COAG No. 72068718CA00001

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Table of Contents

I. EXECUTIVE SUMMARY 5 II. INTRODUCTION 10 III. Main Achievements During Quarter 3 10 III.1. IR 1: Enhanced coordination among the public, nonprofit, and commercial sectors for reliable supply and distribution of quality health products 11 III.2. IR2: Strengthened capacity of the GOM to sustainably provide quality health products to the Malagasy people 13 III.3. IR 3: Expanded engagement of the commercial health sector to serve new health product markets according to health needs and consumer demand 23 III.4. IR 4: Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy people 29 III.5. IR5 - Increased demand for and use of health products among the Malagasy people 37 III.6. Cross-Cutting Activities 41 III.6.1. Monitoring, Evaluation, Research, Learning 41 III.6.2. Gender and Social Inclusion 48 III.7. Environmental mitigation and monitoring report 51 IV. KEY CHALLENGES AND SOLUTIONS 53 VI. MAJOR ACTIVITIES PLANNED FOR NEXT Quarter (YEAR 1, July – September 2019) 54 VI.6.1. Cross-Cutting Activity: Monitoring, Evaluation, Research, and Learning 55 VI.6.2. Cross-Cutting: Gender and Social Inclusion 56 FINANCIAL SUMMARY 58 ANNEXES 59 ANNEX A - Performance Monitoring Plan (PMP) 60 ANNEX B - Quarter 3 Workplan Update 70 ANNEX C - Environmental Mitigation and Monitoring Report 86 ANNEX D: Descriptions of the seven quality dimensions for the RDQA 92 ANNEX E – STOCK INVENTORY 94

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ACRONYMS

ABM Accès Banque ADDO Accredited Drug Dispensing Outlet A2F Access to Finance AMC Average of Monthly Consumption AMM Agence de Médicaments de Madagascar BHS Business Health Survey CGL Comité de Gestion Logistique CHRD Centre Hospitalier de Référence de District CHV Community Health Volunteer CNFM Conseil National des Femmes de Madagascar CRL Regional Coordinator in Logistics CSB Centre de Santé de Base CSR Corporate Social Responsability CSV Creating Shared Value CoP Chief of Party DCA Development Credit Authority DCoP Deputy Chief of Party DEPSI Direction des Etudes de la Planification et du Système d’Information DHIS-2 District Health Information System - 2 DPLMT Direction de la Pharmacie, des Laboratoires et de la Médecine Traditionnelle DLMNT Direction de Lutte contre les Maladies Non Transmissibles DLMT Direction de Lutte contre les Maladies Transmissibles DSFa Direction de la Sante Familiale DSI Direction du Système d’Information DTK Diarrhea Treatment Kit EMMP Environmental Mitigation Monitoring Plan MEL Monitoring, Evaluation and Learning FP Family Planning GAS Gestion des Approvisionnements et des Stocks GESI Gender and Social Inclusion GESIS Gestion du Système d’Information de la Santé GF Global Fund GHSC-PSM Global Health Supply Chain – Procurement and Supply Management GOM Government of Madagascar HCM Health Commodity Manager IMPACT Improving Market Partnerships and Access to Commodities Together IR Intermediate Result IPTp Intermittent Preventive Treatment during pregnancy LLIN Long Lasting Insecticide-treated Net LRA Logistic Regional Advisor LMIS Logistic Management Information System MNCH Maternal Newborn and Child Health MERL Monitoring Evaluation Research and Learning MOH Ministry of Health MoP Ministry of Population 3

MOPH Ministry of Public Health MoS Month of Stock MSH Management Sciences for Health MYS Ministry of Youths and Sports (MYS) NMCP National Malaria Control Program NGO Non-Governmental Organization PA Point d’Approvisionnement PARC Point d’Approvisionnement Relais Communautaire PMI President’s Malaria Initiative PMP Performance Monitoring Plan PNILS Programme National de Lutte contre le Sida PPR Performance Plan and Report PSHP Private Sector Humanitarian Platform PSM Procurement and Stock Management Pha-G-Dis Pharmacie de Gros de District Pha-Ge-Com Pharmacie à Gestion Communautaire RH Reproductive Health RDT Rapid Diagnostic Test RDQA Routine Data Quality Assessment SBCC Social and Behavior Change Communication SHOPS Plus Sustaining Health Outcomes in the Private Sector Plus SP Sulfadoxine Pyriméthamine SSM Supply and Stock Management SPD Superviseurs de Point de Distribution TMA Total Market Approach TMI Total Market Initiative ToR Terms of Reference TWG Technical Working Group UASM Unité d’Approvisionnement en Solutés Massifs UTGL Unité Technique de Gestion Logistique UHC Universal Health Coverage UNFPA United Nations Population Fund USAID United States Agency for International Development WMD World Malaria Day

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I. EXECUTIVE SUMMARY

Official Launch:

IMPACT was officially launched on April 15th, 2019 at the offices of SALAMA. The main objective of this event was to present IMPACT program goals and targets to the government, private sector, and various health stakeholders. 150 people from different sectors attended the ceremony, including the press.

Year 2 Workplan Preparation

IMPACT started the preparation for a Year 2 workplan workshop that will be held from July 1st to 5th with all consortium partners in order to identify and define activities to be undertaken for the next fiscal year.

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

During Quarter 3, the main achievement for IR1 was the preparation for the first multisectoral technical working group (TWG) meeting scheduled on July 16, which will ensure the development and the implementation of the TMI roadmap for health products that serve all segments of the Malagasy population across the three priority health areas (Malaria, FP/RH, and MNCH). The General Secretary of the Ministry of Public Health (MOPH) has demonstrated his full commitment to the TMA implementation process.

Additionally, the market assessment for malaria has been conducted from June 14 and included a literature review of malaria-related documents, a routine data collection on malaria products distribution and procurement from the public, private, and commercial sectors, a malaria stakeholder analysis, a household survey, and an outlet survey. These studies are being conducted by Capsule and ATW, two external research agencies, in close collaboration with IMPACT.

IMPACT has organized a training for 116 people (malaria: 27; FP/RH: 21; MNCH: 16; and 52 for other programs such as FANOME, DLMNT, SIDA, and UASM) from UTGL, various divisions of the MOPH, technical and financial partner organizations, referral hospitals, and the private sector on quantification methods and tools using Quantimed and Pipeline softwares on malaria, FP/RH, and MNCH products as well as essential medicines. Participants were able to develop forecasting and supply plans for 2019 to 2021 that will be validated by the logistic management steering committee (CGL: Comité de Gestion Logistique) in July. The quantification plans will be used to mobilize financial resources for procurement. With USAID and PMI, IMPACT will work with the Global Health Supply Chain – Procurement and Supply Management (GHSC-PSM) Non-Field Office (NFO) to start the procurement process for malaria, FP/RH, and MNCH commodities to cover the public and social marketing channels. The private sector has been invited and four pharmaceutical wholesalers (SOMAPHAR, SOPHARMAD, OPHAM and MEDICO) participated to the malaria national quantification. This is a first promising initiative that IMPACT in collaboration with the Supply and Stock Management Committee and the UTGL will improve in the next exercise.

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Intermediate Result 2: Strengthened capacity of the GOM to sustainably provide quality health products to the Malagasy people

IMPACT continued to support the Procurement and Stock Management (PSM) committee to analyze the availability and consumption of malaria and MNCH commodities distributed at district pharmacy (Pha-G-Dis) level on a quarterly basis. SALAMA has ensured the transport of malaria commodities to 115 districts in 22 regions, and MNCH commodities to the 13 USAID-supported regions and the UNFPA supported region of Androy.

IMPACT continued to train, coach, and mentor Pha-G-Dis staff in stock management, requisition processes, and the use of CHANNEL software to report LMIS data. During the period, a total of 221 PHA-G-Dis staff (52% female and 48% male), one person respectively in charge of commodities at the district public hospital and district management team (3 person per district) from 76 districts of 15 regions (, Sofia, Atsinanana, Analanjirofo, Sava, Vatovavy , Ihorombe, Melaky, Amoron’i Mania, Haute Matsiatra, Alaotra Mangoro, Atsimo Atsinanana, Betsiboka, Androy, and Anosy) were trained. USAID and World bank supported regions have been prioritized for training, but other regions (Ihorombe, Alaotra Mangoro, Atsimo Atsinanana, Betsiboka, Androy and Anosy) have been selected due to their high incidence of malaria and presented iteratively stock out of health commodities.

Emergency Distribution Plan of FP Products

Based on the distribution plan from DSFa, IMPACT distributed Sayana Press, Triclofem, Combination 3, and Microgynon to Pha-G-Dis in 13 USAID-supported regions.

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

On April 23rd and May 20th, IMPACT was presented to 20 PSHP (Private Sector Humanitarian Platform) members in Atsimo Andrefana and 28 PSHP members in Boeny. The purposes of the presentations were to share the goals, intermediate results, geographic coverage of the project, and to facilitate the coordination between local private actors and the PSHP local focal points.

During Quarter 3, an Extraordinary General Assembly was held on May 15th as requested by the MOPH, during which the General Secretary explained the MOPH concepts, strategies, and approaches for Universal Health Coverage to the PSHP members. Additionally, an Ordinary General Assembly was held on June 21st to present the PSHP activity reports for the first semester of 2019.

On June 21st, a health commission was created within the PSHP led by the Akbaraly Foundation. This commission works towards IMPACT’s objective to increase the private sector’s commitment to public health, including the availability of the Malaria, FP/RH, and MNCH health products at all levels of the health facilities. This commission has also the objective to facilitate participation of health actors within the PSHP in technical working group workshops. This commission is composed of multiple companies from various sectors (Fondation Akbaraly, IBL Logistics, drugs wholesaler importers, etc.).

IMPACT has established strong collaboration with the two health DCA partner banks, Accès Banque Madagascar (ABM) and Baobab Banque Madagascar. By sharing information among IMPACT partners and 6

ensuring ongoing support to the banks’ teams, the Year 1 loan targets have already been exceeded, with three loans totaling $14,107 disbursed to stakeholders in the health commodities supply chain.

In Quarter 3, the Access to Finance (A2F) team provided training to 77 bank staff at the partner banks’ branch offices in Toliara, Fénerive Est, and Toamasina, on topics including credit analysis, loan structuring, and on how to approach health commodities supply chain stakeholders. Training sessions provided opportunities to show the banks the potential market of borrowers in this sector (drug shops, PAs, PARCs, and pharmacies) and to allow the staff to practice the training received directly during field visits with PA/PARC or drug shops being trained by IMPACT.

A pilot training was conducted in Fénerive Est for 22 drug shops owners and managers from the Analanjirofo region. This pilot training incorporated a number of innovations, including positive self-selection of participants and cost-sharing arrangements. The pilot training showed areas of improvement to be made to the curriculum. The A2F team determined that the training materials should be in Malagasy, using simple tools. The team also recommends that short modules on clinical and regulatory compliance be included in the training.

On May 9th, IMPACT organized and facilitated a workshop with 75 representatives of the MOPH, SALAMA, donors (USAID, UNICEF, UNFPA, Global Fund), and partners to build a consensus on pharmaceutical registration processes and to advocate for tax exemptions on essential medicines and supplies in order to increase access. On May 17th, IMPACT technically and financially supported the validation workshop of the List of Essential Medicines and Supplies for Madagascar, which will serve as a legal document for health products procurement. A hundred participants attended the workshop, including medical doctors, nurses, representatives of the MoH, donors, NGOs, implementing partners, and Pharmacists and Medical Doctors councils.

Intermediate Result 4 Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy people 58,600 Pneumox were received in June and sent to PSI regional warehouses for immediate distribution to PARCs.

In Quarter 3, 552 responsible of Point d’Approvisionnement Relais Communautaire (PARC) and Point d’Approvisionnement (PA) were trained in addition to the 320 trained in Quarter 2, with 221 men and 331 women for Quarter 3. In total, IMPACT has 66 PARCs and 859 PAs. One PARC is assigned per district and one PA per commune in the 13 USAID-supported regions.

Intermediate Result 5 Increased demand for and use of health products among the Malagasy people Communication campaigns were implemented in 13 USAID-supported regions through the broadcast of radio spots, production of posters, and sensitization of the community. Seven communication teams were mobilized. Each team was composed of an animator and a driver who use a mobile sound system in order to promote Sur’Eau Pilina and Protector Plus to increase sales. The communication campaign on Sur’Eau Pilina targeted the caregivers of children under five years old for diarrhea prevention, and women and men for the Protector Plus campaign. Both target audiences were located in rural areas but accessible by car. During their visits in the community, the communication team provided explanations about the product benefits and usage guidelines. 7

Additionally, IMPACT contributed to the development of the National Malaria Control Program (NMCP) Communication Plan 2019-2022, participated at the celebration of the World Malaria Day held on May 26th in Ambanja , and provided television broadcasting and radio spots related to Rapid Diagnostic Tests (RDT) targeting the family members, Intermittent Preventive Treatment during pregnancy (IPTp) for pregnant women, their husbands, and their mothers in law, and Long Lasting Insecticide-treated Nets (LLIN) for all family members. Broadcast schedules were organized according to type of messages and targets availability.

Since May 2019, IMPACT has supported the “910” hotline, which provides information on FP/RH, MNCH, and malaria, and 50,934 calls were received during this quarter. The “910” call center is also used as a monitoring tool for suspected cases of epidemics, such as malaria, plague, and measles. The detailed report on “910” calls received was submitted daily to the MOPH.

At the end of Quarter 3, the first SMS broadcast focused on the use of RDTs was launched targeting women and men above 15 years old in the 10 USAID-supported regions using Telma and Orange networks where 1,821,382 people were reached. The SMS message was sent in Malgasy: Ny fitiliana na test eny amin'ny Tobim- pahasalamana irery ihany no manamarina fa tena voan'ny tazomoka ianao na tsia. Translated in English it means: Only the diagnostic test to be performed at the health center will confirm whether you have malaria or not.

The strategy to target youth was initiated through different meetings with stakeholders. IMPACT has technically supported the Youth Champion approach update, in collaboration with ACCESS, and attended a consultative and participatory workshop on the youth strategy with the Ministry of Youth and Sports (MYS).

Cross-Cutting

Monitoring Evaluation, Research and Leaning From May 10 to 14, 2019, IMPACT conducted two training sessions for 10 pharmacies and 10 drug shop staff who accepted to report their LMIS data on a monthly basis from the end of May using a paper-based tool on malaria, FP/RH, and MNCH health products in Atsinanana.

