest and villages have strict screeing points. The flood situation in addition worsened the situation and many of the villages were cut off for several days, and CMEP province and districts were also cut off due to water logging. CMEP team with OD staff and HF staff ensure that all malaria patients were provided with malaria services through outreach activity and the VMWs and MMWs were provided enough stocks to manage screeing and testing during the flooding season.

19 There was some misunderstanding with CNM around the timeline for supporting the Kep, Kampot, and Koh Kong on the entire malaria elimination package. This was resolved in Q1 by PMI giving a clear written communication to CNM that the support will be provided with the follow on project (the current CMEP project does not have the funds and the contract does not specify it). CNM later agreed and decided to fund the 3 provinces with Global Fund grant for a 10 months duration until October 2021. 3. CHALLENGES AND ACTIONS TAKEN OR PROPOSED Since the inclusion of P.v. investigation and radical cure treatment, there was discussion and debate on the need for the surveillance manual to be updated and a series of surveillance meetings were called with CMEP, PMI, WHO, UNOPS and CHAI (who are the key members in these meetings). The team had several rounds of review and the updated version was circulated for input. The final decision on agreeing/approving the updated version is pending. Since the implementation of the project one of the important activity for private providers was the PP quarterly meeting. CMEP as per the protocol for PP meeting only invites registered PPs for quarterly meetings, after the PRAKAS CMEP and OD have experienced reduction of PPs participation in quarterly meetings and also in referral services. While asking about why PPs don’t refer, the response CMEP and OD got was that, PP don’t test and treat so they are not interested to refer patients and want to provide services to patients on their own, they also expressed that if they refer they will loose out on their patients, and thus they want to provide services and retain the patients. Secondly if PP come to attend PP quartetly meeting they loose out on their business and they expressed that they also don’t get any incentives for case referral thus they manage and are busy in their own clinic. CMEP is trying all possible ways to influence PHDs and ODs to motivate the PPs as the PPs are expecting some incentives for referring patients, this is still being debated and no final decision by PHDs have been reached. CMEP still has to agree and discuss with PMI before agreeing on the incentives support to PPs. With the COVID crisis still very much unpredictable and keeps spiking in regular intervals, CMEP team is very much concerned with the Year 5 activity implementation as it is the last year of the project and most of the activities is of utmost importance for the project phase out and closeout process. CMEP will keep monitoring the situation and will keep USAID/PMI updated and informed. 4. PLANS FOR NEXT QUARTER AND UPCOMING EVENTS CMEP as part of the Year 5 workplan will implement the following:  AOP review meeting with PHD, OD and CMEP staff;  Central program review meeting with CNM and other key stakeholders;  District and provincial special working group meeting(s);  ITNs continuous distribution and monitoring;  Surveillance manual TOT in Kp Speu in Feburary.  Surveillance manual training for ODs and HFs in CMEP 6 provinces;  Administraiton of P.v. radical cure treatment with quantitative G6PD testing;  Implementation of IP 2 in KRK and PKV;  Sub grantee field monitoring and quarterly meeting;  LLIN durability monitoring exercise to be conducted;  CME staff 6 months program review meeting and preparation abd action plan for selected ODs phaseout and merger;  OD Team Leader and CMEP PP staff quarterly meeting to review project performance and target tracking.

20 ANNEX 1 CSO FY21 Q1 RESULTS TABLES Table 1. AHEAD Results for FY21 Q1 (BTB, MRS, PLN, SPL and TMK elimination ODs) Indicators Target Actual Target explanation 1. # of health education campaigns Reached target. organized in high transmission 50 50 villages 2. # of mobile/migrant and new 1,250 1,511 Reached over target due to more new settlers reached with BCC messages MMP came for corn harvesting and through interpersonal collecting cassava so more participants communication participated in the campaign. # of suspected cases during the campaign is 722 (M=352 and F= 370) 3. # of ITNs distributed to 1,110 1,228 Reached over target due to new MMPs mobile/migrant population came for working in seasonal collection of corn and cassava. 4. # of mobile/migrant settlements 48 68 Reached over target due to more new mapped MMP settlers came for seasonal working in collection of corn and cassava. 5. # of suspected malaria patients 189 261 Reached over target due to MMPs referred to VMWs/HFs understood about benefit of doing malaria blood test. 6.# or % of suspected referred reach 183 261 Reached over target. to service VMW/MMW or HFs 1 case of P.v found in BTB OD. 7.# of report any increased malaria 1 0 Did not occur as there were no cases or outbreaks increased cases of malaria in AHEAD’s targeted areas 8.# of meeting organized with OD 5 5 Conducted at MRS OD and PHD organized by CSOs 9. # of government meeting attended 9 9 Reached target by CSOs (Pro-TWGH meeting)

21 Table 2. PFDA Results for FY21 Q1 (BKN and SPM elimination ODs) Indicators Target Actual Target explanation 1. # of health education Achieved 83% vs target because 2 campaigns organized in high 12 10 campaigns were moved to PKV-OD (many transmission villages new MMPs in PKV OD). 2. # of mobile/migrant and new Achieved 86% vs target (2 campaign were settlers reached with BCC moved to PKV OD). messages through interpersonal Total MMPs reached through BCC communication 340 291 messages=291 (M=107, F=184) There were 134 (49 males, 85 females) suspected patients received test on-site, but there’s no positive case found. 3. # of ITNs distributed to Over achieved the target: 192 of the MMP mobile/migrant population family members were found with no ITNs. 160 326 Total ITNs distributed=326 ITNs (LLINs: 135 LLIHNs: 191) 4. # of mobile/migrant Achieved as plan: A total of 10 maps were settlements mapped updated by GPS tool used to determine in old location before the education provided to the 7 10 newly discovered mobile population in elimination-OD coverage. A total of 291 (M=152, F=139) MMPs were found at those sites. 5. # of suspected malaria patients Over-achieved the target: many suspected referred to VMWs/HFs 39 47 patients were found by contact point. 6.# of suspected referred reach to Over-achieved the target: all suspected cases service VMW/MMW or HFs 39 47 were followed up within the same day. There were no positive cases found. 7.# of report of any increased N/A (there was none) malaria cases or outbreaks 8. # of meetings organized with Achieved as plan ODs, HCs and/or PHD by CSOs 1 1 9. # of government meeting Achieved as planned: PFDA joined Pro- attended by CSOs (Pro-TWGH 3 3 TWGH and quarterly meeting at SPM and meeting) Bakan ODs.

