COAG No. 72068718CA00001

TABLE OF CONTENT

I- EXECUTIVE SUMMARY ...... 5 II. INTRODUCTION ...... 12 III. MAIN ACHIEVEMENTS DURING QUARTER 1 ...... 12

III.1. IR 1: ENHANCED COORDINATION AMONG THE PUBLIC, NONPROFIT, AND COMMERCIAL SECTORS FOR RELIABLE SUPPLY AND DISTRIBUTION OF QUALITY HEALTH PRODUCTS ...... 12 III.2. IR2: STRENGTHENED CAPACITY OF THE GOM TO SUSTAINABLY PROVIDE QUALITY HEALTH PRODUCTS TO THE MALAGASY PEOPLE ...... 18 III.3. IR 3: EXPANDED ENGAGEMENT OF THE COMMERCIAL HEALTH SECTOR TO SERVE NEW HEALTH PRODUCT MARKETS ACCORDING TO HEALTH NEEDS AND CONSUMER DEMAND ...... 40 III.5. IR 4: IMPROVED SUSTAINABILITY OF SOCIAL MARKETING TO DELIVER AFFORDABLE, ACCESSIBLE HEALTH PRODUCTS TO THE MALAGASY PEOPLE ...... 50 III.7. IR5 - INCREASED DEMAND FOR AND USE OF HEALTH PRODUCTS AMONG THE MALAGASY PEOPLE ...... 58 III.8. CROSS-CUTTING ACTIVITIES ...... 65 IV. SUCCESS STORIES ...... 76 V. ENVIRONMENTAL MITIGATION AND MONITORING REPORT ...... 77 VI. SUMMARY OF THE SUB-ACTIVITIES NOT COMPLETED IN QUARTER 1 ...... 79 VII. KEY CHALLENGES AND SOLUTIONS ...... 81 VIII. MAJOR ACTIVITIES PLANNED FOR NEXT QUARTER (YEAR 2, JANUARY – MARCH 2020)...... 82

IR 1: ENHANCED COORDINATION AMONG THE PUBLIC, NONPROFIT, AND COMMERCIAL SECTORS FOR RELIABLE SUPPLY AND DISTRIBUTION OF QUALITY HEALTH PRODUCTS ...... 82 IR 2: STRENGTHENED CAPACITY OF THE GOM TO SUSTAINABLY PROVIDE QUALITY HEALTH PRODUCTS TO THE MALAGASY PEOPLE ...... 82 IR 3: EXPANDED ENGAGEMENT OF THE COMMERCIAL HEALTH SECTOR TO SERVE NEW HEALTH PRODUCT MARKETS ACCORDING TO HEALTH NEEDS AND CONSUMER DEMAND ...... 83 IR4: IMPROVED SUSTAINABILITY OF SOCIAL MARKETING TO DELIVER AFFORDABLE, ACCESSIBLE HEALTH PRODUCTS TO THE MALAGASY PEOPLE ...... 83 IR5: INCREASED DEMAND FOR AND USE OF HEALTH PRODUCTS AMONG THE MALAGASY PEOPLE ...... 84 CROSS-CUTTING ...... 84 IX. FINANCIAL SUMMARY ...... 86 ANNEXES ...... 87

ANNEX A - PERFORMANCE MONITORING PLAN (PMP) ...... 88 ANNEX B – YEAR 1 WORKPLAN UPDATE ...... 98 ANNEX C - ENVIRONMENTAL MITIGATION AND MONITORING REPORT ...... 129 ANNEX D - SUCCESS STORIES ...... 138 ANNEX E – STOCK INVENTORY AS OF DECEMBER 2019 (USAID AND PMI FUNDED) ...... 148 ANNEX F – STOCK STATUS BY END OF DECEMBER 2019 ...... 151 ANNEX G: DESCRIPTIONS OF THE SEVEN QUALITY DIMENSIONS FOR THE RDQA ...... 153

ACRONYMS A2F Access to Finance LLIN Long Lasting Insecticide-treated Net ABM AccèsBanque Madagascar RLA Regional Logistic Advisor ADDO Accredited Drug-Dispensing Outlet LMIS Logistic Management Information AFD Agence Française de Développement System A2F Access to Finance MEL Monitoring, Evaluation and Learning AMM Agence de Médicaments de MCH Maternal and Child Health Madagascar MDA Market Development Authority cCD Community-based Continuous MEL Monitoring, Evaluation and Learning Distribution MENETP Ministère de l’Education Nationale et CCDS Comité Communale pour le de l’Enseignement Technique et Développement Social Professionnel CGL Comité de Gestion Logistique MERL Monitoring Evaluation Research and CHV Community Health Volunteers Learning CILCMIM Comité Interministériel de Lutte contre MOPH Ministry of Public Health le Marché Illicite des Médicaments MSH Management Sciences for Health CISCO Circonscription Scolaire MYS Ministry of Youth and Sport CMS Credit Management System NGO Non-Governmental Organization CNFM Conseil National des Femmes de NHMIS National Health Management Madagascar Information System CSR Corporate Social Responsibility NMCP National Malaria Control Program CSB Centre de Santé de Base NSP National Supply Plan CoAg Cooperative Agreement ONP Ordre National des Pharmaciens de COGS Cost of Good Sold Madagascar CPT Certified Peer Trainer PA Point d’Approvisionnement DCA Development Credit Authority PAIS Plan d’Action d’Intégration des Intrants DEPSI Direction des Etudes de la Planification de santé et du Système d’Information PARC Point d’Approvisionnement Relais DFC United States International Communautaire Development Finance Corporation PBO Pyrethoid and Piperonyl Butoxide DGFS Direction Générale de Fourniture des PDPN Plan Directeur Pharmaceutique Soins Nationale DGMP Direction Générale de la Médecine PMI President’s Malaria Initiative Préventive PMP Performance Monitoring Plan DHIS-2 District Health Information System - 2 PPR Performance Plan and Report DPS Direction de la Promotion de la Santé PPN Politique Pharmaceutique Nationale DLMT Direction de Lutte contre les Maladies PSHP Private Sector Humanitarian Platform Transmissibles PSI/M Population Services DRENETP Direction Régionale de l’Education International/Madagascar Nationale et de l’Enseignement Pha-G-Dis Pharmacie de Gros de District Technique et Professionnelle Pha-Ge-Com Pharmacie à Gestion DPLMT Direction de la Pharmacie, des Communautaire Laboratoires et de la Médecine RBM Roll Back Malaria Traditionnelle RH Reproductive Health DRSP Direction Régionale de la Santé RDT Rapid Diagnostic Test Publique

DSFa Direction de la Santé Familiale SBCC Social and Behavior Change DSS Division Santé Scolaire Communication DSSB Direction des Services de Santé de SHOPS Plus Sustaining Health Outcomes in Base the Private Sector Plus EFOI Entreprendre au Féminin Océan Indien SILC Savings and Internal Lending EMMP Environmental Mitigation Monitoring Communities Plan SLRC Service de la Législation, de la FANOME Financement pour Réglementation et du Contentieux l’Approvisionnement Non-stop en SP Sulfadoxine Pyriméthamine Médicaments SPD Superviseurs de Point de Distribution FEFO First Expiry – First Out STTA Short-term Technical Assistance FP Family Planning TA Technicien Accompagnateur GAS Gestion des Approvisionnements et TMA Total Market Approach des Stocks TMI Total Market Initiative GBV Gender Based Violence ToT Training of Trainers GESI Gender Equality and Social Inclusion TWG Technical Working Group GFEM Groupement des Femmes UCP Unité de coordination des Projets Entrepreneurs de Madagascar UHC Universal Health Coverage GF Global Fund UNFPA United Nations Population Fund GHSC-PSM Global Health Supply Chain – UTGL Unité Technique de Gestion Logistique Procurement and Supply Management USAID United States Agency for International GOM Government of Madagascar Development HPN Health Population and Nutrition VSLA Village Savings and Loan Association HRD Health Regional Director WHO World Health Organization IMPACT Improving Market Partnerships and ZAP Zone d’Administration Pédagogique Access to Commodities Together IR Intermediate Result IPTp Intermittent Preventive Treatment during pregnancy ISM Integrated Social Marketing

I- EXECUTIVE SUMMARY

Intermediate Results 1: Enhanced coordination among public, non-profit, and commercial sectors for supply and distribution of health products Under the leadership of the Ministry of Public Health (MOPH) through the DEPSI, DAMM, and the DPLMT the Total Market Approach (TMA) roadmap was finalized, including the detailed action plans for the three objectives identified by the TMA TWG: to improve (i) the lack of communication around the national pharmaceutical policy, (ii) the availability and quality of data, and (iii) the application of regulatory texts. During Quarter 1, IMPACT initiated the market assessments for Maternal Newborn and Child Health (MNCH) and Family Planning (FP) in collaboration with the DSFa. The DSFa will lead the implementation of this activity and convert findings into an action plan.

For the malaria market assessment, an analysis of the initial findings from the data collection agencies has begun and the final report will be available and shared to all stakeholders in March 2020.

Seven new TMA Champions have emerged and five have already started engaging in the in the process. These new Champions include the Champion from the National Malaria Control Program (NMCP) for malaria, the Champion from DSFa for FP and MNCH, the Champion from Parliament, and two Champions from the private sector, including the President of the National Order of Pharmacists and the Vice President of the National Association of Pharmacists. A one-day leadership training was led by Corban Consulting on December 19, 2019 for the first group of three Champions. Due to the limited availability of Champions, an additional training will be held in early Quarter 2 for those who could not attend this first session. The training was requested by the Champions to help them to (i) improve their leadership capacities with a focus on TMI initiative including the Champion roles and responsibilities; (ii) facilitate TMA TWG meetings and interventions and (iii) implement the TMA roadmap and all Total Market Initiatives.

Intermediate Results 2: Strengthened capacity of the GOM to sustainably provide quality health products to the Malagasy people During Quarter 1, IMPACT continued to strengthen the GAS committees at the central and district level to collect and analyze data on distributed quantities and consumption of malaria, FP/RH, and MNCH health products to inform the resupply of commodities in all 115 Pha-G-Dis. Once commodities were delivered at Pha-G-Dis, the Regional Logistics Advisors (RLA) supported the districts to analyze data and plan distribution of malaria, FP, and MNCH commodities to health facilities.

In Quarter 1, IMPACT provided technical and financial support to the UTGL for conducting two workshops in Antananarivo and Toamasina to (i) review the quantification of malaria and FP commodities and (ii) adjust the supply plans based on current logistics data (i.e. health commodities deliveries and consumption, stock status at SALAMA and Pha-G-Dis level, the number of days of stock out, and leakages) and health services data (i.e. malaria cases diagnosed and treated, woman of childbearing age that need contraceptives, etc.). Results of the review were validated by the CGL (Comité de Gestion Logistique) for FP/RH commodities and shared with key stakeholders in order to mobilize resources to cover the gap of needed commodities.

Through the RLA, IMPACT in collaboration with EMAR and EMAD conducted supportive supervision visits in 68 districts in the 13 supported regions to (i) continue to improve Pha-G-Dis staff competencies in supply chain management and (ii) assess their capabilities on practicing the Manuel de Gestion de Stocks procedures

through on-the-job supportive supervision visits. The objectives of the supervision consisted of (i) ensuring that Pha-G-Dis staff are able to correctly enter and analyze stock status of malaria, FP/RH, and MNCH commodities; (ii) estimating health commodities needs for requisitions and quantities to redistribute in case of overstock; (ii) checking the correct use of stock management tools; (iii) assessing the record of stock movement and transaction reports in CHANNEL and to DPLMT; (iv) verifying the last mile distribution strategy implementation to ensure commodities are transported and continuously available at health facilities.

During Quarter 1, IMPACT collaborated with GHSC-PSM to prepare the EUV survey (new guidelines and questionnaires on how to conduct the EUV survey, training curriculum, sampling methodology, as well as the use of Survey CTO software recommended to collect data). The data collection, analysis, and interpretation are planned in Quarter 2.

From December 9th to December 13th, IMPACT technically and financially supported the workshop to review the quantification of malaria commodities held in Antananarivo. In total 26 participants attended the workshop. A Short-term Technical Assistance (STTA) from the Supply Chain Advisor of PMI Washington and the PMI Madagascar Resident Advisor was provided during the workshop to train on quantification review and to share global PMI guidance on quantification and procurement.

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

Review the scope of the private sector humanitarian platform to engage businesses in health product markets Through the Private Sector Health Humanitarian Platform (PSHP), IMPACT continued to encourage the involvement of private health actors in the TMA TWG. Besides the three wholesalers INTERPHARMA, SKPHARMA, and PHARMATEK, new health actors have integrated the PSHP. The exercise to identify outlets (pharmacies and drug shops) willing to work with IMPACT was conducted in Atsinanana, Diana, and Boeny. As a result, 29 pharmacies and 75 drug shops located in these regions accepted and signed the agreement to collect/record LMIS data at their level and submit it to the national system.

Increase access to finance for private health commodities supply chain stakeholders • 49 bank staff at partner banks (40% of annual target of 120), AccèsBanque Madagascar (ABM), and Baobab Banque Madagascar have received training on the market opportunities and financing needs of health commodities enterprises. • Designed three new financial products for health commodities enterprises with the partner banks including Pharma loans, automated withdrawals to facilitate payments from drug shops to wholesalers, and motorbike loans for PAs. The three financial products are at the design phase during Quarter 1. Pharma loan and motorbike loans for PAs will be operational in Quarter 2. • Presented to USAID/Madagascar the initial findings from the A2F visit to evaluate the potential for a risk- sharing financing mechanism and a written summary will be submitted soon. • 14 loans totaling $57,281 were given to pharmacies and drug shops, of which two were placed under the DCA guarantees disbursed by ABM and Baobab.

Strengthen the business management of enterprises in health products supply chain

• Finalized a simplified curriculum for the business and financial management training for drug shops, considering the educational level of drug shop managers and including four modules: (i) Business financial and operational diagnostic, (ii) Regulatory compliance and drug usage, (iii) Inventory management, and (iv) Financial book-keeping. The simplified curriculum is a key component to the sustainability of the proposed low-cost peer training program. • In November, conducted drug shop training in Toamasina for the first joint IMPACT/DPLMT mission. The DPLMT team led a half-day information session on the legal and regulatory framework for 43 drug shops, followed by an optional 1.5-day business training by IMPACT for 27 drug shops. Provided one-on-one post-training coaching to three drug shop owners and managers in Toamasina.

GOM facilitates the work of the commercial sector In Quarter 1, the preliminary report of the literature review of 128 texts and regulations in the pharmaceutical sector (texts related to registration, inspection, rational use of medicines, best storage practices, Pha-G-Dis and Pha-Ge-Com management, training and capacity building, LMIS, etc.) was shared with the DAMM and members of the TMA subcommittee on regulation for review, as well as to identify additional texts that were not included in the literature review. In parallel, the DAMM also requested that the private and public sector provide additional comments to be considered and included in the existing registration manual developed in 2016. The literature review and the list of comments to be inserted in the registration manual will be analyzed by the TMA regulatory subcommittee to identify necessary texts and regulations to update or develop.

Intermediate Results 4 Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy people In Quarter 1, IMPACT achieved the expected results for distribution of FP products with 484,152 cycles of Oral Contraceptives and 513,453 doses of Intra-muscular injectable contraceptives. However, there was stockout of the Sub-cutaneous Injectable Sayana Press because the agreement to borrow 300,000 doses from UNFPA was in progress. It is estimated that the products will be available and distributed from May 2020.

For the MNCH products, the distribution target for Quarter 1 is at 25% of the annual target. The distribution is based on the Average Monthly Consumption (AMC) plus an additional security stock of three months. The following are the achievements per product:

• For Arofoitra, the achievement was 43% exceeding the target of 25% (Quarter target). After the stock out occurred in Year 1, all the PA needed to replenish their stock. As the level of stock is now normal, the PAs will follow the usual monthly consumption. As a result, the risk of overstock at PA and PARC is reduced to a minimum level (or none) as they have their level of stock maximum (up to 5 months) based on the AMC plus security stock. • For ORS/Zinc, the achievement was 36% exceeding the target of 25% (Quarter target) • For Sur’Eau Pilina, the achievement was 19%, which is slightly lower than the target of 25% (Quarter target). IMPACT reduced the promotion of this product because the stock available was limited leading to the reduction of the distribution achievement. • For Pneumox, the achievement was 22%, which is slightly lower than the target of 25% (Quarter target). There was overstock at the PARC and PA level after the peak in distribution in Year 1, which reduced the orders from PARC and PA explaining the low achievement.

Evaluation criteria of PA and PARC were defined and established in order to see how to set up and implement a motivation system for community volunteers. The personal performance review and development (PPRD) has begun and the final results will be available at end of January 2020.

PARC and PA were also trained on LLIN Community-based Continuous distribution (cCD). The LLIN are stored at PARC and PA. The total number of LLIN to be distributed in Year 2 is 989,000 with 104,000 LLINs already distributed to the PARC during Quarter 1.

For the drone pilot phase, 16 flights were completed in Quarter 1. For each flight 2.5 liters were transported. The flight tests during served 7 selected PA in Maroantsetra located at between 8 km to 42 km from the take- off point of the drone. Products delivered were Sûr’Eau Pilina, Arofoitra, Triclofem, Microgynon, and Sayana Press. Two SPD were recruited to prepare and supervise the delivery by drone.

Intermediate Results 5 Increased demand for and use of health products among the Malagasy people The demand creation subcommittee of the TMA TWG led by the Health Promotion Directorate (Direction de la Promotion de la Santé - DPS) of the MOPH was set up. This subcommittee includes all TMA stakeholders, with around 30 members, and holds at least one meeting each quarter. During Quarter 1, two meetings were organized. The first one identified the barriers and opportunities in terms of communication on health commodities, and the second one was organized with the objective to revise and improve the decree of the regulatory text on the advertising of health commodities. As a next step, the subcommittee will continue to address the barriers identified and will share communication activities on health commodities to public, private, commercial, and nonprofit. IMPACT products are promoted according to the inventory turnover and the stock status which means that only products that have enough stock until the next shipment are promoted to avoid stock-out. In Quarter 1, 1,700 radio spots were broadcasted (with a frequency of 5 times per day per radio station) for the promotion of Arofoitra from December 18th to December 30th in 31 districts belonging to 10 USAID supported regions. Approximately 3,700,000 people were reached, calculated based on the radio station coverage and the proportion of the target group who listen to the radio. SMS Activity:

• SMS were sent to 492 PA and to 3,494 Community Health Volunteers (CHV) to encourage them to purchase Arofoitra. • SMS were used to sensitize providers on how to store medicines. • SMS were sent to 3,512 CHVs, 475 PAs, and 64 PARCs. • Each month an SMS reminder is sent to the 115 Pha-G-Dis to send the Channel report to the central level, report the orders of commodities, and report the physical stock at the end of the inventory.

A Memorandum of Understanding (MOU) has been developed with the Ministry of Youth and Sport (MYS) which establishes the collaboration agreements between MYS and IMPACT Project. The signature is scheduled in Quarter 2 proposed by MYS. The main goal of the MOU is to raise youth awareness on health, their access to health commodities, and encourage them to adopt healthy behaviors, such as to going to health facilities and using FP products to avoid early pregnancy.

Cross-Cutting Monitoring Evaluation, Research and Leaning

Monitoring and Evaluation: • Implementing a short roadmap: IMPACT and DPLMT, DEPSI, and DSFa met at the DPLMT office in Antananarivo to develop a short-term LMIS roadmap following the five main challenges identified after a situational analysis of all 78 Pha-G-Dis in terms of LMIS: - 21 Pha-G-Dis providers were not trained on CHANNEL. The RLA has started to supervise and train these Pha-G-Dis. - 38 Pha-G-Dis providers did not have valid contract to allow them to act as a Pha-G-Dis provider or to receive the laptops for LMIS to be offered by USAID through IMPACT in January 2020. Contracts are ready at the DPLMT central office and will be sent to Pha-G-Dis providers after signature by DPLMT scheduled in Quarter 2. - 37 Pha-G-Dis that have no functional computers for CHANNEL will receive computers during the official event to be led by the MOPH. - 44 Pha-G-Dis did not have Internet connection to submit LMIS data. A plan is being developed with all partners to set up with high-speed Internet connection for these Pha-G-Dis. It should be carried out from the end of Quarter 2. - 5 Pha-G-Dis did not have electricity. The RLA sought to use neighboring buildings to submit data as an interim solution.

• A call center was set up at the IMPACT head office to remind Pha-G-Dis to submit LMIS data. A test was conducted in Quarter 1 with 19 Pha-G-Dis that had missing data for September and October. 12 out of the 19 Pha-G-Dis submitted data after the reminder. 7 Pha-G-Dis did not submit LMIS data after the reminder because of electricity issues and unavailability of personnel. The issues that cannot be addressed by the call center will be communicated to DPLMT, RLA, and IMPACT.

 As a result, after implementation of the roadmap and set up of the call center, the reporting rate from Pha-G-Dis to DPLMT was 71% in October and 63% in November (see MERL section for more details). It was observed that active data collection was reduced significantly from an average of 24 Pha-G-Dis visited in each Quarter of Year 1 to 16 in Quarter 1 Year 2 (mainly in Analanjirofo, Atsimo andrefana, Atsinanana, Melaky regions).

RDQA exercises were conducted in Quarter 1 in 4 regions (Sofia, Diana, Sava, and Haute Matsiatra) within 9 Pha-G-Dis, 18 Pha-Ge-Com, 6 PARCs, and 9 PAs. The challenges among Pha-G-Dis and Pha-Ge- Com included: availability (76%) and accuracy (56%). For PARC and PA, the overall data quality score was 96% which means that data submitted are of good quality.

Research: IMPACT finalized the tools used for the malaria market assessment: dashboards for household and outlet survey, dummy table for routine data, and additional analysis for key informant interviews, such as government, donors, implementing partners, private sector, and supply chain actors.

The study protocol is designed to evaluate the pilot phase of using drones as last mile distribution innovation for delivering health commodities to PAs experiencing stock out in the Maroantsetra region (Northeast of Madagascar) and shared with USAID for feedback.

Knowledge Management: During Quarter 1, Knowledge Management activities focused on collecting project success stories and photos from the field. The objectives of these visits are to (i) discuss with the target audiences concerning their views and perceptions of IMPACT interventions; (ii) collect success stories

developed by field staff and partners of the project (presented in Annex D) and (iii) initiate local staff to take photos meeting the required standards and recounting the life of the project with signed consent forms and full descriptions.

Gender Integration and Social Inclusion (GESI)

• Conducted a training of 45 journalists and police department communications officers responsible for enforcing the Gender Based Violence (GBV) laws on the relationship between GBV and equality of access to health commodities on December 13, 2019. • Conducted GESI capacity building session with 45 IMPACT staff (23 men, 22 women) during an all-staff retreat on October 24, 2019. • Published 4 articles focused on GBV, women’s access to finance, and the relationship between gender and health every Saturday in December in three daily newspapers (Midi Madagascar, Express de Madagascar, and Les Nouvelles). • Ensured the participation of two women’s organizations (CNFM and GFEM) during the TMI Technical Working Group on malaria during the Roll Back Malaria meeting held on November 14, 2019.

Graph 1: Summary of the sub-activities achieved vs sub-activities planned for October – December 2019

14 12 12

8 7

6 5

0 Nbr Activities to be Activities completed Continued activities completed Quarter 1

Twelve (12) sub-activities were planned to be completed in Quarter 1. Five (5) sub-activities (48%) were completely achieved. 7 sub-activities are continued in Quarter 2. Explanations on sub-activities not completed are provided in page 66.

II. INTRODUCTION

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

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

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

III. MAIN ACHIEVEMENTS DURING QUARTER 1

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

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

IR1.1.1: Support the implementation, monitor and evaluate the overarching TMA roadmap for all health products based on the discussions and decisions taken during the TMA

During Year 1, the TMA TWG identified three main issues hindering the access to quality health commodities of the total market for the most vulnerable groups of the Malagasy population. Those three issues were: (i) the lack of communication around the national pharmaceutical policy, (ii) the unavailability of quality data, and (iii) the regulatory texts in the pharmaceutical sector are not applied. These issues were translated into objectives and operational plans by the TMA TWG. The first month of Quarter 1 was dedicated to the finalization of the operational plan for each issue under the leadership of the relevant directorates/departments of the MOPH, with the support from the TMA Champions (both from the public and private sectors).

With the DPLMT leadership, one subcommittee has been created to focus on the issue of communication around the national pharmaceutical policy: Plan Directeur Pharmaceutique National (PDPN) and Politique Pharmaceutique Nationale (PPN) subcommittee. The existing document needs to be updated and has been disseminated even though not broadly enough (nationwide). In addition, the implementation has taken place but only few activities were realized. The TMA TWG subcommittee works on updating these documents based on the WHO guidelines on strategy and policy development with all stakeholder inputs in order to improve the contents of these documents for more effective work in the pharmacy sector. This subcommittee has

begun the analysis of each part of the PPN, identified the necessary rearrangement of some main components (mainly the Strategic Objectives), and integrated the requirement by the private sector on issues related to importation, distribution training, and research areas. Once the document has been updated and validated by the MOPH and all stakeholders involved during the process, it will be disseminated by DPLMT at the national and regional level.

Under the lead of the Agence du Medicament de Madagascar (AMM), a second subcommittee was established to address the issue of the application of regulatory texts related to health commodities that was identified during the TMA TWG meeting. The objective is to identify the texts and regulations which need to be promoted, amended, or created to improve the legal environment for health commodities. Other entities were also invited to join the group including the Service de la Législation, de la Figure 1: The subcommittee reviewing the inventory report of Réglementation et du Contentieux (SLRC) of the the existing texts and regulations related to health MOPH. In Quarter 1, with technical and financial commodities under the leadership of the AMM support from IMPACT, an inventory of all the texts and regulations has been carried out. To facilitate access and to ensure availability of the texts, IMPACT supported the scanning of all the documents which will then be shared to all relevant stakeholders and entities in order to digitalize them and to make them more accessible to everyone through a Google drive platform. With the support of an international consultant, IMPACT plans to have a working session with the subcommittee in January 2020 to validate the report of the documentary review to classify (based on its subject area: type of health commodities, type of pharmaceutical profession, professional orders, regulatory function, policy, missing texts) and analyze the existing texts and regulations, and to develop a workplan for the update and the dissemination of the texts. A third subcommittee was set up under the lead of DEPSI to ensure continuous availability of logistical and statistical data on health commodities (with an emphasis on timeliness and quality) through stakeholder engagement. This subcommittee finalized its action plan, ensured that each activity is SMART (Specific, Measurable, Achievable, Realistic, and Time bound), and clearly specified the roles of each actor and discussed the needed resources for carrying out the activities. In Quarter 2, the subcommittee plans to work with IMPACT on the dissemination of the LMIS evaluation results during a workshop and to advocate to include the TMA TWG large group as part of UTGL.

IR1.1.2: Support the development and implementation of the malaria TMA roadmap and monitor and evaluate its progress to ensure the availability of quality malaria products at all

On November 14, 2019 under the lead of the National Malaria Control Program (NMCP) a TMA subcommittee was created under the existing RBM group. This subcommittee conducted a PESTEL analysis (analysis of the Political, Economic, Social, Technologic, Environmental and Legal context) of the main factors blocking the access/availability of malaria health commodities to the most vulnerable population. The methodology adopted for this analysis is similar to what the TMA TWG has done to identify the three main barriers.

Graph 2: TMA Roll Back Malaria subcommittee composition

DONORS, 3%

NGO, 20% PUBLIC SECTOR, 37%

ASSOCIATIONS, 23%

PRIVATE SECTOR, 17%

The PESTEL analysis identified that the three most important issues affecting the availability of quality malaria commodities at all levels were: (i) the lack of behavior change communication campaigns for malaria commodities users and providers; (ii) the non-integration of private health facilities data into the national health information system and non-harmonization of database management at the national level (standardization of public-private use); and (iii) the non-application of existing laws for the illicit sales of medicine and drugs. The subcommittee will meet early in Quarter 2 to develop an action plan to address these issues with technical and financial support from IMPACT, which will be complemented with the results from the malaria market assessment.

Figure 2: The RBM TMA subcommittee members at the NMCP

IR1.1.3: Collaborate with relevant actors and stakeholders for the evaluation of the 'Roadmap to accelerate the reduction of maternal and neonatal morbidity and mortality 2015-2020'

In preparation for the FP and MNCH market assessments and roadmap development, IMPACT participated in the first meeting of actors led by the DSFa working on women’s health to discuss ways to involve the DSFa (SME,SMSR and PF), UNFPA as well as the private sector TMA Champion to develop tools and frameworks related to FP and MNCH market assessments.

IMPACT has learned from its previous experience that it is essential to involve all the actors prior to conducting and implementing activities to ensure their approval and ownership of the intervention.

During Quarter 4 of Year 1, IMPACT initiated discussions with DSFa on the importance of setting up a TMA subcommittee on FP/RH and MNCH. IMPACT, through its mandate, helps the public sector in terms of quantification to solve the recurrent stockouts. In addition, IMPACT also encourages the private sector to be more involved in the market for them to see the potential and demand, so that end users can seek other options from different sources. The subcommittee is thus important for the actors to collaborate and to create a more favorable environment to fill in the gaps in the needs for FP commodities. However, instead of creating additional subcommittees, IMPACT has been advised by DSFa to join the existing subcommittees and to align with their initiatives. DSFa plans on beginning the evaluation of the roadmap to accelerate the reduction of maternal and neonatal morbidity and mortality 2015-2020 with a focus on FP commodity security, initiated in 2015 as part of the Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA). IMPACT is waiting for the approval from DSFa to join the evaluation committee which is expected to start in Quarter 2 of Year 2. Similarly, as there are updates in certain case management protocols in newborn and child health, DSFa is seeking IMPACT’s support in updating the “Plan Opérationnel pour la réduction de la mortalité maternelle et néonatale incluant le Plan d’action pour chaque nouveau-né" with a focus on MNCH commodity security. Given that these initiatives are scheduled to begin in 2020, IMPACT will use the FP and MNCH TMA subcommittees to advocate on the points relating to health commodities in the strategic documents.