A Routine Data Quality Assessment (RDQA) was implemented with six Pha-G-Dis and twelve PhaGeCom of the public sector and four PARC and eight PA from the PSI Social Marketing sector from June 11th to 21st in Atsinanana and Vatovavy Fitovinany regions. This is the first RDQA exercise conducted that helped to define targets for the next RDQA planned for every Quarter (see further details in cross-cutting RDQA section). The objective of the RDQA was to check data quality based on seven quality dimensions (availability, completeness, timeliness, integrity, confidentiality, precision, and accuracy (see Annex D for descriptions) and to provide a qualitative assessment of the strengths and weaknesses of the functional areas of the data management and reporting system. The RDQA tool was adapted from the RDQA standard tool developed by Measure Evaluation. The average data quality score for PARCs and PAs was above 90%, which means that the data collected by the social marketing sector is high quality. Among the Pha-G-Dis visited, the overall data quality score was 88%. The challenges among Pha-G-Dis included:

- Issues with the data not being available on time (63%), - Issues with data integrity meaning that some data was not protected from unauthorized changes or manipulation (77%),

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- Issues with data accuracy meaning that some data did not correctly reflect what it was intended to measure (80%).

For the PhaGeCom, the main challenge was related to data availability, meaning that data and its supporting documentation were not always available (68%).

Supportive supervision for Logistic Management Information System (LMIS) data collection was conducted from April 28th to May 8th for the Sofia region and from June 11th to 23rd for the Haute Matsiatra, Atsimo Andrefana, Vakinankaratra, and Menabe regions. The average completeness rate in May was 65%. Best practices in the regions with high reporting rates (100%) namely in Amoron’i Mania, Sofia, and Haute Matsiatra are identified, shared and duplicated in other regions to improve completeness.

The protocol for the LMIS evaluation was finalized in collaboration with the LMIS Expert from the HERA agency and was approved by USAID. The data collection will be conducted in July 2019. Findings from this evaluation will be used to perform and improve the LMIS through the Year 2 work plan.

The key informant interviews for the market assessment started on June 15th. The protocol and routine data collection to be used for the market assessment were finalized. The additional studies including an outlet survey and customer survey on willingness to pay were finalized and conducted from July 2019. The findings of the market assessment studies will be obtained in September.

The development of the IMPACT Intranet and website are ongoing. The contracting agency to create these tools was selected and has started working on the design.

Gender Integration and Social Inclusion (GESI)

The Gender Equality and Social Inclusion (GESI) Analysis and Action Plan report was developed during Quarter 3 and submitted for feedback to IMPACT staff before submitting the revised version to USAID on June 24, 2019.

Some key findings from this study are shared in the main text below, and the full report is included as an attachment. The study findings will be used to inform Year 2 work planning and to enhance accessibility and equitability of health commodities to improve the well-being of women, men, girls, and boys within a Total Market Approach (TMA).

Workplan summary Quarter 3

Table 1: Summary of the activities achieved vs activities planned for April – June 2019

Status Activities planned Activities completed Will be completed in Q4 Number 21 13 8 Percentage 100% 62% 38%

Sixty-two percent of planned activities during Quarter 3 were completed. Eight activities are rescheduled to Quarter 4. Further explanation of the delay is presented in the section of perspective for Quarter 4 in Table 22.

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II. INTRODUCTION

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

IMPACT supports the Government of Madagascar to improve the capacity of the Malagasy health system to ensure that quality pharmaceuticals and health commodities are available and accessible to all Malagasy people on a sustainable basis. IMPACT’s expected outcome is to increase total market performance for and use of health products and sustained health system performance. IMPACT has five intermediate results such as (i) enhanced coordination among the public, nonprofit, and commercial sectors for reliable supplies 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 and (v) Increased demand for and use of health products among the Malagasy people.

This report summarizes the activities carried out from April to June 2019 (Quarter 3) by the consortium partners. The Performance Monitoring Plan (PMP) figures and the workplan update are presented in Annex A and Annex B respectively. The narrative provides updates on accomplishments, challenges, and solutions during the period.

III. Main Achievements During Quarter 3

Official Launch:

Under the leadership of the Minister of the MOPH and the U.S. Ambassador, IMPACT was officially launched on April 15th at the offices of SALAMA. The main objective of this event was to present the goal, intermediate results, geographic coverage, and targets including IMPACT strategies and innovative approaches to the government, private sector, and various partners. 150 people from public and private sectors, Non-Governmental Organizations (NGO) partners, and the press were present at the ceremony. Several presentations and speeches were pronounced followed by dance choreography and films illustrating the project:

- The Director General of SALAMA welcomed Figure 1: Dance choreography illustrating IMPACT during official launch the audience and hosted the event. - The Country Representative of PSI/Madagascar gave an overview of IMPACT with a focus on the innovative

use of drones. The Chief of Party presented more generally about IMPACT’s strategies. - The U.S. Ambassador and the Minister of the MOPH gave speeches focusing on the importance of collaboration between USAID and the Government of Madagascar.

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After the official ceremony, there was a tour of SALAMA’s warehouse to see where and how the commodities are stored followed by a press conference led by the Minister of health.

Figure 2: Press conference in the warehouse of SALAMA during official Figure 3: General audience during the ceremony of the official launch launch

Year 2 Workplan Preparation:

IMPACT started the preparation of a workshop that will be organized in July with the consortium partners in order to agree on the activities to be undertaken for Year 2. A committee was created with representative of IMPACT consortium partners. The committee met every week for the preparation.

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

TMA Champions Identification and Training

The General Secretary has been supportive of IMPACT’s Total Marketing Initiative (TMI) approach and has suggested two potential TMI Champions, whom IMPACT met with in Quarter 3 to measure their level of motivation and interest in the TMI process. The two TMI Champions identified are the General Director for the Provision of Care (DGFS) and the General Director for the Preventive Medecine (DGMP) They have proven to be highly Figure 4: First meeting between USAID, IMPACT, and TMI Champions. motivated in becoming TMI Champions and expressed their interest in facilitating and leading the TMA TWG.

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Through attendance and participation in different meetings and workshops related to health commodities, IMPACT has identified a third TMI Champion, the Director of the Drug Agency of Madagascar (DAMM). All three TMI Champions were trained in TMI concepts through a working session. The training lasts one full day; and is provided by the IMPACT team. However, given the busy schedule of the Champions, the training was splitted into 2 half- day sessions, and were done in Antananarivo, at the Havana Resort Hotel. We are evaluating their skills in

Figure 5: Training session on TMA for the Champions TMI through their ability to moderate debates during the TMI TWG meetings. We are also measuring their competencies through their capacity to facilitate group discussions while developing the TMI roadmap. They are now prepared to lead the TMI TWG meetings and to facilitate the development of the overarching TMI roadmap.

TMI Technical Working Group The first TWG on TMI will be held on July 16th, 2019. In collaboration with the Champions, the participants for the TWG meeting were identified coming from all stakeholders involved in the procurement and distribution of health commodities in Madagascar, the MOPH, non-profit organizations, donors, and for-profit entities and companies.

Malaria Market Assessment Three studies (key informant interview, customer survey on willingness to pay, and outlet survey) and routine data collection are planned for the malaria market assessment. The key informant interviews have started. IMPACT has participated in the training of the interviewers led by an external firm and has accompanied them during some of the interviews in order to ensure the quality of the interviews. The design and protocols of the outlet and customer’s surveys have been finalized and validated. The survey will be conducted among the 10 USAID/PMI regions only with high burden of malaria. The household survey will analyze the behavior of consumers and caregivers of children under five seeking malaria treatment and their use of malaria products, and the outlet survey will assess the availability of malaria products on the market. They will be conducted in July and August 2019.

Further details on the market assessment studies are described in the research section of this Quarter 3 report.

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

In order to strengthen the quantification capacity of MOPH staff and its partners at the central level, 116 people from the National Malaria Control Program (NMCP), Direction de la Santé de la Famille (DSFa), Direction de la Pharmacie des Laboratoires et de la Médecine Traditionnelle (DPLMT), Direction de Lutte contre les Maladies Non Transmissible (DLMNT),

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Direction de Lutte contre les Maladies Transmissible (DLMT), Programme National de Lutte contre le Sida (PNILS), technical and financial partners, Unité de Coordination des Projets (UCP), Global Fund, UNFPA, USAID, IMPACT, Mahefa Miaraka, ACCESS, private sector wholesalers’ representatives, pharmacists from referral hospitals, SALAMA, and Solid Solutes Supply Unit (UASM) attended the first session of the quantification training

Four sessions of quantification exercises were held from April to June 2019 to create multi-year forecasting and supply plans for 2019 to 2021 for malaria, FP/RH, and MNCH health products and other essentials drugs and medical supplies. The forecasting and supply plans defined the needs of the public sector, community/social marketing sectors, and hospitals and will be used for resource mobilization and procurement. The commercial sector was invited for national quantification. Only four private wholesalers participated in the malaria quantification in May 2019, however with IMPACT’s strategy of private sector engagement, there will be more participants in the next quantification. sessions. IMPACT has supported UTGL in all steps of the three quantifications exercises from selection of participants, data collection, and preparation meetings to quantification report redaction.

The plans have been discussed with the Supply and Stock Management committees of malaria, including Roll Back Malaria, the NMCP, PMI, Global Fund, and the DSFa, and will be validated in July through the Logistics Management Committee led by the General Secretary of the MOH.

Figure 6: Participants in the Training of trainers on quantification, Ivato, April 21-May 3,2019.

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 available and accessible in the public sector 2.1.1 Central Level During Quarter 3, IMPACT continued to coordinate the deliveries of health products and medical supplies in Madagascar in close collaboration with the GHSC-PSM NFO and SALAMA.

a. Institutional support and capacity building: 13

IMPACT has technically and financially supported the UTGL on the preparation, organization, data collection and producing the final report of the 3 quantification trainings sessions held respectively in Antananarivo, Antsirabe and Tamatave including the review and consolidation of all existing forecasting exercises for all priority health areas (FP/RH, Malaria, MNCH) in collaboration with PSM committee. In addition, IMPACT has participated on the initial training based on LMIS and commodities management of the new hired 22 RTA (Regional Technical Assistant) funded by the Global fund under the UCP leadership and supported them on the development of their respective work plan. The contract between IMPACT and SALAMA for storage and distribution of Malaria, MNCH and FP/RH commodities was signed to the district and HFs level. With SALAMA, IMPACT has developed and implemented an emergency plan for the distribution of malaria and FP/RH products to avoid stock-out and produced a budgeted national distribution plan for SALAMA of all health products for 10 regions and only FP for 3 PARN Regions SALAMA is also in charge of storage of commodities procured by Global Fund but SALAMA/IMPACT agreement only covers payment of costs for USAID procured commodities.

b. LLINs continuous distribution During the period, IMPACT has drafted the strategy for the LLIN continuous distribution, which will be validated in Quarter 4 by the NMCP and all stakeholders. In addition, the quantification of the LLINs and the selection of the targeted districts (12 districts) were set-up and finalized.

Table2: Malaria health products received at SALAMA Warehouses for Quarter 3 (April to June 2019) Delivery Items Donor Quantity date

ARTESUNATE 100mg recto-capsule USAID 14,000 5/22/2019

20,250 4/2/2019 ASAQ 2 – 11 months 25mg/67,5mg tablet B/3 GF 137,675 6/4/2019

126,000 4/2/2019 ASAQ 1 – 5 years 50mg/135mg tablet B/3 GF 282,450 6/4/2019

USAID 320,000 5/20/2019 ASAQ 6 – 13 years 100/270MG tablet – B/3 GF 29,825 6/4/2019

ASAQ 14 years and more 100/270mg tablet– USAID 380,000 5/22/2019 B/6

PRIMAQUINE tablet B/100 GF 51 4/3/2019

QUININE 300mg tablet B/100 GF 5,416 4/3/2019

In collaboration with the SSM committee, IMPACT ensured that all 115 health districts submitted their quarterly requisitions for commodities resupply to maintain a continuous availability of malaria health products at the decentralized level. 115 distribution plans were submitted to SALAMA on a quarterly basis and

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quantities will be transported either during an emergency plan or through the cyclic calendar distribution previously established by SALAMA.

Table 3: Family Planning health products for community distribution for Quarter 3 (April to June 2019)

Delivery Items Donor Quantity date

Depo (IM) Medroxyprogesterone Acetate 150mg/mL (1 mL) Vial, SR, 1 Vial [PT Tunggal] USAID 573,500 6/6/2019 [Triclofem]

Depo (IM) Medroxyprogesterone Acetate 150mg/mL (1 mL) Vial, SR, 1 Vial [PT Tunggal] USAID 784,500 5/7/2019 [Triclofem]

In collaboration with the PSM committee, IMPACT ensured that all 115 health districts submitted their quarterly requisitions for commodities resupply to maintain a continuous availability of malaria health products at the decentralized level. 115 distribution plans were submitted to SALAMA on a quarterly basis and quantities will be transported either during an emergency plan or through the cyclic calendar distribution previously established by SALAMA.

Table 4 below summarizes the distribution of malaria commodities during Quarter 3:

Table 4: Summary of the distribution of malaria commodities transported by SALAMA during Quarter 3

Quantity Total quantity transported by distributed from Item Quantity transported by SALAMA through - Salama to SALAMA - regular/ Cyclic emergency orders PhaGDis in Q3 to 115 PhaGDis to 24 districts to 139 Districts ASAQ NOURRISSON 25/67.5MG - 24,000 1,400 25,400 CP - B/25*3, 1 treatment ASAQ JEUNE ENFANT 50/135MG- 78,775 1,575 80,350 CP-B/3, 1 treatment ASAQ ADOLESCENT 100/270MG - 104,275 5,275 109,550 CP - B/3, 1 treatment ASAQ ADULTE 100/270MG - CP - 121,725 11,000 132,725 B/6, 1 treatment SULFADOXINE-PYRIMETHAMINE 500-25MG - CP - Box of 150 513,450 16,300 529,750 tablets RAPID DIAGNOSIS TEST, 1 KIT 803,250 12,725 815,975 ARTESUNATE 60 MG-INJ-BTE/ 1 18,190 1,064 19,254

IMPACT provided technical and financial support to DSFa for collecting demographic data (Number of population) , ensured the distribution of MNCH health products procured by USAID, stored at SALAMA, distributed to the CSB through the last mile distribution strategy as shown in the table 5 .

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In Quarter 3, IMPACT filled out all required documentation to allow the DAMM to approve the registration of Gentamicin and MgSO4. Distribution plans for Gentamicin, MgS04, and Oxytocin were developed and approved by SMSR/DSFa and implemented by IMPACT in July to 78 districts within the 10 USAID and 3 World Bank supported regions, including Misoprostol procured and donated by UNFPA(see table 5 below) Quantities distributed of Gentamycin, Magnesium Sulfate and Oxytocin cover only the district needs for 6 months but the stock available of Misoprostol at SALAMA matches with the needs of the 78 targeted districts for one semester.

