PHOTO: USAID GLOBAL HEALTH SUPPLY CHAIN PROJECT

BURUNDI MALARIA OPERATIONAL PLAN Fiscal Year 2021

DISCLAIMER This Malaria Operational Plan reflects collaborative discussions with the national malaria control program and other partners. Funding available to support the plan is pending finalization of the FY 2021 appropriation. Any updates will be reflected in a revised posting. OVERVIEW USAID delivers funding for cost-effective, lifesaving malaria interventions alongside catalytic technical and operational assistance to support Burundi to end malaria. USAID has provided malaria funding to Burundi since FY 2009.

The proposed fiscal year (FY) 2021 planning budget for Burundi is $8 million. This Malaria Operational Plan (MOP) outlines planned activities in Burundi for FY 2021 funds. See accompanying FY 2021 Budget Tables for activities and budget.

Developed in consultation with the National Malaria Control Program (NMCP) and key stakeholders, proposed activities reflect national and PMI strategies, draw on best-available data, and align with the country context and health system. Proposed investments support and build on those made by the Government of Burundi as well as other donors and partners.

The paragraphs below describe updates to key interventions:

ENTOMOLOGICAL MONITORING With FY 2021 MOP funds, USAID will continue to support entomological surveillance and insectary management. USAID will also support chemical analysis of insecticide-treated nets (ITNs) and molecular analysis of mosquitoes for insecticide resistance, which were not planned with FY 2020 funds due to budget limitations. USAID will also support implementation of a DHIS2-based platform for improved storage, analytics, and visualization of entomological data that will also facilitate data transfer to the national DHIS2 system. These activities will increase the technical assistance budget compared to the FY 2020 budget. We anticipate that these activities will not be implemented every year and the vector control budget will be reduced during the next cycle.

MALARIA IN PREGNANCY In Burundi, the package of interventions for controlling malaria during pregnancy includes the promotion and use of ITNs, intermittent preventive treatment (IPTp) with sulfadoxine- pyrimethamine under directly observed treatment, and prompt and effective treatment. The NMCP has not yet implemented 2016 WHO guidelines increasing the recommended number of prenatal care visits from four to eight. With FY 2021 MOP funds, the team intends to pilot an evidence-based group prenatal care strategy to increase uptake of IPTp (in the first quarter of FY 2021, 54 percent of women received the recommended three doses in U.S. Government- supported health centers per DHIS2). Support for private and faith-based health centers will also be continued and expanded to more than 120 private and faith-based health centers through the USAID Momentum Private Health Delivery mechanism (see below).

1 | USAID BURUNDI FY 2021 MALARIA OPERATIONAL PLAN USAID.GOV CASE MANAGEMENT

HEALTH FACILITY ASSESSMENT The health facility assessment conducted by Burundi’s integrated health bilateral project (Tubiteho) across the project’s six target provinces in March 2020 shows that 96 percent of facilities offer malaria case management services. Most health facilities offer both malaria diagnosis (91 percent rapid tests (RDTs) and 92 percent microscopy) and treatment services. Prevention activities were available at 88 percent of facilities. The proportion of facilities that delivered the core malaria service package (diagnosis, treatment, and prevention) was 88 percent: 67 percent (hospital), 89 percent (health centers), 55 percent (private sector) and 100 percent (faith-based facilities).

The average score of facilities with malaria diagnosis and new treatment guidelines shifting from ASAQ to AL (validated in December 2019) was 17 percent. During the three months prior to the assessment, 75 percent of health facilities experienced a stockout of antimalarials. Improving coverage of updated care guidelines and service delivery quality remains a priority for USAID and will be a focus for collaboration with the NMCP.

COMMUNITY CASE MANAGEMENT FOR ALL AGES Analysis shows that many people in Burundi face financial barriers to accessing health services (for example, three quarters of adults do not possess medical insurance per the most recent demographic health survey), which is increasingly an issue in districts experiencing elevated malaria cases in recent years. Following lessons learned from the 2017 and 2019 malaria epidemic response, the World Health Organization (WHO) recommended improving access to health care in remote areas and extending community-based care to all ages. Burundi intends to align to that recommendation by complementing existing community-based service delivery with community case management of malaria for adults. A pilot of community case management for adults will be implemented in two districts (N’gozi and Nyanbikere) during FY 2021 with Global Fund support. The strategy will be expanded in U.S. Government-supported districts during FY22. Extension of free malaria case management at the community level for adults will help ensure wider health coverage for populations lacking access to care.