IR1.1.4: With the MOPH, build the capacity of TMA Champions to successfully steward and lead the TMA TWG and subcommittees (including the study tour to a country that has successfully implemented the TMA)

Quarter 1 has been marked by the identification/selection of five new TMA Champions, including the NMCP National Coordinator, the Family Health Director (DSFa), the President of the Health Commission at the Parliament, and two Champions from the private sector namely the President of the National Order of Pharmacists and the Vice President of the National Association of Pharmacists. These new TMA Champions are highly motivated to be part of the TMA process, especially in the implementation of the TMA roadmap.

IMPACT has organized a leadership training in December 2019. The need for this training as well as its general contents have been expressed by the Champions themselves and their request has then been used to tailor the one-day training session. The training consisted in identifying the personal leadership practices of the Champions, building their leadership capacity, and improving their competence in team management, time management, and in communication. Only three Champions received the leadership training in Quarter 1 due to issues of availability, but the others will be trained in January 2020. Similarly, three of the new Champions have received a training on TMA and the others will be trained in January Figure 3: One of the TMA Champions at the 2020. leadership training

Although a date has been set for the study tour and steps have been taken in terms of logistics due to the recent developments of the Coronavirus epidemic in Vietnam, IMPACT has been advised to postpone the study tour until the safety of the participants can be ensured. Depending on the evolution of the epidemic, new dates will be set and suggested to the TMA Champions.

IR1.1.5: Disseminate the official TMI roadmap documents (overarching, Malaria, FP and MNCH) signed by representatives of the public, private and non-profit sectors

In Year 1, an overarching TMI roadmap was developed for all three health areas by the members of the TMA TWG to solve the priority issues they have identified, including: (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, the roadmap is supported by an action plan detailing the specific joint actions to be taken towards the achievement of each solution. During Quarter 1, IMPACT finalized these two documents with the help of a consultant (General Razakafoniaina).

The first draft has been validated by USAID in December 2019, and this validated version will be submitted to the MOPH for their final approval before being officially presented in Quarter 2.

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

IR1.2.1: Organize meetings to revise and validate the Terms of Reference (ToR) of the UTGL to ensure its updated tasks and responsibilities.

IMPACT collaborated with PSI, UCP (Global Fund Principal Recipients) and NMCP to support the UTGL in organizing a two-day workshop in November to review roles and responsibilities of different supply chain actors at all levels (from central to community levels). Participants from different directions of the MOH (DPLMT, NMCP, DLMNT, DPEV, DEPSI, DGFS), and technical and financial partners understand the importance of coordination committees established at central, regional, and district levels to manage commodities (UTGL and GAS committees). The workshop was organized for technicians to draft the ToR which will be validated by health authorities before dissemination. The document developed during the workshops will be validated by the MOPH through the DPLMT and the NMCP in Quarter 2 and disseminated to all actors for implementation.

The following are some examples of amendments to roles and responsibilities of the UTGL: new roles and responsibilities of UTGL regions and GAS committee districts, role of districts, Pha-G-Dis, CSB, DSSB, DPLMT, partners in the implementation of the last mile distribution strategy, roles of new directions as per the new organigramme of the MOPH (DLMT, DGMP, DGFS, etc.).

Example of amendment on roles and responsibilities of UTGL and GAS committee: a) GAS committee at district level: • Collect and analyze data from CHV and health facility • Ensure the quantification at the district level based on each health facility /CHV average monthly consumption • Submit on time data to the regional level

• Provide feedback to health facility and CHV • Participate on the formative supervision and conduct on the job-training • Etc… b) UTGL at regional level : Providing technical assistance and capacity building to the district team on: • Stock management • Data reporting • Etc.

IR1.2.2: Organize quarterly meetings (UTGL, CGL, and GAS committee) to analyze routine data on key indicators in public hospitals, such as stock-out, LMIS issues, etc. for learning and adapting the use of DHIS2 in collaboration with the MERL team.

During Quarter 1, the UTGL performed many activities through its multiple subcommittees which are described in other sections of this report: • IR2.1. Quantification • IR2.2. Procurement and Distribution • CC2.1 LMIS

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

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

Emergency distribution of Family Planning products for the public sector In Quarter 1, IMPACT delivered 240,289 Triclofem and 12,000 Microgynon to 33 Pha-G-Dis belonging to the 13 USAID-supported regions as part of the FP products dedicated to the public sector emergency plan. These quantities of products were delivered following the distribution plan commanded by DSFa. The quantity distributed was from the remaining quantity of the emergency plan from Year 1.

Table 1: Distribution during Quarter 1

Qty Qty delivered to To be Remaining Qty for FY 20 PRODUCTS provided by Pha-G-Dis in Achievement distributed for (As of October 1st, 2019) USAID Quarter1 YEAR 2 Quarter2 Year 2 SAYANA PRESS 301,600 - - - (Dose) Depo-Provera 950,320 316,362 240,289 75.95% 76,073 (Dose)/TRICLOFEM Oral 537,800 31,960 12,000 37.55% 19,960 Contraceptive

The remaining quantity for the emergency plan is to be distributed in Quarter 2.

IR2.1.1: Provide capacity building through trainings and consistent coaching to GOM and partner members of UTGL on forecasting and supply planning, including the use of Quantimed

From December 9th to December 13th, IMPACT technically and financially supported the workshop to review the quantification of malaria commodities in Antananarivo. During the workshop, Andualem Oumer (STTA: Short-term Technical Assistance) provided a refresher training on quantification concepts, data analysis and compilation using the quantification software Quantimed, and the supply planning software Pipeline. In total 26 people participated at the workshop (11 males and 15 females). The Supply Chain Advisor of PMI Washington and the PMI Resident Advisor of Madagascar contributed to the quantification review and shared global PMI guidance on quantification and procurement.

Table 2: Participants at the workshop for semester review quantification of malaria, December 2019

Participants Female Male Total % Public Sector (UTGL, NMCP) 4 4 8 31% Private Sector (pharmaceutical wholesalers) 1 0 1 4% Partners (IMPACT, ACCESS, Mahefa Miaraka, 6 11 17 65% UCP Global Fund, PSI) Total 11 15 26 100% % 42% 58% 100%

IR2.1.2: Assist the GOM and UTGL members in leading the annual system wide forecasting exercises for the public and private sector for FP/RH, MNCH, and malaria commodities and support UTGL and SALAMA to help mobilize resources to procure commodities in the supply plans

In Quarter 1, IMPACT provided technical and financial support to the semester review of the quantification of malaria and FP/RH commodities. The objective of this review is to (i) update the annual supply plans; (ii) identify gaps in terms of health commodities and funding and (iii) adjust the supply plans accordingly in order to ensure a continuous availability of essential commodities.

From November 20th to November 22nd, in close collaboration with UNFPA, IMPACT, JSI Collaborative, and other partners, the DSFa organized a workshop in Toamasina to review the quantification of FP/RH commodities. The annual supply plan was revised and updated according to the stock status (quantity available at SALAMA and in the districts), orders in the pipeline, and current consumption data. This revision of the supply plans showed that there is an estimated gap of approximately $11,000,000 to cover the needs for FP/RH commodities in 2020 and 2021 (table below summarize the gap in funding). DSFa is planning to organize a mobilization of resources session for potential partners in Quarter 2, including UNFPA, USAID, the World Bank, The Global Fund, GIZ (Coopération Allemande), AFD (Agence Française de Dévelopement), and Coopération Technique Belge to address this gap. The MOPH is advocating to increase the GOM’s contribution to cover at least 15% of needs (the current contribution is estimated at 1.9% of total needs).

Table 3: Summary of the gap in funding

Designation Year 2020 2021 Comment Total budget to procure FP/RH $6,515,996 $5,262,776 commodities (US$) 2020 commitment * GoM : 123,195 USD Commitments (US$) 496,690$ 0 *PARN/ World Bank: 249,310 GAP (US$) $6,019,306 $5,262,776

From December 9th to December 13th, 26 participants from public, private, technical, and financial partners have analyzed the health services and logistics data and developed three scenarios to improve the quantification and supply plans at national level:

• based on historical service data of 3 past years (i.e. treated and diagnosed cases) and predict future trends by applying a defined growth rate. • based on predictions and the National Strategic plan (PSN) programmatic objectives. • based on logistics data (i.e. consumption, stock on hand, leakage, days of stock out). The three scenarios will be presented to Roll Back Malaria meeting in January 2020 to select that will be validated by the CGL in February 2020.

During the workshop, participants agreed to no longer consider the ambitious projections and objectives of the National Supply Plan (NSP) and only compare forecasting results based on service data and logistics data. Below are the key changes made during the quantification review:

• Consider an annual increase of 20% to project fever cases to be tested with RDT: the NSP was projecting a yearly reduction of 6%. • Consider an annual increase of 10% of simple malaria cases to be treated with ACT: the NSP predicted a decrease of 42, 18% in 2019 due to national mass distribution campaign of LLIN, which didn’t happen. • Apply a rate of 2.278% to all malaria cases to project severe malaria cases to be treated with Artesunate injectable: NSP predicted a rate of 1.34% • Consider that only 21% of pregnant women that attended the ANC will receive IPT-3, while NSP projected 60%.

Main recommendations for future quantification are:

• Conduct an active data collection to get accurate data reported from the health facility and stock levels at district (including expiry dates). • Consider stock parameters to stock according to plan at all levels, and not at SALAMA levels. • Collaborate with DEPSI to improve the reporting mechanism and format to correctly capture consumption data at health facility (CSB). Harmonize logistics data reported in the two main systems: HMIS (DHIS2) and LMIS (Channel).

Work with ACESS and Mahefa Miaraka to harmonize type of data and data collections tools for community level. As data for community level are not yet integrated in DHIS2, quantification is using data reported by the two programs for USAID supported regions and do a proxy for other non-USAID supported regions. It was a privilege to have the PMI Supply chain Advisor from USA and the Resident PMI Advisor in the workshop and obtain their perspectives and guidance; it helped to get donor perspective and also gave the opportunity to the quantification committee to convey important messages to the donor representatives. Feedback from the Global Fund LFA was also considered in developing the quantification scenarios.

In October, a TWG was created to set up a mechanism of coordination to improve the management of the MNCH commodities procured by SALAMA and donors. This TWG is based at DSFa and acts in lieu of a GAS Committee for MNCH.

Currently, DSFa is not aware of stakeholder’s contribution in procurement of MNCH commodities so a TWG has been set up to correct this situation for the next quantification calendar. The donated medicines are stored at SALAMA but with no clear guidance on how to distribute them to Pha-G-Dis and CSB. A strong coordination is needed to avoid multiple distribution channels for MNCH commodities and avoid duplication between donated commodities procured by donors and those sold through the FANOME recovery system by SALAMA.

More discussions on current issues related to MNCH commodities will continue under the leadership of the General Secretary of the MOPH to jointly try to solve key issues around stock management, reporting distribution and consumption of MNCH commodities, proper storage/cold chain of Oxytocin, correct use of Oxytocin and misoprostol in both prevention and treatment of post hemorrhage conditions, resource mobilization to cover the needs, and management of both SALAMA and donor-funded MNCH commodities at the facility level.

IR2.1.3: Coordinate orders, deliveries generation and pipeline monitoring according to agree upon supply plan with SALAMA, PSM, GOM institutions and USAID

During Quarter 1, IMPACT continued to coordinate and receive shipments from GHSC-PSM NFO that were not completely delivered in 2019. Below is a table summarizing the orders and the pipeline status.

Table 4: Summary of orders and the pipeline status

Pending orders of 2019 to be delivered in 2020

Family Planning/RH Quantity Quantity Delivery Product Unit Note Ordered Delivered Date Depot (IM) Medroxyprogesterone Acetate 150 mg/mL (1 mL) Vial, SR, 1 vial 2,999,900 2,999,900 8-Nov-19 Delivery Completed 1 Vial [PT Tunggal] [Triclofem] Etonogestrel 68 mg/Rod, 1 Rod 1 rod implant 16,676 16,676 12-Nov-19 Delivery Completed Implant, 1 Each [Implanon NXT] Levonorgestrel/Ethinyl Estradiol 150/30 mcg + Fe 75 mg, 28 1 Cycle 1,052,352 24-Mar-20 Tablets/Cycle (SM), 1 Cycle [Zinnia- F] Levonorgestrel/Ethinyl Estradiol 150/30 mcg + Fe 75 mg, 28 1 Cycle 948,696 948,696 23-Jan-20 Delivery Completed Tablets/Cycle (SM), 1 Cycle [Zinnia- F] Standard Days Method Color- Alert shipment Coded Plastic Beads, 1 Each [Cycle PCS 21,000 3-Feb-20 notice sent by PSM Technologies] [CycleBeads] in January Malaria Commodities Estimated Quantity Quantity Product Unit Delivery Comment Ordered Delivered Date

Partial delivery. (Campaign) Long Lasting Insecticide Pending shipment of Treated Net (LLIN) 190x180x170 75,300 units (PBO) UNT 1,000,000 924,700 12/4/2019 cm (LxWxH) Rectangular (White), 1 with estimated Each delivery date of February 2020

(Campaign) Long Lasting Insecticide Treated Net (LLIN) 190x180x170 Distribution in 2021 UNT 677,000 1/11/2021 cm (LxWxH) Rectangular (White), 1 mass LLIN campaign Each

Furthermore, IMPACT also submitted new orders in ARTMIS for quantities of PMI malaria and USAID FP/RH commodities planned and budgeted for 2020. The table 5 below shows the quantities ordered per each product as well as the estimated delivery date.

Table 5: The quantities ordered per each product as well as the estimated delivery date.

New Procurement for 2020- New orders introduced in ARTMIS/ PSM

Family planning/ reproductive health commodities

Requested Quantity 1Delivery Product Unit Ordered Date Notes Depot (IM) Medroxyprogesterone Acetate 150 mg/mL (1 mL) Vial, w/ AD Syringe, 1 Each UNT 900,000 3/31/2020 Etonogestrel 68 mg/Rod, 1 Rod Implant, 1 Each UNT 35,064 6/30/2020 Standard Days Method Color-Coded Plastic Beads, 1 Each PCS 17,000 5/29/2020 Depot (IM) Medroxyprogesterone Acetate 150 mg/mL (1 mL) Vial, w/ AD Syringe, 1 Each UNT 1,600,000 3/31/2020 Levonorgestrel/Ethinyl Estradiol 150/30 mcg + Fe 75 mg, 28 Tablets/Cycle (PS), 1 Cycle UNT 3,200,400 6/30/2020

Malaria commodities - 2020

Requested Quantity Delivery Product Unit Ordered Date Notes Artesunate/Amodiaquine 100/270 mg Tablet, No shipment alert 25 x 3 Blister Pack Tablets [Cipla] BOX 8,549 9-Dec-19 notice yet received Artesunate/Amodiaquine 50/135 mg Tablet, 25 No shipment alert x 3 Blister Pack Tablets [Cipla] BOX 21,896 9-Dec-19 notice yet received Malaria Rapid Diagnostic Test (RDT) HRP2/pLDH No shipment alert (Pf/PAN) Cassette, 25 Tests BOX 51,613 12-Dec-19 notice yet received Malaria Rapid Diagnostic Test (RDT) HRP2/pLDH No shipment alert (Pf/PAN) Cassette, 25 Tests BOX 40,000 23-Jan-20 notice yet received Artesunate/Amodiaquine 100/270 mg Tablet, 25 x 6 Blister Pack Tablets [Cipla] BOX 7,461 17-Mar-20 Artesunate (w/ 1 Amp NaHCO3 5% + 1 Amp NaCl 0.9%) 60 mg Vial, 1 Set [Guilin] UNT 25,000 22-Apr-20 Artesunate/Amodiaquine 25/67.5 mg Tablet, 25 x 3 Blister Pack Tablets BOX 210 12-May-20 Artesunate/Amodiaquine 50/135 mg Tablet, 25 x 3 Blister Pack Tablets BOX 15,440 12-May-20 Artesunate/Amodiaquine 100/270 mg Tablet, 25 x 3 Blister Pack Tablets BOX 3,664 12-May-20 Artesunate/Amodiaquine 100/270 mg Tablet, 25 x 6 Blister Pack Tablets BOX 12,065 12-May-20

1 At the time of this report writing, the GHSC- PSM has not yet confirmed the estimated delivery dates

Artesunate/Amodiaquine 25/67.5 mg Tablet, 25 x 3 Blister Pack Tablets [Cipla] BOX 2,094 20-May-20 Sulfadoxine/Pyrimethamine 500/25 mg Tablet, 150 Tablets UNT 10,000 9-Dec-20

IR2.1.4: Provide technical assistance to support the central GAS Committees level to develop quarterly distribution plans for malaria, MNCH, and FP/RH products based on quarterly stock status obtained from district/GAS committees

At the central level, IMPACT supported the GAS committees (malaria and MNCH) in collecting and analyzing quarterly requisitions and LMIS data from Pha-G-Dis to generate efficient, and timely distribution plans. IMPACT assisted the NMCP and GAS committees to compare data reported through various systems (CHANNEL, Web malaria, and DHIS2) to take decisions on quantity to distribute for each Pha-G-Dis. The GAS Committee was able to compare the number of malaria cases tested or treated with quantities of RDTs and ACTs consumed in each district. Nevertheless, the discrepancy is very high for ACTs 2-11 months and 1-5 years. The committee will conduct an analysis in the coming period to explore if this is due to lack of reporting quantities from the CHV by the CSB through the Rapport Mensuel d’Activités (RMA) results. Results will be discussed with DEPSI to assess the situation based on its community data reporting through DHIS2. Additional actions to implement will be decided in the meeting with DEPSI and other Implementing partners assisting the community level. Results will be reported in the next quarterly report.

Graph 3: Comparative analysis of service and logistics data reported by Health centers

450,000 407,443 393,989 400,000

350,000

300,000

250,000 213,856 198,601 197,820 190,733 200,000 176,300 164,531 150,000 130,344 103,257 109,258 100,000

50,000 15,461 0 ACT 2-11 months ACT 1-5 years old ACT 6-13 years old ACT 14 years old +

Reported treated cases Reported ACT consummed Reported ACT received

Source of data: DHIS2, cumulative data from January to December 2019

During Quarter 1, IMPACT assisted the malaria GAS committee to ensure that the quarterly distribution plans were accurate and sent in timely manner to SALAMA. IMPACT contributed to GAS committee meetings dedicated to analyzing and deciding on quantities to transport to districts. All the 115 Pha-G-Dis received their resupply during this quarter. The table below shows the quantities of malaria commodities distributed by SALAMA to Pha-G-Dis. PMI and Global Fund malaria commodities are managed in a common basket at SALAMA for distribution.

Table 6: Distribution of FP commodities in Quarter1 from SALAMA to Pha-G-Dis

Targets for Total Quantity Distributed in Product Distribution in October November December Quarter 1 Year 2 Distribution of PMI procured malaria commodities Artemisinin-based combination 3,006,530 97,575 78,625 96,450 272,650 therapy (ACT) treatments (AS/AQ) ACT Newborn 0 0 0 0

ACT Infant 0 0 0 0 ACT Adolescents 55,475 35,925 53,825 145,225 ACT Adult 42,100 42,700 42,625 127,425 ARTESUNATE 60 N/A 15,153 11,075 13,415 39,643 MG-INJ-BTE/ 1 Rapid diagnostic 3,903,011 0 0 0 0 tests (RDTs) Sulfadoxine- pyrimethamine (SP) 13,365,690 112,250 66,500 73,350 252,100 tablets Distribution of GF procured malaria commodities Artemisinin-based combination N/A 81,900 61,375 114,550 257,825 therapy (ACT) treatments (AS/AQ) ACT Newborn 19,400 14,800 33,100 67,300 ACT Infant 61,575 45,650 81,450 188,675 ACT Adolescents 925 925 0 1,850 ACT Adult 0 0 0 0 Rapid diagnostic N/A 328,300 373,225 308,475 1,010,000 tests (RDTs) Sulfadoxine- pyrimethamine (SP) N/A 0 0 0 0 tablets Total PMI and GF Artemisinin-based N/A 179,475 140,000 211,000 530,475 combination

therapy (ACT) treatments (AS/AQ) ACT New born 19,400 14,800 33,100 67,300 ACT Infant 61,575 45,650 81,450 188,675 ACT Adolescents 56,400 36,850 53,825 147,075 ACT Adult 42,100 42,700 42,625 127,425 Rapid diagnostic N/A 328,300 373,225 308,475 1,010,000 tests (RDTs) Sulfadoxine- pyrimethamine (SP) N/A 112,250 66,500 73,350 252,100 tablets

The distribution to Pha-G-Dis was completed by SALAMA through the contract signed by Management Sciences for Health (MSH) for regular and emergency shipments.

There is a huge stock of Sulfadoxine-Pyrimethamine (SP) available in the country which is at risk of expiration if the consumption rate remains the same. The GAS Committee estimates that there are approximately 5,000,000 tablets which need to be transferred to another country for this year to avoid expiration. Ongoing discussions are being held with GHSC-PSM to explore a country that can receive the SP. Furthermore, the GAS Committee plans to organize a meeting with the MIP (Malaria in Pregnancy) TWG to explore strategies and action plans in order to increase the consumption of SP at the CSB level.

At the district level, the Regional Logistics Advisor (RLA) continued to reinforce the capacity of Pha-G-Dis staff in supply chain management through on-the-job supportive supervisions visits and assess their capabilities on practicing the Manuel de Gestion de Stocks procedures through on-the-job supportive supervision visits. Below a table summarizing subjects covered during the supervision, results and comments.

Table 7: Summary of subjects covered during the supervision, results and comments

Subjects covered by the RLA during supportive supervision Results Comments visits * 78 Pha-G-Dis (100%) analyzed stock and Evaluating available stock of developed a dashboard to detect risk of stock out malaria, FP/RH, and MNCH or overstock. commodities to estimate the * 41 Pha-G-Dis have an overstock and organized needs for requisitions to redeployment of stocks to other 44 Pha-G-Dis to SALAMA or redeployment in correct stock imbalances and avoid stock outs case of overstock and expiry of malaria commodities. Submitting orders to SALAMA 78 Pha-G-Dis (100%) submitted a requisition to on time to avoid emergency SALAMA for resupply of malaria and FP/RH orders commodities Complying with good storage Other Pha-G-Dis are storing practices, including equipment, their sensitive medicines in the * 68 Pha-G-Dis (78%) comply with best storage procedures, space Immunization program practices. management, products refrigerators. DPLMT is * 36 Pha-G-Dis (46%) are equipped with a management based on First mobilizing resources and functional refrigerator and able to correctly store Expiry- First Out (FEFO), and procuring additional the sensitive medicines such as Oxytocin. management and disposal of refrigerators to cover all the expired stock Pha-G-Dis Correctly using stock management tools (stock cards, 74 Pha-G-Dis (90%) are reporting stock CHANNEL) and archiving the movement on stock card stock related documentation. The reporting rate is still low especially for Pha-G-Dis in * The reporting rate varies between 55% - 80% of Updating of stock movement in regions of Haute Matsiatra, Pha-G-Dis that submitted LMIS report through CHANNEL and submit an Sava, Atsinanana and Atsimo CHANNEL at DPLMT (in the 13 supported accurate LMIS report to DPLMT Andrefana. The RLA will do a regions). close follow up to increase reporting through CHANNEL Pha-G-Dis to review orders 78 Pha-G-Dis (100%) organized resupply of submitted by Pha-Ge-Com to malaria, FP, and MNCH commodities to their analyze correctness for resupply respective Pha-Ge-Com This is still very low due to lack of understanding of the process by districts. The RLA Preparing and processing and ATR/UCP organized GAS invoices for reimbursement for 17 Pha-G-Dis (21%) submitted invoices for committee meetings to explain last mile distribution of malaria reimbursement to UCP for implementing last the last mile distribution commodities. mile distribution. strategy The last mile distribution policy is taking into consideration the following criteria:

• At Pha-G-Dis level: 2% of malaria, HIV/AIDS, and Tuberculosis total value of stock was reimbursed by the Global Fund while IMPACT is responsible for 2% of FP and MNCH commodities total value of stock, • At PhaGeCom level, there are two systems: - - a forfeit of Ar 5,000 in terms of transportation for CSB located at less than 10km from the Pha-G-Dis

• For CSB located at more than 10 km from the Pha-G-Dis, they received an additional amount of Ar 200 per km. • For reimbursement, Pha-G-Dis and CSB should submit a correct and original invoice with vouchers (a signed copy of an MOU, stock inventory report with value, correct report- purchase order) , stock status analysis within Min-Max stock status ) on time (15th day following the end of quarter) to SDSP (districts Medical Inspector). • Request of reimbursement is submitted by the SDSP/districts every 30th day following the quarter to DSSB. Once verified and approved by DSSB, the request is sent to DPLMT for a second check and approval and then finally submitted to UCP for payment.

IMPACT collaborated with ACCESS, Mahefa Miaraka, and various directions of the MOPH (DSSB, DSFa, DPLMT, DEPSI, Service de Formation Professionnelle (FP), and DLMNT) to compose a central level team to conduct a pretest of the revised training curriculum for stock management at CSB and (CHV). The main revision is related to quantification, LMIS reporting, dispensing, storage, and inventory stock. Twenty-one personnel from seven CSB (7 heads of CSB, 7 dispensers, and 7 presidents of Comité de Gestion /COGE) were trained in Foulpointe on this new curriculum. The central level team involved in revising the training curriculum finalized the training curriculum after the pretest by integrating feedback from the trainees. The final training curriculum has been validated by the MOPH (Service de Formation du Personnel) in Quarter 1.

From December 16th to December 20th, a total of 15 personnel (6 men and 9 women) from 5 CSB of Sainte Marie district were trained on the revised curriculum on stock management. The training sessions will continue in Quarter 2 in order to complete trainings for all CSB of the Analanjirofo region. ACCESS and Mahefa Miaraka will replicate the same training and use the same training curriculum in other USAID supported regions.

IR2.1.6: Assist the MOPH in creating a five-year LMIS strengthening roadmap and developing and testing a new LMIS software using results from the LMIS in-depth evaluation

The CHANNEL software is used to manage the stock of commodities and report on logistics data (consumption, stock on hand, stock out, wastage) needed for decision-making. CHANNEL is installed in all the 115 Pha-G-Dis, but the reporting rate still varies between 55- 80%. Every month, the RLA support the Pha-G-Dis to ensure that data are up-to-date and submitted to DPLMT on time. IMPACT will leverage resources with UCP-Global Fund and World Bank to equip Pha-G-Dis with laptops and IMPACT is planning a distribution of 37 laptops in Quarter 2.

In Year 1, IMPACT collaborated with DPLMT and DEPSI to conduct an in-depth assessment of the existing LMIS and collect the evidence-base for improvement (infrastructure and equipment, architecture of CHANNEL, human resources capacity, interoperability with DHIS2, etc.) in the public, private, and social marketing sectors. The report is still being reviewed and edited internally before dissemination and this has taken longer than planned due to the amount of information collected through qualitative and quantitative surveys to be processed and IMPACT is working closely with the research agency that conducted the data collection to finalize the report. The report will be shared with USAID for feedback and comments in March 2020. IMPACT will organize a workshop in March 2020 to share findings and support the MOH in establishing a 5-year consensus-based strategic roadmap for the implementation of a comprehensive and efficient LMIS in Madagascar.

IR2.1.7: Generate evidence through a national supply chain assessment and End User Verification surveys to develop adequate strategies, policies, and SOPs for securing commodities and strengthening the public supply chain

To generate the evidence necessary to develop appropriate strategies related to the supply chain, IMPACT plans to conduct End-User Verification (EUV) surveys in Year 2 on a semester basis and one National Supply Chain Assessment (NSCA) throughout this fiscal year under the MOPH leadership.

During Quarter 1, IMPACT collaborated with GHSC-PSM to prepare the EUV survey and the NSCA. GHSC-PSM shared new guidelines and questionnaires on how to conduct the EUV survey, training curriculum, sampling methodology, as well as the software recommended to collect data (Survey-CTO) and report on 18 key indicators related to stock management (10 indicators), facility and storage management (3 indicators), and case management of malaria (5 indicators).

In October, IMPACT started preparations for the first EUV survey and procured all the necessary materials to collect data (smartphones, Survey-CTO software).

In November, IMPACT worked with various directions of the MOPH to nominate members to the EUV national committee that will lead and supervise the survey. The EUV national committee is comprised of 13 representatives of IMPACT, DSSB, DEPSI, DPLMT, NMCP, DSFa, DGFS, and the Secretariat General office. From November 25th to November 30th, IMPACT organized a 5-day orientation for the EUV national committee members on their terms of reference including the concept of EUV, the questionnaire and guidelines, the timeline of the EUV in Madagascar, the list of products, the sampling methodology, and the software. The committee was able to select samples of facilities to be surveyed. IMPACT also recruited data collectors though an open/public advertisement.

IR2.1.8: Conduct continuous distribution of LLINs in 12 targeted districts.

Malaria remains a public health problem in Madagascar because it is the third reason for consultation at health facilities level and the fifth cause of mortality in hospitals.