Table 5: Summary of the distribution of MNCH commodities during Quarter 3

Items Unit Quantity by Units Gentamicin 40mg/ml, vial of 2ml ampoule 18,100 Gentamicine 10mg/ml, vial of 2ml ampoule 44,000 Magnesium sulfate ampoule 11,590 Misoprostol tablet tablet 49,784 Oxytocin 10UI/ml ampoule 192,338

These distribution plans, which will be finalized in July, are estimated to cover a six-month period based on demographic data as there is no accurate consumption data reported by districts. In collaboration with ACCESS and Mahefa Miaraka, IMPACT will support the DSFa to set-up a decentralized Logistic subcommittee at the district level to closely monitor the use of the health products quantities received by districts, regularly provide data consumption and report to central level in case of stock-out or overstock in the 10-USAID supported regions. Transportation and storage of Oxytocin are integrated into the Expanded Program of Immunization cold chain systems.

To support the MOPH in developing evidence-based strategies to improve the supply chain, IMPACT has conducted a literature review of the past studies and evaluations in order to better master and assess the existing public supply chain. A local consultant is compiling past studies and evaluations on the supply chain for past 10 years (since 2009) in Madagascar and will identify key recommendations. The literature review will be completed with the LMIS in-depth evaluation and assessment of existing pharmaceutical regulations so that IMPACT will have and will be able to provide the MOPH with a complete picture of the local current state of the supply chain in Madagascar. IMPACT will facilitate a dissemination workshop in September to share the findings and establish a set of actions to redesign an improved supply chain in Madagascar.

2.1.2 Regional /District level

During Quarter 3, five Regional Logistics Advisors (CRL) organized initial trainings for Pha-G-Dis and District Reference Hospital Center (CHRD) staff to orient and reinforce capacity building in logistic management information system and the use of CHANNEL software. The trainings were an opportunity to share the Terms of Reference for the decentralized Supply and Stock Management (SSM) and stock management forums at the district level and encourage regional and district teams to set up those coordination committees that will serve as a forum to create solutions for supply chain improvements. Participants are those who are linked to commodities management and partners (IMPACT, MAHEFA MIARAKA, ACCESS) if applicable. At the end of Q3, 221 participants that 107 male and 114 female from 76 districts in Boeny, Sofia, Atsinanana, Analanjirofo, Sava, Vatovavy Fitovinany, Ihorombe, Melaky, Amoron’i Mania, Haute Matsiatra, Alaotra Mangoro, Atsimo Atsinanana, Betsiboka, Androy, and Anosy regions attended at the trainings including the 16

calculation of the monthly data consumption for malaria, FP/RH, and MNCH commodities within their respective regions and districts. Participants also defined the real needs of these health products in their districts and used them as a practical exercise in terms of quarterly requisitions to be submitted to the NMCP and DSFa. The USAID and world bank supported regions were selected in priority to profit the first training sessions but Alaotra Mangoro, Atsimo Atsinanana, Ihorombe, Betsiboka, Androy and Anosy were chosen because they are part of the 67 districts at risk where the incidence of malaria is high with constant health commodities stock out issues. Table 6: District staff trained on stock management and ordering system.

# partici REGIONS DISTRICTS M F Functions pants DRSP, Fanome, Pha-G-Dis, ALAOTRA MANGORO AMBATONDRAZAKA 4 4 0 CHRR ALAOTRA MANGORO AMPARAFARAVOLA 3 3 0 PCHRD2, Pha-G-Dis, Fanome ALAOTRA MANGORO ANDILAMENA 3 1 2 Pha-G-Dis, Fanome, CHRD2 ALAOTRA MANGORO ANOSIBE ANALA 3 2 1 Fanome, Pha-G-Dis , CHRD2 ALAOTRA MANGORO MORAMANGA 3 1 2 Pha-G-Dis, Fanome, CHRD2 AMORON' I MANIA AMBOSITRA 4 2 2 RGIS, Pha-G-Dis , CHRR, ATR AMORON' I MANIA AMBATOFINANDRAHANA 3 1 2 Fanome, Pha-G-Dis, CHRD2 AMORON' I MANIA FANDRINA 3 1 2 RGIS, Pha-G-Dis, CHRD2 AMORON' I MANIA MANANDRINA 3 3 0 RGIS, Pha-G-Dis , CHRD2 DRSP, PF Channel, Pha-G-Dis , ANALANJIROFO FENERIVE EST 5 3 2 CHRR, ATR, JSI/MAHEFA Médecin Inspecteur, Pha-G- ANALANJIROFO MANANARA NORD 3 2 1 Dis, Gestionnaire CHRD2 ANALANJIROFO MAROATSETRA 3 1 2 RGIS, Pha-G-Dis , CHRD2 ANALANJIROFO SAINTE MARIE 3 1 2 RGIS, Pha-G-Dis , CHRD2 ANALANJIROFO SOANIERANA IVONGO 3 1 2 RGIS, Pha-G-Dis , CHRD1 ANALANJIROFO VAVATENINA 3 0 3 PF Channel, Pha-G-Dis, CHRD1 ATSIMO ANTSINANANA BEFOTAKA DU SUD 2 2 0 RGIS , Pha-G-Dis ATSIMO ANTSINANANA FARAFANGANA 2 1 1 Pha-G-Dis, CHRD2 ATSIMO ANTSINANANA MIDONGY DU SUD 3 2 1 RGIS, Pha-G-Dis, CHRD2 ATSIMO ANTSINANANA VANGAINDRANO 3 3 0 RGIS, Pha-G-Dis , CHRD2 ATSIMO ANTSINANANA VONDROOZO 2 1 1 RGIS, Pha-G-Dis ANTANAMBAO ANTSINANANA 2 2 0 RGIS, RPD MANAMPOTSY ANTSINANANA BRICKAVILLE 3 2 1 SR/PF, Pha-G-Dis, CHRD2 ANTSINANANA MAHANORO 3 1 2 SR/PF, Pha-G-Dis, CHRD2 ANTSINANANA MAROLAMBO 3 1 2 RGIS, Pha-G-Dis , CHRD2 SIG DRSP, SR/Palu, Pha-G-Dis ANTSINANANA TOAMASINA I 5 2 3 , CHU, DR ACCESS Atsinanana ANTSINANANA TOAMASINA II 2 1 1 SR/PF, Pha-G-Dis ANTSINANANA VATOMANDRY 3 1 2 PF Channel, Pha-G-Dis, CHRD2 BETSIBOKA KANDREHO 2 1 1 RGIS, Pha-G-Dis BETSIBOKA MAEVATANANA 3 2 1 RGIS, Pha-G-Dis, CHRR BETSIBOKA TSARATANANA NORD 3 2 1 RGIS, Pha-G-Dis, CHRD2 Coordonnateur SDSP BETSIBOKA TSARATANANA SUD 2 1 1 Tsaratanàna sud, Pha-G-Dis, RGIS, Pha-G-Dis ,CHU, DR BOENY MAJUNGA I 6 2 4 ACCESS Boeny , 17

# partici REGIONS DISTRICTS M F Functions pants BOENY AMBATOBOENY 2 1 1 Fanome, CHRD2 BOENY MAJUNGA II 2 0 2 Fanome, PF Channel BOENY 3 1 2 Fanome, Pha-G-Dis , CHRD2 BOENY 2 1 1 RGIS, Pha-G-Dis BOENY 3 1 2 RGIS/PALU, Pha-G-Dis , CHRD2 HAUTE MATSIATRA AMBALAVAO 3 2 1 RGIS, Pha-G-Dis, CHRD2 HAUTE MATSIATRA AMBOHIMAHASOA 2 1 1 Fanome, Pha-G-Dis Fanome DRSP, ATR UCP.NMF, HAUTE MATSIATRA FIANARANTSOA 6 4 2 RGIS, Pha-G-Dis, 2 Resp CHU, HAUTE MATSIATRA IKALAMAVONY 2 1 1 RGIS, Pha-G-Dis HAUTE MATSIATRA ISANDRA 2 1 1 RGIS, Pha-G-Dis HAUTE MATSIATRA LALANGINA 2 1 1 RGIS, Pha-G-Dis HAUTE MATSIATRA VOHIBATO 2 1 1 RGIS, Pha-G-Dis RGIS, Pha-G-Dis, Pharmacie IHOROMBE IHOSY 4 0 4 CHRD2, ATR UCP/NMF IHOROMBE IAKORA 2 0 2 RGIS, Pha-G-Dis IHOROMBE IVOHIBE 2 1 1 RGIS , Pha-G-Dis IHOROMBE RANOHIRA 1 1 0 CHRD2 DRSP, Médecin Inspecteur , MELAKY MAINTIRANO 7 3 4 RGIS, Pha-G-Dis, 2 Mahefa Miaraka, DR ACCESS AT/RPD, PF Channel, MELAKY AMBATOMAINTY 3 1 2 Dispensatrice CHRD1 Resp RGIS/RPD , Pha-G-Dis, MELAKY ANTSALOVA 3 2 1 Dispensateur CHRD2 MELAKY MORAFENOBE 2 0 2 PF Channel, Pha-G-Dis Responsable RGIS/Palu, Pha- SAVA ANDAPA 3 1 2 G-Dis, au CHRD2 Fanome, Pha-G-Dis, SAVA ANTALAHA 3 1 2 pharmacie au CHRR Fanome, Pha-G-Dis, SAVA SAMBAVA 3 0 3 pharmacie au CHRR Fanome, Pha-G-Dis, SAVA VOHEMAR 3 1 2 Coordinateur District Mahefa Miaraka PF Channel, Palu, Pha-G-Dis, SOFIA ANTSOHIHY 8 3 5 CHRR, DR ACCESS et 1 CRRCC, 2 équipe Mahefa Miaraka Resp Fanome/PF Channel, SOFIA ANALALAVA 2 2 0 Pha-G-Dis Resp Fanome/PF Channel, SOFIA BEALANANA 2 1 1 Pha-G-Dis Resp Fanome/PF Channel, SOFIA BEFANDRINA NORD 2 1 1 Pha-G-Dis Resp Fanome/PF Channel, SOFIA MANDRITSARA 2 1 1 Pha-G-Dis Resp Fanome/PF Channel, SOFIA MAMPIKOMY 2 1 1 Pha-G-Dis Resp Fanome/PF Channel, SOFIA PORT BERGE 2 1 1 Pha-G-Dis

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# partici REGIONS DISTRICTS M F Functions pants VATOVAVY ATR UCP/NMF, RGIS, Pha-G- 4 3 1 FITOVINANY Dis, au niveau du CHRR VATOVAVY IFANADIANA 3 2 1 RGIS, Pha-G-Dis, CHRD2 FITOVINANY VATOVAVY 3 1 2 RGIS, Pha-G-Dis, CHRD2 FITOVINANY VATOVAVY MANANJARY 3 2 1 RGIS, Pha-G-Dis, CHRD2 FITOVINANY VATOVAVY NOSY VARIKA 3 3 0 RGIS, Pha-G-Dis, CHRD2 FITOVINANY VATOVAVY 2 1 1 RGIS, Pha-G-Dis FITOVINANY ANOSY TOLAGNARO 3 1 2 RGIS, Pha-G-Dis, CHRR RGIS, Pha-G-Dis , CHRD2/Resp ANOSY BETROKA 3 0 3 SIG ANOSY AMBOASARY SUD 2 0 2 RGIS , Pha-G-Dis Adjoint Technique, Pha-G-Dis, ANDROY TSIHOMBE 3 1 2 CHRD2 ANDROY BELOHA 2 2 0 RGIS, Pha-G-Dis ANDROY AMBOVOMBE 3 0 3 RGIS, Pha-G-Dis, CHRR ANDROY BEKILY 2 2 0 RGIS, Pha-G-Dis TOTAL 76 221 107 114

Percent of participants by gender: Gender % Male 48% Female 52%

Some immediate actions were implemented in Quarter 3:

- All 13 USAID-supported regions have organized quarterly coordination meetings led by DRS or his representative where stock status is discussed and actions were taken to increase stock availability and address challenges for an improved supply chain. Members of this regional supply chain coordination committee are the DRS, EMAR staff, all partners working on supply chain at the regional level, and reports on a quarterly basis to the SSM national committee. It compiles and validates requisition and purchase order from districts and submits them to the national level. - SSM regional committees were officially set up in the six regions of Boeny, Analanjirofo, Atsinanana, Vatovavy Fitovinany, Haute Matsiatra and Amoron’i Mania. The remaining regions are currently identifying members and will launch their SSM committees in Quarter 4. - 37 districts have launched SSM committees to analyze LMIS data, provide feedback to the HFs (CSB) and use them to establish needs in terms of commodities for resupplying (prepare requisition and purchase orders) where members are composed by the Medical Inspector, EMAD staff (RGIS, CHRD , Responsible FANOME, Responsible PHA-G-Dis) , partners working on Supply chain. The SSM district committee should regularly report in a monthly basis to the Regional supply chain coordination committee.

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- 36 districts with overstock organized redeployment to districts in need of malaria commodities to avoid expiration and stock out. These actions were organized during supervision visits without additional costs in collaboration with the EMAR, EMAD, ACCESS and Mahefa Miaraka. - For Vohémar and Antsohihy districts, health products have been returned to the Pha-G-Dis circuit where they have been directly managed by the district malaria focal point. - 55 districts installed the new version of CHANNEL, which is interoperable with DHIS2, in order to improve LMIS reporting rates.

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Success story on “Redeployment of Malaria Commodities Saves 4 Sofia Districts from Stock-Out”

In May, the District Pharmacy of Soalala (Pha-G-Dis) in the Boeny region was overstocked with anti-malarial products (ACT 2-11 months, ACT 1-5 years old, and RDTs) while districts in neighboring regions were in stockout.

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

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

These inter-regional and inter-district redeployments helped to avoid stock-outs in the four districts of the Sofia region and to avoid the destruction of overstocked drugs equivalent to USD 2,193 in the Soalala district. Figure 7: Redeployment of Malaria Commodities

During their supervision visit, IMPACT also provided on-the-job training to the responsible of the malaria program in Soalala on the correct calculation of their commodity needs, inventory management, and good storage practices. IMPACT is conducting supervision visits each semester in hard to reach districts like Soalala to follow up on progress. In practice, EMAR or EMAD mainly conduct supervision and training activities and the IMPACT team brings support in organization and preparation of didactic materials for training and result restitution.