SUPPORT TO PRIVATE SECTOR FOR MALARIA CASE MANAGEMENT The 2018 annual report of Direction des Statistiques Nationales et de l’Information Sanitaire (DSNIS) estimates only 35.8 percent of private health centers deliver malaria services and report health data to DHIS2. Public-private partnership remains weak in Burundi, although the private sector is actively involved in providing curative care. Effective involvement of the private sector in health service delivery is an asset for geographic equity. USAID/Burundi is funding the Momentum Private Health Care Delivery (MPHD) mechanism to expand support to malaria interventions in private and faith-based health centers (including case management and malaria in pregnancy). MPHD is a USAID-funded global cooperative agreement designed to provide targeted technical assistance to malaria and other health services in private and faith-based sectors while engaging with local organizations and the Ministry of Health (MOH) to improve governance and support.

USAID.GOV USAID BURUNDI FY 2021 MALARIA OPERATIONAL PLAN | 2 SOCIAL AND BEHAVIOR CHANGE USAID is supporting the NMCP to improve their strategy for malaria-related SBC and is refining the USAID Tubiteho project’s SBC strategy to improve key behaviors where gaps are noted. SBC messages need to be improved to increase the uptake and correct use of malaria interventions. Priority areas include increasing IPTp uptake, use of ITNs especially by pregnant women and children, and proper ITN care given the attrition concern raised by a durability monitoring baseline report.

SUPPLY CHAIN USAID supports procurement of vital malaria commodities and supply chain strengthening. This includes sourcing and delivering nets, tests, and medicines to the central-level warehouse. Over the past year USAID worked with the DPML and NMCP on the stockout reduction initiative, further aligning malaria investments to improve commodity availability at SDPs. USAID also continues to support DPML, CAMEBU, and PNILP in coordinating the national malaria forecasting and supply planning subcommittee for regular commodity security and supply plans. With FY 2021 MOP funds, USAID hopes to continue stockout reduction support and assist Burundi's transition to the Quantification Analytics Tool (QAT) for supply planning. Finally, USAID will continue to support end-user verification surveys at districts and health facilities to monitor malaria commodity availability at the last mile and community

3 | USAID BURUNDI FY 2021 MALARIA OPERATIONAL PLAN USAID.GOV FISCAL YEAR 2021 BUDGET TABLES

USAID.GOV USAID BURUNDI FY 2021 MALARIA OPERATIONAL PLAN | 4 Table 1: Budget Breakdown by Mechanism U.S. President's Malaria Initiative - BURUNDI Planned Malaria Obligations for FY 2021

Mechanism Budget % USAID $804,488 10% Global Health Supply Chain Procurement and $5,184,044 Supply Management (GHSC PSM) Malaria 65% PMI Measure Malaria $155,000 2% PMI VectorLink $760,000 10% Tubiteho $723,973 9% Momentum Private $372,495 Health care Delivery 5% TOTAL $8,000,000 100% Table 2: Budget Breakdown by Activity U.S. President's Malaria Initiative - BURUNDI Planned Malaria Obligations for FY 2021 Geographic Reach of PMI Activity

If coverage is If coverage is focused by Proposed Activity Mechanism Budget (in $) focused by Description of Proposed Activity district(s), name(s) of region(s), name(s) district(s) of region(s)