The use of Long-lasting Insecticide-treated Nets (LLIN) is one of the methods that have been demonstrated as effective in preventing malaria. As a result, the National Malaria Strategic Plan (PSN) 2018-2022 set an objective to "Protect at least 90% of the population for the LLIN targeted areas, by the end of 2022".

To maintain high LLIN coverage at household levels one year after a mass distribution campaign, it is recommended to implement a community-based continuous distribution (cCD) of LLIN (recommended after a successful activity and lessons learned cCD in 2017). In 2020, 12 districts are selected for the cCD to complete the mass distribution campaign conducted in 2018.

The MOPH collaborates with the MENETP at the community level. The MENETP contributes to SBCC programs through the school's "Child-Community" approach. The strategy is to educate the children about the need to sleep under an LLIN every day. This way parents will be sensitized about the value of using LLIN.

The cCD LLIN supply chain strategy is as follow:

- Push strategy: from PSI warehouse to PARC and from PARC to PA. - Pull strategy from PA to PARC, from Kom’lay to PA, and from household to Kom’lay. The “Kom’lay“ is a committee created at the community level composed of CHW, teachers, and school directors in charge of procuring LLINs at the PA level and distributing to targeted households.

Scheme 1: cCD Implementing scheme:

Roles and responsibilities of the actors:

• CNC: central level coordination • CRC: Regional level coordination • CDC: Coordination at district level • CCDS (Comité Communale pour le Développement Social) : coordination at commune level • KOMLAY: implementation of cCD activities • KOMLAY: (CHV, School Director, Teacher): ensuring transportation of LLINs from PA to Kom’lay, storage and security, communication activities to students, checking non-covered sleeping spaces at household level, distribution of coupons, distribution of LLINs in exchange of coupons at Kom’lay sites. • Chief of CSB: providing training and supervising Kom’lay activities and ensuring monitoring and validation of Kom’lay reports • Chief of ZAP (Zone d’Appui Pédagogique): training and supervision of communication activities at school level. Checking teacher reports on sensitization • TA: Providing technical support to Kom’lay, Chief of CSB and Chief of ZAP Logistics, activities, reports • STA: Ensuring supervision of TA activities, providing technical support of the EMAD team • SDSP EMAD: Ensuring training and supervision of cCD activity at commune level in • DRSP/EMAR: Ensuring training and supervision of cCD activity at district level • PARC: Ensuring storage and the security of LLIN at District level • PA: Ensuring storage and the security of LLINs at commune level

Procure 1,000,000 LLINs in coordination with the National Malaria Control Program, PSM, Roll Back Malaria, and PMI and organize the logistics to store 1,000,000 LLINs in PSI's warehouse and transport the LLINs to 12 targeted districts (approximately 500,000 households)

Following the validated quantification of LLINs in May 2019, 1,000,000 LLINs were needed for the 12 targeted districts, including buffer stock. In collaboration with NMCP, RBM, GHSC-PSM, and PMI, the IMPACT project launched the procurement of the LLINs in July 2019. The procurement process followed the approved technical specifications, including 924,700 standard LLINs and 75,300 of new generation nets or Pyrethroid Piperonyl Butoxide nets (Pyrethroid-PBO). During Quarter 1, IMPACT began receiving and storing 924,700 LLINs at the central level in Antananarivo, representing 92% of the total procured LLINs.

Table 8: Reception status of LLINs

ORDER RECEPTION Ordered Received LLIN specification Period Period Comments Quantity Quantity - The delivery of LLINs to Madagascar began November 19, Standard White 2019; July 2019 924,700 Dec 2019 LLIN 924,700 - This quantity covers the needs of 11 targeted districts (excluding Port Bergé) - The shipment is in progress and the ETA is January 29, 2020; PBO nets July 2019 75,300 - The quantity is for the district of Port Bergé, which will be the PBO nets pilot district;

TOTAL 1,000,000 924,700

According to the established schedule, the LLIN transportation from the central level to the targeted districts will occur in two groups. Transportation of nets to Brickaville and Toamasina II was completed in December 2019 and for the 10 remaining districts will happen in Quarter 2.

Table 9: LLIN Transportation Schedule

LLIN QUANTITY for PARC (1st DISTRICTS PERIOD Comments delivery) Brickaville 12 200 December19 - 02 months of stock according to the forecast for the districts Toamasina II 13 900 December19 - LLIN available at PARC of Brickaville and Tamatave II Group 1 from December 2019 Manakara 26 900 January-20 - 02 months of stock Mananjary 22 500 January-20 - Transportation to PARC Vohipeno 8 700 January-20 scheduled the week of Toliara II 19 800 January-20 January 13th 2020

LLIN QUANTITY for PARC (1st DISTRICTS PERIOD Comments delivery) Port Bergé 22 350 February-20 - Waiting for the PBO nets for Bekily 18 600 February-20 Port Bergé Antanambao February-20 - 02 months of stock for each Group 2 5 400 Manampotsy district Mahanoro 25 650 February-20 - Transportation to PARC Farafangana 34 950 February-20 scheduled the week of January 13th 2020 Vangaindrano 33 750 February-20 Total 244 700

Ten PAs have received their LLINs during the week of December 16, 2019 for the Tamatave II district, which represents 56% of the total quantity to be delivered to this district. In total, 26,100 LLINs were transported from the central level to the districts (PARC) for group 1 in December 2019.

Scheme 2: Logistic of LLIN Distribution circuit

IMPACT WAREHOUSE

Storage of the 1,000,000 LLIN upon received in the

country

COMMUNITY RELAY SUPPLY POI(12 P.A.R.C) Storage/security of LLIN at district level Storage at district level

SUPPLY POINT

(281 P.A) Procuring LLIN at PARC level, ensuring

their storage and security at commune level

KOMLAY (2,930) Procuring LLIN at PA, ensuring storage and distribution to household

Household Beneficiary

Develop training materials and organize cascade trainings of key actors involved in the continuous distribution of LLINs, including PAs, CHVs, teachers, school directors, etc.

In conjunction with the Community-based Continuous Distribution (cCD) strategy review, the training materials have been updated. After validation from the MOPH and MENETP, the training of trainers (TOT) and Kom’Lay curricula were shared, duplicated, and sent to the training venues defined in the training plan outlined in Table 10.

IMPACT, in collaboration with the National Coordination Committee, conducted two TOT sessions to participants coming from Mananjary, Manakara, Vohipeno, Brickaville, Tamatave II, and Tulear II districts held from December 4th to 6th in Antananarivo. Forty-six (46) participants were trained (24 men and 22 women) and comprised EMAR and EMAD staff from the MOPH and Direction Régionale de l’Education Nationale et de l’Enseignement Technique Professionnelle

(DRENETP), Circonscription Scolaire (CISCO) teams from Vatovavy Fitovinany, Atsinanana, and Atsimo Andrefana regions. Table 10: Training plan

LEVEL THEME TARGET DURATION TRAINERS PERIOD DISTRICTS CENTRA TOT -MoPH : EMAR , 03 days CNC members from Group 1 : Tamatave II, L EMAD DLMT, NMCP, Brickaville, 04 to 06 IMPACT and Mananjary, -Education : December MENETP Manakara, Regional school 2019 Vohipeno, Tulear health responsible II, Mahanoro, and Circonscription A/bao Scolaire (CISCO) ; Group 2 : Manampotsy, Educational Early March Farafangana, assistant 2020 Vangaindrano, -IMPACT : SRD Bekily, Port Bergé Regional Distribution Supervisors (SRD) and Supervisors of TA DISTRIC Chief of CSB, Chef 02 days Regional training Group 1 (6 Tamatave II, T of ZAP and TA team districts) : Brickaville, Mananjary, week of 06 Manakara, and 13 Vohipeno, Tulear January 2020 II,

Group 2 (6 Mahanoro, A/bao districts): Manampotsy, Planned on Farafangana, March 2020 Vangaindrano, Bekily, Port Bergé COMM CHV Mobilizer – 02 days Chief of CSB- Chief All Kom’Lay UNITY CHV distributors- of ZAP – TA members Chief of Fokontany- School Director – Teachers

Table 11: Training Schedule for Quarter 2

Period Group 1 Group 2 February 6th Organize training for CSBs and ZAPs (Zone d’administration Pédagogique: Pedagogical administration area) at the district level starting February 20th CSBs and ZAPs will conduct the training of Kom’Lay Early March 2020 Conduct a TOT for a pool of trainers from the districts of Mahanoro, Antanambao Manampotsy, Farafangana, Vangaindrano, Port Bergé, and Bekily Late March 2020 The CSB, ZAP, and TA (Technicien Accompagnateur: technical Assistant) at the district level will be trained.

April 2020 Kom’Lay members will be trained from April 2020

Train and supervise new PARCs and PAs for Continuous LLIN Distribution. In December 2019, 6 PARC and 144 PA received training on LLIN community-based continuous distribution as presented in the table 11. The attendance rate was 98.7%, with two PA from Tamatave II and Mananjary districts absent. The training took place in the district where the PARC are located. The training lasted two days per district and focused on the following aspects:

- Malaria disease and prevention - Distribution of LLIN through the continuous distribution - Management tools and the payment system of the transportation and storage

Table 12: Summary of the participants to the training in December

PARC PA Total (PARC + PA) Scores 75% Dates Districts Femal Femal Pre- Post- Male Total Male Total Female Male Total e e testing testing 13,14 Dec Brickaville 1 0 1 11 7 18 7 12 19 0 8

Tamatave II 10,11 Dec 1 0 1 7 10 17 10 8 18 0 8 Tuléar 2 11,12 Dec 1 0 1 16 10 26 10 17 27 0 4 Vohipeno 10,11 Dec 1 0 1 9 12 21 12 10 22 1 18 Manakara 12,13 Dec 1 0 1 14 18 32 18 15 33 2 25 Mananjary 16,17 Dec 1 0 1 12 18 30 18 13 31 3 25

Observations during the trainings:

- High attendance (only two PA absent among 152 PA and PARC) - Topics about malaria were appreciated by the trainees - 59% of the trainees obtained a score more than 75% at the post-testing

- Area for improvement is evaluated and identified for each participant to be used during the following training supervision - Participants are aware that the continuity and extension of the cCD for the period 2019-2020 stands from the success of the pilot phases - All PA and PARC who attended the training signed the partnership agreement related to the cCD, which defines the PARCS and PAs roles and responsibilities pertaining to the LLIN cCD.

A follow-up session/on-job training will be scheduled by SPDs for the trained PA and PARC during the monthly supervision. They will consider the score obtained during the post-training evaluation and the area that need improvement to help decide what specific needs will be provided during the monthly supervision for each participant.

The districts of Bekily, Farafangana, and Vangaindrano that are part of group 2, are among the 12 selected districts based on the criteria approved by the MOPH and RBM. These three districts are outside of the USAID intervention areas where there is no PARC and PA to ensure the LLINs supply chain for the cCD. Therefore, IMPACT has identified new PAs and PARCs in these three districts.

In total, the CCD activity needs an additional 83 PAs and 03 PARCs in the 3 non-USAID supported districts. In Quarter 1, 3 PARC and 73 PA were recruited. IMPACT continues to recruit the 10 missing PA to be completed in Quarter 2. They are already identified with the recruitment process to be finalized in January 2020 prior the effective distribution. The training for those 10 missing PA is already planned in February 2020.

Table 13: PARC and PA situation in the three districts outside of the USAID intervention zones

New PARCs and PAs to be Recruitment completed in Districts identified Quarter 1 PARC PA PARC PA Bekily 1 20 1 15 Farafangana 1 32 1 30 Vangaindrano 1 31 1 28 TOTAL 3 83 3 73

The recruitment process for four new Distribution Supervisors (SPD) who will supervise the new PAs and PARCs was initiated in December 2019 and will be finalized in January 2020.

Coordination of continuous distribution of LLINs in 12 targeted districts

Based on the strategy developed and approved by the MOPH, MENETP, and RBM in Year 1, IMPACT continued to finalize all of the operational/implementation documents for the cCD (training curricula, management tools, and communication tools).

The national coordination committee (CNC) has been revitalized. The committee was set up during the mass LLIN distribution campaign in 2018 and strengthened with the integration of MENETP to ensure coordination at the central level for a smooth implementation of cCD activities.

Since there are many partners located in the same intervention areas (same district, same municipality) and since partners intervene at the community level using the same CHVs, a local technical coordination session for the activities was initiated in Quarter 1 between USAID/PMI implementing agencies such as Mahefa Miaraka, TIPTOP, ACCESS, and IMPACT.

During the coordination meetings with partners, the following topics were discussed and agreed:

• Coordination of implementation (training, grouping of CHVs, and supervision), • Standardization of reporting by CHVs, • Harmonization of the allowances for the CHVs, • Synergy between the field teams (CHVs and TA).

In collaboration with the MOPH and DSS (Division Santé Scolaire), a one-pager on the cCD was developed and duplicated. The purpose of this document is to make the involved entities aware of the objectives, approaches, and expected results of the cCD which will be distributed to local authorities, regional and district health officials, regional and district education officials, traditional and religious leaders, civil society, and the community.

In addition, representatives from the NMCP, DSS (Division Santé Scolaire), and IMPACT conducted field visits to supervise the preparatory work of the cCD distribution and share useful information on the CCD in Vatovavy Fitovinany, Atsimo Andrefana, and Atsinanana targeted regions to local authorities such as prefects,

regional governors, regional managers (DRSP, DRENETP), and health district managers (District Chiefs, SDSP, and CISCO).

During Quarter 1, the key technical and logistical players (TA supervisor from IMPACT) who will ensure the implementation of the cCD 's field activities were put in place.

Seven Supervisors and 60 Support Technicians were identified after the recruitment process at six recruitment locations in Tamatave, Mahanoro, Manakara, Farafangana, Tulear, and Port Bergé.

Three TA Supervisors and 33 TAs have already begun working in the Tamatave II, Brickaville, Mananjary, Manakara, Vohipeno, and Tulear II districts. The MSANP, through NMCP, DRSP, SDSP, and MENTEP through the DRENETP and CISCO, participated as members of the recruitment committees. At the central level, one M&E Supervisor has been recruited and has been working since December 2019.

The above resources (TA supervisors and TA) have been operational since their orientation from December 9 to December 11 at the IVOTEL in Antananarivo. The distribution of the municipalities to be served has been established in consensus with SDSP and the ACCESS and Mahefa Miaraka partner projects. The team composed of NMCP, SDSP, ACCESS, Mahefa-Miaraka and IMPACT is already involved in the organization of the cCD and is conducting trainings at the district and at community level.

Based on the lessons learned during the LLIN campaign in 2018, a specific payment strategy (that is a mobile money combined with the use of banks and payment agents) for cCD was developed. The experiences from the cCD will be duplicated and applied to the next LLIN distribution campaign in 2021. Sessions have been initiated with BMOI bank and mobile money operators like Telma and Orange to discuss the feasibility and challenges for this payment strategy.

In collaboration with PMI, MOPH, and MENETP, it has been decided that the official launch will take place on February 6, 2020 in Mahavelona (Foulpointe), Tamatave II district.

In coordination with IR5, develop and disseminate Behavior Change Communication through mass media campaigns, household visits, radio spots, posters, etc. to mobilize households and school children in the 12 targeted districts to correctly use and maintain LLINs

The communication tools (community posters, posters for schools, etc.) for the cCD were sent to the field with the management tools stipulated above. The following topics have been included in the communication tools:

• LLINs universal coverage strategy (1 LLIN for 02 persons). • LLINs use and maintenance. • LLINs acceptance and waste management (pictogram) part of the innovation of the cCD 2020.

Table 14: Social mobilization supports of the DCC:

Activity type Items Advocacy 700 one pagers IPC at school 6 000 posters for schools 3 000 multi-pocket boards 3 000 stickers boards 770 000 stickers 45 000 pink wristlets 45 000 green wristlets IPC with the CHVs 12 000 posters for the community 8 500 job aids for CHVs

Provide technical and financial support to the NMCP to develop and implement activities for the preparation of 2021 LLIN campaign including the procurement of LLIN

The National Coordination Committee (CNC) core team coordination meetings were organized during Quarter 1 to discuss the LLINs quantification and the budgeting campaign activities in 2021.

Table 15: Quantification of LLINs for the 2021 campaign

Description Number Comments Estimated total population in 2021 28 094 302 Projected population by RGPH3 106 targeted districts or 85,47% of Targeted population in 106 districts in 2021 24 012 200 the total population proportion of 1 LLIN for every 1.8 Number of LLIN for the 2021 mass campaign 13 340 111 people by WHO Buffer stock 1 334 011 10% Total LLIN need: Mass Campaign 2021 14 674 122 LLIN planned by PMI 3 677 000 MOP Year 1 & Year 2 Total LLIN gap for 2021 10 997 122

The gap of 10,997,122 LLINs has been proposed to the Global Fund and they have already shared an official notification to GoM for the allocation of an additional $24 million to finance the acquisition of the 10,997,122 LLINs.

In the meantime, discussions on the technical support are underway between the NMCP, IMPACT, and the AMP (Alliance Malaria Prevention) and a capacity building plan for NMCP (scheduled in May) was created based on the lessons learned during the 2018 mass LLIN distribution campaign, especially in terms of micro planning and reporting.

During the setup of the cCD activities, the CNC has been revitalized at every level: central (CNC), regional (CRC: Comité Régionale de Coordination), district (CDC: Comité de District de Coordination) and commune (CCDS: coordination at commune level). Each level has the same role and responsibility of coordinating the cCD activity at their respective levels. The main discussion is focused on cCD activities but at CNC the mass campaign may be added to the agenda as needed (for instance, in February the LLIN specification for the 2021 mass campaign was discussed during a cCD coordination meeting).

The preparatory activities planned in Quarter 2:

- Data analysis for macro plan: triangulation PEV data vs census data from mass campaign conducted in 2018 vs RGPH3 data conducted in 2018 in order to have a reliable and up-to-date population data (CSB, population, Fokontany, etc.). - Entomology data analysis for insecticide resistance to determine the number of districts to be covered by new generation net (PBO); - Participation during the National Strategic Plan 2018 – 2022 reviews which determines the strategic guidance for the LLINs distribution; - Starting LLINs procurement.

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

IR2.2.1: Conduct a total cost analysis of the public supply chain and propose an alternative and more efficient supply chain model by establishing at least two scenarios with the MOPH to improve SALAMA's financial sustainability

Since 2008, Madagascar has adopted a “Programme d’action pour l’intégration des Intrants de Santé” (PAIS) to ensure the full integration and management of essential medicines and commodities through SALAMA. To date, there is only partial integration due to the total dependency on donor funding for supply chain functions of vertical program commodities (malaria, FP, Tuberculosis, vaccinations, HIV/AIDS, etc.) as well as insufficient capacity of the public supply chain system.

From October 29th to 30th, IMPACT supported the DPLMT to conduct a two-day workshop to (i) analyze the current status of the integration since the PAIS document was initially developed for 2008-2012; (ii) identify bottlenecks and (iii) recommend solutions for the next PAIS document to be developed for 2020-2024. Forty four participants attended the workshop in Antananarivo and comprised of the central level directions of the MOPH (SG, DGFS, DPLMT, DAMM, DSSB, DLMNT, DLMT, DSFa DPEV, DTS, UASM, ONN, NMCP, PNLIST, and PNLT), referral hospitals, representatives from regions and districts, CSB, technical and financial partners, and SALAMA. During the workshop, DPLMT presented findings from a rapid evaluation of the PAIS 2008- 2012 showing that some of the supply chain functions related to vertical program commodities (FP, malaria, MNCH, STI/HIV/AIDS, Tuberculosis, Plague, and blood transfusions) are integrated into SALAMA. Other vertical programs (immunization, nutrition, and Intravenous2 solutions) are not yet integrated into SALAMA and are managed in parallel distribution systems outside of SALAMA . IMPACT shared the findings of two preliminary literature reviews of the pharmaceutical sector legal texts and all past studies and evaluations on the supply chain during the period of 2009-2019. Participants held a SWOT analysis to define the next steps, including: 1) Conduct qualitative and quantitative evaluation of the supply chain 2) Add a total cost analysis of the supply chain to complement findings of past evaluations done on the viability of the FANOME recovery system 3) Develop a PAIS for 2020-2024 based on findings of studies and evaluations conducted 4) Mobilize resources to stakeholders for implementing the PAIS.

In December, IMPACT recruited an international STTA and national consultant to assist the MOPH/DPLMT on the implementation of the activities towards the development of new PAIS and start preparatory work such as the methodology of the analysis, sampling size, terms of reference of the TCA steering committee, and questionnaires and tools for data collection.

IR2.2.2: Strengthen management of FANOME at Pha-G-Dis and Pha-Ge-Com levels to increase transparency and good governance.

No activities planned during Quarter 1.

2 Those programs have own stock outside SALAMA and organize direct distribution to regions, districts and CSB.

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

Review the scope of the private sector humanitarian platform to engage businesses in health product markets

IR3.1.1: Create partnerships with PSHP and non-PSHP members to collaborate in generating innovative solutions on transportation, data collection, and health-focused CSR and CSV.

In Quarter 1, IMPACT continued to recruit new members. As a result, three pharmaceutical wholesalers namely INTERPHARMA, SKPHARMA, and PHARMATEK, integrated the PSHP. They joined the MOPH led TMI TWG as active members.

In addition, in order to create a long-term partnership, two meetings with SOMAPHAR were held in Quarter 1 to discuss health commodities transportation. The discussion was focused on the feasibility of innovative solutions with adequate transport conditions and by using GPS tracking to ensure real-time monitoring of each trip using computers or smartphones. IMPACT is also exploring technological solutions such as barcodes to track the products in order to identify where the product final destination is. This is an efficient system for tracking whether the commodity arrives at the expected destination. The MOU between IMPACT and SOMAPHAR will be finalized in Quarter 2.

IR3.1.2: Organize quarterly meetings to monitor and assess the progress of health commission action plan.

During Quarter 1, activities focused on increasing private sector commitment in health commission were implemented.

During Quarter 1, a quarterly meeting was held to monitor the health commission activities focused on increasing private sector commitment.

Table 16: Health commission Quarter 1 achievements

Objectives Achievements Observations Recruit new members to 3 wholesalers recruited SKPharma, InterPharma and Pharmatek. These new implement IMPACT activities members are integrated in health commission and participated in IMPACT activities Sensitize health commission SOMAPHAR Two meetings held and MOU will be finalized in members to involve in the health Quarter 2. The transport is focused on Social commodities transportation Marketing products. Discussions with SALAMA to sustain transportation is in progress and should be concluded in Quarter 3. Participate in TWG - TMA All health commission The health commission is represented in all TWG members participated committees. They actively contributed to develop in 8 TWG - TMA in the operational plan of each subcommittee (there Quarter 1 are 3). IMPACT team sensitized and ensured their participation by individual call and mailing.

IR3.1.3: Conduct exercise to identify/select outlets to collaborate with IMPACT among representative sample of pharmacies and drug shops

The process to identify outlets (pharmacies and drugs shops) to partner with IMPACT started in Atsinanana, Diana, Boeny, and Menabe regions. The objective of this exercise is to have a representative sample for the LMIS data reporting. The commercial sector (pharmacies and drug shops) will integrate the LMIS national system within DEPSI as planned in the TMA LMIS roadmap. The TMA LMIS committee, including the MOPH, starts with a representative sample within 4 regions cited above and foresees a progressive scale up from Year 3.

Based on the list of drug shops for each targeted region created by IMPACT, a systematic selection is conducted by using a random number and skip interval calculated as follows: number of total of drug shops in the region divided by the required number of drug shops to be selected (25 per region). Since there are not many pharmacies an exhaustive selection was completed.

The logistics data collected will be used for quantification exercises, monitoring of stock, market share between public, non-profit (social marketing), and for-profit sectors (pharmacies and drug shops), etc. For the 4 initially selected regions, the strategy is to concentrate the efforts such as ADDO, training on finance and stock management, and LMIS data collection within the same outlets. In Quarter 1, IMPACT visited the selected pharmacies and drug shops in Boeny, Atsinanana, and Diana regions (Menabe is scheduled in Quarter 2) to explain the purpose of the LMIS data collection.

As a result, an agreement letter was signed by 113 private actors (38 pharmacies, and 75 drugs shops) to confirm their commitment, particularly on submitting their LMIS data to the national database using DHIS2. Below is the summary of the exercise: a random selection of representative samples of pharmacies and drug shops has been completed so 25 drug shops in each region and all pharmacies were selected, visited, and accepted to work with IMPACT through an agreement letter

Table 17: Results of Outlets identification exercise

Outlets REGION TYPE targeted DRUG SHOPS 25 ATSINANANA PHARMACIES 5 DRUG SHOPS 25 BOENY PHARMACIES 15 DRUG SHOPS 25 DIANA PHARMACIES 18 TOTAL 113

Table 18: Other findings:

Topics Observations

Localization: Urban vs rural 96% of the drug shops in Diana and 56% in Boeny are located in rural areas as opposed to Atsinanana where 60% are urban and 40% rural)

Owner profile - 59% Men - 41% Women

Study level - 91% Brevet d’Etude du Premier Cycle (BEPC) - 9% Baccalaureate

Use software on stock management - 5% of drug shops are are using software, and 60 % for the pharmacies - Among those pharmacies using software, 50 % Pharmacies are using “Pharmaplus”

Interest in credit/loan - Atsinanana: 72% - Diana 20% (preference in using their own funds) - Boeny 56%

Table 19: Opportunities

Internet network coverage 80% of actors are covered by an internet network.

Availability of electricity More than 90% have electricity (JIRAMA or solar panel)

FP/Malaria/MNCH Commodities Most of the drug shops are interested in selling product. The current average percentage of drug shops selling commodities is as follows: - Malaria: 61% - FP: 60% - MNCH: 70%

IR3.1.4: Ensure that the Health Commission members of the PSHP participate in the TWG and follow up on the roadmap as a way to engage the commercial sector to identify barriers in the health sector and provide solutions

During Quarter 1, the Health Commission members actively participated in seven TWG meetings. Two Champions from the private sector were identified and they are highly motivated to be part of the TMA process, especially in the implementation of the TMA roadmap. This apportionment was reported at the PSHP meetings

Table 20: Participants during TWG meetings

Date TWG / subcommittee Number of participants (/6 members)

22nd October 2019 PPN PDPN 06

Date TWG / subcommittee Number of participants (/6 members)

05th November 2019 LMIS 03 07th November 2019 PPN PDPN 02 14th November 2019 RBM TMA 06 26th November 2019 PPN PDPN 01 06th December 2019 PPN PDPN 05 13rd December 2019 Demand Creation 03 Subcommittee

The active participation of health commission members in TMA TWG workshops shows their willingness and interest to be involved on the improvement of the health market environment in Madagascar.

Main results: (i) Participating to the National Pharmaceutical Policy (PPN) improvement: Private sector proposed amendment to lighten up the AMM procedure and the need to clarify/document private sector supply system per outlet type (ii) Improving awareness and the application of the laws and regulations related to drugs and health commodities: the TMA TWG on text and regulation conducted inventory and organization of the existing texts for further analysis. (iii) Ensuring the continuous availability of LMIS data and respect the quality standards of health commodities: the LMIS data for private sector is included in the TMA TWG LMIS action plan.

IR3.1.5a: Revitalize regional drug shop associations in preparation of the ADDO pilot phase to be conducted in Year 3

On October 15, IMPACT conducted a debriefing meeting with MOPH authorities (Minister, Secretary General, DPLMT, and DAMM Directors) on the ADDO study tour in Tanzania conducted in August 2019 to identify lessons learned and best practices on implementing the ADDO approach in Tanzania. The study tour allowed the MOPH (Secretariat General, DAMM, and DPLMT), the National order of pharmacists, the Association of Pharmacists, and IMPACT representatives to acquire a good understanding on how to set up the ADDO approach in Madagascar. Using the lessons learned from Tanzania, the MOH and participants at the debriefing defined an implementation plan to introduce the ADDO in Madagascar under the DPLMT leadership. The implementation plan includes:

• Conduct advocacy meetings with the Pharmacy Council and professional associations (including drug shops) to explain the ADDO approach and get their buy-in (November 2019-January 2020) • Conduct an exercise to identify existing drug shops legally licensed and those without licensing in the 22 regions and sensitize all the drugs shops to comply with regulations (in Quarter 3 and Quarter 4). • Select two regions to pilot the ADDO (February 2020). • Develop and/or revise training curriculum for dispensers and owners of drug shop (February to May 2020). • Conduct cascade trainings (June-August 2020). • Plan supervision and monitoring of the implementation of the ADDO in two regions, • Evaluate the implementation of the ADDO in two regions for at least 6 months to inform the scaling up phase.

The five identified candidates in the Atsinanana region are now leading the preparation of creating a regional drug shop association, with a meeting planned in January 2020. IMPACT also continues to encourage drug shops in the Analanjirofo region that were trained last year to formalize the creation of their association.

IR3.1.5b : Develop curriculum for training of peer trainers with simplified materials and tools, to be used in piloting a sustainable mechanism for business strengthening program of drug shops

In Year 2, IMPACT plans to pilot the selection and initial training of a group of Certified Peer Trainers (CPT) for drug shops. The goal is to identify drug shop owners or managers who have the capacity and interest to learn and train their peers at other drug shops in order to establish an affordable and sustainable drug shop training program throughout the country. IMPACT will offer business and financial management training to drug shops in five regions and will select trainees as potential CPT candidates to receive a Training of Trainers (TOT) later in Year 2. In subsequent years, the CPT certification process will be developed and tested along with the low- cost, sustainable peer training program. The sustainability concept to be tested is whether using regional peer trainers with simple materials to conduct trainings at drug shops in the field, rather than external consultants with more expensive daily rates, travel costs, and infrastructure needs (e.g. renting hotel conference rooms). This would determine if it would be possible to offer business trainings at cost which drug shops are both able and willing to pay.