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

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

2.1.3 Community Level(CSB/Pha-Ge-Com)

In May, IMPACT continued to explore an emergency transportation mechanism from the central level to Pha- G-Dis and from Pha-G-Dis to Pha-Ge-Com. IMPACT collaborated with SALAMA to organize a cargo airplane transportation to Marolambo district for the first time as it is a rural district which is hard to reach most of the year specifically during the rainy season. The district was resupplied with malaria, FP/RH, MNCH, and essential medicines. These supplied commodities will cover Marolambo district needs until next SALAMA distribution planned on 28 October 2019.

IMPACT collected information on how the last mile distribution policy will be implemented for malaria products and the costs to address challenges encountered in distribution from Pha-G-Dis to Pha-Ge-Com for FP and MNCH commodities. In Quarter 3, the last mile distribution policy was validated as follows: UCP will use funding from Global Fund to pay the storage and transportation fees for malaria, Tuberculosis, and HIV while IMPACT will pay the storage and transportation fees for MNCH and FP/RH. During Quarter 3, each district

21 completed a micro planning exercise with defined routings and estimated budgets. At this stage, MOU between District and UCP for malaria products was dispatched to District Medical Inspector for signature. The policy will be implemented in Quarter 4 after collecting signed MOU and in later of in Q4 for MNCH products. UCP newly recruited ATR will work closely with IMPACT and ACCESS team for policy implementation and after reviewing of the costs recovery system planned for year 2 it is expected that these transportation costs will be generated and the district will not need further support. The policy will be implemented in Quarter 4.

Emergency Distribution Plan of FP Products

In Quarter 3, IMPACT continued to distribute the FP Commodities through the Emergency Plan to Pha-G-Dis as shown below:

Table 7: Summary of the FP distribution by emergency plan

Percent Percent Distribution Received from Delivered at delivered delivered Product Item Plan by DSFa USAID Pha-G-Dis from DSFa from USAID (i) Plan (i) Donation

SAYANA PRESS(Vial) 301,600 301,600 267 840 88,8% 88,8% Depoprovera/ 950,320 226,800 100,840 44.46% 10.6%1 TRICLOFEM (Vial) Combination 3/ 537,800 417,840 417 840 100% 77.7% Microgynon (Cycle) 1: The rate delivery was low because the distribution plan from DSFa was delayed than expected and the distribution was set by district demands

The 13 USAID-supported regions (10 IMPACT and 3 PARN) could beneficiate the FP products of the emergency plan in Quarter 2 and 3.

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

During Quarter 3, discussions were held between IMPACT and DPLMT about past studies of the FANOME recovery model in order to identify actions that could be implemented quickly to strengthen the FANOME and make it more viable and sustainable. A workshop will be organized in Quarter 4 to discuss on those recommendations and develop an appropriate action plan to strengthen the FANOME recovery model.

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

Sub-IR 3.1: Commercial actors are incentivized to expand into new health product markets

Present IMPACT to the PSHP

● Extraordinary General Assembly of PSHP at MOPH The MOPH invited the PSHP to hold a General Assembly led by the General Secretary on May 15th. The purpose of the meeting was to present the MOPH strategies and approaches of the Universal Health Coverage and the “Caisse Nationale de Solidarité pour la Santé” to the PSHP members. This meeting was used to mobilize and sensitize private sector to reinforce their contribution in health Figure 8: General Assembly of the PSHP at the headquarters of the MOPH sector. 17 participants from the PSHP, USAID, and other partners (private sectors, Medair, UNFPA and IMPACT) attended the meeting. The General Assembly was an opportunity to strengthen the partnership between the public and private sectors. The MOPH encouraged the private sector to continue their efforts in helping vulnerable populations in Madagascar and encouraged the PSHP members to not only support the GOM during emergency response, but also to be a permanent partner in the transport of health products.

● General Assembly of the PSHP at Andraharo United Nations Office

During the PSHP ordinary General Assembly on June 21st, The Chief of Party (COP) of IMPACT explained the interest of private sector in developing Corporate Social Responsibility (CSR) and Creating Shared Value (CSV) focused on health to 23 members of the PSHP. During this General Assembly, a health commission inside the PSHP was set-up and will be led by the Akbaraly Foundation. The members of health commission are motivated to identify solutions for health commodities transport and Figure 9: Second General Assembly of the PSHP, June 2019, at United Nations central office at Andraharo engaged to support the private sector data collection, and TMA TWG promoted by IMPACT project. The health commission held a meeting on June 27th to develop an action plan to be implemented during the Quarter 4.

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▪ IMPACT Presentation to Regional Members of PSHP

IMPACT goals, intermediate results, and geographic coverage were presented to the PSHP regional members in the Boeny and Atsimo Andrefana regions during Quarter 3. This presentation will be shared with other regions in Madagascar in order to explain IMPACT and to develop an action plan to be implemented in the respective regions by the PSHP members.

During the regional missions, the PSHP members are requested to ban illegal pharmaceutical sales and to encourage the local and national authorities to apply the law. Facing challenges with illegal pharmaceutical sales, IMPACT explained that it would support the GOM on setting up an action plan against the illegal pharmaceutical market. Furthermore, the private sector actors were encouraged to share their sales forecast in health commodities which should be included in the national quantification for procurement. Figure 10: Presentation of IMPACT, Atsimo Andrefana Region For pharmacies and pharmaceutical wholesalers that did not attend the regional meetings, IMPACT conducted one-on-one meetings to collect their thoughts and encouraged them to integrate into the PSHP.

Establish a Formal Partnership between IMPACT and the MOPH

A formal meeting with the two MOPH General Directors was held on June 13th to discuss the content of the Memorandum of Understanding (MOU) between IMPACT and the MOPH regarding private sector engagement. The MOPH committed to facilitate administrative and regulatory procedures on tax regulation in collaboration with the Ministry of Finance. The MOPH will act as a key coordinator and advisor to the PSHP members’ activities by providing technical support and sharing useful and relevant information.

The MOU will be signed in Quarter 4.

Expand the PSHP by engaging new commercial actors active in health

During Quarter 3, the pharmaceutical wholesaler COFARMA, which represents the Association of Wholesalers Importers of drugs of Madagascar (AGRIMM), integrated into the PSHP. COFARMA is among the leaders in the import and health product distribution in Madagascar. Three health actors also joined the PSHP in Quarter 3: Aga Khan Foundation, Salama Industries in Indian ocean (I.O.I: Industrie de l’Océan Indien), and Akbaraly Foundation. These actors are motivated and accepted to contribute on IMPACT approaches and integrated the health commission.

Akbaraly Foundation is already working on health with a focus on clinical aspects and wishes to contribute on the IMPACT goal to align with GOM and USAID priorities, particularly on commodities. They joined the TWG TMI, led by the MOPH as an active member through the following objectives to (i) participate on the improvement of the National pharmaceutical policy (PPN), (ii) respect and apply the laws and regulations related to the drugs and health commodities and (iii) ensure the continuous availability of logistical data, statistics, and respecting health commodities quality standards. 24

Work with partner banks and SHOPS Plus platform to expand financing to health supply chain stakeholders through the DCA guarantees and adapted financial products.

Facilitating access to finance for health commodities supply chain actors like pharmacies, drug shops, and PA/PARC helps them to grow and sustain their activities, ensuring a more reliable availability of quality health commodities for populations in IMPACT’s target regions. USAID has signed DCA guarantee agreements supporting health sector lending with two banks in Madagascar: Accès Banque Madagascar (ABM) and Baobab Banque Madagascar. The SHOPS Plus project has provided technical assistance to these two partner banks, helping them learn about the needs of private health providers and developing pipelines of health sector loans, both with and without DCA guarantee coverage. This strong collaboration has created a solid foundation for the IMPACT program to work with these banks to expand their health sector lending to more health commodities. By sharing information among IMPACT partners and ensuring ongoing support to the banks’ teams, Year 1 loan targets have already been exceeded. Partner banks were invited to meet with health commodities supply chain stakeholders during IMPACT training to PAs, PARCs, and drug shops as well as at IMPACT events organized for the private sector, such as the regional launches of PSHP in Diego and Toliara.

The IMPACT team is also working with bank technical staff to design and develop financial products tailored to supply chain activities. The A2F team visited and met with staff at some of the partner banks’ branch offices to provide information about IMPACT and about the stakeholders in the health commodities supply chains in Madagascar. For this quarter, branches in Toliara, Fénerive Est, and Toamasina were visited, and the team also met with health supply chain representatives from drug shops, pharmacies, PA/PARC and CHV in order to fine-tune the understanding of their financing needs. From these visits, it was noted that financial literacy is very low. Initial surveys of 71 PAs, PARCs, and drug shops in three regions showed that only 20 had worked with banks or microfinance institutions. This is attributed to the institutions’ limited geographical coverage and the actors’ lack of knowledge on services offered. Village Saving and Loan Associations (VSLAs) or Savings and Internal Lending Communities (SILCs) are used for most financing needs. The A2F team will continue such activities for a better understanding of financial needs of private sector evolving in supply chain.

Three non-DCA loans were disbursed by Baobab Bank during Quarter 3:

- The 1st loan for $5,569 equivalent was disbursed to a drug shop in the Analanjirofo region in March for inventory. - The 2nd loan for $3,898 equivalent was disbursed to a PARC in Diego in May 2019. The IMPACT A2F team and Baobab Bank visited this PARC in March to discuss potential loan needs. The loan was used to purchase a tuc-tuc taxi in order to improve the PARC’s revenues, and the tuc-tuc will also be used to deliver health commodities to PAs in the region. - The 3rd loan for $4,640 equivalent was disbursed in June to a drug shop in the Atsinanana region for the purchase of inventory.

The A2F team has exceeded its loan targets for Year One: 3 loans disbursed (to 2 female and 1 male borrowers) out of a target of 2 (150%), for a total of $14,107 representing 282% of the target of $5,000.00.

Develop capacity building plans and training curricula for DCA partner banks utilizing experience from SHOPS Plus The training curriculum developed for partner banks in Year 1 included market information on potential clients in each region (number of PAs/PARCs, drug shops and pharmacies) as well as market strategies for working 25 with the health commodities supply chain stakeholders. Hence the training curriculum is tailored for each region in terms of the market potential in that area and the specific clients for staff to prospect.

Train and support DCA partner banks in credit analysis and loan structuring for health businesses In Quarter 3 the A2F team provided training to 77 bank staff at the partner banks’ branch offices in Toliara, Fénerive Est, and Toamasina. The cumulative number of bank staff from ABM and Baobab trained in Year 1 is 105 (57 women and 48 men). The staff were trained in credit analysis, loan structuring, and on how to approach health commodities supply chain stakeholders. Training sessions are providing opportunities to show to the bank the potential market of borrowers in this sector (drug shops, PAs and PARCs, pharmacies) in each region and to allow staff to practice the training directly during field visits with PA/PARC or drug shops being trained by the IMPACT project.

Develop and adapt a training and coaching curriculum to build the financial management capacity of health businesses that will borrow money through the DCA through collaboration with SHOPS Plus A training and coaching curriculum has been developed and tested on a pilot basis with drug shops owners and managers from Analanjirofo region. The curricula were developed based on the training needs assessment conducted with the IMPACT MEL department during the mapping exercise in Q2. Combined with the experience of the A2F team in working with the private sector, the priority modules that were developed focused on inventory management and financial book-keeping for drug shops. This training curriculum is subject to improvement and other modules such as regulation compliance and drugs usage may be considered next quarter.

Provide training and coaching to strengthen the financial management skills of all borrowers through the DCA (e.g., Dépôts, pharmacies, wholesalers, retailers) A pilot training was conducted in Fénerive Est on May 21-22, with the participation of 22 drug shops owners and managers (16 men, 6 women) from the Analanjirofo region. This pilot training was the first of its kind in the private health supply chain sector. It was innovative not only because it provided needed financial training to a new audience, but also in participant identification. The A2F team tested a positive self-selection approach, meaning that the drug shop training was publicized through a local association, and participants needed to indicate their interest, instead of the IMPACT team specifically choosing participants. Because participants were self-selected and incurring the cost of transportation to the training venue and accommodations during the two-day training, they were much more motivated and showed genuine interest in improving the business practices of their drug shops. Another innovation incorporated by the A2F team into this training also is the financial participation of cost-sharing partner. The cost of the training was 30% financed by SOMAPHAR pharmaceutical wholesaler. The pilot training showed areas of improvement to be made to the curriculum. The A2F team determined that the training materials should be in Malagasy, using simple tools. The team also recommends that short modules on drugs use and regulatory compliance be included in the training. Other consortium partners in the IMPACT program may be able to provide the materials for these additional modules. The Year 1 target for business and financial management training was 15 participants, and A2F team completed the pilot training for 22 participants (147%).

Success story on: Using Innovative Approaches to Provide Business and Financial Training to Drug Shops

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

In 2019, PSI conducted a drug shops survey to identify training needs. Findings of this survey showed that bookkeeping and inventory management are the main areas in which drug shops most urgently need training. The A2F Figure 11: Participants doing group exercise on bookkeeping team tailored the training to meet those needs.

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

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

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

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

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

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

In Quarter 3, IMPACT and HP+ group, supported the MOPH/DPLMT and DAMM to organize a workshop to share best practices in the prequalification of suppliers selected by donors (Global Fund, USAID, UNFPA, UNICEF, World Bank etc.) and SALAMA as well as the in-country pharmaceutical registration process. The workshop examined opportunities to leverage the prequalification and quality assurance process of donors and SALAMA in order to fast track the registration process and speed up the importation process, which would result in the increased availability of essential medicines and supplies procured by donors to support the MOPH health programs. 75 people representing the MOPH, Ministry of Finance, Malagasy customs, UNICEF, WHO, USAID, and other key stakeholders attended this workshop and agreed upon the following immediate next steps:

1) Develop and sign a Memorandum of Understanding that clearly defines the roles and responsibilities of each party working in quality assurance of drugs and supplies imported by donors and stakeholders to support the MOPH programs; 2) Donors will reinforce the capacity of DAMM to streamline the registration process and other key functions of imported high-quality health products 3) Update/revise the List of Essential Medicines and supplies and advocate to the Ministry of Finance for tax exemptions to increase financial accessibility of essential drugs and medical supplies; 4) Review and streamline the DAMM registration process and SOPs to harmonize with the prequalification processes of SALAMA and donors.

The Regulatory Expert is currently conducting a literature review of the regulatory functions of the DAMM and has already collected 114 legal texts (decrees, laws, and ministerial decrees) related to the pharmaceutical sector. In June, the IMPACT Regulatory Expert and the Supply Chain Advisor attended a workshop with pharmacists in Manakara where pharmacists have expressed their wishes to participate on the literature review and revision of the existing legal texts. They were able to understand the importance of the existing regulations and shared concerns and suggestions on the content of the new regulations depending on barriers and challenges related to drugs and medical supplies importation. IMPACT is planning interviews with DAMM, DPLMT, Pharmacy Council, Associations of Pharmaceutical wholesalers, Ministry of Finance, Ministry of Commerce, Custom Services and Taxation office to gather additional information before completing the literature review where findings will be presented to all partners in Quarter 4 in order to develop an action plan on how to update and develop necessary legal and regulatory texts.