22 Table 3. PFDA Results for FY21 Q1 (KRK and PKV transitional ODs) Indicators Target Actual Target explanation 1. # of health education Over-achieved the target: 2 campaign were campaigns organized in high 34 36 moved from Bakan OD. transmission villages 2. # of mobile/migrant and new Over-achieved the target: there were 582 (340 settlers reached with BCC males, 242 females) of suspected patients 800 862 messages through interpersonal received tested in place during campaign communication session. But no positive cases were found. 3. # of ITNs distributed to Over-achieved the target because of 417 MMPs mobile/migrant population family’s members were found who did not 410 736 receive ITN during OD mass distribution. A total 736 ITNs (LLINs: 401, LLIHNs: 335) were distributed to them. 4. # of mobile/migrant Over-achieved the target: A total 36 maps were settlements mapped updated by GPS tool used to determine in old location before the education provided to the newly discovered mobile populations. In those 23 36 mapped MMPs there were 3 new of the mobile/migrant settlements were scaled-up in PKV OD. A total of 1,262 (428 males. 834 females) of MMPs, stay and work in those sites and into the forests for their benefit. 5. # of suspected malaria patients Over-achieved the target: contact point actively referred to VMWs/HFs identified more MMPs, who came from the forest with suspected malaria symptoms and 411 644 quickly referred to VMW/MMW on time for screen and treatment, than the target in this reporting period. 6. # or % of suspected referred Over-achieved the target: All 644 (100%) of reached service to VMW/MMW referred patients were monitored. PFDA field or HFs staff collaborated with contact points to follow up with the patients (in person and/or by phone) 411 644 in the same referred day. There were 21 (18 males, 3 females) of the positive cases found with P.v. species only and received on time treatment by VMW’s/MMW's house. 7.# of reports of any increased No abnormal case or outbreak in the year 4 malaria cases or outbreaks 1 0 reporting period 8. # of meeting organized with N/A ODs, HCs and/or PHD by CSOs 9. # of government meeting Achieved by 83% of the target because HC/OD attended by CSOs (Pro-TWGH 6 5 were busy with ITN mass distribution. PFDA meeting) joined quarterly meeting at KRK OD.

23 ANNEX 2 LABORATORY QUALITY ASSESSMENT/MICROSCOPY TRAINING TABLES Table 1: Slides crosscheck for Laboratory Quality Assessment (QA) Oct. – Dec. 2020 in BTB and PLN Provinces HC Lab HC Lab QA Lab QA Lab OD Name of HC result result result result Negative Positive Negative Positive PLN Ou Chrar, RDTs malaria and RDTs G6PD (7 to 9 Dec. Krachab, - Good storage 2020) Phnom Spong, - Well performance Phnom Preal, Well quality follow up Phsar Prom - RDTs malaria and RDTs G6PD Kompong - Good storage Lpov and Plov - Well performance BTB Meas HC - Well quality follow up (19 to 22 Oct. 2020) Tasanh 19 P.v. 1 19 P.v. 1 Sdao 14 P.v. 1 14 P.v. 1 BTB RH 15 0 15 0 Beoung Run 18 P.v. 2 18 P.v. 2 SPL RH SPL 03 0 03 0 (17 to 18 Nov. 2020) RDTs malaria & RDTs G6PD Bour and Trav - Good storage Chou HC - Well Performance - Well Quality follow up TMK TMK RH 03 0 03 0 (8 to 10 Dec. Bovel I RH 05 0 05 0 2020) RDTs malaria and RDTs G6PD Klang Meas - Good storage and Beoung - Well performance Pram - Well quality follow up MRS MRS RH 05 0 05 0 (13 to 14 Oct. 2020) RDTs malaria and RDTs G6PD Prey Trolach, - Good storage , Prek Chik, - Well performance - Well quality follow up TOTAL 21 HFs 82 4 82 4 ACCURACY 100% 100%

24 ANNEX 3 – P.v. Radical Cure Treatment Status Results of CMEP P.v. Radical Cure in FY21 Quarter 1 (in BTB and PLN ODs) P.v. radical cure data from October to December 2020 (Q1, Year 5)

Female # of G6PD test performed # of P.v. Radical cure Treatment (14-days Remark Name Total patient PQ) P.v. of OD cases On Drop Normal Deficiency Invalid Enrolled Complete going out 1 (<20 BTB 5 1 2 1 1 2 2 0 0 kg) 1 ( re MRS 4 2 1 1 2 2 0 0 infection) TMK 1 1 0 1 1 0 0 SPL 2 2 0 0 0 0 0 0 1 (mobile PLN 2 1 0 1 1 1 0 0 and left) Total 14 3 6 2 0 3 6 0 0

Total P.v. cases detected in Q1, Year 5 = 14 There were 3 female (2 in SPL and 1 in BTB OD) 1 less than 20 Kg (in BTB OD) 1 patient in Pailin was mobile person 1 re-infection in MRS OD 2 patients were deficient 6 patients have normal G6PD and received completely 14 day PQ treatment

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