During the November drug shop training in Toamasina (see below under IR3.1.7), IMPACT identified five potential CPT candidates for the Atsinanana region. The initial identification criteria for these candidates were based on their participation level during the training as well as the geographic distribution of drug shops in the region. The IMPACT team is currently reviewing research on criteria used by Catholic Relief Services in the selection of their Private Sector Provider peer leaders for their Savings and Internal Lending Communities (SILCs) in Madagascar and other countries in order to refine the pilot CPT identification process going forward. Additional tests and training may also be organized to confirm potential CPT candidates.

The curriculum for the training of peer trainers will be developed in Quarter 3 Year 2.

Increase access to finance for private health commodities supply chain stakeholders Smaller urban and peri-urban pharmacies have limited financing options because wholesalers and financial institutions view them as being riskier. In addition, drug shops and rural pharmacies have minimal access to finance and are generally forced to pay for health commodities in cash. This lack of financing impacts the ability of these commercial businesses to expand and to maintain adequate levels of essential commodities, resulting in stock-outs During Year 2, IMPACT is providing support to financial institutions to better serve the private health supply chain by facilitating their access to credit and by developing financial products adapted to their needs.

IR3.1.6: Strengthening partner banks and other financial institutions' capacity to better serve private health commodities supply chain.

IMPACT focused on the following three sub-activities in Quarter 1 to strengthen financial institutions.

Train and support DCA partner banks in credit analysis and loan structuring for health commodities businesses

In Quarter 1, IMPACT provided training to 49 staff (25 women and 24 men); 40% of the target of 120 for Year 2) at the Toamasina branches of the two DCA partner banks, AccèsBanque Madagascar (ABM) and Baobab Banque Madagascar on the market opportunities and financing needs of health commodities enterprises and on financial products adapted to meet their needs. In Year 1, IMPACT trained 105 bank staff in five cities, including Toamasina, for a total of 154 bank staff receiving new or refresher training since the beginning of the project.

The six bank health champions identified through the SHOPS Plus project in Quarter 1 will serve as information resources on the private health sector for their colleagues, and as such, will also provide support to IMPACT’s work with health commodities enterprises. The champions will receive on-going training from both projects on appropriate financial products and on how to better serve the health sector. In addition, ABM has a new focal team managing its health DCA guarantee, and IMPACT supported training for the new ABM team on USAID’s Credit Management System (CMS), provided by the officers from the United States Development Finance Corporation (DFC, formerly USAID’s Office of Development Credit) in Washington in December 2019.

Develop and adapt loan products and financial tools for small and micro health enterprises in health commodities sector (e.g., scoring, nano loans, pharma loans, motorbike loans).

Three new financial products are being developed with the two partner banks:

• Pharmaloan: a financial product designed and developed by IMPACT A2F in partnership with ABM’s health focal point team. The product would facilitate access to credit for pharmacies and drug shops for the purchase of health commodities from wholesalers willing to partner with the bank. The concept of the loan has been validated by the bank’s Managing Director, and IMPACT is now working with the bank team to collect information on drug shops’ purchasing habits in order to finalize the technical design of the product by end of Quarter 2.

• Automated withdrawal: a financial service designed with Baobab Banque to encourage wholesalers to grant payment terms to drug shops agreeing to automatic payments from their Baobab accounts. IMPACT A2F has discussed this service with the bank’s team, and its development is ongoing.

• PA Motorbike Loan: a loan product designed to allow PAs to purchase motorbikes, which could be used for the transportation of social marketing commodities from PARCs. This need was identified following a survey undertaken by IMPACT with PAs and PARCs in Year 1. With support from the IMPACT distribution team and COP, the project is working closely with ABM to finalize the product for pilot testing in a few regions by the end of February 2020. This product is designed to allow ABM to base its lending decision in part on validation from PSI that the PA is a distributor in good standing, giving the bank more flexibility in making loans in rural areas outside coverage areas of its 29 branches.

Design and develop new financial mechanism (e.g. risk sharing facility), following principles of USAID's Blended Finance Roadmap for Global Health, possibly including additional financial institution partners, to facilitate A2F within the pharmaceutical supply chains and other stakeholders.

This sub-activity was initiated in Year 1 Quarter 4, with the visit of the A2F Specialist from Washington. The objective of the visit was to identify the potential for a risk-sharing instrument that will lead to increased

financing for IMPACT target sectors, and activities included: (i) defining the characteristics of target sectors; (ii) identifying the financing available vs. what is needed, and (iii) analyzing the challenges associated with securing financing. In addition, the A2F Specialist conducted a preliminary evaluation of donor and other non- financial institution instruments such as guarantees and grant funds that might be leveraged. The initial findings from the visit were presented to the USAID Madagascar mission in December 2019, and a summary report will be submitted soon Once the report has been finalized, IMPACT will work with USAID and other stakeholders to gather any additional information needed to choose among options and move forward in next steps towards implementation.

Results IR3.1.6:

In collaboration with the two partner banks, through bank staff training, IMPACT works to develop new financial products for the health commodities sector, has yielded strong results. In Quarter 1, ABM and Baobab disbursed 14 loans totaling $57,281 to pharmacies and drug shops, of which two were placed under the DCA guarantees. One of the DCA loans was within the IMPACT target regions (Atsinanana), and one was in Antananarivo.3 In general, the loan purposes were for inventory purchases and working capital.

Table 21: Loans Disbursed to Health Commodity Enterprises in Year 2, Quarter 1

% of Revised Non DCA Total Revised Y2 DCA loans Y2 Target loans Quarter1 Target Achieved Number of loans 12 2 14 50 28% Value of loans (USD equivalent) $35,657 $21,624 $57,281 $90,000 64%

Strengthen the business management of enterprises in health products supply chain Commercial health commodities businesses struggle to expand their product offerings, hampered by harsh competition of low cost, poor quality commodities from illegal markets. In Year 2, IMPACT is focusing on drug shops, to strengthen their capacity in business and finance management and their knowledge of the legal and regulatory framework. The program works with the MOPH for the supervision of and support to drug shops, and five priority regions have been jointly selected for the implementation of the awareness and training campaign in Year 2: Atsinanana, Boeny, Diana, Menabe and Melaky.

IR3.1.7: Provide business strengthening capacity building to enterprises in health commodities supply chain and develop partnership with private companies to sustain the training.

In Quarter 1, the project worked on the following three activities to strengthen the business capacity of health commodities enterprises.

Develop and adapt business-strengthening training curricula for drug shops In Quarter 1, a simplified curriculum was finalized for the business and financial management training for drug shops. The training is designed to consider the educational level of drug shops managers (IMPACT surveys in Year 1 found that 58% have less than a high school diploma). The curriculum includes four modules: (i) Business financial and operational diagnostic, (ii) Regulatory compliance and drug usage, (iii) Inventory management,

3 Neither bank’s DCA guarantee agreement places any geographic restriction on eligibility requirements.

and (iv) Financial book-keeping. The diagnostic module is an interesting innovation; it helps drug shops to evaluate their current business practices, and also serves as a data-gathering tool for IMPACT, allowing the program to establish a baseline “score” of drug shop business practices and to follow up with monitoring surveys of these practices over time.

The simplified curriculum is a key component to the sustainability of the proposed low-cost peer training program. The curriculum is designed to have only about 20 slides, which could in the future be printed as laminated cards for CPTs to keep and take with them to conduct peer trainings, without needing to have access to an expensive computer and equipment for projecting PowerPoint training presentations. The curriculum may be revised based on field testing during Year 2.

Provide initial business-strengthening training to drug shops On November 13-14, 2019, the first joint IMPACT/DPLMT mission was conducted in Toamasina. The DPLMT team led a half-day information session on the legal and regulatory framework, with 43 drug shops in attendance. This was followed by an optional 1.5-day business training by IMPACT. The training followed the same successful self-selection model tested by IMPACT A2F in Year 1: drug shops volunteered to participate and were required to cover their own transportation and lodging costs for the training. A total of 27 drug shop owners and managers (15 men, 12 women; 34% of the Year 2 target of 80 trainees) participated in the business training. COFARMA, a pharmaceutical wholesaler member of the PHSP platform, co-financed 50% the training costs (venue, refreshments, meals) with IMPACT, and has confirmed its commitment to co-finance the trainings in other regions.

The next training sessions for the four remaining regions, already communicated to the audiences in collaboration with the DPLMT are as follow: • Boeny, 27-28 February, • DIANA, 25-26 March, • SAVA, 22-23 April, • Melaky, 27-28 April.

Provide one-to-one coaching on business strengthening to enterprises/individuals identified as potential peer trainers in health commodities supply chain Following the training, three drug shops owners and managers (30% of the Year 2 target of 10) expressed interest in having on-site post training coaching: one in Toamasina II, one in Antsapanana (Brickaville), and one in Vatomandry. All of the coached drug shops were already using at least sales books and a prescription registry book. They also expressed their willingness to use the new management tools from the training session, not only for the drug shop business, but also for their other businesses.

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

IR3.2.1 : Facilitate high-level advocacy meetings involving the MOPH, Ministry of Commerce, customs services, Ministry of Economy and Finance, the National Order of Physicians and the National Order of Pharmacists to develop policies and regulations that will favor importation and commercialization of a packet of vital Essential medicines, including contraceptives, anti-malarial, and key MNCH products.

IMPACT supported the MOPH under the leadership of DPLMT to review and update the National List of Essential Medicines and Commodities. The list includes medicines and commodities necessary for proper case management of priority health conditions in Madagascar, including malaria, FP, and MNCH. The list was officially signed by the MOPH in November 2019. The list serves as a basis for procurement of medicines in all hospitals and CSB to treat patients and for tax exemption of imported essential medicines and commodities to increase access to universal healthcare services for the Malagasy people.

IR3.2.2 : Support DAMM and MOPH to put in place strong regulatory processes related to the registration, importation, and distribution of medicines based on reviews of the Common Technical Document, New Law on Regulatory Body in Africa, and experience from other countries through study tours.

During Year 1, IMPACT completed a literature review of 128 legal and regulatory documents in the form of laws, ministerial decrees, guidelines, and instructions related to pharmaceutical management.

During Quarter 1, the following are the activities completed: - Preliminary report of the literature review was shared with the DAMM and members of the TMA Subcommittee on Regulation for review and inputs, as well as to identify additional texts that were not included in the literature review. In parallel, the DAMM also requested that the private and public sector propose additional elements to be considered on the update of the existing registration manual developed in 2016. - Recruiting an international STTA to review the work already done and provide inputs to complete the literature review and analysis of the existing texts.

The STTA will be in country in the next quarter to work with the DAMM, DPLMT, and TMA Sub-committee on the regulation of pharmaceutical sector.

IR3.2.3 : Support DAMM in streamlining the registration and importation procedures for medicines based on the latest WHO recommendations.

In May 2019, IMPACT facilitated a workshop on the harmonization of registration and procurement procedures required and implemented by DAMM, SALAMA, and technical and financial partners while importing essential medicines and commodities. Key recommendations from the workshop were to develop a MOU between DAMM with SALAMA and DAMM with PTF to capitalize mutual quality assurance procedures that are followed on selecting medicines and manufacturers. Thus, registration processes will be simplified and lead to quick availability of commodities procured by technical and financial partners to support vertical programs.

During Quarter 1, IMPACT facilitated the development of the two MOUs to standardize quality assurance procedures that are followed by donors and SALAMA to select medicines and manufacturers in order to

simplify the registration processes of imported medicines and supplies. Currently, the MOU between MOPH and the technical and financial partners is finalized and ready to be shared with USAID for feedback and later with the MOPH authorities for signature. The MOU between DAMM and SALAMA will be also finalized in Quarter 2.

IR3.2.4 : Support the MOPH and the professional associations to revitalize the inter-ministerial committee to fight counterfeit and illegal medicines. A strategy will be defined through a mid-term evaluation of the Stratégie de Lutte Contre le Marché Illicite and the Contrefaçon des Medicaments et Intrants de Santé and an action plan will be developed.

Madagascar created an inter-ministerial committee to fight counterfeit medicines and illicit market (CIMLCCVI) hosted by the Prime Minister. In 2017, the Committee defined strategies to fight counterfeit and illegal medicines for 2017-2021, but to date no strategy has been implemented due the lack of recognition of the Committee and unavailability of both human and financial resources.

In Quarter 1, IMPACT continued discussions with the Executive Secretary of the Committee to identify immediate measures to implement such as writing a memo for the Prime Minister (President) and Minister of Health (Vice President) to review the function of the committee (membership, resources, institutional organization, and legal documentation), organize meetings with members of the Committee, and implement activities that are already defined in the strategic document. As we secure necessary appointments with the office of the Prime Minister, IMPACT will continue to work with DPLMT and DAMM and implement some activities while waiting the restructuring of the committee by the Prime Minister.

III.5. IR 4: Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy people

Sub-IR 4.1: Socially marketed products are continuously available at convenient and accessible locations IR4.1.1: Distribution of socially marketed products across 10 regions for MNCH and FP/RH products and distribution of only FP/RH products in three PARN Regions through PARCs and PAs.

In Quarter 1, IMPACT continued to distribute a range of socially marketed FP/RH and MNCH products to support the national program. Table 22 and 23 shows the distribution of FP/RH and MNCH health products in Quarter 1 against annual targets.

Table 22: Distribution of FP/RH commodities in Quarter 1

YEAR 1 YEAR 2 Quarter 1 % of Y2 Target FP PRODUCT Achievement Target Achievement Achieved OC Community 1 382 159 1 724 880 484 152 28.07% Injectable (Depo- 926 044 1 473 355 513 453 34.85% Provera/TRICLOFEM) Community FP Condom Protector Plus 868 896 1 633 794 557 904 34.15% (Community and Commercial) FP Youth Condom Yes 269 100 671 689 N/A 0.00% (Commercial) Sayana Press 221 017 474 355 6 601 1.39% Pregnancy Test (Community) 48 645 100 000 4 245 4.25%

- Oral Contraceptive (Microgynon and Combination 3): Oral contraceptives maintained a normal distribution rate and reached 28% of the annual target. - Intra-muscular Injectable Contraceptive (Depo-Provera/Triclofem): The quantity distributed is higher than expected (average of 25% per quarter) because the quantity of Sayana Press (390,000) procured from UNFPA is still in progress and not yet available and the regular users reported by Mahefa Miaraka has slightly increased from 278,402 to 284,742 in November 2019 (difference is 6,340 new users). - Sub-cutaneous Injectable Contraceptive (Sayana Press): In Quarter 1, IMPACT has distributed the remaining stock of Sayana Press to the PARC. Sayana Press has experienced a stock-out at the central level while waiting for the availability of 390,200 units borrowed from UNFPA, but the product was still available at the PA level during Quarter 1. - Sayana Press is already included in the national quantification and the procurement plan for 2020. Currently, the order is confirmed, and the delivery is expected in Quarter 2. - PSI was audited by UNFPA during Quarter 1 as part of the process for granting funding and commodities from UNFPA. The audit was successful and conclusive, and a MOU will be signed between IMPACT and UNFPA in January 2020. - Yes With You Male Condom: The portfolio analysis results recommend maintaining Yes condoms and introducing a new flavor of banana or vanilla depending on the consumer panel choice. The consumer panel are groups of consumers using condoms and who will respond to specific questions relating to YES product testing. The procurement of this product is not yet initiated pending the validation from

PSI Washington expected in February. Nevertheless, the Authorization Market process has already been initiated. - Protector Plus Male Condom: IMPACT has distributed 557,904 units of Protector Plus male condoms through the community and commercial channels during Quarter 1 in the 13 regions of Madagascar. This results in 34.15% of the annual target, mostly from the commercial channel. - Pregnancy Test Kit: - Up to know, only SOFIA region has distributed pregnancy tests but IMPACT expects that Mahefa- Miaraka will scale up the distribution to other regions in Year 2. ACCESS is also expected to train their CHVs on the use and distribute the pregnancy test kits.

Table 23: Distribution of MNCH commodities in Quarter 1

YEAR 1 YEAR 2 Quarter 1 % of Y2 Target MNCH PRODUCTS Achievement Target Achievement Achieved ORS/Zinc DTK (Community) 2 873 58 906 21 008 35.66% Sur Eau 150 ml Commercial 344 595 904 910 N/A 0.00% Sur Eau Pilina (67mg Tablet) 2 299 680 3 620 780 703 300 19.42% (Community) Arofoitra (CHX 7,1%) (Community) 16 109 30 378 12 946 42.62% Pneumox (amoxicilline) (Community) 102 404 219 635 48 182 21.94%

- ORS/Zinc: The high achievement in Quarter 1 is due to the rainy season, which caused the number of diarrhea cases increased - Sûr’Eau 150 ml (commercial): The procurement of this product is in progress and delivery is expected in March 2020. - Sûr’Eau Pilina (community): This result is slightly lower than the Year 1 average monthly consumption (234,433/255,520) due to the reduction of the quantity distributed in November (82,400) and December (44,200) compared to October (576,700).

Sûr’Eau Pilina is available at the PA level with a zero stock out rate but the CHVs don’t procure it as they are used to stocking up on products that people ask for more often, such as FP products and Pneumox. In brief , demand decreased in November and December compared to October. CHVs need to be retrained to distribute this product and its promotion to the targeted population should be organized at the field level.

- Arofoitra (Chlorhexidine 7.1%): In July 2019, 50,000 tubes arrived and the high achievement (42.62%) is due to the resupplying by PARC and PA during October and November 2019 but the quantity distributed has stabilized from December 2019. - Pneumox: In Quarter 1, The percentage of quantity distributed was slightly reduced compared to the expected achievement (22%/25%) but the rate stabilized after an intensive replenishment by the PARC and PA in Quarter 4 of Year 1.

The MCH product procurement 2020 was launched as stated below:

Table 24: MNCH Procurement

ETA (Estimated Time Product Quantity Status of Arrival) Pneumox 23,700 Boxes of 10 blisters Contract under preparation June 2020 of 10 tablets ORS 152,000 sachets Request of Quotation sent to June 2020 SALAMA, SALAMA has not yet received the Quotation from the manufacturer Zinc sulfate 20 mg 18,400 boxes of 10 blisters Waiting for the approval of the June 2020 of 10 tablets Waiver Request

Sur’Eau Pilina 5,786,800 tablets PO sent to MedTech, Artwork sent March 2020

All requests for quotations were launched in September 2019. IMPACT has finalized the procurement process of the MNCH products after USAID approval on November 4th, 2019.

IR4.1.2: Establish a motivation system for PAs and PARCs and follow up on their quarterly performance to address supply chain inefficiencies in social marketing in order to prevent stockout.

IMPACT has set up a motivation process for PARCs and PAs that SPDs upload the evaluation information in DHIS2 at the central level.

Evaluation information include: • GPS coordinates of the PA and PARC confirming that they are visited/supervised • No stock out of products at PARC level of products should be available at PSI warehouse level • No stock out of products should be available at PARC level for PA • No expired products • Good storage of the products • Availability and good filling of all management tools: Order forms/Invoices/Calculation sheet/Stock sheet/FP Oral Contraceptive/Injectable monitoring tools

The PA and PARC are evaluated every quarter. The first quarter evaluation will be conducted in January 2020. The PA and PARC will be rewarded with promotional articles. At the end of the Year 2, the highest performing PA and PARC of their region will benefit from an exchange experiences and will be invited to share their success stories and best practices to other PA and PARC in other regions.

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

After the first successful test flight for delivery by drone at PA on October 18th, 2019, 14 other flights under 25 km were conducted successfully. 10 of those flight tests were real delivery of PA’s needs.

For each flight information (GPS coordinates of mountains, geographic features of the itinerary, distance from take-off point and the PA, etc.) is requested for each destination to help manage the drone's itinerary. Example: which PA is concerned with which products, what is the distance, how many flights will be conducted to deliver the needed products to the PA, speed of the wind, etc. Aerial Metric needs to collect all requested information in advance and IMPACT has developed and used a software application to prepare, monitor, and follow-up each flight. The SPD is equipped with Tablet in which the “drone application” to prepare and follow up the flight delivery was installed, and GPS is enabled for geographic coordinates.

The drone application is used to: • Analyze stock status and health commodities movement in coordination with SPDs, PARCs, and PAs • Prepare, organize, and schedule deliveries based on PAs orders by using drones • Record all flight operations, PAs orders, and delivery data • Record and report incidents/accidents (if there is an incident) • Develop a dashboard (Excel) including important information such as the packing list for the delivery, the number of flights it requires, the distance, the destination and all the historic of the delivery flight.

Awareness Raising IMPACT visited the Regional Health Director of Analanjirofo and Atsinanana, and the District Medical Inspector of Maroantsetra in October 2019 to introduce the pilot project on using drones to deliver health products. The local population and authorities have also been informed and are interested in the project. Each local authority received one t-shirt and one cap as a symbol of partnership. 100 T-shirts, 100 caps, 2,000 flyers, and 250 posters have been produced for local health authorities and sites at district, commune, and Fokontany level.

In order to inform the people about the drone project, a sensitization through the local radio in Maroantsetra was carried out. Posters (see annex H) have been produced and posted in town at the PA and Fokontany level.

Training Cascade trainings have been conducted at each level and 6 persons were trained. • 1st training at district level: A workshop led by Aerial Metric (3 trainers) was conducted to explain the needs and requirements for data collection. For this session, 4 IMPACT staffs were trained in October 2019: one drone project coordinator, one M&E supervisor, two SPD. • 2nd training on data collection: The drone project coordinator and the M&E Supervisor trained 2 SPD on how to collect data, the procedures to follow for the flight, and how to report on the delivery flight with the drone application in October and December 2019, following the workshop held in October 2019.

Flight After the 1st flight test aborted in October 2019 due to the high speed of wind, IMPACT and Aerial Metric have realized 15 successful flights between October and December 2019. For this pilot phase in Quarter 1, the selection of PA is based on the distance from the take-off point (TOP) (<25 km), accessibility and PA needs.

Table 25: Flight history

Distance to Bird Product flight between PA weight Flight No Date Supply Point and the South Product transported Comments TOP

1 09-oct-19 Ankofabe 9 km Sur’Eau Pilina 20 strips 616 g Aborted 2 18-oct-19 Ankofabe Sur’Eau Pilina 20 strips Flight test 9 km 616 g successful 3 24-oct-19 Anjanazana Sur’Eau Pilina 20 strips Flight test 9 km 616 g successful 4 27-oct-19 Ankofalava Sur’Eau Pilina 20 strips Flight test 8 km 616 g successful 5 19-nov-19 Andranofotsy Sur’Eau Pilina 20 strips Flight test 14 km 616 g successful 6 24-nov-19 Ankofabe Sur’Eau Pilina 20 strips Flight test 9 km 616 g successful 7 28-nov-19 Madiotsifafana Triclofem 80 doses 926 g Flight test 14 km successful 8 29-nov-19 Madiotsifafana Arofoitra 4 tubes 922 g Flight test 14 km Sur’Eau Pilina 40 strips successful 9 30-nov-19 Madiotsifafana Microgynon 10 strips Flight test 14 km successful 10 04-déc-19 Antsirabe Arofoitra 10 tubes 480 g Flight test Sahatany 10 km Microgynon 24 strips successful Triclofem 60 doses 11 04-déc-19 Antsirabe Microgynon 66 strips 1194 g Flight test 10 km Sahatany successful 12 04-déc-19 Antsirabe Triclofem 60 doses 1208 g Flight test 10 km Sahatany Microgynon 16 strips successful 13 09-déc-19 Antakotako Triclofem 40 doses 1808 g Flight test 18 km Microgynon 90 strips successful 14 11-déc-19 Antakotako Triclofem 80 doses 1126 g Flight test 18 km Sayana press 20 pieces successful 15 13-déc-19 Antakotako Triclofem 80 doses 1126 g Flight test 18 km Sayana press 20 successful 16 16-déc-19 Anjanazana Triclofem 30 doses 1776 g Flight test 9 km Microgynon 90 strips successful Arofoitra 4tubes

During Quarter 1, the drone did flights up to 18 km distance to Bird flight between PA and the South TOP with a highest product weight of 1776 g.

Process Delivery process, flight process and data collection process are available.

Table 26: Data collection (about the GPS coordinates, distances, geographic features) completion and sensitization

Districts Villages Data collection Sensitization and courtesy visits MAROANTSETRA ANKOFA Completed Done MAROANTSETRA VOLOINA Completed Done MAROANTSETRA ANKOFABE Completed Done MAROANTSETRA ANDRANOFOTSY Completed Done MAROANTSETRA ANJAHANA Completed Done MAROANTSETRA MAHALEVONA Completed Done MAROANTSETRA ANJANAZANA Completed Done MAROANTSETRA ANTAKOTAKO Completed Done MAROANTSETRA ANTSIRABE-SAHATANY Completed Done MAROANTSETRA AMBODIMANGA RANTABE Completed Done MAROANTSETRA RANTABE Completed Done MAROANTSETRA MANAMBOLO Completed Done MAROANTSETRA SAHASINDRO Completed Done MAROANTSETRA AMBINANITELO Completed Done MAROANTSETRA MARIARANO Completed Done MAROANTSETRA PA Maroantsetra Completed Done MAROANTSETRA Morafeno Completed Done MAROANTSETRA Ambanizana rantabe Completed Done MAROANTSETRA PARC Maroantsetra Completed Done MAROANTSETRA Anandrivola Completed Done MANANARA NORD PA Mananara_Avaratra Completed Done MANANARA NORD Analampotsy Completed Done MANANARA NORD Saromaona Completed Done MANANARA NORD Manambolosy Completed Done MANANARA NORD Antananivo Completed Done MANANARA NORD Antanambaobe Completed Done MANANARA NORD Mahanoro Completed Done MANANARA NORD Vanono Completed Done MANANARA NORD Antanambe Completed Done MANANARA NORD Imorona Completed Done MANANARA NORD PARC Mananara_Avaratra Completed Done MANANARA NORD Ambatoharanana Completed Done MANANARA NORD Tanibe Completed Done MANANARA NORD Sandrakatsy Completed Done MANANARA NORD Andasibe Completed Done ANTALAHA Ampanavoana Completed Done ANTALAHA Vinanivao Completed Done ANTALAHA Antsahanoro Completed Done ANTALAHA Ampahana/Maromikotro Completed Done ANTALAHA Antananambo/Ambodigavo Completed Done ANTALAHA Ambalabe Completed Done ANTALAHA Sarahandrano Completed Done ANTALAHA Ambohitralanana Completed Done ANTALAHA Ampohibe Completed Done ANDAPA Ambodimanga Completed Done ANDAPA Sahantaha Completed Done

Districts Villages Data collection Sensitization and courtesy visits ANDAPA Ambalavelona Completed Done ANDAPA Andranomena Completed Done ANDAPA Bealampona Completed Done ANDAPA Marovato Completed Done ANDAPA Andasibe Kobaina Completed Done ANDAPA Ambodivaina Completed Done ANDAPA Matsohely Completed Done ANDAPA Belaoka-Marovato Completed Done ANDAPA Anoviara Completed Done ANDAPA Ambodiangezoka Completed Done ANDAPA Ankiakabe Completed Done ANDAPA Andrakata Completed Done

The Distribution Supply Point Supervisor has organized a courtesy visit to MOPH staff in each town.

IR4.1.6: Define the needs for a product monitoring system and conduct a study of a product tracking system. Find technological solutions which allow IMPACT to earn and grow brand loyalty while protecting the brand from supply chain fraud, including counterfeiting and theft.

In Quarter 1, IMPACT explored technological solutions such as barcodes to mitigate the leakage of FP products. Up to now, the number of batches, which is the same for numerous products sent to different areas of Madagascar, could not help the IMPACT team to track the leakage of products properly. In parallel, the MOPH integrated the fight against products leaks into its PDPN with the possibility of using barcodes in the fight against product leaks.

Technical specifications for the use of a tracking technology are defined. The specifications detail what IMPACT will need to protect the brand from supply chain fraud including counterfeit and theft. The main objective is to find and set up a system for a subsidized product and to trace each stage of its distribution until it reaches the target consumer. During field visits, it will be easy to read the tracking code and check the stock of the product in warehouses by using laser readers/scanners or to know the origin of the product by using a cellphone.

Sub-IR 4.2: Socially marketed products achieve cost recovery at an affordable price for consumers IR4.2.1: Explore introduction of new brand of Pharmaceutical products pending the results of the COGS analysis

In Quarter 1, Cost of Goods Sold (COGS) were analyzed and finalized. New COGS were proposed and integrated in the product portfolio analysis. The document was updated and was submitted for approval by PSI Headquarters before sharing with USAID.

According to the portfolio analysis, the cost recovery of several FP products can be improved by offering the whole range of methods so that users can freely make a choice . A gap of condoms is noticed in the commercial channel after visiting retailers despite the existence of a few brands which do not cover the market. Yes With You was identified not only to be maintained but also the scent should be diversified. Quantification of Yes needs was conducted and a procurement plan was developed and finalized. The Market Authorization process is in progress pending USAID approval. Through the re-introduction and exploration of the extension of Yes With You condoms and with Protector Plus serving the commercial market, and other brands of condoms in pharmacies, all segments of the condom market will be served.

III.7. IR5 - Increased demand for and use of health products among the Malagasy people IR5.1.1 : In collaboration with the demand creation subcommittee of the TMA TWG, develop and implement activities to increase demand and use of health products

During Quarter 1, the demand creation subcommittee of the TMA TWG held two workshops:

The first workshop was organized on October 2nd, 2019 led by the Director of the Health Promotion at the MOPH, with participation of all TMA stakeholders. 32 participants were present with 12 from the MOPH (Health Promotion Department, Agence Malgache du Médicaments (AMM), Direction de la Pharmacie, des Laboratoires et de la Médecine Traditionnelle DPLMT, National Malaria Control program (NMCP), 3 pharmaceutical wholesalers from private sector, and 14 from NGOs. The concept of health commodities demand creation and the interests in building a subcommittee were raised. Also, barriers and opportunities in terms of communication on health commodities were identified.