On May 17th, IMPACT provided support to the MOPH through a workshop to facilitate the validation of the National List of Essential Medicines and Commodities, which will be the basis to advocate for tracer drugs tax exemptions. Currently, IMPACT is collaborating with HP+ and other stakeholders to develop a justification memo that will guide the Ministry of Finance to approve a tax exemption on essential health products and medical supplies.

IMPACT met with the President of the inter-ministerial committee in charge of the “Stratégie Nationale de Lutte contre la Contrefaçon et le Marché Illicite de Médicaments” to discuss current status of this strategy for moving forward and analyze planned key activities to support the GOM in developing an action plan with an emphasis on malaria, FP/RH, and MNCH products. The immediate next steps include: 1) Plan a mid-term review of the “Stratégie Nationale de Lutte contre la Contrefaçon et le Marché Illicite de Médicaments” in October under the leadership of the Prime Minister 2) Suggest a restructuring of the National steering Committee overseeing the “Lutte contre le Marché Illicite et la Contrefaçon” (membership, staffing, resources, 28

and equipment) to the Prime Minister 3) Develop legal texts related to sanctions in case of fraud and mismanagement of commodities.

What about data collection among private sector actors? (use of third party vendor for data collection) - This activity is planned for Q3

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

Sub-IR 4.1.1: Socially marketed products are continuously available at convenient and accessible locations

Addressing stock out of commodities (transition from SHOPS Plus to IMPACT)

A six-month emergency plan of FP/RH products (starting from the reception of the FP commodities) was developed for the community level with USAID to avoid stock-outs of FP/RH commodities after the SHOPS Plus project ended in December 2018. In addition to the emergency plan, IMPACT developed a social marketing procurement plan on FP commodities for Year 1. The arrival of the MNCH products has encountered delays.

Table 8: Procurement Plan on FP/MNCH Commodities for Year 1

Products Quantities Expected arrival date FP Triclofem 1,640,920 Sayana Press 591,600 Combination 3 (C3) 2,448,850 Triclofem is expected in August 2019. Sayana Implanon NXT 16,761 Press, C3, Implanon NXT, cycle beads, and Cycle Beads 20,925 pregnancy tests expected in September 2019 Pregnancy Test Kit, HCG, Urine, 50 Each [ Blue cross Bio Medical] 200,000 MNCH ORS arrived on June 25th at the supplier, but IMPACT is still waiting for testing to be ORS & Zinc (Generic) completed so it is not yet available at PSI. Zinc is expected in August 2019 because of a 120,000 production delay. Expected in May, but arrived on June 17th There is no significant impact due to the delay. IMPACT will accelerate the distribution to the Pneumox (Amoxicillin) PARC, and the PA will be notified in advance. Additionally, IMPACT provided a starter kit of the product to Mahefa Miaraka to compensate 58,600 the delay of 17 days. Expected in June but delayed. The new

112,340 estimated arrival is to be confirmed by SALAMA. Arofoitra (Chlorhéxidine) 50,000 Expected in June and will arrive on July 3rd.

Family Planning and Maternal, Neonatal and Child Health products

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IMPACT offers a range of socially marketed FP/RH and MNCH products to support the national programs Table 9 shows the Quarter 3 distribution of these products against annual targets (since this activity transitioned from SHOPS Plus at the end of Quarter 1, the annual targets are from Quarter 2 to Quarter 4, and the achievement starts from Quarter 2).

The Year 1 Target was revised.

Table 9 a : Distribution of FP commodities in Quarter 3 against Year 1 targets at PARC level Year 1 Year 1 Year 1 Quarter 2 Quarter % of Target Cumulative Products Year 1 Target Achievem 3 Achieved Achievement ent Achieve (Q2+Q3) (Q2+Q3) ment Oral Contraceptives (cycles) 1,232,057 286,692 577,726 864,408 70% Depo Provera injectable 268,760 285,453 1,052,396 554,203 53% contraceptive (doses) Sayana Press injectable 41,598 130,016 338,825 171,607 51% contraceptive (doses) Yes With You condoms 269,100 103,500 119,700 223,200 83% 518,823 (community Protector Plus condoms and commercial 86,928 89,472 176,400 34% channels)

The distribution of the FP products follows the number of women who use the product regularly, also called regular users, which is defined as every month for Oral Contraceptives and every three months for Injectables provided by Mahefa-Miaraka. Where Mahefa Miaraka is present, the number of regular users was provided by Mahefa Miaraka. In the ACCESS zones, the list of regular users was obtained from CSBs until ACCESS can provide the number of regular users in their intervention zones. In Quarter 3, the distribution of Oral Contraceptives doubled compared to Quarter 2 due to the update of the number of regular users per CHV provided by Mahefa Miaraka at the end of April.

In terms of results, the cumulative achievement during Quarter 2 and Quarter 3 versus Year 1 target increased from 23% to 70% for Oral Contraceptives and from 25.5% to 53% for Depo-Provera. The quantities distributed remained stable but may increase when the number of regular users (oral contraceptive and injectable) from two Mahefa Miaraka regions namely SAVA and DIANA becomes available. Sayana Press distribution has tripled during the period compared to the results registered in Quarter 2. Notice that the baseline was the 2018 achievement during which point the public sector was experiencing a long stock-out period of FP products, which led to an increase in the quantity distributed. Since Quarter 2 of Year 1, IMPACT has respected the distribution by regular users.

- Through the commercial channel, IMPACT distributed 223,200 Yes with You condoms, which represented 83% of the forecasted target of Year 1. - IMPACT distributed 176,400 units of Protector Plus through community channel, which represents 34% of the forecasted target of Year 1. The annual target of Protector Plus includes both the community channel and the future shift of the distribution of this product to the commercial channel since the stock of Yes With You condoms will be finished at the beginning of Quarter 4. The future of Yes With You condoms will be determined after the product portfolio analysis which will be completed in Quarter 4.

In Quarter 3, IMPACT delivered 10,106 pregnancy test kits through PAs and PARCs in Sofia region for the CHV of Mahefa Miaraka. Sofia region was selected by Mahefa Miaraka as a pilot area for the training and

30 distribution/use of the product. Furthermore, based on the estimate provided by Mahefa Miaraka, the available stock of 200,000 pregnancy test procured by USAID may not be sufficient for its 7 regions

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

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

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

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

Contraceptives and 4,040 use injectable contraceptives. Figure 12: The boat KEA DELFINI of the Aqualma Company which ensures the transport of products.

Table 9b : Quantities of drugs shipped by AQUALMA to Besalampy

Sayana Press Sur'eau Pilina Protector + Triclofem Microgynon Avril 2019 0 0 0 0 0 Mai 2019 0 400 15 0 2 160 Juin 2019 200 200 5 2 880 720 Total 200 600 20 2 880 2 880 AMC 70 200 7 960 960 MoS 3 3 3 3 3

In addition, IMPACT recently trained the PARCs and PAs in Besalampy on health commodity management. The training enabled the PARC and PA to be informed about IMPACT, to be aware of the importance of health product availability, the correct use of management tools, storage, waste, expired product management, and review of average monthly consumption calculation.

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Figure 14: Training of Supply Points in Besalampy, made possible Figure 13: Transport of products by air thanks to the collaboration with Aqualma

Child Health: Diarrhea, Water Treatment, and Pneumonia IMPACT distributed diarrhea treatment kits, water treatment, and pneumonia in 10 USAID-supported regions. Almost all of the MNCH products were in stock-out during Quarter 3 due to the end of the SHOPS Plus project and the lead time for the procurement. It is relevant to note that the request for pricing and supplier contact were made in August 2018 but due to the availability of funding, the orders were only launched in December 2018 after USAID’s approval in November 2018.

Quality Control: The 50,000 tubes of Arofoitra (Chlorhexidine) were expected to arrive in the third week of May. The quality control was completed and Arofoitra will be received on July 3rd.

The delivery of 5,860 boxes of Pneumox from SALAMA was completed in June 17th by air shipment, and 11,234 boxes will be shipped and will arrive on July 17th.

The 2,400 boxes of ORS arrived on June 25th but currently remained under testing and sampling. The arrival of 120,000 kits of ORS/Zinc are postponed due to a delay in manufacturing (Table 10). After the testing and sampling, the estimated time of arrival has been rescheduled to the end August by SALAMA.

Table 10: Months of stock for each item after delivery Forecast Average Monthly Quantity to be MOS (Months ETA (Estimated time of PRODUCTS Consumption (data delivered of Stock) arrival) from Mahefa Miaraka and ACCESS ) ORS arrived but IMPACT is currently waiting for testing to be done at the ORS & Zinc 120,000 6,863 17.5 supplier. (Generic) The delivery of Zinc was delayed and is now expected in August 2019 Pneumox 58,600 blisters Arrived on 170,940 12,756 13.4 (Amoxicillin) June 17th Arofoitra 50,000 6,525 7.7 Delayed in July 3rd (Chlorhéxidine)

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Table 11: Distribution of MNCH commodities in Quarter 3 of Year 1 against yearly targets

Year 1 Year 1 Year 1 % of Target Year 1 Cumulative Products Quarter 2 Quarter 3 Achieved Target Achievement Achievement Achievement (Q2+Q3) (Q2+Q3) Diarrhea Treatment Kits - 2,140 530 2,670 - (ORS/Zinc) Sur'Eau Pilina 3,515,320 660,400 868,440 1,528,840 43% Sur'Eau 150 ml bottle 337,862 143,840 153,884 297,724 88% Pneumox pneumonia 53,309 - - - treatment kits (boxes) Arofoitra (Chlorexidine) 7,373 - - -

Table 11 shows that:

- IMPACT distributed 530 Diarrhea Treatment Kits (DTKs) in Quarter 3 and a total of 2,670 DTKs in Year 1. This quantity of ORS/Zinc kits distributed through Quarter 3 were the remaining stock from the SHOPS Plus project in Manakara warehouse. - IMPACT distributed 868,440 Sur’Eau Pilina in Quarter 3. The distribution increased 31.5% compared to Quarter 2 as promotion campaigns were launched in March and April to increase demand for Sûr Eau Pilina. 10% of this increase resulted from flash sales by the communication teams. To date, the total achievement represents 43% of the annual target. The target was calculated using the following parameters: distribution data from the 10 USAID-supported regions and the estimated AMC (Average Monthly Consumption) using the 2018 achievements as a baseline. Although IMPACT has a very low stock-out of Sûr Eau Pilina at the PA level (around 1%) but the average monthly consumption has decreased compared to the 2018 (318 463/256 807) within the 10 USAID-supported regions for the following reasons: some communities still need to be sensitized after the end of Mikolo and the beginning of ACCESS to use Sûr Eau Pilina and ACCESS CHVs should receive starting batches. Finally, there was no long rainy season this year which reduced the length of the season and diarrhea cases. - IMPACT distributed 153,884 Sur’Eau bottles of 150 ml, which represented 88% of the annual target.

Pneumox and Arofoitra (Chlorhexidine) were in stock-out at PSI’s warehouses during Quarter 3. 58,600 blisters of Pneumox arrived by air on June 17th and have been sent to regional warehouses in order to be quickly distributed to the PARCs.

During Quarter 2, IMPACT trained 296 PAs and 24 PARCs from six regions and 26 districts and additional 37 PARCs and 515 PAs from 11 Regions and 44 districts were trained during Quarter 3. The attendance rate for this second training was 96.84% (552/570).

Trainings were focused on (i) information about IMPACT; (ii) importance of the product availability; (iii) methods to calculate the average monthly consumption; (iv) status of regular users (not complete from Mahefa Miaraka); (v) distribution for health products; (vi) use of management tools, good storage, how to manage waste and expired product, and (vi) sharing of successful practices and stories. A manual of participants including all topics listed above was developed, served as a guide and distributed to PAs and PARCs. 33

All the PAs and PARCs who participated in the training were pre-tested on their knowledge (using a questionnaire) related to the topics listed above. The same questionnaire was again used to test the participants after the training and the average score was obtained by 97% of them with an increase of 15.69 points from the pre-test.

Table 12: Summary of findings from the training

Attendance rate of the PA & PARC: 96.84% PA who obtained the average mark during Pre-test: 86,41% PA who obtained the average mark and plus during Post-Test 97.82% PA who gained scoring points 82.43%

The PAs and PARCs who received the training will be followed up after one month during the monthly supervision by the Superviseurs de Point de Distribution (SPD) who will strengthen their capacity. The PAs and PARCs who weren’t able to attend the training will be received an on-the job-training t during the monthly supervision.

Table 13: Summary of PAs and PARCs attending the first-month training per Regions and Districts

TRAINEES TRAINING Number # Total Dates of REGIONS DISTRICTS # PA of Venue PARC Trainees Trainings Trainings TOAMASINA I 1 0 23 and 24 18 1 Toamasina I TOAMASINA II 17 MAy 02 and 03 BRICKAVILLE 18 1 Brickaville 1 17 April ANTSINANANA VATOMANDRY 1 15 05 and 06 ANTANAMBAO 19 1 Vatomandry April MANAMPOTSY 1 2 09 and 10 MAHANORO 12 1 Mahanoro 1 11 April 16 and 17 MANANARA NORD 1 Mananara Nord 1 16 17 April ANALANJIROFO 07 and 08 MAROANTSETRA 1 Maroantsetra 1 20 21 May V7V IKONGO 0 7 MATSIATRA 9 and 10 FIANARANTSOA I 18 1 Fianarantsoa AMBONY 1 0 April ISANDRA 0 10 29 and 30 AMBOHIMAHASOA 1 Ambohimahasoa 2 16 18 April AMBOHIMAHASOA 0 1 11 and 12 LALANGINA 0 13 17 1 Fianarantsoa April VOHIBATO 0 3 VOHIBATO 1 11 15 and 16 19 1 Fianarantsoa IKALAMAVONY 1 6 April IKALAMAVONY 0 2 18 1 Ambalavao

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TRAINEES TRAINING Number # Total Dates of REGIONS DISTRICTS # PA of Venue PARC Trainees Trainings Trainings 18 and 19 AMBALAVAO 1 15 April AMORON'I AMBATOFINANDRAHANA 24 and 25 0 3 22 1 Ambositra MANIA AMBOSITRA 1 18 April 19 and 20 SAMBAVA 25 1 Sambava 1 24 April 12 and 13 VOHEMAR 18 1 Vohemar 1 17 April SAVA 9 and 10 ANTALAHA 17 1 Antalaha 1 16 April 16 and 17 ANDAPA 21 1 Andapa 1 20 April 8 and 9 BEFANDRIANA 15 1 Befandriana 1 14 April 11 and 12 SOFIA MANDRITSARA 1 30 1 Mandritsara 29 April 15 and 16 BEALANANA 20 1 Bealanana 2 18 April BOENY MITSINJO 1 7 12 1 Mitsinjo 7 and 8 May SOALALA 1 3 21 and 22 MELAKY BESALAMPY 9 1 Besalampy 1 8 May BETIOKY 1 11 08 and 09 BEZAHA 1 10 25 1 Betioky April BENENITRA 2 25 and 26 ATSIMO TOLIARA II 1 Toliara 1 30 31 April ANDREFANA 11 and 12 AMPANIHY 14 1 Ampanihy 1 13 April SAKARAHA 1 11 18 and 19 21 1 Sakaraha ANKAZOABO 1 8 April From 23 au AMBATOLAMPY 17 1 Ambatolampy 1 16 24 May ANTANIFOTSY 1 8 From 20 to 16 1 Antsirabe FARATSIHO 1 6 21 Mai VAKINAKARATRA ANTSIRABE I From 13 to 1 20 21 1 Antsirabe ANTSIRABE II 14 Mai BETAFO 1 14 From 16 to 23 1 Betafo MANDOTO 1 7 17 Mai 1 There is one PA serving one commune.