VECTOR CONTROL Entomological Monitoring Bujumbura Mairie, Support the insectary at Gihanga and nine sentinel surveillance sites to understand the malaria Bujumbura Rural, Vumbi, Nyanza-Lac, Mutaho, vector population. Testing for insecticide susceptibility will be expanded to new insecticides as they Karusi, Kayanza, Kiremba, Gihofi, Cankuzo, become available. Insecticide resistance monitoring will be conducted on rotation basis in nine Support Entomologic Monitoring PMI VectorLink $592,806 Nationwide Muramvya, Muyinga, Mabayi, Matana, Mpanda, provinces (Bujumbura Mairie, Bujumbura Rural, Karui, Kayanza, Muramvya, Muyinga, Mwaro, Mwaro, Rumonge, Gihanga Rumonge and Ruyigi). TA will also include the implementation of Vectorlink collect DHIS2 Ruyigi database. Support 24-month data collection for net durability monitoring covering the December 2019 mass Support ITN Durability Monitoring PMI VectorLink $150,000 Nationwide Kirundo, Muyinga Vumbi, Gashoho campaign distribution, analysis of physical durability, and insecticide effectiveness and content.

Subtotal : $742,806 Insecticide-Treated Nets Global Health Supply Chain Procurement of 965,558 ITNs for continuous distribution channels through ANC and early Procure ITNs for Continuous Distribution Procurement and Supply $2,668,039 Nationwide immunization programs with standard ITN (632,985 nets), IG2 (203,819 nets), and PBO (128,755 Channels Management (GHSC PSM) nets). Malaria Global Health Supply Chain Distribute ITNs for Continuous Distribution Procurement and Supply $159,546 Nationwide Distribution of ITNs through ANC and EPI channels. Channels Management (GHSC PSM) Malaria Subtotal : $2,827,585 Indoor Residual Spraying Funds will be used to provide technical assistance for IRS implemented by others partner, including environmental compliance and testing of insecticide resistance, share tools and best practices for IRS Implementation PMI VectorLink $17,194 Nationwide IRS planning and implementation from the other PMI VectorLink spray countries, support implementation of a successful IRS operation per international standards, monitor the insecticide decay on sprayed walls after IRS, provide inputs to the end of spray report. Subtotal : $17,194 SBC for Vector Control Support comprehensive SBC (IPC and mass media) for correct and consistent use and care of ITNs SBC Implementation for Vector Control Tubiteho $55,000 Nationwide (delivered together with SBC to increase IPTp uptake, and to improve early and accurate diagnosis and treatment of malaria at facility and community levels). Subtotal : $55,000 Total : $3,642,585 DRUG-BASED PREVENTION Prevention of Malaria in Pregnancy Momentum Private Health MIP includes IPTp and provision of insecticide treated nets in at least 120 private and faith-based Private sector MIP Implementation $100,000 Nationwide Care Delivery health care centers. Support delivery of comprehensive MIP services including IPTp under DOT and distribution of ITNs at health facility level to ensure pregnant women receive at least three doses of SP and receive ITNs MIP Implementation Tubiteho $100,000 Nationwide on first encounter (first ANC). ANC group strategy will be pilote to increase the quality of service delivery for pregnant women. Subtotal : $200,000 SBC Support SBC to improve ANC uptake of 4+ visits and inclusion of IPTp promotion in outreach SBC Implementation for Prevention Tubiteho $55,000 Nationwide activities. Support production of SBC materials for use at community and facility levels to promote health prevention and treatment behaviors. Subtotal : $55,000 Total : $255,000 CASE MANAGEMENT Procure Case Management-Related Commodities Global Health Supply Chain Procurement and Supply Provide 1,694,720 of diagnostic kits for malaria at both health facility and community level to bridge Procure RDTs $813,465 Nationwide Management (GHSC PSM) the commodities gap not covered by Global Fund. Malaria Global Health Supply Chain Procurement and Supply Procure 1,185,083 blisters of Artemeter-Lumefantrine to cover both health facility and community Procure ACTs $722,901 Nationwide Management (GHSC PSM) level to bridge the commodities gap not covered by Global Fund. Malaria Global Health Supply Chain Procurement and Supply Procure 105,795 vials of injectable Artesunate for treatment of severe malaria cases at health Procure Drugs for Severe Malaria $231,690 Nationwide Management (GHSC PSM) facilities to bridge the commodities gap not covered by Global Fund. Malaria Subtotal : $1,768,056 Case