The following barriers were identified during the meeting: - No communication about regulatory texts in the communication of health commodities. Stakeholders are not aware of legislation regulating health commodities advertising. - Self-medication and lack of awareness about proper use of medicines. - No engagement of the GOM to communicate and protect against the health commodities supply chain fraud including counterfeit and theft.

Opportunities to communicate on health commodities: - Ensure continuity, sustainability, and coordination of communication activities. - Capacity building of stakeholders communicators.

The second meeting was held on December 13th, 2019 with 25 participants: 10 from MOPH (Health Promotion Department, AMM, DPLMT, NMCP), 4 pharmaceutical wholesalers, (1 representative of National Order of Pharmacist), and 10 NGOs (IMPACT, ACCESS, Mahefa-Miaraka, and SALAMA). The National Strategy for the Fight against Counterfeiting and the Illicit Drug Market (Stratégie Nationale pour la Lutte contre la contrefaçon et le marché illicite des medicaments) was presented by the executive secretary of Comité Interministériel de Lutte Contre le Marché Illicite des Médicaments (CILCMIM) - Inter-ministerial Committee for the fight against Illicit Drug Market. The second item of the agenda was the revision and the improvement of the regulatory texts on the advertising of health commodities. The recommendations of this workshop will be submitted to the regulatory text subcommittee of the TMA TWG. During the last part of the meeting, needs for capacity building in communication for the members of the subcommittee were identified, such as media training, advocacy, or photography.

IR5.1.2: Provide technical and financial support to contribute to the activities of the MoPH

The Policy and Strategy on Health Promotion of MoPH 2013-2017 has expired and needs to be updated according to WHO recommendations. IMPACT participated in the workshop organized by the Health Promotion Directorate of the MOPH and the WHO to review and develop a new Policy and Strategy on Health Promotion of MOPH for 2020-2024. It was held in Tamatave from December 16th to 21st, 2019 with participants from different directorates of MOPH from central and regional levels and NGOs. This workshop strengthened the five action levels of health promotion, including:

- Dissemination of public policies for health - Creation of enabling environments (legislation, tax measures, detaxation, etc.) for overall health - Communication, community mobilization, and advocacy - Acquisition of individual skills to public health actors - Reorientation of health services

At the end of the six days, a committee had been set up to draft the final version of the document which should be validated by the end of March 2020.

On November 13th and 14th, IMPACT has provided a technical and financial support to DPLMT to organize in Atsinanana region a sensitization and training sessions on the regulation of drug shops. To encourage drug shops to participate at the workshop, 126 radio advertisements were broadcasted from November 7th to 12th in six districts of Atsinanana region. Twenty-seven drug shops owners and dispensers were present.

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

According to the inventory turnover and the stock of Chlorhexidine (Arofoitra), there was a need of product promotion so 1,700 radio spots were broadcasted from December 18th to 30th in 31 districts of the 10 USAID- supported regions. The radio stations working with IMPACT are located in 31 districts. Those radio stations cover 62 districts out of the 78 USAID-supported regions. Thus, to have high coverage when using radio channels, IMPACT selected those 31 districts where radio stations are located.

SMS messages were also sent to providers, such as PA, PARC, and CHVs, to inform them of the availability of Chlorhexidine and to encourage them to prescribe it to people who needed it (Number summarized in Table 27 below).

Protector Plus condoms substituted the YES condoms in the commercial sector and 2,000 posters were produced to promote the Protector Plus brand.

Table 27: Summary of the Radio Spots Aired

Communicatio Period Region Number Number of Comment District Number n Campaign of Spots Aired s of Radio Districts Stations Broadcasting Decemb Sofia 2 100 Antsohihy/Mamp 2 of Arofoitra er 18 to ikony Radio Spots Decemb Diana 4 200 Diego/Ambilobe/ 4 er 30, Ambanja/Nosy 2019 Be Boeny 2 150 2 stations Majunga/Marovo 3 in ay Majunga Melaky 1 50 Morafenobe 1 V7V 3 150 Vohipeno/Manak 3 ara/Mananjary

Communicatio Period Region Number Number of Comment District Number n Campaign of Spots Aired s of Radio Districts Stations Menabe 2 100 Miandrivazo/Mor 2 ondava Sava 4 250 2 stations Sambava/Antala 5 in ha/Vohémar/And Sambava apa Atsinanana 7 350 Vatomandry/Ma 7 hanoro/Maroant setra/Tanambao Manampotsy/Ma rolambo/Manana ra Nord/Tamatave Analanjirof 3 200 Fenerive 3 o Est/Vavantenina/ Ste Marie Atsimo 3 150 Tuléar/ 3 Andrefana Ampanihy/ Sakaraha Total 31 1,700 Radio Atsinanana 6 126 18 spots Tamatave 2 advertisement Novem aired per s for the ber 7 to district Sensitization Novem except Brickaville 1 of Drug Shops ber 12, Tamatave Vatomandry 1 2019 where Tanambao 1 there Manampotsy were 2 Mahanoro 1 radio Total 1,826 Marolambo 1 stations

ORS is now available without Zinc. 10,000 flyers for the community and 100 posters for providers were produced to inform providers that ORS without Zinc was available.

The IMPACT communication team used and sent SMS messages to inform targeted providers (PA, PARC, and CHVs) on how to store medicines.

Each month, a reminder SMS is sent to the 78 Pha-G-Dis to: o Report CHANNEL data to DPLMT o Submit commodities orders to SALAMA and malaria commodities orders to the GAS/NMCP committee. o Report the monthly physical stock at the end of the inventory to the RLA or to Regional Technical Assistant of MoPH. It is noted that the report goes first to the Inspector Medical Doctor in charge of Pha-G-Dis before sharing a copy to the RLA.

The SMS reminders are effective. For instance, in September before the SMS reminder 67/78 districts (86%) sent the inventory. After the first reminder at the end of September 74 out of 78 districts sent data inventory

(95%). in October. In November and December, 70 out of 78 districts (90%) sent inventory reports, a slight decrease was noted because of the festivities at the end of the year.

Table 28: Impact on inventory submission after SMS reminder to the Pha-G-Dis

Number of districts Number of districts Number of districts Number of districts Number of who sent inventory who send who send inventory who send inventory districts report in inventory report in report in November report in December September October 78 67 74 70 70 100% 86% 95% 90% 90%

Table 29: Summary of SMS Sent

Health Messages Translation Target Network Number Period Area of People Reached MNCH Miarahaba anao. Hi! Remind the CHV to PA Telma - 492 Nov. Ampatsiahivo ireo AC haka purchase Arofoitra at Orange - 2019 AROFOITRA ao aminao PA their usual PA. Airtel mahazatra azy. Miaro ny Arofoitra prevents foitran’ny zaza tsy hidiran’ny umbilical cord otrikaretina ny AROFOITRA. infections. Takio eny @ PA mahazatra Request Arofoitra at CHV Telma - 3,494 Nov. anao ny AROFOITRA. Entano your usual PARC. Orange - 2019 ny vehivavy izay hiteraka Sensitize pregnant Airtel hampiasa AROFOITRA women to use hisorohana ny otrikaretina tsy Arofoitra to prevent hiditra amin'ny foitran'ny zaza umbilical cord infections. EMMP Salama, Tahirizo @ toerana Hi, keep medecines in CHV Telma - 3,512 Oct. maina, mazava sy tongan’ny a cool and dry place, Orange - 2019 rivotra ny fanafody. Ny moisture and poor Airtel hamandoana sy tsy ventilation can fahampian’ny rivotra dia mety damage them. Thank hanimba azy ireo, you. Mankasitraka Salama, Tahirizo @ toerana Hi, keep medecines in PA Telma - 475 Oct. maina, mazava sy tongan’ny a cool and dry place, Orange - 2019 rivotra ny fanafody. Ny moisture and poor Airtel hamandoana sy tsy ventilation can fahampian’ny rivotra dia mety damage them. Thank hanimba azy ireo, you. Mankasitraka Salama, Tahirizo @ toerana Hi, keep medecines in PARC Telma - 64 Oct. maina, mazava sy tongan’ny a cool and dry place, Orange - 2019 rivotra ny fanafody. Ny moisture and poor Airtel hamandoana sy tsy ventilation can fahampian’ny rivotra dia mety damage them. Thank hanimba azy ireo, you. Mankasitraka Monthly Salama, ampahatsiahivina Hi, just a reminder to Pha-G- Telma - 115 Oct. to Reminder isika mba handefa ny rapport send out the channel Dis Orange - Nov. Channel isaky ny le 27 du report every 27th of Airtel 2019 mois, misaotra tompoko the month, thank you. Salama! Alefaso alohan’ny Hi! send before Telma - 01/11/2019* any @ SALAMA 01/11/2019* to Orange - ny rapport bon de commande SALAMA the 4th Airtel 4ème trimestre ; alefaso quarter order form @komité GAS/NMCP ny report; send to the komandy intrants palu. GAS/NMCP committee Mankasitraka. the orders for malaria commodities. Thank you

Health Messages Translation Target Network Number Period Area of People Reached Salama, ampahatsiahivina Hi! reminder to send Telma - isika handefa ny situation de the physical stock Orange - stocks physique any @CRL update to the IMPACT Airtel IMPACT na ATR rehefa vita ny Regional Logistics inventaire fin du mois Coordinator or to ATR d’octobre. Mankasitraka. at the end of the inventories for October. Thank you

- SMS were sent to 492 PA and to 3,494 CHVs to encourage them to purchase Arofoitra. - SMS were used to sensitize providers on how to store medicines. - SMS were sent to 3,512 CHVs, 475 PAs, and 64 PARCs.

IR5.1.4 : Provide technical and financial support to the Ministry of Youth and Sport (MYS) to develop and implement Youth activities in collaboration with Telma Foundation based on the Human Centered Design (HCD) study and support training for youth on health, leadership, communication, etc.

During Quarter 1, an MOU was developed between IMPACT and the Ministry of Youth and Sport (MYS) to define collaboration agreements. The main goal of the MOU is to (i) raise youth awareness on health, (ii) access to health products, and (iii) encourage them to practice healthy behaviors, such as to going to CSBs/ACs or using FP products to avoid early pregnancy. Peer educators will be trained to be a model on increasing demand and using health products (malaria, MNCH, and FP/RH) in youth centers of the MYS. Due to unavailability of the Minister of MYS during Quarter 1, the signature ceremony will be held in Quarter 2.

During the USAID Integrated Social Marketing (ISM) project, the mobile application named Tanora Cool was developed. On December 10th, a meeting was held at ACCESS’s office with 15 partners from MOPH, MYS, and NGOs to review the content of the application as part of the ongoing project to update the application in collaboration with ACCESS.

IMPACT produced 600 branded Tanora Cool tee shirts and 600 bags for Youth activities. The production of job aids and pens are ongoing. These items will be distributed to youth leaders as part of a collaboration with MYS and other NGOs such as Blue Venture, Mahefa Miaraka, or ACCESS in Quarter 2.

IR5.1.5: Support the 910 Call Center in Partnership with ACCESS

IMPACT continued to support the MoPH “910” call center during Quarter 1. The transfer of the “910” call center to ACCESS is ongoing so the communication cost was supported by IMPACT through the end of December 2019. The human resource costs for the hotliners will be supported by IMPACT until the end of June 2020.

The number of calls received (Quarter 1, Year 2 vs Quarter 4 Year 1) decreased slightly (-3.5%) because IMPACT did not implement specific activities to promote the “910” hotline due to the ongoing transfer to ACCESS. However, in September 2019, during Family Planning World Day, an SMS was sent to women and men in the 13 USAID-supported regions to encourage them to use FP and to call the “910” hotline so calls received for FP

increased from 4,943 in Quarter 4 YEAR 1 to 9,928 in Quarter 1 YEAR 2 because the SMS was sent at the end of September. . In total, the number of the call received decreased from 120,849 in Quarter 4 Year 1 to 116,684 in Quarter 1 Year 2.

Table 30: Summary of the number of hotline calls received during Quarter 1 vs Quarter 4 Year 1

Quarter 4 Year 1 (July - August - Quarter 1 Year 2 September 2020) (October -December 2019) Number % Number % Hotline calls received on 35,271 29% 27,810 24% Malaria (% of total)

Hotline calls received 4,943 4% 9,928 9% on Family Planning (% of total)

Hotline calls received on 12,813 11% 14,820 13% Maternal, Child, Health (% of total) Hotline calls received on other 67,822 56% 64,126 55% (% of total) Total hotline calls received 120,849 100% 116,684 100%

III.8. Cross-Cutting Activities Cross-cutting activities focus on five aspects: Monitoring, Evaluation, Research, Learning, and Gender/Social Inclusion.

III.6.1. Monitoring, Evaluation, Research, Learning

6.1.1. Monitoring and Evaluation CC2.1: Strengthen LMIS/HMIS (all sectors: public, private, non-profit, and commercial) including formative supervision, capacity building of data senders, and supporting implementation of the LMIS roadmap with consideration of DHIS2 as the main LMIS electronic tool.

Strengthen LMIS using short roadmap

In Quarter 1, active data collection was replaced with two approaches to strengthen the public LMIS current system: a. First approach: A quick evaluation was conducted to identify the barriers at 78 USAID-supported Pha-G-Dis with low reporting rates. Five criteria were analyzed as presented in graph 4: - 37 Pha-G-Dis did not have functional computers for CHANNEL. - 44 Pha-G-Dis did not have Internet connection to submit LMIS data - 5 Pha-G-Dis were not equipped with electricity - 21 Pha-G-Dis providers were not trained on CHANNEL - 38 Pha-G-Dis providers did not have valid contract to allow them to act as a Pha-G-Dis provider and to receive a laptop for LMIS (33 renewal contracts and 5 new contracts).

Graph 4: Barriers at Pha-G-Dis level leading the lowest LMIS reporting rates

Pha-G-Dis provider contract 49% 51%

Training in CHANNEL 73% 27%

Electrical installation 94% 6%

Internet access 44% 56%

Availability of a computer for Channel 49% 51%

0% 20% 40% 60% 80% 100% Yes No

Results were presented to the LMIS committee with the participation of DEPSI, DSFa, NMCP, and Measure Evaluation. While waiting for the LMIS evaluation restitution workshop, a provisional LMIS roadmap for Pha- G-Dis was developed and established by the committee based on the findings from the quick situational analysis. From November 2019, the implementation of the roadmap was conducted mainly by EMAR, EMAD, RLA, and the central team composed of DPLMT, IMPACT, DEPSI, and DSFa.

Priority activities were identified and inserted in the roadmap as presented in graph 5.

Graph 5: The priority action to address challenges on LMIS at the Pha-G-Dis level

100%

80%

60%

40% 47% 20% 32% 6% 14% 1% 0% Formative supervisions PC Alocation CHANNEL training for providers Internet connexion GIS training

- The DPLMT with EMAR support is finalizing the 38 Pha-G-Dis provider contracts. It is already at the DPLMT central office and will be sent back to the Pha-G-Dis provider after signature by DPLMT. Owning a valid contract is a condition requested to donate the laptops provided by the donors (USAID, World Bank, and Global funds) to the Pha-G-Dis. - Sixty Pha-G-Dis were visited by EMAR/EMAD, RLA, and the central team (DPLMT, IMPACT, DEPSI, and DSFa) in November 2019. Formative supervisions were combined with other activities, such as RDQA and RLA periodic supervision on commodities management. Training/refresher trainings on CHANNEL were provided for those who are new or have demonstrated the need. - The USAID HMIS group presented a long-term solution to the MOPH and the other partners such World Bank, UCP, and the GF-NFM2 program through PSI in order to equip the SDSP (Service de District de la Santé Publique) with unlimited and high-speed Internet connection. On average each USAID funded project will pay Internet speed connection for 22 SDSP. A concept note was presented to the General Secretary of the MOPH who approved the initiative. With the lead of the MOPH, a meeting with the mobile companies is scheduled in Quarter 2 to present the concept note and then to get their financial proposal. - Additionally, IMPACT provided a 50 GB Internet connection per month for the CHANNEL focal point at the DPLMT office. With this initiative, IMPACT expects more proactive action from the CHANNEL focal point, including consistent communication with Pha-G-Dis providers, creating solutions to LMIS challenges, downloading the LMIS data submitted by Pha-G-Dis providers on time, following the progress of the LMIS data submission with an emphasis on the Pha-G-Dis who have challenges.  Note: To make sustainable the plan of providing Internet connection, the MOPH will pay 10% of the total budget from Year 3. This participation would gradually increase starting from Year 4 in order to ensure full MOPH commitment after USAID-funded projects. - Thirty-seven laptops were purchased by IMPACT and will be distributed to the Pha-G-Dis after installing CHANNEL software and antivirus software to each laptop. The official hand over of the laptops to the MOPH is scheduled in Quarter 2. - For the electricity issue, the RLA with EMAR support tried to arrange the data submission outside of the Pha-G-Dis using a Cybercafé.

- Second approach: Set up a call center located at PSI office (where internet connection is available) to strengthen the LMIS reporting rate at the Pha-G-Dis level (data extracted from CHANNEL). The call center is used to remind the Pha-G-Dis providers of the LMIS data submission. The call center team checks the

reporting rate using a dashboard in Intranet. All Pha-G-Dis that did not submit LMIS data are called and reminded to submit data for the relevant period. Challenges and barriers are managed as tickets and shared to the CHANNEL focal point, RLA, and IMPACT. If the issues cannot be solved by the call center then field visits will be organized. It is noticed that the call center does not collect LMIS data but was set up to remind Pha-G-Dis provider to submit LMIS data extracted from CHANNEL. The following are the activities carried out in Quarter 1 for this approach: - Activation of two used SimCards to call the Pha-G-Dis and three green numbers (Telma, Airtel, and Orange) that the Pha-G-Dis can call free of charge when they need to reach the central team for assistance (managed as tickets). - Setup of ZOIPER software, which is a call center tool to manage outgoing and incoming calls. For example, when two or more incoming calls enter into the ZOIPER software then the first one is received by the call center agent and the second/other incoming calls are placed in a call queue. - Test with 19 Pha-G-Dis having missing data for September and October. 12 out of the 19 Pha-G-Dis submitted data after the reminder. The 7 Pha-G-Dis that did not submit LMIS data after reminder had other issues such as electricity issues and unavailability of qualified staff.

Graph 3: Overall progress on reporting rates in Quarter 1 Year 2

100% 95.1% 95.4% 95.5% 95.5% 93.1%

76.9% 75.6% 80% 71.8% 70.5% 62.8% 60%

40%

20%

0% J U L Y 1 9 A U G . 1 9 S E P T . 1 9 O C T . 1 9 N O V . 1 9

Channel DHIS2

The reporting rate from Pha-G-Dis to DPLMT was at 71% in October and 63% in November which is similar to the average rates noted for Year 1 (62%). During Quarter 1 Year 2, IMPACT started to reduce active data collection which was the main approach during Year 1. On average 24 Pha-G-Dis were visited each Quarter for active data collection in Year 1 compared to 16 Pha-G-Dis in Quarter 1 Year 2 (mainly in Analanjirofo, Atsimo Andrefana, Atsinanana, and Melaky regions). As a result, the two approaches mentioned above are promising to improve the LMIS reporting rate. The 13 USAID-supported regions will have at least one RLA from the beginning of Quarter 2 Year 2 who will support formative supervision and follow-up of the implementation of the provisional roadmap.

Reporting rates from DHIS2 is stable at more than 90%. The data entry is ensured by the Commodity Health Manager based at SDSP. This person is dedicated to 100% of DHIS2 data entry which is different from the Pha- G-Dis system with generally one or two people who ensure several activities at the Pha-G-Dis level (stock management, inventory exercise, management of the order from CSB, CHANNEL data entry, etc.).

Supporting implementation of the LMIS roadmap

The LMIS roadmap will be defined during the workshop that will be organized after the finalization of the final report on the LMIS evaluation conducted in Year 1. The following are the activities conducted for the LMIS evaluation in Quarter 1 Year 2. The expert shared the preliminary report on LMIS evaluation to IMPACT that provided feedbacks/recommendations, which will be included in the final report.

CC2.2: Support the identification of outlets exercise to identify and train pharmacies and drug shops for LMIS data.

The exercise to identify outlets is an approach used to identify pharmacies and drug shops (outlets) to partner with the MOPH and IMPACT to collect LMIS data and submitting it to the National HMIS. In Year 2, four regions were selected (see explanation and details above in the IR3 section).

The MERL team supported the following technical activities:

- Calculated a representative sample of pharmacies and drug shops. - Finalized the questionnaire used to collect views and perceptions of pharmacies and drug shops on LMIS data. - Selected randomly pharmacies and drug shops for applying systematic sampling (using random skip number). - Participated in 13 pharmacies and 25 drug shops interviews in Boeny.

CC2.3: Support technically and financially the DPLMT to conduct Routine Data Quality Assessment (RDQA) at all levels and sectors.

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 quality dimensions). The tool used for the RDQA exercise was adapted from the Measure Evaluation RDQA tool to fit the LMIS context in Madagascar.

Two main activities were conducted on the RDQA: a. Implementation of the action plan based on the results of the RDQA conducted in Year 1

The LMIS committee led by DPLMT organized a meeting at the beginning of Quarter 1 to discuss data quality issues and set up an action plan based on the recommendations. The committee monitored the implementation of the action plan (table 31 and table 32) using a small questionnaire created from the list of RDQA issues.

The RLA with EMAR ensured the follow-up of the recommendations using a short questionnaire during supervision visits. 60 Pha-G-Dis and 127 Pha-Ge-Com were supervised. The Pha-G-Dis and Pha-Ge-Com supervised by RLA in Quarter 1 Year 2 were not necessarily the entities visited for the RDQA conducted in Year 1.

Table 31: Results of the implementation of action plan based on the recommendations from previous RDQA (Year 1)

Pha-G-Dis evaluated Result at Pha-G-Dis Quarter 1/Year 2 in Year 1 visited in Questionnaires (n= 60) Quarter 1 Year 2 (n =15) Yes No Yes Use of stock card per product at Pha-G- 58 2 15 Dis Insertion of inventory line in the stock 54 6 15 card at the end of each month Elaboration of activity monthly report on 57 3 15 logistic per program at Pha-G-Dis level Access to the computer using CHANNEL 31 29 11 password CHANNEL password needs to be unique 25 35 12 per user A copy of the CHANNEL database needs to be stored in another backup system 32 28 15 such as external hard drive Training of new Pha-G-Dis providers and Pha-Ge-Com dispensers on LMIS and GIS 57 3 15 by EMAR and EMAD Pha-G-Dis need a manual on GIS 59 1 15 management.

Table 32: Results of RDQA recommendations at Pha-Ge-Com level in Year 1

Pha-Ge-Com evaluated in Year 1 Result at Pha-Ge-Com Quarter 1/Year 2 visited in Quarter 1 Questionnaires (n=127) Year 2 (n =3) Yes No YES Commodity management is only at Pha- 56 71 2 Ge-Com level Use of stock card per product at Pha-G- 68 59 3 Dis and Pha-Ge-Com levels Insertion of inventory line in the stock 49 78 3 card at the end of each month Training of new Pha-Ge-Com dispensers 43 84 1 on GIS by EMAR and EMAD Pha-Ge-Com need a manual on GIS 75 52 3 management.

b. Conducted RDQA in Quarter 1 Year 2

RDQA activities were conducted in Quarter 1 with participation of DPLMT, DEPSI, DSFa, DLMNT, and EMAD in 4 regions (Sofia, Diana, Sava, and Haute Matsiatra) for 9 Pha-G-Dis, 18 Pha-Ge-Com, 6 PARCs, and 9 PAs.

For Pha-G-Dis, the overall data quality score was 85% (calculation method shown in the footnote of tables 33 and 34 below). The challenges among Pha-G-Dis included: - 74% Timeliness score: data is not available or not submitted on time as described in the Pha-G-Dis manual. - 56% 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. - 89% Integrity score: the tool was not protected from unauthorized changes or manipulation especially for the stock monitoring sheet. - 78% 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 96% which means that data submitted are of good quality.

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 SPD is asked to follow the recommendation linked to the RDQA issues outlined in red in Table 34.

Table 33: Summary of the RDQA findings for the public sector

Storage level Pha-G-Dis (n=9) Pha-Ge-Com (n= 18) Haute Average Haute Average SOFIA DIANA SAVA SOFIA DIANA SAVA Region Matsiatra Quarter1 Matsiatra Quarter1 (n=2) (n=2) (n=3) (n=4) (n=4) (n=6) (n=2) Year 2 (n=4) Year 2 Data Quality Parameter Availability 100% 100% 96% 62% 90% 52% 76% 76% 100% 76% Completeness 100% 89% 94% 99% 96% 48% 83% 66% 100% 73% Timeliness 50% 100% 67% 83% 74% 92% 100% 74% 100% 90% Integrity 100% 100% 67% 100% 89% 100% 100% 83% 74% 89% Confidentiality 100% 100% 83% 100% 94% 84% 79% 67% 25% 64% Precision 100% 100% 100% 50% 94% 52% 68% 71% 88% 70% Accuracy 54% 43% 60% 65% 56% 65% 71% 83% 88% 78% Summary Overall Data Verification Score 1 86% 90% 81% 83% 85% 71% 83% 74% 82% 77% System Assessment Score 2 81% 83% 88% 83% 84% 73% 74% 75% 61% 71% Overall Data Quality Score 3 84% 87% 85% 83% 85% 72% 78% 75% 71% 74%

Table 34: Summary of the RDQA findings for social marketing PARC and PA

Storage level PA (n=09) PARC (n=6) Haute Average Haute Average SOFIA DIANA SAVA DIANA SOFIA SAVA REGION Matsiatra Quarter Matsiatra Quarter (n=3) (n=2) (n=2) (n=1) (n=1) (n=2) (n=2) 1 Year 2 (n=2) 1 Year 2 Data Quality Parameter Availability 100% 91% 97% 94% 96% 88% 100% 100% 100% 97% Completeness 100% 91% 97% 94% 96% 88% 100% 100% 100% 96% Timeliness 100% 100% 100% 94% 99% 100% 100% 100% 100% 99% Integrity 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Confidentiality 100% 97% 50% 100% 87% 100% 100% 100% 100% 87% Precision 100% 91% 100% 94% 96% 100% 100% 100% 100% 96% Accuracy 83% 87% 91% 100% 90% 78% 88% 100% 92% 90% Summary Overall Data Verification Score 98% 94% 94% 97% 96% 93% 98% 100% 99% 98% 1 System Assessment Score 2 92% 94% 90% 69% 86% 88% 88% 65% 98% 85% Overall Data Quality Score 3 95% 94% 92% 83% 91% 90% 93% 83% 98% 91% - 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%

CC2.4: Implementing monitoring and evaluation system ITN community continuous distribution, including creating M&E tools, training, data collection and supervision, RDQA (budget included in the continuous distribution activities)

- IMPACT completed the recruitment of the Monitoring and Evaluation Supervisor of the community-based continuous distribution (cCD). - The M&E team took the opportunity of the training of trainers organized in Antananarivo to train 45 trainers composed of EMAR/EMAD and MENETFP (Ministère de l’ Education Nationale, de l’Enseignement Technique et Formation Professionnelle) on M&E tools from 6 districts: Toamasina II, Brickaville, Toliara II, Mananjary, Manakara and Vohipeno belonging to 3 regions (Atsinanana, Atsimo Andrefana et Vatovavy Fitovinany). The purpose of the training was to explain the use and the process of completing the management tools report. The remaining six districts will receive the same training in Quarter 2. - Organizing printing and distribution of the management tools (Table 35).

Table 35: Management tools printed

Name of the tool Contents Number printed - Tools for TA (Technicien Accompagnateur) - Guide used at commune level to assess the Review Guide 820 progress of the cCD (good practices, areas for improvement, etc.) - Tools for district supervision - Follow-up of recommendations from previous District supervision grid for supervision 528 scoring - Data quality assessment - Recommendation and action plan - Tools for commune supervision - Follow-up of recommendations from previous Commune supervision grid for supervision 3014 scoring - Data quality assessment - Recommendation and action plan - Tools for CHV supervision - Follow-up of recommendations from previous CHV supervision grid for supervision 33864 scoring - Data quality assessment - Recommendation and action plan Monitoring sheet on ITN - Tools for PA 274 management - Monitoring sheet on quantity procured by CHV

6.1.2. Research CC2.5: Conduct market assessment studies for FP and MNCH, including key informant interviews, outlet surveys, and routine data in collaboration with IR1.

• Market assessment surveys on FP and MNCH: - An initial discussion on the information needs for the FP and MNCH market assessment was conducted within IMPACT (MERL team and market assessment program team).

- Development of the market assessment framework is ongoing. - The different data collection tools to be used for creating the market assessment design are created following the information needs based on the market assessment framework. The research team started to create the data collection tools base on the first discussion.

• Market assessment surveys on malaria (continuous activity from Year 1): four survey tools were used to create the malaria market assessment. The findings from the surveys were sent to the market assessment program team in order to complement the malaria market assessment data and information.

CC2.6: Implement additional studies, including archetype study/segmentation, journey mapping, assessment of pharmacies and drug shops on products supply, KAP study on IPTp use, and an evaluation on the introduction of the last mile distribution strategy (drones) at the community level.