Note: Table 17 provides the number of PARCs and PAs trained. 221 Men and 331 Women attended the training. The training will continue for the remaining PARCs and PAs in Melaky region in July.

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Sub-IR 4.1.2: Innovative last mile distribution ventures

The feasibility study on the use of Unmanned Aerial Vehicles (UAV) to reduce stock out issues for Community- based Distribution of Health Commodities was completed in Quarter 3.

One (1) UAV, specifically designed for the transportation of health commodities will be deployed in Maroantsetra as the base to serve 92 PA (Supply Points) located in difficult-to-reach areas and experiencing stock out through 6 districts (Befandriana Avaratra, Antalaha, Andapa, Mananara, Mandritsara, Maroantsetra) and 3 regions (Analanjirofo, Sava and Sofia). A test flight is scheduled early in September while the inaugural and official flight will be planned on November.

This innovative means of distribution will transport FP & MNCH commodities to the PAs who have GSM coverage and they will receive messages about the operation and acknowledge safe delivery over the phone.

The contract with Aerial Metric, the UAV provider, is underway and will be signed in Quarter 4.

The figure below shows the Supply Points that will benefit this new mean of transportation in the 3 regions.

Portfolio Analysis

The product portfolio analysis followed by the Cost of Goods Sold (COGS) analysis began in Quarter 3 and will continue in Quarter 4. An analysis is scheduled in Quarter 4 in order to take decision with all stakeholders.

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III.5. IR5 - Increased demand for and use of health products among the Malagasy people

Innovative Demand Creation and Product Promotion Campaigns In Quarter 3, in coordination with the distribution team, two promotion campaigns were conducted for Sur’Eau Pilina and Protector Plus in order to promote these IMPACT products and increase uptake. Activities included:

Sur’Eau Pilina: Radio spot broadcasts started in Quarter 2 and continued through Quarter 3 with a total of 760 spots aired in Quarter 3 until April 18th in 16 districts (presented in table 14). To reinforce radio broadcasts, sensitization activities were conducted in seven regions, namely Diana, Atsinanana, Analanjirofo, Atsimo Andrefana, Menabe, Sofia and Vatovavy Fitovinany. Seven communication teams composed respectively of one animator and one driver promoted the correct use of Sur’Eau Pilina by the population and its importance to prevent diarrhea in seven regions. The promotion campaigns by the communication team contributed to 9.6% of the sales of Sur’Eau Pilina in Quarter 3 (868,440 tablets of Sur’Eau Pilina were sold including PARC and PA in Quarter 3 with 83,580 tablets were sold through sensitization that represents 9.6% of the total sales).

Protector Plus: From May 25th to June 21st, IMPACT intensified promotion campaigns for Protector Plus through 3,200 radio spots broadcasted in 37 districts and distribution of 1,000 posters. The radio spots were translated into 13 local dialects of Malagasy in the 13 USAID-supported regions

Table 14: Summary of the broadcasting per campaign and per district

Communication Number of Number of Period Region Explanations campaign districts spots aired Atsinanana 6 280 40 spots aired per Analanjirofo 4 160 radio station per Vatovavy district except 2 80 Broadcasting Radio 1st to 18th Fitovinany Tamatave, spot of Sur'Eau Pilina april,2019 Menabe 2 120 Morondava, Atsimo Andrefana 2 120 Toliary with 2 radio stations Total 16 760 respectively DIANA 4 400 SAVA 4 320 Analanjirofo 6 480 Atsinanana 5 480 80 spots aired per Vatovavy radio station per 3 240 Fitovinany district except 25th May Broadcasting Radio Atsimo Andrefana 3 240 Diego, Tamatave, to 21st spot of Protector Plus Menabe 2 160 Majunga with 2 June,2019 Boeny 2 240 radio stations Sofia 2 160 respectively Haute Matsiatra 2 160 Amoron'I Mania 2 160 Vakinakaratra 2 160 Total 37 3200

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Communication Number of Number of Period Region Explanations campaign districts spots aired Atsinanana 2 30 Atsimo Andrefana 1 15 SAVA 2 30 Sofia 1 15 26th April Broadcasting TV spot Vatovavy 15 spots aired per to 11th 2 30 of IPTp Fitovinany district May, 2019 Menabe 1 15 DIANA 1 15 Boeny 2 30 Total 12 180 Atsinanana 1 45 15 spots aired per Atsimo Andrefana 1 15 radio station per DIANA 1 30 district except 26th April Broadcasting TV spot Diego and Majunga to 11th Boeny 1 30 of RDT with 2 radio May, 2019 SAVA 1 15 stations respectively and 3 Total 5 135 for Tamatave. Atsinanana 1 52 26 spots aired per Atsimo Andrefana 1 52 radio station per DIANA 1 26 district except Broadcasting of radio 26th April Boeny 1 52 Majunga, spots using sketches to 11th SAVA 2 78 Tamatave , Tuléar comedy May, 2019 Sambava with 2 radio stations Total 6 260 respectively

Communication Plan at the National Level IMPACT contributed to the implementation of the National Malaria Control Program Communication Plan 2019-2022 in Quarter 3.

IMPACT participated in the celebration of World Malaria Day (WMD) on April 26th in Ambanja. The event was led by the MOPH, under the leadership of the Minister himself. The week of mother and child health was launched with the WMD event. IMPACT held a booth to present its products.

Figure 15: Event of the celebration of the World Malaria Day lead by the Figure 16: Presentation by IMPACT of its products and activities Minister of Health 38

During the World Malaria Day celebration, the NMCP, in collaboration with the Ministry of National Education, launched a national school competition for the fight against malaria. The competition targeted students who were about 10 years old because malaria is included in their school curriculum. The competition included 157 schools with 75,480 students in 15 districts (Ambositra, Antsohihy, Farafangana, Fenerive Est, Ihosy, Maevatanana, Maintirano, Manakara, Miarinarivo, Sambava, Taolagnaro, Tuléar I,Tsiroanomandidy, Majunga, Ambatondrazaka). Each school had to illustrate how they participate in the fight against malaria. IMPACT will reward the top 46 schools by equipping them with materials to weed the bushes, including shovels, rakes, wheelbarrows, and also a TV and DVD player to allow the school to broadcast awareness programs on the control of malaria.

NMCP and the Responsible for school health at the Ministry of National Education are the members of the jury and they will choose the best projects.

In order to promote malaria prevention and treatment in the broader community, 180 TV spots on IPTp, 135 TV spots on RDTs, and 260 radio spots using comedy sketches were broadcasted from April 26th to May 11th in 12 districts.

Mobile Technology to Increase Demand Creation

During Quarter 3, IMPACT supported the call center “910” hotline, which had been supported previously under the SHOPS Plus project.

Two teams of hotline staff worked every day from 6 a.m. to 10 p.m. to provide information to callers on FP, MNCH, and malaria, and other health topics. In all IMPACT communication tools (posters, radio spots, and TV spots), the “910” hotline is used to encourage people to call if they need further information related to Malaria, FP and MNCH health products. A brief initial training on these three health areas and the use of Malaria, FP and MNCH health products are required before becoming a hotliner.

The hotline staff also contributed to information monitoring by preparing a report of the calls received for the MOPH. Suspected cases of epidemics (malaria, plague, measles) were highlighted so that the MOPH could follow-up on time as appropriate (Table 19). Table 15: Summary of number of hotline calls received by topic

May June Topic N % N % Hotline calls received on Malaria (% of total) 3,546 17.6 6,929 22.5 Hotline calls received on Family Planning (% of total) 103 0.5 196 0.6 Hotline calls received on Maternal, Child, Health (% 1,370 6.8 3,183 10.3 of total) Hotline calls received on other* (% of total) 15,127 75.1 20,480 66.6 Total hotline calls received 20,146 100 30,788 100 *: The other diseases are related to plague, measles, headache, stomach pain, etc. Calls on measles have been especially high (55% of the total) because of the latest epidemic.

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SMS Broadcast

SMS broadcasts were initiated in Quarter 3 and the first SMS campaign on the use of RDTs (targeting women and men above 15 years old in the 10 USAID-supported regions using Telma and Orange networks), validated by the NMCP and DPS, occurred from June 28th until the beginning of July. SMS messages were sent to 1,821,382 people (women and men above 15 years old). The SMS messages were sent in collaboration with the MOPH. The NMCP created the message and the Health Promotion Direction (Direction de la Promotion de la Santé: DPS) validated it. The SMS message was sent in Malgasy: Ny fitiliana na test eny amin'ny Tobimpahasalamana irery ihany no manamarina fa tena voan'ny tazomoka ianao na tsia; and translated in English it means: Only the diagnostic test to be performed at the health center will confirm whether you have malaria or not ».

The Communication Plan Targeting Youth

IMPACT initiated the creation of a strategy targeting youth in Quarter 3. It will be implemented in collaboration with partners such as ACCESS, MYS, and Telma Foundation.

From May 6th to May 9th, IMPACT participated in the workshop organized by ACCESS to update its “Champions Approach,” which defines the criteria for a youth to become a “Champion.” IMPACT will develop activities for the Youth Champions, such as sensitization adolescents on RH, FP, and malaria components.

From June 11th to June 15th, IMPACT participated in the workshop of the MYS, supported by ACCESS, as the first step of the elaboration of the strategy for Youth. Representative of youth from four regions (Atsimo Andrefana, Vatovavy Fitovinany, Vakinakaratra, and Atsinanana) were presented to the participants to better understand their needs and barriers in different health areas. These 4 regions have been selected because they have the highest population of youth in Madagascar (11% in Atsimo Andrefana, 12% in Vatovavy Fitovinany, 11% in Atsinanana and 16% in Vakinankaratra). On June 21st, a meeting was held with the MYS to develop a partnership with IMPACT. IMPACT will revitalize youth centers of the MYS by providing training on leadership, on IMPACT products, to become a sales agent, and by sensitizing youth to have good health behavior, such as going to CSBs or CHVs (Community Health Volunteers) and using FP products to avoid early pregnancy. Telma Foundation who has an “Information for All” program will be also integrated. A MOU between IMPACT and MYS will be signed in Quarter 4.

Other Activities

World Health Day was celebrated on April 12th in Antananarivo. For this year, the theme was «Tolotra fahasalamana ho an’ny daholobe, ho fanatsarana ny fahasalamambahoaka » translated in English :“ Universal Health Coverage, for the improvement of public health” For this event, IMPACT supported the MOPH to broadcast 20 TV spots and 90 radio spots. IMPACT also gave 500 drinking cups to reward those who participated in the quiz during the sensitization.

On May 2nd, IMPACT attended the Communication Working Group led by the Development and Communication Outreach department of USAID. This was a sharing session on communication activities between USAID’s NGO partners. Different topics and tips were discussed, including story checklists, story collection guidance, and photo and video release forms.

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III.6. 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

Finalization of the PMP

The MERL team led the activity on the determination of PMP baseline and targets with the consortium partners. IMPACT received first feedbacks from USAID and resubmitted the PMP for second review.

Training of Pharmacy and Drug Shops on LMIS Data Submission

IMPACT conducted a training of pharmacy and drug shop staff in order to collect LMIS data on malaria, FP/RH, and MNCH health products. In addition to the 21 outlets (11 pharmacies and 10 drug shops) who also participated in the mapping exercise conducted in Quarter 2 in the Atsinanana region under IMPACT, the trainers invited the four remaining pharmacies (not available for the mapping exercise in Quarter 2) to the training.

Figure 17: Training of drug shops on LMIS data submission at Royal Hotel in Tamatave Training participants included:

- On May 10th, five drug shop staff were trained where: Atsinanana and a representative from the Regional Health Directorate officially opened the training. Five drug shops who were not available at the training and were visited at their respective outlets. - On May 11th, twelve participants from local pharmacies were trained, including auxiliary officers, vendors, pharmacy owners, and pharmacists. Three pharmacies who were not available during the training were approached at their respective outlets.

The content of the LMIS training included:

- Presentation of IMPACT, including the objectives of the project, main activities, and a specific focus on private sector interventions. - Presentation of the priority health areas including malaria, FP/RH, and MNCH, under IMPACT. - Training of a paper-based tool for stock management with practical examples and exercises. The tool includes a simple monitoring sheet on stock management to capture data on the current level of stock, entries, and the number of health products distributed during the last month. A consultant was recruited to ensure data collection using paper-based tool and an electronic tool will be introduced after the LMIS evaluation. 41

- Presentation of the letter of agreement that stipulates that the outlets will share LMIS data to IMPACT on a monthly basis. The outlets will benefit through trainings on stock management, finance management, and potential loans from banks.

Ten out of 15 pharmacies and all 10 drug shops agreed to sign the letter of agreement (Table 20). The five pharmacies that have not signed the letter of agreement will be visited by IMPACT team members responsible for the private sector during Quarter 4. The main reason raised was that the win-win system between the outlet and IMPACT is not yet clarified and well defined. Those that have not signed the letter of agreement will not be required to share their LMIS data.

Table 16: Summary of the Outlets benefited of LMIS Training Pharmacies Drug Shops Received formal Training 12 5 Received on-the-job Training 3 5 Signed Letter of Agreement 10 10

At the beginning of May, the consultant visited the 20 outlets (10 pharmacies and 10 drug shops) who had signed letter of agreements in order to collect LMIS data, complete data entries into Excel using a simple data entry form, and submit data to the IMPACT Monitoring and Evaluation team based in Antananarivo. The data was used for reporting to USAID and for follow-up of activities among the private sector. The data from May was used for the PMP baseline and data from June is used as results for Quarter 3.