Management Implementation Busoni, Kirundo, Vumbi, Makamba, Nyanza-Lac, Support case management ensuring that providers at health facilities provide quality services for Bururi, Karusi, Gashoho, Giteranyi, Muyinga, uncomplicated and severe malaria cases including supportive supervision to improve quality of care, Facility-based case management Tubiteho $273,973 Kirundo, Makamba, Bugarama, Rumonge, Matana, and data collection and analysis for decision making at central, subnational level. This activity Muyinga, Rumonge Mukenke, Buhiga, Nyabikere, includes also mobile clinics during seasonal peaks to mitigate any outbreak. Bururi Support malaria case management by community health workers including continuous training on testing, treatment and referral systems. Support the supply chain sytem to provide iCCM in Bururi, Karusi, Busoni, Bugarama, Rumonge, targeted districts with low access to health facilities. iCCM strategy will be extended in other Community-based case management Tubiteho $100,000 Kirundo, Makamba, Mukenke, Buhiga, Nyabikere Tubiteho's health districts (4 HD in north and 2 HD in South). In addition to iCCM, Tubiteho will Muyinga, Rumonge support CHW to implemente malaria case management for adults in the six health districts at community level. Support case management of uncomplicated malaria including appropriate treatment (with Momentum Private Health Private sector case management $272,495 Nationwide artemisinin-based combination therapies) or referral of clients in 120 private and faith-based health care Delivery centers. Subtotal : $646,468 SBC Busoni, Kirundo, Vumbi, Makamba, Nyanza-Lac, Bururi, Karusi, Support SBC through interpersonnal communication by CHWs and through mass media to improve Gashoho, Giteranyi, Muyinga, SBC Implementation for Case Management Tubiteho $70,000 Kirundo, Makamba, early care-seeking behavior. Support the production of SBC materials for use at community and Bugarama, Rumonge, Matana, Muyinga, Rumonge facility levels to promote health prevention and treatment behaviors. Mukenke, Buhiga, Nyabikere, Bururi Subtotal : $70,000 Total : $2,484,524 SUPPLY CHAIN In-Country Supply Chain Global Health Supply Chain Procurement and Supply Warehousing and Distribution $88,403 Nationwide Warehousing 5% of malaria commodities cost. Management (GHSC PSM) Malaria Global Health Supply Chain Provide TA to build capacity for malaria commodities quantification and forecasting, and improve Pharmaceutical Management Systems Procurement and Supply coordination of malaria supply chain partners through quarterly reviews and supply chain $400,000 Nationwide Strengthening Management (GHSC PSM) monitoring. Contibute to eLMIS implementation, malaria comodities waste management activities, Malaria printing and distribution of stock management tools to fill the gap as needed. Global Health Supply Chain Conduct end-user verification survey at district and health facilities to monitor the availability of key Pharmaceutical Management Systems Procurement and Supply $100,000 Nationwide malaria commodities, to review available data from health facilities and relate logistical malaria Strengthening Management (GHSC PSM) supply chain to case consumption data, to review facilties management and drug storage conditions. Malaria Subtotal : $588,403 Total : $588,403 MONITORING, EVALUATION & RESEARCH Surveillance, Monitoring, and Evaluation Provide short-term TA to strengthen national health management information system at national and operational levels including data review, data analysis and data use. Provide short-term TA to Support Routine Surveillance PMI Measure Malaria $155,000 Central malaria surveillance including capacity-building, developement of protocols, surveillance monitoring and evaluation technical working group. PMI measure activities will be extended to Provinces to ensure that each level of the system is strengthen for data use for decision making. Subtotal : $155,000 Total : $155,000 OTHER HEALTH SYSTEMS STRENGTHENING Other Health Systems Strengthening Tubiteho $70,000 Central Support for malaria partners meetings and health facilities supervision. Implementation Subtotal : $70,000 Total : $70,000 STAFFING & ADMINISTRATION USAID In-Country Staffing and Administration: USAID $710,000 Staffing for one USAID TCN Malaria Advisor and one 100% USAID FSN Malaria Specialist. Staffing USAID In-Country Staffing and Administration: USAID $94,488 Administration and PD&L Administration Subtotal : $804,488 Total : $804,488 GRAND TOTAL: $8,000,000