Evaluation of drones: Prior to scale up, the pilot of using drone for last mile distribution at the community level will be evaluated. The following aspects will be addressed during the evaluation:

- Success of the flights. - Practicality of the drone to address stock out: advantages, cost-effectiveness, etc. - The perception of the actors (MOPH, local authorities, local population, PA, etc.) involved in the drone pilot. - Lessons learned/best practices/challenges identified.

The data collection is scheduled in March 2020 after the pilot phase ends by the end of February. Since the pilot phase is implemented in Maroantsetra district then the evaluation will be conducted with the actors in Maroantsetra. The research brief was received from the distribution team and the study protocol has been drafted. Prior to sharing with USAID in January for their review and comments, the study protocol will be sent to the PSI regional researcher for feedback. Since the activity is an USAID pilot activity, USAID will take the lead of the evaluation per the ADS 201.3.5.13: An evaluation for which completion fulfills a requirement. Required evaluations must be external and managed, in most cases, by USAID Program Office staff.

6.1.3. Knowledge Management CC2.7: Knowledge Management: Support partners in developing and collecting success stories and documenting IMPACT's innovations in the field.

Three main activities were carried out in Quarter 1: • IMPACT organized field visits in Atsinanana region to (i) discuss with the target audiences concerning their views and perceptions of IMPACT activities; (ii) collect the success stories developed by field staff and partners of the project and (iii) initiate local staff to take photos meeting the required standards for the life of the project. Atsinanana region was selected as it benefited from most activities carried out by IMPACT in the public and social marketing sectors. • In Quarter 1, IMPACT also worked with USAID Madagascar to disseminate success stories through USAID platforms, such as websites and social media. During Word Entrepreneurship Week, IMPACT’s story on Business and Financial Training to Drug Shops was published on the USAID Madagascar website and Facebook page. During the Men’s World Day, IMPACT and USAID Madagascar published a story on men working in the supply chain.

• ASTMH: IMPACT participated in the 68th ASTMH annual meeting held in Maryland, USA from November 20th to 24th, 2019. The purpose of the participation at the ASTMH annual meeting was:

- Presenting the abstract accepted as a poster presentation: “Efficacy of continuous bed net distribution to maintain high coverage after a mass distribution campaign in Madagascar, 2017.” - Learn from other platforms through their successes on the fight against malaria.

Results: Poster session: - The poster session was attended by more than 15 people. - The audience asked the comparison between the two approaches: i) school vs ii) home visit by CHV. This was not done but would be considered in the evaluation for the next cCD. - Recommending an article to publish the research and to capitalize the learning. This has already been discussed with the PSI regional researcher. The preparation of the dataset is ongoing for further analysis.

Examples of learning from other participants: - The study conducted in Côte D’Ivoire on factors associated with the use of IPTp can be used in Madagascar to understand the low IPTp uptake and to identify factors associated with the use of SP. - Evaluation of PBO nets presented by Uganda’s team. Overall, PBO-nets provide 25% additional protection against malaria infection compared to standard nets based on data from both trials. The introduction of the PBO nets in Port Berger should be the focus on evaluation.

Other MERL activities implemented in Quarter 1 Year 2

HMIS/LMIS meeting

IMPACT hosted the USAID HMIS group meeting at Le Louvre Hotel Antaninarenina on December 19th. Each implementing partner provided the progress on HMIS/LMIS and the issues that required input or solutions from the group. There was a brainstorming of priorities for 2020 presented in the meeting minutes attached to this report.

III.6.2. Gender and Social Inclusion

This quarter, IMPACT’s gender equality and social inclusion (GESI) cross-cutting work was focused primarily on building relationships with strategic women and human rights associations to play an active role in the TMA, as well as awareness raising around GESI issues in the health sector through participation in the Ministry of Population’s 16 Days of Activism against Gender-based Violence. The GESI team also conducted a follow-on capacity building with IMPACT staff to develop their knowledge and skills to serve as GESI champions within their respective areas of work.

Participation in the 16 days of Activism against Gender Based Violence

IMPACT contributed actively throughout the 16 Days of Activism against Gender Based Violence. In 2019, the theme was ‘Generation Equality against Rape.’ The international campaign ran from November 25th to December 10th, but the Ministry of Population extended it until the end of December. The Ministry of Population and the First Lady of Madagascar launched the GBV awareness-raising campaign with the

inauguration of two new health centers for victims of GBV in two neighborhoods of Antananarivo (Mahamasina and Anjanahary). IMPACT provided in-kind donations of mosquito nets and Sur’Eau water purifiers to both health centers, making these health commodities more accessible for women victims of violence served by the GBV health centers.

On December 6, 2019, IMPACT attended a roundtable discussion organized by the Ministry of Population and UNFPA to coordinate activism against GBV with different stakeholders working on gender equality and social inclusion. By participating in the event, the IMPACT team raised the awareness of the General Directorate of Women's Empowerment of the Ministry of Population and other implementing partners about IMPACT's objectives to improve the access of health commodities through gender equality and social inclusion by targeting all categories of the Malagasy population and working with all sectors - public, private and social marketing. IMPACT displayed its GESI banner as part of the exposition and handed out 150 brochures containing the key findings from the IMPACT GESI analysis conducted at the beginning of the project. IMPACT’s GESI Advisor also contributed to the roundtable discussion during the conference.

On December 13, IMPACT conducted a training session with 45 journalists and communications officers from the police department on equality of access to health commodities. The training included examples of how gender equality issues are related to FP and MNCH to increase journalists’ awareness on their roles as educators and communicators to the general population. This training was conducted jointly with leading gender partners such as UNFPA and other USAID-funded programs. The objective of the training was to increase the knowledge and awareness of journalists about gender inequity and inequality in accessing health commodities. By raising their awareness, they can serve as champions for GESI through the media to communicate to large audiences the importance of equal access to health commodities regardless of sex, race, religion, or socio-economic status to improve the health condition and welfare of the Malagasy population.

The involvement of communications officers from the police department in the training was also strategic on the part of the Ministry of Population, because law enforcement is responsible for addressing issues and responding to reported incidences of violence against women. IMPACT shared the importance of access to health commodities with this group of communications officers within the police force so that they can also serve as advocates for women's rights, including women’s right to access health services and health commodities. Due to cultural constraints, women in certain regions of Madagascar must hide their use of health commodities for family planning from their spouses and partners, and this puts them at greater risk for gender-based violence. It is important for law enforcement officials to be aware of this connection between access to health commodities and GBV when they are responsible for enforcing the law.

To further educate and reach an even wider audience, IMPACT published articles focused on GBV, women’s access to finance, and the relationship between gender and health every Saturday in December in three daily newspapers (Midi Madagascar, Express de Madagascar and Les Nouvelles). The articles served to raise the public’s awareness about GBV – what it is, how to recognize it, and its prevalence in Madagascar. The articles also explained how GBV negatively impacts women’s economic empowerment by affecting women’s experience in the workplace and how GBV affects their access to and control over resources. The articles also discussed how GBV affects women’s health, particularly when it comes to FP and access to health commodities like contraception.

Inclusion of strategic GESI partners within TMA During Year 1, IMPACT identified two strategic partners working in GESI to become engaged in the TMA: CNFM and Groupement des Femmes Entrepreneurs de Madagascar (GFEM). Both partners were invited to join the TMI TWG in the malaria TMA during the RBM meeting held on November 14th at the NMCP office. The objective was to introduce them to the TMA and to bring more gender expertise into the group of partners working on the TMA. They contributed their expertise during the identification of socio-cultural challenges related to availability and accessibility of malaria commodities in Madagascar. Based on outreach to CNFM and GFEM following the RBM meeting, it is expected that CNFM will remain actively engaged in the project and will participate in the development of the road map, but that GFEM will be less engaged based on the interest and availability of its leadership. IMPACT has identified another women’s business network, Entreprendre au Féminin Océan Indien (EFOI), and will begin reaching out and engaging with them during Quarter 2.

IMPACT staff capacity building A capacity building session for IMPACT staff took place during an all-staff retreat on October 24, 2019 at the Ibis Hotel in Antananarivo. First, IMPACT staff participated in an assessment of their knowledge on gender equality and social inclusion based on the first training received in March 2019. This assessment was used to determine where staff stand in terms of their current knowledge and understanding of GESI concepts and to collect feedback on additional topics for future training. Following the assessment, the staff broke up into three groups to discuss case studies related to GESI in the public sector, commercial sector, and social marketing to practice gender mainstreaming and identify strategic activities to undertake in Year 2 to achieve specific GESI objectives outlined in the GESI action plan. Groups developed more specific action plans for how their planned activities can integrate gender and social inclusion considerations, and then discussed and validated their ideas during a plenary.

IV. Success Stories • Story on the development of a TMA Roadmap to improve availability of life-saving supplies for the Malagasy population • Story on how public and private sector work together to support the health commodities supply chain in Madagascar • Story of Harimalala Euphrasie Sandrine, beneficiary of family planning, Vatomandry: How availability of birth control products helps meet the needs of women in rural communities • Story of Isaac Ivoara, District Pharmacy Manager at the Pha-G-Dis of Brickaville: How accurate commodity forecasting helps Brickaville to be prepared for a malaria outbreak • Story of Soazara Philomène, Community Health Volunteer, Brickaville: How the use of Sur’Eau Pilina save lives in remote communities of Brickaville. • Strengthening organizational capacity of Pha-G-Dis in Menabe, Atsimo Andrefana, and Boeny regions • Electrification of a Pha-G-Dis in Haute Matsiatra

V. Environmental Mitigation and Monitoring Report

Public Sector:

General findings for the public sector: - 85 CSBs and 39 Pha-G-Dis were visited during Quarter 1. - 61% of CSBs visited had infrastructure for handwashing with non-medical equipment for infection prevention. - 89% of CSB visited in Year 1 had medical equipment for infection prevention (safety box, sharp container, gloves, garbage for disposal) - 87% of Pha-G-Dis and 26% of Pha-Ge-Com providers visited in Quarter 1 have been trained on management of expired and surplus commodities. - 32.466 Expired commodities were detected in 11 out of 39 (28%) Pha-G-Dis supervised in Quarter 1. - 33% of Pha-G-Dis and 20% of Pha-Ge-Com visited had communication tools in their storage rooms. Job aids and communication tools for commodities storage were designed. RLA start to print and paste them during supervision visits.

Challenges identified included: - Eleven out of 39 (28%) Pha-G-Dis providers and EMAD do not consider expiry date in stock management. That increased risk of expiration of commodities. - 52 GAS committees were created in USAID and PARN Regions (66% of 78 districts) from the beginning of IMPACT but their members have not enough capacity to conduct monthly stock analysis and to prepare proper quarterly orders. - Numbers of Pha-Ge-Com and Pha-G-Dis having communication tools are stills low.

Recommendations: - Three new RLA were recruited and will join their region in February 2020. As a result, each 13 USAID- supported regions will have at least one RLA to supervise the Pha-G-Dis and Pha-Ge-Com on EMMP. - IMPACT will provide on-site training and refresher trainings during supervision visits to strengthen capacity of Pha-Ge-Com and Pha-G-Dis providers on stock management and expiry date management. Based on monthly stock inventory report, the Pha-G-Dis and Pha-Ge-Com analyze stock available and detect a risk of expiry. In this case, redeployment will be organized to another Pha-G-Dis or Pha-Ge-Com. Additionally, job aids will be shared to train people and will be posted on the Pha-G-Dis wall. As expected, they will be able to anticipate and take actions earlier to avoid expiry products, to reduce destruction and mitigate environmental impacts. - Each RLA will support SDSP to provide expiry date and quantity of expired commodities in their monthly report. Quantity of expired drugs will be considered as indicator of good stock management practice. That indicator will be followed up both by Malaria GAS Committee and District GAS committee. - IMPACT with other partners (UCP) will plan training from Quarter 2 to strengthen capacity in analysis, coordination, and distribution of commodities within GAS committee members created since Year 1.

General findings for the Social Marketing:

During site visits, the following good practices were observed: - Warehouse staff (6) as well as PARCs (55) and Supply Points (778) were properly trained on management of expired or surplus commodities.

- No expired products were identified at all outlets which indicate a good management of product expiry. However, findings highlighted that obsolete and surplus products were identified at PA and PARC with 835 obsolete and 5,122 surplus products. The SPD organized redeployment to address surplus products at PARC and PA levels.

As per Year 1 recommendations: - The 2 non visited warehouses during Year 1 were supervised during Quarter 1. - Warehouse staff were trained on management of expired products. This training will continue in Quarter 2 among 6 warehouse agents and regional coordinators, 7 warehouse regional assistants, 2 stock keepers, and 4 central staff.

General action for both public and marketing social sectors To improve the management of the commodities at Pha-G-Dis and Pha-Ge-Com levels, some tools were designed and duplicated, including: - Jobs aids on • The roles and responsibilities of Pha-G-Dis and Pha-Ge-Com on health commodity management • The management of expired dates - Guide for proper storage of commodities

VI. Summary of the sub-activities not completed in Quarter 1

Table 36: Explanations on Activities not Completed

Activity Codes Description of Activities Explanations

IR 1.1.2.1 Present the market assessment results to the Analysis of findings took more TMI Malaria subcommittee (under the Roll Back time than planned due to the Malaria group), seek solutions to identify issues, amount of information. and develop a Malaria TMI roadmap and Activity will be completed in corresponding action plan Quarter 2

IR 1.1.4.1 Training of newly emerged TMI Champions on Activity delayed in Quarter 2 due TMA 101 to unavailability of Champions

IR 1.1.4.2 Train all eight TMI Champions in leadership Activity delayed in Quarter 2 due to unavailability of Champions

IR 1.1.4.3 Conduct an exchange trip in a country (study Activity delayed in Quarter 2 due tour) that has already operationalized a TMI for to unavailability of Champions the TMI Champions to identify best practices, key performance indicators, and tools in TMI

IR 4.1.3.1 Conduct drone test flight 6 test flights conducted: 5 effective and 1 aborted <25 km

USAID visit in Maroantsetra: Reported in January 2020

IR 4.1.3.2 Organize information session with MOPH on Activity to be conducted in drone Quarter 2 due to delay of official launch

IR 4.1.3.3 Official launch of drone Postponed in Quarter 4

LMIS Assessment report There is a lot of information that was collected and being triangulated with other data collection before finalizing the report. This is being edited and Other delayed will be sent to USAID. We commit activities to sharing the report to USAID by the end of March. Malaria market assessment The internal approval and commenting process took more time Malaria TMA road map Due to stakeholders approval and commenting process:

Activity Codes Description of Activities Explanations

Although initially planned in quarter 1, this report was delayed because we are waiting for stakeholders and TMA Champions feedbacks PPN/PDPN review Due to the unavailability of the DPLMT team the working session on updating the PPN and PDPN documents were delayed

VII. KEY CHALLENGES AND SOLUTIONS

Table 37: Key challenges and solutions

Key Challenges Solutions (A2F) Getting the current, up to date list of drug Collaborate with DPLMT and the regional MOPH staff shops to be contacted and invited for training from Direction Régionale de la Santé Publique (DRSP) who are more familiar with drug shops in the field. The support of the Coordinateur Régional en Logistique (CRL)/IMPACT team is also very helpful for this exercise. Local radio broadcasting is also an additional solution. A census with the MERL team in IMPACT’s target regions intervene may also help. (A2F) The low level of education of drug shops Continuously update and adapt the training materials to makes it difficult for them to assimilate some of the participant levels. training topics. (GESI) In Year 1, IMPACT identified Groupement des IMPACT has identified another women’s business Femmes Entrepreneurs de Madagascar (GFEM) as network, Entreprendre au Féminin Océan Indien (EFOI), one of the strategic women’s associations to partner that is strategically focused on women’s economic with IMPACT and to play a role in the TMA. GFEM’s empowerment in Madagascar and is also part of a leadership is less interested and available to regional network of women business owners, and will engaged and we do not anticipate they will be a key begin reaching out and engaging with them during partner moving forward. Quarter 2. To ensure private sector remain engaged Highlight concrete advantages that can be proposed by IMPACT: - New product, new market through market assessment result - Visibility of the members in TWG participation - Networking - Transition of a proportion of the market from Social Marketing to commercial sector Arrival of procured product according estimated Contact the supplier as much as often time to avoid stock out Payment of LLIN of Continuous Distribution storage Payment by Mobile banking (in progress) and transportation allowances for PA and PARC on time

VIII. MAJOR ACTIVITIES PLANNED FOR NEXT Quarter (YEAR 2, JANUARY – MARCH 2020)

IR 1: Enhanced coordination among the public, nonprofit, and commercial sectors for reliable supply and distribution of quality health products • Continue to support the implementation and monitor and evaluate the overarching TMA roadmap for all health products. • Disseminate the findings of the malaria market assessment and support the development and implementation of the malaria TMA roadmap based on these findings. • Start to conduct the FP and MNCH market analysis. • Train remaining TMI Champions in leadership. • Conduct an exchange trip in a country that has already operationalized a TMI for the TMI Champions. • Disseminate the official TMI roadmap document.

IR 1.2 . GOM leads TMI stakeholders to coordinate health product quantification and forecasting, procurement, and distribution according to market assessments and segmentation • Finalizing the Terms of Reference (ToR) of the UTGL to ensure its updated tasks and responsibilities. • Organizing quarterly meetings (UTGL, CGL, and GAS committee) to analyze routine data on key indicators in public hospitals, such as stock-out, LMIS issues, etc. for learning and adapting the use of DHIS2.

IR 2: Strengthened capacity of the GOM to sustainably provide quality health products to the Malagasy people • Finalization and validation of quantification review report of malaria commodities. • Quarterly distributions of malaria commodities to 115 Pha-G-Dis. • Last mile distribution strategy implemented in all the 114 districts. • Investigations to identify causes of high consumption of malaria commodities. • Stakeholders’ meeting on the management of MNCH commodities. • Resource mobilization meetings to raise funding to cover the needs of FP/RH commodities. • Supervision visits to Pha-G-Dis and Pha-Ge-Com in the 13 supported regions. • Conduct EUV survey: 1) Training of data collectors by the EUV national committee members assisted by IMPACT and two STTA from GHSC- PSM Ghana and Burkina Faso offices. 2) Data collection and analysis will then follow to get a report out by mid of March 2020. • Dissemination of LMIS report and development of road map to strengthen LMIS. • Qualitative evaluation of status of integration of vertical programs commodities to SALAMA distribution system. • Finalization of the preparation of Total cost Analysis of the public sector supply chain (methodology and questionnaires, sampling, set up of TCA committee, training of data collectors).

LLIN Continuous Distribution • Identification of 10 new PAs by the end of February 2020 for the 3 districts outside the USAID- supported regions. • Finalization of SPD recruitment by the end of January 2020. • SPD training and set up is planned for February 2020. • National launch of the cCD in February 2020. • Transportation of communication support to the six districts of the 2nd group in February 2020.

• Production of audio/video spots for the cCD. • Dissemination of cCD spots starting in January 2020. • Social mobilization at the school and AC level starting February 2020. • Organization of 2021 LLIN campaign strategy review workshop in March 2020. • Participation in the meeting of AMP 2020 partners from February to March 2020.

IR 3: Expanded engagement of the commercial health sector to serve new health product markets according to health needs and consumer demand Review the scope of the PSHP to engage businesses in health product markets • Continue to recruit new members of the PSHP to join IMPACT. • Organize meeting to create partnerships and develop an MOU with IMPACT. • Identify outlets (pharmacies and drug shops) in the Menabe region willing to submit LMIS data. • Ensure that all of the Health Commission members of the PSHP participate in the TWG.

Strengthening partner banks and other financial institutions' capacity to better serve private health commodities supply chain: • Revise capacity building plans and training curricula for DCA partner banks to incorporate GESI issues and, as needed, to consider newly identified needs. • Train and support DCA partner banks in credit analysis and loan structuring for health commodities businesses (in Boina and Diana regions). • Develop and adapt loan products and financial tools for small and micro health enterprises in health commodities sector (e.g., pharma loans, motorbike loans). • Design and develop new financial mechanism (e.g. risk sharing facility), following principles of USAID's Blended Finance Roadmap for Global Health, possibly including additional financial institution partners, to facilitate A2F within the pharmaceutical supply chains and other stakeholders.

Provide business strengthening capacity building to enterprises in health commodities supply chain and develop partnership with private companies to sustain the training: • Provide initial business-strengthening training to drug shops (in Boina and DIANA regions). • Provide one-to-one coaching on business strengthening to enterprises/individuals identified as potential peer trainers in health commodities supply chain (in Boina and DIANA regions). • Advocacy to the Ministry of Finances and Budget to harmonize the code of taxation with the new List of Essential Medicines and Commodities. • Dissemination of the literature review of legal texts in pharmaceutical sector. • Development of a strategic plan of DAMM and based on Global Bunch marking tool assessment results. • Facilitation of meetings between the Executive Secretary of the committee, DAMM, and DPLMT to develop revitalize the inter-ministerial committee to fight counterfeit and illicit medicines.

IR4: Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy people • Continue the distribution of social marketing products to the 10 regions of IMPACT and 3 regions of PARN. • Finalization of the technical specifications for the tracking system to launch the process to find an agency to study the feasibility of a tracking system and implementation.

• Approval of the portfolio analysis and the COGS analysis. • Procurement of Yes With You male condoms. • Exploration of the extension of Yes With You by introducing new scent validated by a consumer panel in the commercial market. • Extension of the distance for flight tests (> 25 km) for drones. • Training of the second group of PA and PARC on LLIN Continuous Distribution in January 2020.

IR5: Increased demand for and use of health products among the Malagasy people • During Quarter 2, the demand creation subcommittee of the TMA TWG will develop workplan addressing abuse of the self-medication, lack of awareness about proper use of medicines, and communication on illicit sales. • Organize the kick-off of the continuous distribution of LLINs which will be held on February 6th in Foulpointe, Antsinanana region. • Continue to send SMS broadcasts to the providers: PA, PARC, CHVs, Pha-G-Dis, and Pha-Ge-Com. For example, PAs, PARCs, and CHVs will be alerted by SMS when a shipment of products arrives. Pha-G- Dis will continue to receive reminders to send data each month. • SMS will also be sent to the general population. For example, during March 8th on International Women’s Day. • For the program targeting Youth, the MOU with the MYS will be signed to reflect the collaboration

Cross-cutting Monitoring, Evaluation, Research and Learning Routine system • Continuing the implementation of the short roadmap to improve LMIS reporting rate for public sector. • Participating in the elaboration and implementation of the LMIS roadmap. • Participating in the workshop to define LMIS tool for private for-profit sector (pharmacies and drug shops). • Conducting RDQAs in other regions and monitoring the implementation of the RDQA recommendations translated into action plan from the previous RDQA. • Continuing setup of the M&E system of the cCD. Research Creating and finalizing the data collection tools for the market assessment: • Outlet survey to measure the availability/volume/value of FP and MNCH products among all potential outlets. • Routine data to collect market volume, market value, market share of FP and MNCH products. • Key informant interviews to collect the views of key stakeholders to understand the in-country FP and MNCH landscape. Finalizing or creating study protocols for the following studies: • Creation of the study protocol for archetype and segmentation study (health area to be defined). • Creation of the study protocol for Journey Mapping (health area to be defined). • Creation of the study protocol for IPTp KAP (Knowledge Attitude and Practice) study to understand motivation and barriers related to low SP uptake. • Finalization of the study protocol on evaluation of the introduction of the last mile distribution strategy (drones) at the community level.

Knowledge Management

• Finalization of IMPACT website. • Organization of field visits to collect project success stories and best practices.

Gender and Social Inclusion • Conduct a follow-on, deep-dive GESI training with IMPACT staff to continue strengthening the capacity of IMPACT staff to serve as GESI champions (CC1.6). The first training was completed one year ago in March 2019. • Collaborate with the Access to Finance team and Component 3 to adapt and integrate GESI curriculum into training for financial institutions. • Begin conducting desk research to integrate GESI-informed messaging into SBCC campaigns (CC1.4). Research lessons learned and case studies from other countries on GESI in SBCC campaigns to inform the design, implementation, and monitoring of GESI-informed communications campaigns (planned for April 2020 in alignment with the FP world day and June 2020 for MNCH). IMPACT will also consult with the USAID Gender Focal Point and other experts on social inclusion innovation and best practices in this area. • Continue to forge strategic partnerships with women’s rights organizations and associations to ensure balanced gender representation among the TMI TWG – specifically, CNFM and EFOI.

IX. FINANCIAL SUMMARY

Table 37: Financial summary

Estimated Balance Expenses Cumulative Obligated Amount Expenditures Obligated Y1 Expenses Quarter 1-Y2 Amount Malaria 3 134 500,00 1 535 933,73 790 012,20 2 325 945,93 808 554,07 MCH 2 872 795,00 1 717 814,65 745 569,89 2 463 384,54 409 410,46 FP/RH 3 079 520,00 1 651 319,58 764 126,96 2 415 446,54 664 073,46 TOTAL 9 086 815,00 4 905 067,96 2 299 709,05 7 204 777,01 1 882 037,99

ANNEXES

ANNEX A - Performance Monitoring Plan (PMP)

Note: - PMI Quarterly report is attached in an Excel File sent with this Quarterly Performance Report - HPN Quarterly report is available on DHIS2 website https:// data.psi-mg.org/

Reportin Measur Y2 USAID IRs g Indicator e Achievement Comments and Sub-IRs target to of Unit Quarter1 Intermediate Outcomes/Outputs Short-term Outcomes SO2 PPR Couple Year Protection (CYP) in USG supported

(IR 2.9) USAID programs - There is no target defined for Year 2. the achievement is the remaining emergency FP Public sector 60,872 N/A products not distributed in Year Number 1. - The Quarter 2 remaining CYP is estimated at 48,825 Private for nonprofit sector 163,430 679,148 24% achieved Not data collected yet for Commercial sector N/A 67,915 wholesaler pharmaceutical 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 The TMA TWG large group did not meet during Quarter 1 of Year 2. We have prioritized the GOM-led TMI TWG (Technical Working Group) meets finalization and the PMP at least four times a year as a forum for IR1.1.9 Number 0 4 implementation of the IMPACT consultations and roundtables between public, non- operation plan of the roadmap profit, and commercial stakeholders throughout the 3 TMA subcommittees led by the DEPSI, AMM and the DPLMT. IR2: Strengthened capacity of the GOM to sustainably provide quality health products to the Malagasy people IR2.1. Health commodities and pharmaceuticals are continuously accessible and available in the public sector

IR2.1.1 PMP Average stockout rate at service delivery points (IR2.4.1 USAID (SDP) of tracer essential drugs (MCH, malaria) IR3.1.3)

ACT New born 19 10 - In some districts, ACT new born expired in September ACT Infant 4 10 2019 was not replaced at the appropriate time that caused ACT Adolescents 10 10 stock out. ACT Adult 11 10 - Some districts are not aware that they are concerned by IPT Rapid Diagnostic Test (RDT) 8 10 and did not order SP from SALAMA. Sulfadoxine-pyrimethamine (SP) 16 10 Actions plan: - IMPACT will support districts Malari to estimate needs and to a organize an emergency resupply of SP to address stock Pha- out versus overstock Public sector G- Percent - The GAS committee is Dis Injectable Artesunate 15 10 planning a PUSH system in Q2 (January- March 2020) to ship quantities despite absence of the orders. The stock to ship will be estimated on the basis of women assumed to attend ANC services. Oxytocin (10 IU Injection) 20 21.15 - The districts shipped Magnesium Sulfate (500mg Inj) 44 45 quantities to CSB around Gentamicin (20mg inj) 49 45 August and September 2019. MCH Health centers are still using the same stock shipped as there is Gentamicin (80mg inj) 50 39.6 still stocks of the same products that were sold by SALAMA

under the FANOME mechanism. Then, the Pha-G-Dis and Pha- Ge-Com did not send purchase order to SALAMA. It is expected that districts will send consumption reports and new requisitions/orders in the coming quarters.

- The TWG specific for MNCH commodities will set a procurement management system to organize cyclic orders following SALAMA shipment plan. ACT New born 23 10 Some health facilities are not ACT Infant 12 10 aware that they are concerned ACT Adolescents 13 10 by ITP and did not order SP from Pha-G-Dis. . ACT Adult 13 10 Actions plan Rapid Diagnostic Test (RDT) 7 10 - IMPACT will support districts Sulfadoxine-pyrimethamine (SP) 33 10 to estimate needs and to Malari organize an emergency a Pha- resupply of SP to address stock Ge- out versus overstock - ACCESS will be involved to Com Injectable Artesunate N/A 10 support CSB and promote ITP with SP. - Injectable Artesunate does not appear yet in DHIS2 - Health facilities are not Oxytocin (10 IU Injection) 87 26.05 informed about MNCH MCH commodities supplied by Magnesium Sulfate (500mg Inj) 48 33.3 USAID.