Routine Data Quality Assessment

DPLMT conducted a RDQA from June 11th to 21st in Atsinanana and Vatovavy Fitovinany regions. Prior to the RDQA, a team building meeting was organized on May 31st to explain the RDQA tool, the method and approach used during the RDQA exercise, and to standardize the work for the two teams composed by IMPACT with DSFa and IMPACT with DEPSI including one person from the Regional Health Directorate assigned to each team. DPLMT, NMCP, and Measure Evaluation also participated in this meeting.

Figure 18: RDQA exercise in CSB II Ranomafana, Ifanadiana district, Figure 19: Restitution of the RDQA results in CSB II Marofarihy, in Vatovavy Fitovinany region Manakara district, VV7V region

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The tool used for the RDQA exercise was adapted from the Measure Evaluation RDQA tool and is adapted to fit the local LMIS context in Madagascar.

The objective of the RDQA was to check the seven quality dimensions: availability, completeness, timeliness, integrity, confidentiality, precision, and accuracy (see Annex D for the descriptions of the quality dimensions) of the LMIS data submitted to the systems (DHIS2 for Pha-Ge-Com and CHANNEL for Pha-G-Dis). The findings of the RDQA will be used to identify data quality issues and to share recommendations for data quality improvement to the staff responsible for the LMIS data at the district and central level.

Table 17: Distribution of the Sample for the RDQA

Public Sector PSI social marketing Region District Pha-G-Dis Pha-Ge-Com PARC PA Manakara 1 2 1 2 Vatovavy Fitovinany Vohipeno 1 2 1 2 Ifanadiana 1 2 0 0 Toamasina 1 1 2 1 2 Antsinanana Toamasina 2 1 2 Vatomandry 1 2 1 2 Total 6 12 4 8

As presented in table 17, the RDQA was conducted among six Pha-G-Dis and 12 Pha-Ge-Com for the public sector and four PARC and eight PA for the PSI social marketing. In total, these 30 selected organizations have submitted regular and timely LMIS data reports during Quarter 2.

Table 18: Summary of the RDQA findings

Pha-G-Dis Pha-Ge-Com Storage level N= 6 N=12 Atsinanana Atsinanana Regions VV7V (n=3) VV7V (n=6) (n=3) Together (n=6) Together Data Quality Parameter Availability 100% 96% 98% 50% 86% 68% Completeness 67% 95% 81% 100% 86% 93% Timeliness 27% 100% 63% 100% 73% 86% Integrity 100% 54% 77% 100% 83% 91% Confidentiality 100% 89% 94% 100% 96% 98% Precision 100% 98% 99% 100% 99% 100% Accuracy 79% 80% 80% 87% 100% 93%

Overall Data 82% 87% 85% 91% 89% 90% Verification Score1 System Assessment 92% 92% 92% 82% 90% 86% Score2 Overall Data Quality 87% 90% 88% 87% 89% 88% Score3

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PARC PA Storage level N=4 N=8 VV7V Atsinanana Atsinanana Region VV7V (n=4) (n=2) (n=2) Together (n=4) Together Data Quality Parameter Availability 100% 100% 100% 100% 77% 89% Completeness 100% 100% 100% 100% 82% 91% Timeliness 100% 100% 100% 100% 65% 83% Integrity 100% 100% 100% 100% 80% 90% Confidentiality 100% 100% 100% 100% 93% 97% Precision 100% 100% 100% 100% 100% 100% Accuracy 97% 98% 97% 91% 89% 90%

Overall Data 100% 100% 100% 92% 90% 91% Verification Score1 System Assessment 91% 87% 89% 87% 91% 89% Score2 Overall Data Quality 95% 92% 94% 92% 90% 91% Score3

- 1: Average score on the seven quality dimensions (availability, completeness, timeliness, integrity, confidentiality, precision, accuracy) - 2: Qualitative assessment of the strengths and weaknesses of the functional areas of the data management and reporting system. A series of questions are used to calculate the average score based on the responses - 3: Average score on “Overall Data Verification Score” and “System Assessment Score”

Legend Score 90% and above 80% - 89% Below 80%

Overall, Table 22 shows that among PARC and PA the average data quality score is above 90%, which means that the data collected by the social marketing is good quality. Among the Pha-G-Dis visited for the RDQA, the challenges included issues with the data not being available on time (63%), issues with data integrity, meaning that some data wasn’t protected from unauthorized changes or manipulation (77%), and issues with data accuracy, meaning that some data didn’t correctly reflect what it was intended to measure (80%). For the Pha- Ge-Com, the main challenge was linked to data availability, meaning that data and its supporting documentation were not always available (68%).

All the details of the data quality issues were communicated to the 30 organizations visited. Additionally, one Regional Director, six Medical Inspectors, and four PA and PARC Distribution Supervisors received feedback and recommendations from the RDQA results. A meeting will be organized in Quarter 4 to present the findings of the RDQA to the committee (DPLMT, NMCP, DSFa, SALAMA, DEPSI, and Measure Evaluation) with the aim of taking corrective action and providing general recommendations to all Pha-G-Dis, Pha-Ge-Com, PAs, and PARCs.

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LMIS Active Data Collection and Supportive Supervision

The LMIS committee led by the DPLMT including DEPSI, IMPACT, and Measure Evaluation continued active data collection with formative supervision visits in Quarter 3. The objective of this activity is to improve the submission rates of LMIS data and to provide technical assistance to the data senders. The committee recommended the following regions: Sofia, Haute Matsiatra, Atsimo Andrefana, Vakinankaratra, Melaky, Analanjirofo, Diana, Boeny, and Menabe as they have already experienced data submission issues previously. One supportive th supervision mission was organized from April 28 to May Figure 20: Supervision/active data collection on LMIS in 8th for the Sofia region and one was organized from June Morombe Pha-G-Dis district that was equipped with a new 11th to 23rd for the Haute Matsiatra, Atsimo Andrefana, desktop offered by the UCP (Unité de Coordination de Projet). The office was also renovated Vakinankaratra, and Menabe regions. The regions that were not visited in Quarter 3 will be visited in Quarter 4, including Melaky, Analanjirofo, Diana, and Boeny.

The supervision visits focused on the following areas: - Provide on-the-job-training to the health commodity manager (HCM) on the new version of CHANNEL software to strengthen their capacity in order to supervise Pha-G-Dis on LMIS. - Provide on-the-job training to the Pha-G-Dis who did not yet receive training on the new version of CHANNEL software, including the newly recruited staff and those with low capacity to use CHANNEL. - Check if data for malaria, FP/RH, and MNCH were entered in CHANNEL. - Collect LMIS data that were not yet submitted to DPLMT using a Flashdisk. - Provide recommendations and action plans to improve data reporting using CHANNEL.

Two teams, composed of one person from IMPACT, one person from DPLMT, and one person from the Regional Health Directorate, were furrowed the regions mentioned above.

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Table 19: Results of field supervision and active data collection

Reports Total Reports Total Number Reports Received by Number Received (mail Regions of Districts in Received Mail Prior to or of Visits + active data 13 Regions During Visit After Visit collection) Amoron’i Mania 4 4 0 4 Analanjirofo 6 1 0 1 Atsimo Andrefana 9 1 6 5 6 Atsinanana 7 4 1 1 5 Boeny 6 4 0 4 Diana 5 0 0 0 Haute Matsiatra 7 5 2 2 7 Melaky 5 1 0 1 Menabe 5 0 4 4 4 Sava 4 3 0 3 Sofia 7 7 4 0 7 Vakinakaratra 7 5 5 0 5 Vatovavy Fitovinany 6 3 1 1 4 TOTAL 78 38 23 13 51

Table 20: Summary Progress on Completeness for CHANNEL after active data collection

Health area January 19 February 19 March 19 April 19 May 19 Malaria 59% 74% 66% 61% 65% FP/RH 50% 73% 64% 62% 61% MNCH 21% 23% 24% 25% 22% At Least One Health 59% 74% 66% 61% 65% Area

Among the 13 regions, the average completeness rate obtained was 65% for Pha-G-Dis. Good practice in the regions with higher reporting rate (100%) namely in Amoron’i Mania, Sofia, and Haute Matsiatra will be identified and will be duplicated in other regions to improve completeness. Submission rates for MNCH and FP/RH products were lower compared to malaria. The difference of reporting rates between health areas was linked to the stock-out of health products, especially for MNCH. No products distributed or registered implies that no report was to be submitted, which was the understanding of the CHANNEL focal point. This issue was rectified during the visit and recommended to all Pha-G-Dis.

There was a slight decrease on the completeness of reports over time. During the supervision visits, some of the paper-based reports (RMA: Rapport Mensuel d’Activité) from the Pha-Ge-Com were entered into the system but not submitted to DPLMT as per the recommended timeline and some reports were never entered into the system. Additionally, the CHANNEL focal point did not submit the reports until all the reports were completed by the Pha-Ge-Com belonging to the district.

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Additional data submission issues were explained as follow:

- Lack of computer access for Pha-G-Dis in Bealanana, Antanifotsy, and Betioky-Sud. - Internet connection issues. - No assistance available from DPLMT when there is a technical problem on CHANNEL.

Short term solutions to address the issues include:

- Organizing an on the-job-training for Pha-G-Dis providers and HCM in Sofia and Haute Matsiatra regions in order to provide instructions on the need to always submit reports even though there is no registration and/or distribution of health products in the system. - IMPACT to explore with IT if there is a possibility to check the completeness of the report before submitting the data. - The call center used to improve data submission, data completeness, and data timeliness. - Checking the day-to-day stock for each movement to be entered in the electronic system. - DPLMT has been informed that Pha-G-Dis require support on the use of the different menu of CHANNEL that will help on data reporting and need feedbacks from central level on the quality of the data submitted.

Based on the findings from the active data collection, the LMIS committee will continue to support the regional teams during supervision visits until the road map from the LMIS evaluation is implemented. The Internet connection issue will be discussed within the LMIS committee in Quarter 4.

LMIS Evaluation

An LMIS evaluation is scheduled in order to identify the strengths and weaknesses of the existing LMIS performance with the aim of proposing a long-term solution. The LMIS evaluation will use qualitative and quantitative approaches, and routine data analysis. The public, nonprofit, and commercial sectors will be evaluated and the key actors working on the LMIS will be interviewed. The protocol for this evaluation was finalized in Quarter 3, the LMIS Expert from the HERA agency was approved by USAID, and the external local agency to implement the evaluation was selected. The LMIS Expert will ensure quality control during the different stages of the evaluation implementation, including protocol finalization, review of data collected, supporting data analysis from the local agency, and finalizing the evaluation report. A workshop will be organized in September to create the short and long-term LMIS roadmap to be led by the Expert.

6.1.2. Research

1. The dissemination of the “Assess the Government of Madagascar's (GOM)” study conducted in Quarter 2 (refer to Quarter 2 report) was scheduled in Quarter 3, but due to the unavailability of the MOPH, this dissemination is now planned on July 9th.

2. As part of the TMI, a market assessment is ongoing to understand landscape of the malaria products (ACT, RDT, Artesunate/Quinine Injectable, SP and LLINs) on the market. A market assessment framework will unpack the current landscape for the priority malaria products in terms of the stakeholder views, market size, equity, accessibility, product availability, and market sustainability. The identified needs will be responded to through surveys and routine data analysis such as:

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- Key informant interviews to identify key players in the fight against malaria and to collect the views of key stakeholders, such as government, donors, implementing partners, the private sector, and supply chain players to understand the in-country malaria landscape with an emphasis on the priority products. This study has been conducted in the regions of Analamanga (for the key informants and stakeholders), Atsinanana, Vatovavy Fitovinany and Boeny. The market assessment framework was designed and presented to the RBM committee on June 14th, the selection of the external agency in charge of the study implementation was done, the interviewer training was completed, and the data collection was completed in two weeks starting from June 15th. Dissemination is scheduled in September waiting for other studies planned for the market assessment (outlet survey and household survey and the routine data analysis).

- Outlet survey to measure availability of malaria priority products and to estimate the volume and value among all potential outlets categorized as public sector, private for-profit sector, and private for nonprofit sector. The study design was approved by PSI’s Regional Researcher. The recruitment of an external local agency to implement the study is ongoing. The data collection is scheduled in August and September. Dissemination is scheduled in November.

- A household survey designed to measure the willingness to pay for the primary target group related to the following malaria products: LLIN, ACT, and RDT (including cost of consultation). Additionally, this household survey is designed to measure the knowledge and use of the products. The target audiences include: head of households, caregivers of children under five, caregivers of youth between 5 and 17 years old, women of reproductive age, and pregnant women in 10 USAID-supported regions. The study design was approved by PSI’s Regional Researcher. The recruitment of an external local agency to implement the study is ongoing. The data collection is scheduled in August and September. Dissemination is scheduled in November.

- Collecting routine data is part of the market assessment focused on market volume, market value, market share, and analysis on forecasts versus procurement. The routine data collection is combined with the outlet survey. Dissemination is scheduled in November.

6.1.3. Knowledge Management

During Quarter 3, IMPACT started to design an Intranet to promote knowledge and information sharing among all IMPACT partners. As an internal communication tool, the Intranet will be used to share technical and strategic documents about IMPACT’s implementation, such as project plans, reports, tools, success stories, dashboard to report PMP progress etc. All of the IMPACT local team members and the headquarters staff from each consortium partner will be given access. The design of the Intranet is ongoing and will be finalized in Quarter 4.

III.6.2. Gender and Social Inclusion

The Gender Equality and Social Inclusion (GESI) Analysis and Action Plan report was developed during Quarter 3 and submitted for feedback to IMPACT staff before submitting the revised version to USAID on June 24, 2019.

Some key findings from this study are shared below; the full report is included as an attachment.

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- Gender mainstreaming is missing from universal health coverage (UHC) policies and strategies in Madagascar. A gender-informed and socially inclusive approach to UHC will help alleviate the equity gaps in access to health services, especially for women and youth.

- Female-headed households are one of the most disadvantaged groups because they have fewer assets in terms of education, land ownership, and property.

- Although health services and products are intended to be available to all beneficiaries regardless of sex, there remain social and cultural norms that limit women and youth from seeking help in a dignified and transparent way.

● A significant portion of women hide the use of contraception from their spouses and sexual partners due to misunderstanding and lack of education among men about modern contraceptive methods and family planning practices. Many men are resistant to it due to misconceptions and false information. ● Only 35% of women use modern contraceptive methods, despite widespread awareness among women. ● Pregnant girls often do not use public health centers because of shame and the fear that they will be treated poorly by doctors ● Some boys with sexually transmitted infections are equally fearful and embarrassed to see doctors.