- There are also challenges Gentamincin (20mg inj) 41 38.8 regarding management with FANOME commodities. Action: RLA will support SDSP staff to inform their health facilities regarding orders and uses of USAID MNCH commodities. Gentamicin (80mg inj) 70 40.5 - The TWG specific for MNCH commodities will set a procurement management system (similar to malaria) to organize cyclic orders following SALAMA shipment plan. ORS/Zinc DTK (Community) 22 5 Sur Eau Pilina (67mg tablet) 0 5 PAR (Community) MCH C Arofoitra (CHX 7,1%) (Community) 1 5 Pneumox (amoxycilline) (Community) 0 5 High stock out rate of ORS Zinc. Private for nonprofit Pregnancy Test (Community) 0 5 Awaiting clearance from DSFa Percent sector ORS/Zinc DTK (Community) 21 5 on distribution of only ORS Sur Eau Pilina (67mg tablet) because Zinc was not available. 0 5 (Community) PA MCH Arofoitra (CHX 7,1%) (Community) 0,3 5 Pneumox (amoxycilline) (Community) 0 5 Pregnancy Test (Community) 0 5 Average stockout rate of contraceptive commodities IR2.1.2 PPR at Service Delivery Points by family planning (HL7.1.3) USAID methods Pha-G- Implantable Hormonal - USAID did not supply the Public sector Percent 26 10.5 Dis Contraceptives public sector then the stock out

Injectable Hormonal Contraceptives rates presented for family 17 36.0 (Depo provera) planning are not for USAID products but based on UNFPA Injectable Hormonal Contraceptives distribution. 26 32.3 (Sayana Press) - Fewer CSB were trained on intrauterine devices and Intrauterine Devices 36 28.5 Implant methods then they did not order at Pha-G-Dis and Oral Hormonal Contraceptive. 10 14.3 implicitly Pha-G-Dis do not also Microgynon order at SALAMA level Oral Hormonal Contraceptive. 23 28.5 Microlut - Following is the denominator to calculate the stock out rate: Implantable Hormonal 8 21.8 Either 1) the CSB has had the Contraceptives method in stock at any time in Injectable Hormonal Contraceptives the past 12 consecutive months 10 11.3 (Depo provera) (prior to the month when the Injectable Hormonal Contraceptives indicator is reported), OR, 2) N/A 37.5 (Sayana Press) the CSB has issued the method Pha- to clients at any time in the past Intrauterine Devices 3 39.0 Ge- 12 months, OR 3) the CSB has Oral Hormonal Contraceptive. ordered the method at any time Com 11 13.5 Microgynon in the past 12 months. - The targets will be revised to reflect the results which are Oral Hormonal Contraceptive. significantly lower compared to 7 24.8 Microlut the targets. - For Pha-Ge-Com, Sayanna Press does not appear in DHIS2 Oral Contraceptive (Community) 0 5 Injectable (Community) 0 5 Stock out rate for FP product Private for nonprofit sector PARC FP Condom Protector Plus Percent among PARC and PA is under 0 5 (Community) the benchmark of 5% Sayana Press 3 5

Oral Contraceptive (Community) 0 5 Injectable (Community) 0 5 PA FP Condom Protector Plus 0 5 (Community) Sayana Press 1 5 PMP Number/Percentage of required supply plans IR2.1.16 2 12 IMPACT submitted to GHSC-PSM during the quarter. PPMRm for malaria was Malaria 1 4 submitted. Number FP/RH 1 4 Supply planning of MNCH MCH 0 4 commodities will be planned according quantification results IR2.2. The public-sector supply chain achieves financial sustainability PMP Percent of product that is unusable due to expiry or IR2.2.1 IMPACT damage Expiry SALAMA Percent 0 1 Damaged Expiry Pha-G-Dis Percent 0.01 5 Damaged Expiry This is the ACT new born that Pha-Ge-Com Percent 8 5 Damaged will be destroyed in Quarter 2 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 140% of achievement in PMP Number of loans (in general) disbursed to businesses Quarter 1. The Yera 2 target will IR3.1.2 Number 14 10 IMPACT (excluding service providers) be revised to reflect current performance. 382% of achievement in PMP Value of loans (in general) disbursed to businesses Quarter 1. The Year 2 target will IR3.1.3 USD 57,281 IMPACT (excluding service providers) 15,000 be revised to reflect current performance.

PMP Number of people trained in business and financial 36% of achievement in Quarter IR3.1.4 Number 27 75 IMPACT management 1. We are on the right track IR4: Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy people IR4.1. Socially marketed products are continuously available at convenient and accessible locations PMP IR4.1.2 Number of socially marketed products distributed IMPACT OC Community 484,152 1,724,880 28%: good distribution rate 35%: high rate due to the increase of 6340 regular users in Mahefa-Miaraka regions and Injectable (Depo-Provera/TRICLOFEM) 513,453 1,473,355 complementarity in the use of Community injectable because of the decrease of the number of available Sayana Press 34%: high rate because of FP strong commercial trend. Protector Plus is the only FP Condom Protector Plus (Community) 557,904 1,633,794 Number condom which can cover the commercial market in the 13 regions of USAID and PARN 0%: product not yet available FP Youth Condom Yes (Commercial) N/A 671,689 for Quarter 1 1%: This is the remaining Sayana Press 6,601 474,355 available product that was distributed in Quarter 1 36%: high distribution rate ORS/Zinc DTK (Community) 21,008 58,906 because of the rainy season 0%: product not yet available MCH Sur Eau 150 ml Commercial N/A 904,910 for Quarter 1 19%: less procurement from Sur Eau Pilina (67mg tablet) (Community) 703,300 3,620,780 CHV in Quarter 1

43%: high distribution rate. PARC and PA restocked the Arofoitra (CHX 7,1%) (Community) 12,946 30,378 products after months of stock out due to procurement and delivery delay 22%: distribution rate 3% lower than the normal. The Pneumox (amoxycilline) (Community) 48,182 219,635 distribution stabilized after a huge restock in Quarter4 of Year 1. 4%: distribution in Sofia region only, the target took into Pregnancy Test (Community) 4,325 100,000 account the scale up in other regions IR5: Increased demand for and use of health products among the Malagasy people/Output/Activity PMP - 1700 (11%) radio spots were IR.5.4 Number of mass media spots aired IMPACT broadcasted to promote Arofoitra in the 10 USAID

MALARIA 0 supported regions. 10,000 - No mass media broadcasted in Quarter 1 for malaria since the cCD is planned in Quarter 2 FP 0 10,000 which is the main focus for the first two Quarters Number - FP broadcasting is planned in Health area Quarter 2 - NB : 1,826 ads using radio channel were broadcasted to MCH 1,700 15,000 sensitize the drug shops in order to attend the meeting organized by DPLMT in Novembre 2019 (this number is not counted in this indicator).

ANNEX B – Year 1 Workplan Update

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub

Intermediate Result 1 Enhanced coordination among public, non-profit, and commercial sectors for supply and distribution of health products

1.1 The total market for health products in Madagascar is understood and documented Support the implementation, 50% completed, monitor and evaluate Operational plans the overarching TMA completed, roadmap for all health Next step : IR1.1.1 products based on the X X X X X X X X X X X X Ongoing implementation of discussions and activities within decisions taken during operational plans the TMA Technical

Working Group (TWG) meetings in Year 1 Support the development and implementation of the 50% completed malaria TMA roadmap Malaria market IR1.1.2 and monitor and X X X X X X X X X X X X Ongoing assessment conducted evaluate its progress to Next step: dissemination ensure the availability of of the findings and quality malaria products development of malaria at all levels TMA roadmap

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub Support the 20% completed development and the Tools for analysis being implementation of the developed FP and MNCH TMA Next step: conduction of roadmap to ensure the the market assessment IR1.1.3 X X X X X X X X X X X X Ongoing availability of quality FP and MNCH products at all levels and monitor and evaluate its execution With the MOPH , build 50% completed the capacity of TMA Three new Champions Champions to trained in TMA and successfully steward and three Champions lead the TMA TWG and trained in leadership subcommittees Next step: identification IR1.1.4 X X X X X Ongoing (including the study tour of new Champions to a country that has Continue to train successfully remaining Champions in implemented the TMA) leadership Conduction Exchange trip

100

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub Through the IMPACT Knowledge Management platform and dissemination 50% completed meetings, ensure that TMA roadmap IR1.1.5 X X X X Ongoing TMA results from document commented roadmap analyses, and validated by USAID studies and market Next step: official assessments are known dissemination by the to all key stakeholders Ministry of health 1.2 GOM leads TMI stakeholders to coordinate health product quantification and forecasting, procurement, and distribution according to market assessments and segmentation Organize meetings to The DPLMT worked on revise and validate the identifying members of Terms of Reference the UTGL. A letter was (ToR) of the UTGL to sent to various ensure its updated organizations to IR1.2.1 X X X X Ongoing tasks and nominate members. responsibilities. New members will be officially appointed by the General Secretary during Quarter 2. Organize quarterly IMPACT collaborated meetings (UTGL, CGL, with PSI and UCP / and GAS committee) to global Fund and NMCP Continuous IR1.2.2 analyze routine data on X X X X to support UTGL in activity key indicators in public organizing a two-days’ hospitals, such as stock- workshop (4 and 5 out, LMIS issues, etc. for November) meeting to

101

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub learning and adapting review roles and the use of DHIS2 in responsibilities of collaboration with the different actors in MERL team. supply chain and data at all levels (from central to community levels). As a next step, the results will be presented to RBM and UTGL for validation. Intermediate Result 2 Strengthened capacity of the GOM to sustainably provide quality health products to the Malagasy people

IR 2.1 Health commodities and pharmaceuticals are continuously accessible and available in the public sector Provide capacity 26 Participants building through identified, agenda trainings and consistent developed, STTA coaching to GOM and mobilized. Refresher partner members of Training session UTGL on forecasting and scheduled from Dec 9- supply planning, 13 on quantification IR2.1.1 including the use of X X X X X X X Ongoing tools (Quantimed and Quantimed and Pipeline Pipeline) for 8 (NMCP, DSFa, DPLMT, representatives of SALAMA) public sector, 16 representatives of PTF, and 2 staff of USAID Madagascar. Private sector have been added

102

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub Assist the GOM and Submitted a UTGL members in quantification of MCH to leading the annual USAID as well was system wide forecasting Supply plan for Family exercises for the public Planning. Waiting and private sector for approval of USAID FP/RH, MNCH, and The supply plan of malaria commodities malaria will be and support UTGL and submitted to CGL during SALAMA to help month of January for mobilize resources to official validation IR2.1.2 X X X X X X Ongoing procure commodities in the supply plans Quantification sessions for 2021 are planned in April- May 2020.

For Malaria, the quantification needs to be completed by the end of March as the MOP21 submission is scheduled in mid-April Coordinate orders , deliveries generation All orders for malaria and pipeline monitoring and FP commodities Continuous IR2.1.3 according to agreed X X X X X X X X X X X X have been placed in activity upon supply plan with ARTMIS (SP, ACTs, RDTs, SALAMA, PSM, GOM Artesunate injectable institutions and USAID and gloves, LLIN).

103

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub Placed an order for Microgynon (Pipeline for last FY) in ARTMIS

Provide technical assistance to support the central level GAS Committees to develop The malaria committee quarterly distribution GAS has developed all Continuous IR2.1.4 plans for malaria, X X X X X X X X X X X X the distribution plans to activity MNCH, and FP/RH SALAMA, UCP and products based on IMPACT to close 2019. quarterly stock status obtained from district/GAS committees Conduct TOT and The training curriculum cascade trainings for for Pha-Ge-Com and supply chain CHV is validated by the management at all Ministry of Health levels of the supply (Service de Formation chain, in collaboration Professionnelle) this Continuous IR2.1.5 with the UCP/Global X X X X X X X week. activity Fund, ACCESS, Mahefa Pretest of the Miaraka and other curriculum was partners completed in December in Analanjirofo. Training of CSB staff will be completed in February

104

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub Assist the MOPH in The LMIS evaluation creating a five-year LMIS draft report is being strengthening roadmap reviewed to integrate and developing and internal comments Continuous IR2.1.6 testing a new LMIS X X X X X X X X X X X X (COP, MERL, MSH). The activity software using results workshop to develop a from the LMIS in-depth roadmap is scheduled in evaluation February with the STTA/Ed Vreeke Generate evidence through a national supply chain assessment and End User Verification surveys 3 surveys are planned in IR2.1.7 to develop adequate X X X X X X X X X Ongoing FY 2: EUV survey in strategies, policies, and December 2019, NSCA SOPs for securing in March 2020 and a commodities and second EUV in June strengthening the public 2020. The first EUV is supply chain Ongoing Conduct continuous Coordination, Logistics, distribution of LLINs in training and 12 targeted districts. communications IR2.1.8 X X X X X X X X X X X X Ongoing activities ongoing, launch scheduled on February

105

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub Provide technical and financial support to the NMCP to develop and Review of quantification IR2.1.9 implement activities for X X X X X X X X X Ongoing for LLIN distribution in the preparation of 2021 2021 completed during LLIN campaign including the week of 09 the procurement of LLIN December 2019 IR 2.2 The public-sector supply chain achieves financial sustainability Conduct a total cost Conducted a two days’ analysis of the public workshop (Oct 29- 30) supply chain and to evaluate the PAIS propose an alternative (2008 and 2012) in and more efficient order to develop the supply chain model by next document for 2020 establishing at least two to 2024. scenarios with the . Recruited STTA to MOPH to improve support the costing IR2.2.1 SALAMA's financial X X X X X X Ongoing exercise of supply chain. sustainability TCA is part of the ongoing process to develop a new PAIS (Plan action pour integration des Intrants de santé). In January, present the TCA concept and methodology to DPLMT and DSSB

106

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub Strengthen management of FANOME at Pha-G-Dis Not yet IR2.2.2 X X X X X X Scheduled in Quarter 3 and Pha-Ge-Com levels started to increase transparency and good governance. Intermediate Result 3 Expanded engagement of the commercial health sector to serve new health product markets, according to health needs and consumer demand

IR 3.1 Commercial actors are incentivized to expand into new health product markets Review the scope of the private sector humanitarian platform to engage businesses in health product markets Create partnerships with PSHP and non-PSHP members to collaborate Meeting with Somaphar in generating innovative Continuous IR3.1.1 X X X X X X X X X X X on transportation of solutions on activity commodities transportation, data collection, and health- focused CSR and CSV. Organize quarterly meetings to monitor This activity is to be IR3.1.2 and assess the progress X X X Ongoing initiated in Quarter 2 of health commission action plan.

107

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub Conduct mapping exercise to present IMPACT and LMIS data Identification of Outlets Continuous IR3.1.3 submission among X X X X X X X X X X X conducted in activity representative sample Atsinanana, Boeny and of pharmacies and drug Diana regions. Menabe shops region for Quarter 2 Ensure that the Health Commission members of the PSHP participate in Health Commission the TWG and follow up members of the PSHP on the roadmap as a Continuous IR3.1.4 X X X X X X X X X X X actively participated in way to engage the activity all meetings organized commercial sector to by the TMA TWG identify barriers in the health sector and provide solutions Revitalize regional drug Contributed to shop associations in preparations of the preparation of the sensitization and ADDO pilot phase to be training of depots in conducted in Year 3 Atsinanana (from Nov IR3.1.5 X X X X Ongoing 13- 14). a Developed a presentation to use to sensitize depots to regroup in Regional association

108

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub Develop curriculum for training of peer trainers with simplified materials IR3.1.5 and tools, to be used in Not yet Activity to be started in X X X b piloting a sustainable started June mechanism for business strengthening program of drug shops Increase access to finance for private health commodities supply chain stakeholders Strengthening partner banks and other financial institutions' IR3.1.6 capacity to better serve X X X X X X X X X X X X Ongoing private health commodities supply chain. Revise capacity building Not yet plans and training started curricula for DCA partner banks to IR3.1.6 IR3.1.6.1 x incorporate GESI issues and, as needed, to take into account newly identified needs.

109

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub IR3.1.6 IR3.1.6.2 Train and support DCA Ongoing - 40% Year target partner banks in credit - 49 staff from the two analysis and loan partner banks trained structuring for health from Atsinanana commodities branches: 25F and 24M businesses. on Nov 12, 2019. List of drug shops X X X X X X X X X X X X trained shared with partner banks for prospection. Training session for the new responsible of CMS inside ABM planned in January 2020. Develop and adapt loan Ongoing 32% Year target products and financial - One loan product tools for small and micro “Pharmaloan” to finance health enterprises in health commodities health commodities purchase developed sector (e.g., scoring, with ABM before nano loans, pharma presenting it to IR3.1.6 IR3.1.6.3 X X X X X X X X X X X X loans, motorbike loans). wholesalers. Mini- *** survey to be launched with ABM to get more details about drug shops habits. Elaboration of the questionnaire in progress.

110

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub - One loan product “PA/PARC- Motorbike Loan” in discussion with ABM following survey undertaken to PA/PARC. Elaboration of the questionnaire in progress. Pilot zones to be selected. - One Automatic withdrawal in designing phase with Baobab. Design and develop new Ongoing 10% Year target financial mechanism Initiated during Ignacio's (e.g. risk sharing facility), visit in Tana. following principles of Presentation to USAID USAID's Blended Finance scheduled for 19 Roadmap for Global December Health, possibly IR3.1.6 IR3.1.6.4 X X X X X X X X X X X X including additional financial institution partners, to facilitate A2F within the pharmaceutical supply chains and other stakeholders. Strengthen the business

management of

111

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub enterprises in health products supply chain Provide business strengthening capacity building to enterprises in health commodities IR3.1.7 X X X X X X X Ongoing supply chain and develop partnership with private companies to sustain the training. Develop and adapt 100% Year Target business-strengthening Training material and training curricula for curriculum used during drug shops. the training session in IR3.1.7 IR3.1.7.1 X Completed Toamasina on 13-14 November. A living document to be adapted to the drug shops level of education IR3.1.7 IR3.1.7.2 Provide initial business- 36% Year target in strengthening training number and 20% in nb to drug shops. of region - 27 (15M/12F) drug shops owners and X X X X X Ongoing dispensers from the region of Atsinanana trained on November 13-14 in Toamasina. Training combined with

112

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub a half day sensitization session conducted by DPLMT. other regions planned with DPLMT (Boeny in Feb, Diana March, Menabe April and Melaky May) Provide one-to-one - 30%-year target coaching on business -3 DM coached: 1 in strengthening to Tamatave 2, 1 in enterprises/individuals IR3.1.7 IR3.1.7.3 X X X X X Antsapanana and 1 in identified as potential Vatomandry. All are peer trainers in health identified as potential commodities supply peer trainers. chain. Identify potential partnerships with private training companies to expand Not yet IR3.1.7 IR3.1.7.4 and sustain options for X X X started business training to enterprises in the health commodities supply chain.

113

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub Explore digital inventory management 0% Year target applications for use by private health Not yet IR3.1.7 IR3.1.7.5 X X X X Depends on the SIGL commodities enterprises started evaluation activity and which would be incorporated into future business training. IR 3.2 GOM facilitates the work of the commercial sector Facilitate high-level advocacy meetings involving the MOPH, Ministry of Commerce, customs services, Ministry of Economy and Finance, the The List of Essential National Board of Medicines has been Physicians and the Continuous IR3.2.1 X X X X X X X X X X X X signed by the Minister National Board of activity of Health and being Pharmacists to develop disseminated policies and regulations that will favor importation and commercialization of a packet of vital Essential medicines, including contraceptives, anti-

114

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub malarial, and key MNCH products.

Support DAMM and STTA has been MOPH to put in place recruited and started strong regulatory working on the processes related to the literature review registration, completed last FY. Plan importation, and is to travel to distribution of Madagascar (January, Continuous IR3.2.2 medicines based on X X X X X X X X X X X X depending on DAMM activity reviews of the Common availability) to support Technical Document, DAMM on Common New Law on Regulatory Technical Document in Body in Africa, and relation of Registration, experience from other and support the countries through study GTT/AMT on analysis of tours. legal texts.

115

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub Support DAMM in 2 MOU should be streamlining the signed. registration and Currently, the MOU importation procedures between Ministry of for medicines based on Health and Partners the latest WHO around the H6+ group is recommendations. *** available and shared with the group for inputs. IMPACT met with UNICEF and UNFPA to get their inputs. Continuous IR3.2.3 X X X X X X X X X X X X IMPACT organized a activity meeting with SALAMA to discuss on next steps to harmonize prequalification procedures with DAMM ( review of MOU between SALAMA and DAMM, transfer/sharing of suppliers dossiers and sampling, quality control certificate) Support the MOPH and the professional associations to revitalize Not yet To be started in Quarter IR3.2.4 X X X X X X the inter-ministerial started 3 committee to fight counterfeit and illegal

116

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub medicines. A strategy will be defined through a mid-term evaluation of the Stratégie de Lutte Contre le Marché Illicite and the Contrefaçon des Medicaments et Intrants de Santé and an action plan will be developed. Intermediate Result 4 Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy people

IR 4.1 Socially marketed products are continuously available at convenient and accessible locations Distribution of socially marketed products across 10 regions for MNCH and FP/RH Continuous IR4.1.1 products and X X X X X X X X X X X X Routine activity activity distribution of only FP/RH products in three PARN Regions through PARCs and PAs. Establish a motivation system for PAs and Evaluation criteria of PA PARCs and follow up on Continuous and PARC established IR4.1.2 their quarterly X X X X X X X X X X X X activity Quarterly evaluation performance to address completed supply chain inefficiencies in social

117

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub marketing in order to prevent stockout.

Expand last-mile 25% of activity distribution and completed emergency distribution 18 flight with delivery through a pilot to successful with PA IR4.1.3 deliver health products X X X X X X X X X X X X Ongoing needs (Microgynon, using drones. Sur’Eau Pilina, Triclofem and syringes, Arofoitra, Sayana press). PA <25 km Transition the community distribution model from select PAs and PARCs to the Pha- IR4.1.4 X X X X X X Ongoing Ge-Com and Pha-G-Dis in coordination with DDS/DPLMT/DSFa/ACCE SS/Mahefa Miaraka. Select and introduce socially marketed products across 10 To be started in Quarter IR4.1.5 X X X X X X X X X IMPACT regions and 3 2 PARN regions through the private sector

118

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub (pharmaceutical and commercial channels) pending the results of the COGS analysis.

Define the needs for a product monitoring system and conduct a study of a product tracking system. Find technological solutions Continuous Identification of service IR4.1.6 X X X X X X X X X X X which allow IMPACT to activity providers ongoing earn and grow brand loyalty while protecting the brand from supply chain fraud, including counterfeiting and theft. IR 4.2 Socially marketed products achieve cost recovery at an affordable price for consumers

119

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub Leverage TMA findings from IR1 to analyze COGS and continue to propose options for the optimization of financial sustainability for the current socially marketed products Continuous IR4.2.1 X X X X X X X X X X X X Ongoing portfolio and explore activity brand extension of Yes With You condoms and introduce a new brand of pharmaceutical products depending the results of the COGS analysis. Continue to explore optimization of financial sustainability for the current socially Continuous IR4.2.1 IR4.2.1.1 X X X X X X X X X X X X Ongoing marketed products activity portfolio and explore brand extension of Yes With You condoms Explore introduction of new brand of Continuous IR4.2.1 IR4.2.1.2 X X X X X X X X X Ongoing Pharmaceutical activity products pending the

120

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub results of the COGS analysis

Intermediate Result 5 Increased demand for and use of health products among the Malagasy people/Output/Activity In collaboration with the demand creation Demand creation subcommittee of the Continuous subcommittee of the IR5.1.1 TMA TWG, develop and X X X X X X X X X X X activity TMA TWG set up; two implement activities to meetings held increase demand and use of health products Provide technical and Support to LLIN financial support to Continuous continuous distribution IR5.1.2 X X X X X X X X X X X X contribute to the activity activities of the MoPH Conduct communication campaigns for promoting health products of the three - Production of TV spot prioritized health areas on FP (validation (Malaria, FP and MNCH) Continuous ongoing within the IR5.1.3 X X X X X X X X X X X X through radio, TV spots, activity MoPH) job aids, and digital - Preparation of film on communication drones incorporating gender messaging to promote and use health

121

Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub commodities for population and providers Provide technical and financial support to the Ministry of Youth and Sport (MYS) to develop and implement Youth activities in collaboration with Continuous Signature of MOU IR5.1.4 X X X X X X X X X X X X Telma Foundation activity scheduled in Quarter 2 based on the Human Centered Design (HCD) study and support training for youth on health, leadership, communication, etc. Leverage new technology to drive Continuous 910 hotline to be IR5.1.5 demand for malaria, X X X X X X X X X X X X activity transferred to ACCESS FP/RH and MNCH health commodities. Develop a strategy for youth on the use of vouchers for youth Activity to be started in IR5.1.6 X X X X X X health coverage and May implementation of a voucher pilot.

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Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub

Cross Cutting Gender Target women and human rights associations to serve as Involvement of GESI CC1.1 strategic partners of X Ongoing Partners in TMA TWG IMPACT and to play an meetings active role in the Total Market Approach. Ensure the participation The two key GESI of key GESI partners in Partners (Conseil TMI TWG. National des Femmes de CC1.2 X Ongoing Madagascar and Groupement des Femmes Entrepreneurs de Madagascar) Produce and distribute Within the 16 days SBCC tools on GESI for Generation Equality different target groups. against Rape under the leadership of the Ministry of Population, IMPACT project CC1.3 X Ongoing contributes in the insert of articles in the Newspaper. On Saturday 7th and 14th, the articles were focused on Gender Based Violence. On

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Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub Saturday 21st article focused on women and Access to Finance and on Dec 28th Gender Equality and Social Inclusion can improve health. Integrate GESI-informed During the training of messaging into family journalists held on Dec planning & MNCH 13th, IMPACT has communication presented about the campaigns. 'Equality of access into health Commodities in Madagascar' with many examples of Family Planning and MNCH CC1.4 X Ongoing gender-based issues. In partnership with MinPop and the GESI TWG, IMPACT will integrate Gender messages in FP in April 2020 in alignment of the FP world day and in June for MNCH.

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Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub Raise awareness of On Dec 6th, IMPACT IMPACT stakeholders on attended the Gender GESI integration into a Conference organized TMA through meetings by the MinPop with and an annual stakeholders and workshop. partners involved in GESI, on Dec 13th IMPACT was among trainer on the topic 'Equality of access into health Commodities in Madagascar' during the training of journalists. This was a joint activity CC1.5 X Ongoing held by different partners involved in GESI (UNFPA, USAID funded programs) and the TMA approach was presented in front of all the journalists and the stakeholders including the MinPop. MPACT shared 150 brochures on GESI during the conference and the journalists training In partnership with MinPop and the GESI

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Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub TWG, IMPACT will integrate Gender messages in FP in April 2020 in alignment of the FP world day and in June for MNCH. Build the capacity of First short capacity IMPACT staff to serve as building session with GESI champions. *** IMPACT staff for this CC1.6 X X Ongoing Year 2 has been done during retreat October 24th at Ibis Hotel. Cross Cutting MERL Strengthen LMIS/HMIS ( all sectors: public, private, non-profit, and commercial) including: Formative supervisions formative supervision, for the Quarter capacity building of data Continuous CC2.1 X X X X X X X X X X completed senders, and supporting activity Technical test of call implementation of the center LMIS roadmap with consideration of DHIS2 as the main LMIS electronic tool.

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Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub Support the mapping exercise to identify and Continuous Exercise conducted in CC2.2 train pharmacies and X X X X X activity three regions drug shops for LMIS data. Support technically and RDQA Conducted in financially the DPLMT to regions: SOFIA, DIANA, conduct Routine Data Continuous Sava and Haute CC2.3 X X X X X X X X Quality Assessment activity Matsiatra covering 8 (RDQA) at all levels and Pha-G-Dis, 18 Pha-Ge- sectors. Com, 6 PARC and 9 PA Implementing monitoring and evaluation system on continuous distribution, Distribution of including: creating M&E management tools Continuous CC2.4 tools, training, data X X X X X X X X X X completed in six regions activity collection and Training of trainers supervision, RDQA completed (budget included in the continuous distribution activities) Conduct market assessment studies for FP and MNCH, including CC2.5 X X X X Ongoing Framework Ongoing key informant interviews, outlet surveys, and routine

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Timeline YEAR 2 Status Comments Quarter 1 Quarter 2 Quarter 3 Quarter 4 Description of the

Activity Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep activity Code activity

- 19 19 19 20 20 20 20 20 20 20 20 20

Activity Code Activity Sub data in collaboration with IR1.

Implement additional studies, including: archetype study/segmentation, journey mapping, assessment of pharmacies and drug Elaboration of study CC2.6 shops on products X X X X X X X X Ongoing protocols in Quarter 2 supply, KAP study on IPTp use, and an evaluation on the introduction of the last mile distribution strategy (drones) at the community level. Knowledge Management: Support partners in developing Continuous CC2.7 and collecting success X X X X X X X X X X X activity stories and documenting Field visits conducted IMPACT's innovations in and success stories the field. drafted for Quarter 1

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ANNEX C - Environmental Mitigation and Monitoring Report

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Environment monitoring and mitigation report (EMMR)

Table : Summary number of the outlets visited Number Total per Number of field Type of outlet visited outlet team Public sector SALAMA/central warehousing 0 6 Pha-G-Dis 39 78 10 RLA CSB/Pha-Ge-Com 85 1,734 Nonprofit sector (social marketing) Warehouse 6 14 PARC 60 66 27 SPD Supply point 779 859

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ACTIVITY MITIGATION MEASURES Summary Field Outstanding Issues, proposed resolutions

1. Capacity building through technical workshops and training to enhance coordination and distribution of quality health products.

1. Technical assistance, 1.1.2. Provide supervision of CSB Infrastructure and non-medical equipment for Outstanding Issues: trainings, workshops, and providers by using Rapid Monitoring infection prevention should include: Absence of non-medical tools developed must include Tool to assess infrastructure and device and equipment can be appropriate management equipment for handwashing, infection - handwashing device with a bucket to catch due to the lack of financial practices for facilities of prevention (decontamination and water resources, limited water health commodities and containers for infectious waste), waste - soap for washing hands access or organization issue. integrate sound procedures to cans, safety boxes, etc. - tissues for cleaning manage and properly dispose Resolutions: - chlorinated water of health care waste (including IMPACT will conduct deeper expired health Product). investigation to identify 52 CSB were equipped with non-medical challenges for CSBs to install equipment for infection prevention handwashing device and [85 CSB /Pha-Ge-Com visited] procure non-medical equipment and consumables. 61% (52/85) of CSBs visited in Quarter 1 had infrastructure for handwashing with non-medical equipment for infection prevention.

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1.1.3. Provide CSB providers with: Medical equipment for infection prevention should Outstanding Issues: garbage cans & gloves for ordinary include: Pha-Ge-Com do not waste; sharps containers and gloves; systematically order gloves handwashing device with a bucket to - Safety boxes from SDSP. catch handwashing water - Sharps containers - Gloves Resolutions: - Garbage disposal IMPACT will remind CSBs to include gloves and safety boxes in their cyclic orders to 76 CSB equipped with medical equipment for Pha-G-DIS infection prevention ACCESS will be invited to [85 CSB /Pha-Ge-Com visited] remind CSB staff to use glove while administering injection 89% (76/85) of CSB visited in Quarter 1 had medical and eliminate infectious equipment for infection prevention (safety box, waste. sharp container, gloves, garbage for disposal).

3. Storage, management, distribution, tranportation and disposal of public health commodities and equipments 3. Storage, Management, 3.1.1. Include in training curriculum how Nonprofit sector Nonprofit Sector Distribution & Disposal of to properly manage expired (properly Type Male Female Total Outstanding Issues: Public Health Commodities & logged), obsolete or surplus Warehouse 4 2 6 Equipment commodities for PSI central warehouse, PARC 15 45 60 - PA and PARCs received PARC, PA and public sector PA 352 426 778 training except 1 PA (SALAMA/central warehousing, Pha-G- Dis, Pha-Ge-Com and CSB). A disposal [6 Warehouses visited] Resolutions: plan will be created and will be available [60 PARC visited] In Quarter 2: for the trainees following the national [779 PA visited] - Continuing training of field guidelines. Curriculum will be adapted staff including: 6 regional to different literacy or education levels - Six (6) PSI warehouse staffs were trained on coordinators, 7 warehouse to ensure effective understanding expired and surplus products management during regional assistant, 2 stock Quarter 1 Year 2. keeper, and 4 central staff.

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- Providing appropriate training to PA

Public sector (Training on expired and surplus Public sector commodities) Outstanding Issues: Type Male Female Total Last training has been held in SALAMA 0 0 0 2018. Some Pha-Ge-Com Pha-G-Dis 14 20 34 providers were hired recently CSB/Pha- and no training session was 9 13 22 Ge-Com planned after their recruitment. [0 SALAMA visited] [39 Pha-G-Dis visited] Resolution: [85 CSB /Pha-Ge-Com visited] EMAD with RLA will provide on-site training during 87% (34/39) of Pha-G-Dis and 26% (22/85) of Pha- supervision. Ge-Com providers visited in Q1 have been trained on management of expired and surplus commodities 3.1.2. Regularly check expiry date of Nonprofit Sector Nonprofit Sector commodities during monthly visit of PSI Products Expired Surplus Obsolete Outstanding Issues: central warehouse, PARC, PA, and public Warehouse 0 0 0 Surplus and obsolete stocks sector (SALAMA/central warehousing, PARC 0 1,787 0 were identified for PARC and Pha-G-Dis, Pha-Ge-Com and CSB). PA 0 3,335 835 PA supervised.

[6 Warehouses visited] “If there are expired products in the [60 PARC visited] Resolutions: warehouse, the supervisor will take [779 PA visited] Identified surplus or obsolete appropriate action to rectify the products need to be practice" - No expired products were recorded at visited redeployed at districts (PARC) facilities or Community (PA) level

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Public Sector Public sector Products Expired Surplus Obsolete Outstanding Issues: SALAMA 0 0 0 - Management of expiration Pha-G-Dis 32,466 0 0 date is not currently done CSB/Pha- during stock analysis at 737 1,256 74 Ge-Com District level. - SDSP took too much time to [0 SALAMA visited] decide on transfering surplus [39 Pha-G-Dis visited] commodities with near expiry [85 CSB /Pha-Ge-Com visited] date. - Pha-G-Dis providers work Expired commodities were detected in Pha-G-Dis under SDSP staffs control. supervised in Quarter 1 despite of redeployment However, some of SDSP staffs activities conducted by District Staff under RLA are not trained in Stock coordination. management and purchase management.

Resolutions: - Workshop will be held in January to strengthen 13 RLAs in management of expiry date to avoid surplus and expiration of commodities. They will support District GAS committee to consider and manage expiry date of each commodities during stock analysis. - RLA will check and remind District staff to include expiry

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date in each monthly stock report. That data can be used for double monitoring at District level as well as at Central level. - IMPACT will advise and support SDSP to transfer surplus commodities between Pha-G-Dis or between CSBs until commodities are stocked according to plan.

3.1.3. Provide guidelines and Nonprofit Sector Nonprofit Sector appropriate communication tools on Warehouse 6 Outstanding Issues: storage conditions for each product by PARC 55 Six PARC and 27 PA do not following standard guidelines for proper PA 752 have communication tools and storage and distribution of health guideline on storage condition commodities for PSI central warehouse, [6 Warehouses visited] and on transportation of PARC, PA and public sector [60 PARC visited] commodities (SALAMA/central warehousing, Pha-G- [779 PA visited] Dis, Pha-Ge-Com and CSB) Resolutions: - All visited warehouses had appropriate guidelines In Quarter 2, the objective is to on storage condition during visit provide communication tools - 55 out of 60 PARC (91%) and 752 out of 779 (97%) and guideline on storage of PA had the appropriate guidelines condition and on transportation of commodities to non-compliant PARC (6) and PA (27).

Public Sector Public sector SALAMA 0 Outstanding Issues:

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Pha-G-Dis 13 Previous communication tools CSB/Pha-Ge-Com 17 were spoiled.

Resolutions: [0 SALAMA visited] During supervision, [39 Pha-G-Dis visited] communication tools for [85 CSB /Pha-Ge-Com visited] storage conditions will be

approved and printed at 33% (13/39) of Pha-G-Dis and 20% (17/85) of Pha- central level. RLA will start by Ge-Com visited in Quarter 1 had communication printing and posting them tools in their storage rooms. during supervision from Quarter 2 visit. 5. Climate Risk Management 5.1. Proper storage and 5.1.1.2. Organizing capacity building Nonprofit sector Nonprofit sector transportation of commodities through technical workshops and Male Female Total Outstanding Issues and LLIN training to enhance coordination and Warehouse 3 2 5 None distribution of quality health products: PARC 13 47 60 among PSI central warehouse, PARC, PA PA 352 426 778 Resolutions: and public sector (SALAMA/central In Quarter 2 the objective is: warehousing, Pha-G-Dis, Pha-Ge-Com [6 Warehouses visited] - to train all field staff and CSB), and those responsible for [60 PARC visited] including: 6 regional sending commodities and LLINs. [779 PA visited] coordinators, 7 warehouse regional assistants, 2 stock - Five (5) PSI warehouse staffs were trained on keepers, and 4 central staff. coordination and distribution of quality health This training curriculum will be products. included in one central - All visited PARCs and 778 out of 779 PA received an meeting of warehouses team appropriate training combined with central warehouse visit - to include training during supervision of non-trained PA

Public sector Public sector

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Male Female Total Outstanding Issues: SALAMA 0 0 0 Last training has been held in Pha-G-Dis 11 19 30 2018. Pha-Ge-Com providers CSB/Pha- and CSB providers were hired 10 14 24 Ge-Com recently and were not trained in commodity distribution and [0 SALAMA visited] commodity management. [39 Pha-G-Dis visited] SDSP staffs have not sufficient [85 CSB /Pha-Ge-Com visited] ability to analyse and coordinate distribution. 77% (30/39) of Pha-G-Dis providers and 24% (25/85) of Pha-Ge-Com providers supervised in Quarter 1 Resolutions: were trained on distribution management. - Workshops will be held in IMPACT has organized workshop to train 15 staffs Analanjirofo to train 162 staffs from CSB in Quarter 1. from 54 CSB in coordination and distribution of commodities - EMAD with LRA support will include on-site training during supervision of non-trained CSB and Pha-G-Dis. - District GAS committee will be trained in Stock analysis and in coordination of commodities distribution from Q3. IMPACT and UCP will plan a TOT in march to prepare these trainings at District level.

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ANNEX D - SUCCESS STORIES

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Development of a Total Market Approach Roadmap to Improve Availability of life-saving supplies for the Malagasy population The Malagasy health sector contains a wide array of products with varying price ranges and outlets where they are offered. The public sector, private sector, and NGOs all provide products with specific price points for the Malagasy population. However, despite the variety available in the provision of health commodities, the health market is still hindered by recurrent shortages, frequent failures to meet quality requirements for health commodities, and a chronic lack of coordination in the health sector. To address these issues, the IMPACT program is working to bring all of the actors in the health sector together in order to improve the availability and accessibility of quality health products for the Malagasy population in the next four years. Throughout Year 1 of the IMPACT program, three workshops were organized to bring together the different health actors in Madagascar, including the public sector, the private sector, non-governmental Participants during the second workshop working on the Total Market Approach Roadmap organizations, associations, and technical and financial partners. During the first workshop on July 16th, 2019, participants included representatives from donors (USAID, UNFPA, EU), executives from the private sector, representatives from health-related NGOs, and representatives from learning societies and associations, under the leadership of the Government of Madagascar through the Secretary General of Ministry of Public Health. Together, they formed the Total Market Approach Technical Working Group (TMA TWG) which has around 100 members, stewarded by three TMA Champions who are high-level individuals from the Ministry of Health. The workshop had the objective of bringing together a variety of actors from different sectors so that they can identify and agree on the three main issues encountered in the health sector. After conducting an analysis in groups, the TMA TWG selected the following as the main 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. During the second workshop, representatives from the TMA TWG proposed solutions to address the three issues identified by breaking up into three different groups related to each issue. The TMA TWG came up with a draft solution, which was then detailed into specific action items. Together, the solutions found for each issue, and the specific action item for each solution will be developed further to form the roadmap and the operational plan. These workshops, as well as the establishment of the TMA TWG are considered unique and valuable opportunities in a country where each sector has always worked separately to address the same market. The roadmap and its action plan are stronger since they have taken into consideration the expectations of each sector. The process has been greatly beneficial since it has encouraged the involvement and engagement of the members of the TWG and they have been consistently present and have actively taken part throughout the process, especially executives and decision-makers from the private sector. Moreover, the members from the private sector have volunteered to co-lead each activity with the Champions from the public sector.

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“The TMA has helped me improve my contextual “Being TMA Champions gave me more analysis capabilities and my strategic skills in the opening to other healthcare professionals, field of health.” Said the DGMP more sharing.” Said the DGFS

«TMA is an essential approach and it was high time we initiated it in Madagascar. The gathering of all the actors in the field of health commodities regarding this mechanism will certainly be very beneficial for the Malagasy population.» Said the AMM Director

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Public and private sector work together to support health commodities supply chain in Madagascar

Drug shops are a crucial part of the health commodities supply chain in Madagascar. Well-functioning drug shops can help ensure reliable availability of pharmaceuticals, especially in rural and remote areas. To provide needed support to drug shops, this year IMPACT and the Ministry of Public Health (MOPH) have launched a public-private program in five regions (Antsinanana, Boeny, Diana, Melaky, and Menabe). The program aims to improve drug shops’ understanding of legal and regulatory requirements for their activities and to strengthen their business management capacity.

The first drug shop program was held in Toamasina Opening remarks during the information session: (left to right) Dr Raymond RAKOTOARIMANANA (DRSP), Dr Nicole on November 13 and 14, 2019, and was considered a MAHAVANY (DPLMT), Herinjaka Rahamalivony (IMPACT) great success by everyone involved. The program started with a half-day information session conducted by the MOPH’s Direction de la Pharmacie, des Laboratoires et de la Médecine Traditionnelle (DPLMT), followed by an optional one-and-a-half-day business training by the IMPACT Access to Finance (A2F) team. All drug shops in the Antsinanana region were invited to attend DPLMT’s information session, but participation in the business training was voluntary, based on self-selection. In order to encourage self-reliance and program sustainability, IMPACT is not paying per diems or transportation costs to drug shops attending the business training.

The DPLMT information session was designed around the following objectives: - to raise the awareness of drug shop owners on laws and regulations pertaining to their profession; - to update the database of drug shops in the region; - to renew licenses for drug shops that have been operating for over ten years; - to encourage drug shop representatives to create a regional association to liaise with DPLMT; and - to allow drug shops to meet and interact directly with MOPH central staff.

The IMPACT A2F team created a simplified curriculum for the 1.5-day business and financial management training, considering the educational level of drug shops managers (IMPACT surveys found that 58% have less than a high school diploma). The business training curriculum includes four modules: (i) Business financial and operational diagnostic, (ii) Regulatory compliance and drug usage, (iii) Inventory management, and (iv) Financial book-keeping.

Public Sector Engagement - Information Session The IMPACT team worked closely with DPLMT central and regional staff to prepare and organize the half-day session. It was attended by representatives from 43 drug shops (21 women, 22 men) out of 71 existing in the five districts of the Antsinanana region (61% participation rate).

Private Sector Engagement – Business Training

IMPACT also collaborated with a range of different stakeholders from the private health commodities sector for the drug shop program.

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Engagement of drug shops: A total of 27 representatives (12 female and 15 male) from drug shops in all the districts in the Antsinanana region attended the training. The training’s objective was to strengthen the business capacity of drug shop owners and managers, providing practical exercises and simple management tools in stock management and book-keeping. The DPLMT also contributed to the training by providing guidance and advice to participants during the sessions.

Patrick JEREMY, a drug shop owner from Antsampanana, said, “This was the first time I learned about the proper, safe procedures for disposing of expired drugs! Previously, I just threw them in the garbage.”

Engagement of Pharmaceutical Wholesalers: IMPACT negotiated with COFARMA, a pharmaceutical wholesaler and a member of the Plateforme Humanitaire du Secteur Privé (PHSP), to co-finance half of the cost of the business training for the drug shops (venue rental, lunch and refreshments for participants). This demonstrates COFARMA’s commitment to serving rural communities and gives the company the opportunity to reach out to new clients and markets. The CEO said that COFARMA is committed to partnering with IMPACT and the MOPH to support the drug shop Patrick JEREMY, the owner of a drug shop in program in other regions. Antsampanana Engagement of USAID partner banks: The two partner banks, AccèsBanque Madagascar and Baobab Banque Madagascar, each had 30 minutes to present their financial services and products to the drug shops during the training session. This was to let drug shops know that they are eligible to apply for loans from these two banks. This financing could support the growth of drug shops and help them expand the availability of quality health commodities in their communities. Both banks appreciated these sessions as an opportunity to develop a new customer base in more remote areas

At the end of the information session and the business training, the participants expressed their thanks to IMPACT. Lanto from Mahanoro said, “I really appreciated and valued this comprehensive two-day program. We had chance to interact with the ministry representatives and got updated information on our profession. IMPACT gave us the opportunity to meet with wholesalers and banks but also provided us the tools to manage our business.” With the combined strength of public and private sector support, IMPACT and the DPLMT can help drug shops work better and improve the health commodities supply chain throughout Madagascar.

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Accurate commodity forecasting helps Brickaville to be prepared for a malaria outbreak

Late in the afternoon, Isaac is still in his office focused on his computer. He is uploading the monthly product consumption and orders data into the software Channel to send to the central Ministry of Health. Every month, this activity is one of his priorities. “Sending our logistic data on time means that we will Razafitrimo Isaac, District stock manager of Brickaville receive our commodities on time so that health showing proudly the calculation formula to estimate commodity needs, displayed in the pharmacy wall facilities needs are met,” he says. Photo: IMPACT In the district pharmacy of Brickaville, Isaac has served as stock manager for five years. As Madagascar enters the high peak transmission period, the district is getting prepared to face an outbreak of malaria. “It is very important to have enough stock of malaria products to avoid any product shortages. In the district of Brickaville malaria is still a public health issue, especially after the passage of cyclones, which cause flooding and allow for the reproduction of mosquitos. Last year, malaria claimed the lives of four children in the district of Brickaville. Isaac and his colleagues are striving to avoid any fatalities this year. In April 2019, Isaac received on-the-job training provided by IMPACT on how to correctly estimate commodity needs, especially for malaria commodities since the consumption needs evolve according to the season. “Before this training, our calculations were based on consumption data sent by health facilities and we frequently experienced stockouts. After the training, we learned that we need to consider the consumption data during malaria high transmission periods to have the right quantity to order. Accurate quantification of needs is very important to avoid overstock or stock outs.” Isaac is confident that malaria will be controlled in the district this year. From October to December 2019, the district of Brickaville has not experienced any stockout of malaria commodities and after calculation of their accurate needs for the period, they could even redeploy malaria commodities to the neighboring districts. The district pharmacy of Brickaville is reporting complete and on-time data (100%) and the district is among the most high-performing in terms of data reporting.

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Availability of birth control products helps meet the needs of women in rural communities of Brickaville

Harimalala Sandrine lives in the village of Ambodivonta, a rural community about 10 kilometers from Vatomandry. She is 20 years old and a mother of a 10-month-old baby girl. With her husband, Sandrine is running a commerce of local products.

Today, Sandrine woke up early to get her DepoProvera Harimalala Sandrine, beneficiary of family planning in shot at BAO Euphrasie’s house, who is a Community the village of Ambodivonta, Vatomandry Health Volunteer (CHV) in the village. “My husband and I Photo: IMPACT wanted to space the birth of our children; I chose

DepoProvera because it prevents me from the hassle of using a daily birth control method like the pill.” Just after giving birth to her baby, Sandrine started the contraceptive by injection. “DepoProvera is highly effective and accessible. We are very lucky to have it available at community health volunteers, so we do not need to walk long distances to health facilities in town,” she says. IMPACT, through the distribution of social marketing products, ensures the continuous supply of a large range of Family Planning products at the community level so that CHVs like BAO Euphrasie are able to meet the needs of BAO Euphrasie, CHV preparing DepoProvera women in their communities. injection “Thanks to Photo: IMPACT the continuous availability of family planning products at the supply points, we have rarely experienced shortages. As a result, I was always able to serve women coming for contraception,” said BAO Euphrasie. “Accessing birth control allows me to expand our livelihood and make savings. Moreover, I can devote time to my daughter and appreciate every step of her childhood,” says Sandrine.

Sandrine with her family Photo: IMPACT

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Using Sur’Eau Pilina save lives in remote communities of Brickaville Philomène is living in the village of Ambohimanarivo, a village of about 548 households. The mother of four children, she has served as a Community Health Volunteer (CHV) for more than ten years. Philomène’s role as a CHV consists of sensitizing and mobilizing people in all health- related initiatives and providing the first level of care to people in her remote village far from health facilities. One afternoon, Philomène and other villagers are assisting Soazara Philomène, Community Health Volunteer, in the monthly public sensitization conducted by the Ambohimanarivo, Brickaville IMPACT team in her village. As the mobile sound system Photo: IMPACT begins to play, people come out slowly from their houses and gather in the large yard of the village to listen to what is being said. That day, the IMPACT communication team came to sensitize the village on the use of the water treatment pill “Sur’Eau Pilina” and organize a flash sale of the product. “In our village, unsafe drinking water is one of the leading causes of disease,” says Philomène. “In the village, there is no drinking water, so women and children travel long distances to fetch water from the river. After fever, diarrhea is the second reason for consultation and it can cause death, especially for children under five,” she says. As a CHV, Philomène encourages people to use Sur’Eau to avoid the use of contaminated water. “Sur’Eau Pilina is a fast and cost-effective method of treating household drinking water. Thanks to this product, people have access to drinking water even in areas with no running water infrastructure like in our village,” she adds. Cases of diarrhea decreased considerably in the village as the sale of Sur’Eau increased. “Access to safe drinking water reduced diarrhea especially for children under five. Before, I received about eight patients a day due to diarrhea. Now, only one or two cases are IMPACT communication team doing a sensitization on the use of Sur'Eau Pilina in the village of Ambohimanarivo recorded,” says Philomène. Photo: IMPACT IMPACT, through its social marketing products, make sure that CHVs like Philomène are continuously supplied with essential life-saving products like Sur’Eau.

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Strengthening organizational capacity of Pha-G-Dis in MENABE, ATSIMO ANDREFANA, and BOENY Regions The organization of Pha-G-Dis (pharmacie de gros du district) is critical for ensuring efficient and effective supply chain management--pharmacy store rooms must be well organized so that commodities can be well tracked, inventoried, allocated, and distributed correctly to health facilities within the district, and so that expiration dates can be monitored. An overcrowded and disorganized pharmacy makes it difficult for pharmacy managers to know when certain commodities are out of stock, overstocked, or expired. For example, the Manja district pharmacy (Pha-G-Dis) in Menabe was built according to standards with two storerooms. Due to the remoteness of this district, SALAMA makes deliveries to this pharmacy only twice a year--as opposed to four times a year, as is the case in most other districts--which means that these deliveries are twice as large as normal, and therefore require significant storage space. However, during the renovation of the Manja district referral hospital (CHRD) in 2009, one of the storage rooms in the pharmacy was used to store CHRD supplies and commodities. Reducing the Pha-G-Dis storage space from two rooms to one led to overcrowding and disorganization of products. This temporary situation was only supposed to last the length of the renovation, but has been continuing for ten years. As a result, IMPACT took the lead and organized a supply and stock management (GAS) committee meeting to identify and discuss solutions to the situation. Consequently, the team identified storage space in the CHRD and facilitated the transfer of products from the Pha-G-Dis to the CHRD, creating necessary additional storage space in the Pha-G-Dis. The Manja Pha-G-Dis now has enough room to receive, store, and organize large quantities of commodities delivered twice a year by SALAMA.

Right: Manja Pha-G-Dis before reorganization; left: Manja Pha-G-Dis after the reorganization In Atsimo Andrefana, similar problems were identified surrounding inadequate storage standards, inefficient file management, and unavailability of commodities. IMPACT worked with MOPH regional and district teams to discuss solutions to these issues surrounding access to essential medicines, particularly focusing on the Pha-G-Dis in Toliara, Ankazoabo, Beroroha, Maniry, and Morombe. Teams worked to clean and organize each district pharmacy room to effectively monitor malaria, family planning, maternal, and child health commodities to make sure they were being inventoried, tracked, and dispensed properly. Furthermore, in the Beroroha district, IMPACT engaged the GAS committee to address proper management of health inputs, including ensuring that supplies are routinely distributed to remote health centers and that overstocked commodities are redistributed to other districts in need. In addition, a district pharmacy in Boeny had large quantities of expired products and a hole in the ceiling that leaked during the rainy season. IMPACT worked with the MOPH to complete an inventory of each product in the pharmacy, and then proceeded to repair the hole in the ceiling and to organize the store to streamline operational efficiencies. These efforts by the IMPACT team alongside regional and district MOPH teams have contributed to the improved functioning of Madagascar’s public sector supply chain. Once essential medicines and other commodities reach district pharmacies, the pharmacies now have the capacity to manage and organize all the inputs to ensure a) proper storage according to standards, and b) distribution to health facilities according to need.

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Electrification of a Pha-G-Dis in Haute Matsiatra The Vohibato/Isandra district pharmacy (Pha-G-Dis) in Haute Matsiatra was experiencing challenges in the cold storage of certain essential medicines, including oxytocin, because this Pha-G-Dis was not equipped with a refrigerator. The MOPH procured a refrigerator for this Pha-G-Dis, however, this would only resolve part of the problem, because the Pha-G-Dis did not have electricity to power the refrigerator. Consequently, IMPACT regional logistics advisor in Haute Matsiatra negotiated with a private sector company to help bring electricity to the pharmacy. The private sector company covered the installation of equipment and labor to electrify the pharmacy. As a result, the Pha-G-Dis now has a functioning refrigerator, which means that heat-sensitive medicines can now be properly stored and safely used.

Photo: IMPACT

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ANNEX E – STOCK INVENTORY AS OF DECEMBER 2019 (USAID AND PMI funded)

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MALARIA COMMODITIES (SALAMA) Expiry date Quantity Quantity COMMODITY (dd/mm/yy) packs Treatment/Kit/Vial/tablet ASAQ ADOLESCENT(6- 13 years ) - 100/270MG - 3 tablets 01/12/20 2894 72 350 - 25 blisters per pack ASAQ ADOLESCENT(6- 13 years ) - 100/270MG - 3 tablets 01/11/20 1110 27 750 - 25 blisters per pack ASAQ ADULT (14 years and above)- 100/270MG - 6 01/12/20 2320 58 000 tablets - 25 blisters per pack ASAQ ADULT (14 years and above)- 100/270MG - 6 01/12/20 3345 83 625 tablets - 25 blisters per pack ASAQ ADULT (14 years and above)- 100/270MG - 6 01/11/20 1779 44 475 tablets - 25 blisters per pack ASAQ ADULT (14 years and above)- 100/270MG - 6 01/11/20 1373 34 325 tablets - 25 blisters per pack SULFADOXINE-PYRIMETHAMINE 500-25MG -tablets - 01/04/22 6000 900 000 150 tablets per box SULFADOXINE-PYRIMETHAMINE 500-25MG -tablets - 01/08/21 5099 764 850 150 tablets per box SULFADOXINE-PYRIMETHAMINE 500-25MG -tablets - 01/08/21 7928 1 189 200 150 tablets per box SULFADOXINE-PYRIMETHAMINE 500-25MG -tablets - 01/08/21 6994 1 049 100 150 tablets per box RAPID DIAGNOSIS TEST (RDT) - 25 kits per box 01/10/21 21740 543 500 RAPID DIAGNOSIS TEST (RDT) - 25 kits per box 01/10/21 18243 456 075 ARTESUNATE 60 MG-injectable - 1 vial per box 01/03/21 24248 24 248

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MNCH COMMODITIES (SALAMA) Expiry date quantity quantity COMMODITY (dd/mm/yy) packs Treatment/Kit/Vial/tablet MAGNESIUM SULFATE 50% INJ.AMP.10ML - 01/02/21 1672 16 720 10 ampoules per pack MAGNESIUM SULFATE 50% INJ.AMP.10ML - 01/05/21 1098 10 980 10 ampoules per pack OXYTOCINE 10UI/ML INJ. AMP. 1ML - 10 01/05/21 12386 123 860 ampoules per pack OXYTOCINE 10UI/ML INJ. AMP. 1ML - 10 01/06/21 75180 751 800 ampoules per pack OXYTOCINE 10UI/ML INJ. AMP. 1ML - 10 01/06/21 33440 334 400 ampoules per pack GENTAMICINE 40MG/ML INJ - AMP 2ML - 01/02/21 149 14 900 (80MG)- 100 ampoules per pack B/10 GENTAMICINE 40MG/ML INJ - AMP 2ML - 01/11/20 210 21 000 (80MG)- 100 ampoules per pack B/10 GENTAMICINE 10MG/ML INJ - AMP 2ML - 01/05/21 522 52 200 (20MG) - 100 ampoules per pack B/10 GENTAMICINE 10MG/ML INJ - AMP 2ML - 01/06/21 320 32 000 (20MG) -100 ampoules per pack B/10

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ANNEX F – STOCK STATUS BY END OF DECEMBER 2019

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Stcok available Projected AMC used by Projected Procurement December 2019 Month of AMC Month of districts for Shipment Estimated Commodity AMC (April Month of stock agency/funding (SALAMA, district stock (December stock quarterly planned arrival date 2019) source and CSB) 2019) requisitions/Orders ASAQ 2 - 11 52,350 GHSC-PSM/PMI May-20 months, tablet, 140,241 4,820 29 19,455 7.21 31,185 4.50 64,300 PSI/Global Fund June-20 treatment 5,250 GHSC-PSM/PMI June-20 ASAQ 1- 5 years, 547,400 GHSC-PSM/PMI May-20 tablet, 279,489 35,879 8 108,405 2.58 84,295 3.32 75,000 PSI/Global Fund April-20 treatment 386,000 GHSC-PSM/PMI June-20 34,350 PSI/Global Fund January-20 ASAQ 6- 13 213,725 GHSC-PSM/PMI May-20 years, 371,042 15,407 24 58,659 6.33 59,226 6.26 75,000 PSI/Global Fund August-20 tablet,treatment 91,600 GHSC-PSM/PMI May-20 ASAQ 14 years 186,525 GHSC-PSM/PMI March-20 and above, 501,683 16,840 30 60,639 8.27 55,472 9.04 301,625 GHSC-PSM/PMI August-20 treatment Artesunate 25,000 GHSC-PSM/PMI April-20 121,386 7,880 15 61,715 1.97 14,124 8.59 injectable, vial 142,000 PSI/Global Fund April-20 1,911,650 PSI/Global Fund February-20 1,000,000 GHSC-PSM/PMI March-20 Rapid diagnostic 3,434,589 433,960 8 595,785 5.76 446,586 7.69 1,290,325 GHSC-PSM/PMI March-20 test - kit 1,626,313 PSI/Global Fund May-20 1,226,312 GHSC-PSM/PMI December-20 Sulfadoxine Pyrimethamine 11,619,602 570,159 20 198,667 58.49 285,358 40.72 1,500,000 GHSC-PSM/PMI June-21 tablet 78,750 PSI/Global Fund December-20 QUININE tablet 454,085 13,322 34 33,428 13.58 16,118 28.17 PSI/Global Fund January-20 Artesunate - 588 - 7,442 - 70 - 12,672 PSI/Global Fund January-20 suppositoiry Primaquine - 6,170 - 16,936 - 7,666 - 125,000 PSI/Global Fund April-20 tablet

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

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

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

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

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ANNEX H: Poster on drone

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