- Men and women value health differently. Health is seen as a woman’s duty, and men typically do not take responsibility for ensuring their own health or the health of sick family members. ● If household finances are available, women tend to go straight to the doctor if they or their children are sick, whereas men reported that they only bring their wives or children to the hospital if there is a life- threatening medical reason. They often arrive with complicated cases that could have been treated more easily earlier. This delay results in increased health-related expenses for the public sector and financial stress on households.

- Gender inequality is a key driver of early and forced child marriage; 48% of 20-24-year-old females were married by the age of eighteen, particularly in poor, rural areas where access to healthcare is already limited.

- Young married girls are more susceptible to discrimination and mistreatment when seeking family planning and maternal health services because of the social stigma against girls and unmarried women who are sexually active.

- Women and girls are more vulnerable to gender-based violence if they do not follow cultural norms to attend to unpaid household chores and care work.

- Women working in the formal and informal economies are more vulnerable to harassment, discrimination and a range of safety risks.

- Cultural norms dictate the type of jobs that are acceptable for men and women, which limits opportunities for all genders in the labor market. Men are expected to fill more labor-intensive roles that pay more, whereas women are expected to stay at home or hold jobs that are considered easier and therefore pay less.

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- While women more actively participate in the health sector compared to other sectors, there are social and cultural barriers that prevent women and girls from rising to the highest levels of decision-making and influence and limit their ability to benefit from health interventions. ● Women spend approximately four times as many hours on household activities compared to their spouses, yet men typically have the final say when making decisions regarding household affairs. ● After girls reach the age of 10 and the age where they require reproductive health services, their access to health services becomes limited due to cultural norms around women’s sexuality. ● If their businesses are not registered, women may not be eligible for formal financing or have access to appropriate loan collateral. This limits the ability of many women-owned businesses to expand and become more profitable over time. ● In times of economic hardship or emergency, savings are used and assets under women’s care are liquidated first, limiting women’s economic and financial independence. ● Women’s earnings were 34 percent lower on average than men’s earnings in jobs with similar characteristics.

The study findings will be used to inform FY2 work planning and to enhance accessibility and equitability of health commodities to improve the well-being of women, men, girls, and boys within a TMA approach.

- During Q3, the GESI team participated in the following activities: ● Ensured the participation of key GESI partners during the external launch of IMPACT program on April 15, 2019 at SALAMA headquarters, including the President of the Conseil National des Femmes de Madagascar (CNFM) and the gender focal points of other USAID-funded programs. ● Attended of the first training of drug shop owners held in Analanjirofo Fénerive Est on May 21-22, 2019 and integrated gender into the BHS tools, data analysis and training report. ● Met with Banyan Global headquarters staff, Matt Griffith, to discuss the integration of gender equality and social inclusion into commercial sector training design during his mission in Madagascar. ● Attended the Gender Focal Points meeting organized by the Ministry of Population to coordinate with other programs and to establish relationships with the leadership within the Ministry of Population (MoP) leading GESI mainstreaming. Completed the quarterly report submitted to the MoP on behalf of the IMPACT program. ● Prepared presentation on the key findings from the GESI Analysis and Action Plan for IMPACT staff retreat and external workshop taking place next quarter from July 1-5, 2019. ● Attended a workshop on May 8-9 organized by the USAID-funded ACCESS program to introduce, promote and coordinate a VSLA approach within the health sector.

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III.7. Environmental mitigation and monitoring report

Activities Conducted:

● Data collection tools on EMMP have been applied to (1) social marketing circuit from PSI warehouses, PARCs, and PAs; (2) public sector supply chain for SALAMA, Pha-G-Dis, and Pha-Ge-Com. ● During Quarter 3, 5 CRL were in charge of data collection on EMMP for the public sector and 24 Distribution Point Supervisors (DPS) collected data for social marketing using the last version tool (revised based on feedbacks received during Quarter 2). Data from Atsimo andrefana and Menabe were missing as the LRA has resigned. A new LRA for Melaky Region was hired at the end of Quarter 3. She will start her activities from July 2019. ● In total, data were collected in 14 Pha-G-Dis, 11 CSB/Pha-Ge-Com, 66 PARCs, and 859 PAs. ● During the period, 17 out of 21 (target Quarter 3) PHA-G-DIS and 11 out of 42 (target Quarter 3) Pha-Ge- Com were visited for EMMP. Activities in districts were mainly focused on training sessions to prevent and manage the expired/overstock health products and prepare the quarterly orders. Missing data from Atsimo Andrefana and Menabe have also contributed to non-achievement of the target for public sector 21 Pha-G-Dis and 42 Pha-Ge-Com to assess. ● At the end of each data collection, feedback and recommendations were recorded in a copybook left at the health facilities or PAs and PARCs for following-up.

General Findings: Public sector: ● 82% of CSB/Pha-Ge-Com visited have infrastructure for handwashing. Devices and equipment for cleaning and infection prevention are available in 63% of them and 82% used chlorinated water. ● 100% of Pha-G-Dis and Pha-Ge-Com assessed have no communication tool for storage conditions. ● Challenges identified include: o All staff of Pha-Ge-Com assessed were not trained in stock management especially the management of expired drugs. o None of the Pha-Ge-Com assessed have a copy of the official MOPH manual guidelines for storage conditions.

Non-profit private sector ● For the non-profit private sector involved in the storage of social marketing commodities (PSI Warehouses), all visited central warehouse staff were trained on management of expired and overstocked health commodities. Some warehouses had more than two people trained.

Recommendations and activities planned for Quarter 4: ● The 5 CRL will assess two SALAMA regional warehouses, 17 Pha-G-Dis, and 51 Pha-Ge-Com. The scope of the assessment concerns infrastructure, storage, management, transportation, and disposal of commodities to prevent any environmental impacts. ● CSB management committee should be noticed and recommended to permanently provide cleaning consumables to CSB. ● IMPACT will plan to train 100 CSB staff during Quarter 4. Training will be focused in the management of health commodities including expired and overstocked drugs, storage, and cold chain management. The contents of storage management training comply with MoPH commodities management guidelines. CSBs that have no adequate equipment for cold storage are not allowed to use and store Oxytocin. 51

● IMPACT will develop and distribute guidelines and job aids for storage conditions. ● IMPACT will follow-up with DPLMT in charge of incinerating expired products.

Details on findings and recommendations are presented in Annex C

FIELDS VISITS The COP and the DCOP conducted field visits to Antsiranana and SAVA regions from May 24th to May 26th, and June 12th to 15th respectively where the objectives were to (i) officially introduce the CRL to the local authorities; (ii) supervise PARCs and PAs in the region and identify issues related to the health commodities; (iii) identify private operators for a possible partnership and (iv) participate in the Pha-Ge-Dis and the MOPH staff training. Courtesy visits were conducted for the DRS (Regional Health Directorate) and the medical inspectors of Diego I and II, Vohémar and Sambava.

During the supervision, the main findings were the lack of trained staff in charge of stock management, the lack of coordination between districts and the region and the absence of computer equipment as well as the challenge of transport between Pha-G-Dis and Pha-Ge-Com. Corrective measures will be provided by the Logistics Coordinator Advisor.

At the community level, four PARCs and five PAs were visited and most products were available, but the stock out of MNCH products and the absence of temperature control for FP products was noted at some PAs level. The Pneumox has since arrived and thermometers have been placed at the PAs. In addition, the commercial channel large distributor and two wholesalers were visited, and they wish a continuous and permanent availability of health products.

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IV. KEY CHALLENGES AND SOLUTIONS

Table 21: key challenges and solutions N° Key challenges Solutions 1 Drugs and medical supplies for the MOPH Continue advocacy through regional and district local programs are not yet fully integrated and authorities in order to return the management of managed by some Pha-G-Dis and they are still in health products at the Pha-G-Dis. Clearly clarify the some parallel storage and distribution channel at roles and responsibilities of supply chain responsible the district level. at decentralized levels. The central level MoH is involved through dispatching notes to Regional and districts authorities and order of audits if needed 2 Availability of quality data remains challenging Continue to support Pha-G-Dis and districts to collect data in CHANNEL, analyze and used for decision- making. Encourage regional UTGL and district SSM committees to analyze data on a monthly basis and define actions plan to improve the supply chain system Provide IT equipment (laptops and internet connection) to identified PHA-G-Dis in need 3 The number of CRL hired is insufficient to ensure Recruit additional CRL to have at least one CRL in each regular supervision visits to the Pha-G-Dis and of the 10 USAID - supported regions to ensure PHA-GE-Com to reinforce their capacity building supervision visits in each district on a quarterly basis. 4 Lack of additional basic modules in partnership Adopt a holistic approach by considering potential with the ideal partners and resources partnership with existing specialized training providers in collaboration with the MOPH 5 Absence of a sustainable structure or mechanism Create a training structure based on identifying and to deliver training to health commodities supply training peer trainers. chain actors, mainly the drug shops 6 Lack of gender data on commercial sector The questionnaire was refined following the first stakeholders, including ownership and training with drug shop owners. The typical profile of management of drug shops, as well as customer the drug shops, their customers, their habits, and the data. reasons for frequenting the drug shops should be included in the Business Health Survey (BHS) questionnaire. 7 The completion of the BHS questionnaire took up Consider the typical profiles of the participants and a significant portion of time due to participants’ their academic and professional background before low literacy and education level. The training the training to better guide the content and curriculum is in French, but the training had to be approach. The low level of education of the conducted in Malagasy. This is an issue of social participants present at the training requires the inclusion that requires training adaptation. development of a curriculum in Malagasy, rather than French. Allocate more time prior to the training to complete the questionnaire.

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VI. MAJOR ACTIVITIES PLANNED FOR NEXT Quarter (YEAR 1, July – September 2019)

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

- Finalize and submit the TMI market assessment for malaria and incorporate the findings into the TMA malaria roadmap - Establish and train multi-sectoral (private, public, etc.) TWGs led by the TM Champions for health commodities and for malaria products. The TMI Champions will lead the TWG workshops to develop the overarching TMI roadmap for health commodities. - Support the UTGL and CGL on validation of multi-year forecasting and supply plans developed for 2019- 2021 and organize resources mobilization

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

- Generate orders in ARTMIS for commodities to be procured by USAID and PMI based on supply plans. Coordinate with GHSC-PSM and SALAMA on upcoming deliveries. - Support GAS committees to track planned procurements and develop a dashboard on stock status at the central level for malaria, FP/RH, and MNCH commodities. - Support GAS committees to analyze requisitions from districts and distribution plans for malaria, FP/RH, and MNCH. - Through the contract with SALAMA, ensure the transportation of malaria, FP/RH, and MNCH commodities to districts. - The CRL will conduct supervision visits in 17 Pha-G-Dis and 51 Pha-Ge-Com. - Supervise data collection and analysis of the LMIS in-depth evaluation. Organize a multi-stakeholder dissemination workshop to share findings and recommendations from the LMIS evaluation and the literature reviews on legal texts that will lead to the development of a road map to redesign an improved supply chain in Madagascar. - Conduct a national EUV survey of availability of malaria, MNCH, and FP commodities in selected sampling as per new PMI and GHSC-PSM guidelines.

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

- Expand the PSHP by engaging two new commercial actors active in health. - Support the health commission of the PSHP by developing the action plan for Year 2. - Support the M&E team in data collection and the use of the tool to collect LMIS data for FP/RH, MNCH, and malaria tracer health products within private and commercial sectors (pharmacies and drug shops) - Finalize the review of all legal texts related to the pharmaceutical sector to facilitate the involvement of the commercial sector in assuring availability and access to medicines. - Conduct a study tour visit of MOPH authorities from DAMM, Secretary General, DPLMT, and Pharmacy Council on the Accredited Drug Dispensing Outlet (ADDO) in Tanzania to learn about the approach and how it was set up in Tanzania and to start planning to adapt the approach in Madagascar. - Work with partner banks and SHOPS Plus platform to expand financing to health supply chain stakeholders through the DCA guarantees and adapted financial products - Train and support DCA partner banks in credit analysis and loan structuring for health businesses 54

- Work with partner banks and SHOPS Plus platform to expand financing to health supply chain stakeholders through the DCA guarantees and adapted financial products - Develop and adapt a training and coaching curriculum to build the financial management capacity of health businesses that will borrow money through the DCA through collaboration with SHOPS Plus

VI.3. IR4: Improved sustainability of social marketing to deliver affordable, accessible health products to the Malagasy people

- Continue to distribute socially marketed products across 10 regions for all products and an additional three PARN Regions for FP products through PARCs and PAs. - Continue training in Melaky region with 5 PARC and 30 PA. - Conduct the pilot for the delivery of health products to communities using drones in Maroantsetra (IR4.1 A7) - Analyze COGS to revise pricing (IR4.2 A1)

VI.4. IR5: Increased demand for and use of health products among the Malagasy people

- Continue to promote Sur’Eau Pilina by broadcasting radio spots and providing education about its use in the IMPACT regions. - Plan communication campaign to promote health products available - Continue SMS broadcast strategy and Call 910 center to promote products to large audiences in 10 IMPACT geographic areas through targeted communication. For example, PAs, PARCs, and CHVs will be alerted through SMS when a shipment of products arrives. - For the program targeting youth, sign an MOU with the MYS and Blue Ventures to reflect the collaboration. The activities of the demand creation subcommittee will begin in Quarter 4 after the set-up of the TMI TWG. The first meeting will be held on July 16th.

VI.5. Cross-Cutting

VI.6.1. Monitoring, Evaluation, Research, and Learning

Monitoring and Evaluation - Continuing to conduct supervision of LMIS with a focus on the public sector in support to the MOPH at regional and district level. - Provide technical and financial support to DEPSI and DPLMT on the implementation of the LMIS evaluation in collaboration with the HERA LMIS Expert. - Continuing LMIS data collection among pharmacies and drug shops in the Atsinanana region (Toamasina I and Toamasina II). - Continuing RDQAs to assess the data quality standards among the public sector and non-profit sector. - Finalizing PMP baselines versus targets.

Research - Key informant interviews on market assessment: data analysis, dissemination, and final report. - Outlet survey, household survey on willingness to pay, and routine data on market assessment: finalizing recruitment of the external agency, supporting the agency on field work preparation, interviewer training, data collection, data analysis, and report and dissemination.

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- Dissemination of the study on “Assess GOM’s interest and capacity for overseeing the private sector” conducted in Quarter 2.

Knowledge Management - Finalizing the design and the content of Intranet. - Supporting dissemination and knowledge management of the gender analysis conducted in Quarter 2. - Collec