Defeat Malaria Activity Quarterly Report (FY17Q1)

DEFEAT MALARIA

Defeat Malaria Activity Quarterly Progress Report October 01, 2016 to December 31, 2016

Submission Date: January 31, 2017

Agreement Number: AID-482-A-16-00003 Agreement Period: August 15, 2016 to August 14, 2021 AOR Name: Mya Sapal Ngon

Submitted by: May Aung Lin, Chief of Party University of Research Co., LLC. Room 602, 6th Floor, Shwe Than Lwin Condominium New University Ave. Rd., Battan Township Yangon, Email: [email protected]

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

Defeat Malaria Activity Quarterly Report (FY17Q1)

Table of Contents

Acronyms ...... 2

1. Introduction ...... 3

2. Goals and Objectives ...... 3

3. Implementation Progress ...... 4 3.1 Quarterly Summary ...... 4 Objective 1: Achieve and maintain universal coverage of at-risk populations with proven vector control and case management interventions, while promoting the testing of new tools and approaches...... 6 Objective 2: Strengthen the malaria surveillance system to comprehensively monitor progress and better inform the deployment and targeting of appropriate responses and strategies...... 15 Objective 3: Enhance technical and operational capacity of the National Malaria Control Program (NMCP) and other health service providers at all levels of service provision...... 15 Objective 4: Promote the involvement of communities, private healthcare providers, private companies and state-owned enterprises in malaria control and elimination initiatives...... 16

4. Challenges and Opportunities ...... 16

5. Jan-March 2017 Planned Activities ...... 17

6. Annexes ...... 19 6.1 Annex 1– Performance Indicators Tracking Table ...... 19

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ACRONYMS ACT Artemisinin-based Combination Therapy AOR Agreement Officer Representative

ARC American Refugee Committee BCC Behavior Change Communication

BHS Basic Health Staff

CBO Community-based Organizations COP Chief of Party

CSR Corporate Social Responsibility DCOP Deputy Chief of Party

DOPH Department of Public Health

DOT Directly Observed Treatment IP Implementing Partners

ITN Insecticide treated net KDHW Kayin Department of Health and Welfare

LLIN Longlasting Insecticide Net

M&E Monitoring and Evaluation MHAA Myanmar Health Assistant Association

MMP Mobile migrant population MNMA Myanmar Nurses and Midwifery Association

MoHS Minstry of Health and Sport

NGO Non-government Organizations NMCP National Malaria Control Program

NSA Non-state actors PMI President’s Malaria Initiative

PP Private Providers

QAQC Quality Assurance/Quality Control RAI Regional Artemisinin Initiative

RDT Rapid diagnostic tests SOP Standard Operation Procedures

TPR Test Positivity Rate

URC University Research Co., LLC VBDC Vector Borne Disease Control

VBS Village Based Stratification VMW Village Malaria Worker

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1. INTRODUCTION Despite a drastic reduction in morbidity and mortality, persistent malaria is seen at border areas, hard-to-reach hot spots and among vulnerable populations. The continued high malaria burden can be attributed to a combination of the following factors: • A relatively large portion of the population live in or near forested areas or have occasional exposure to forested areas. • Specific malaria control investments have been inadequate, leaving large gaps in finance and service delivery areas. • Topography and climatic conditions are favorable for transmission of malaria, and presence of difference species of efficient vectors also enhances transmission. • Limited information is available for areas controlled by non-state actors (NSA) which are not accessible by the National Malaria Control Program (NMCP). Service delivery is further complicated by differing languages and beliefs related to health The need to sustain progress made is rendered more urgent by artemisinin resistance, which has already spread over much of Eastern and Upper Burma. To prevent spread of drug- resistance, intensified malaria control activities must be conducted across the country. The USAID/Burma Defeat Malaria Activity responds to these challenges, building on the achievements of the USAID│PMI Control and Prevention of Malaria Project (CAP-Malaria), implemented by University Research Co., LLC (URC in Burma, Cambodia, and Thailand. 2. GOALS AND OBJECTIVES The overall goal of Defeat Malaria is to reduce the malaria burden and control artemisinin- resistant malaria in the target areas, and contribute to the long-term national goal of eliminating malaria in Myanmar. This will be achieved by expanding coverage of community- based prevention and case management services, prioritizing highly endemic and hard-to- reach areas, mobile and migrant populations, and non-state actor areas. Defeat Malaria will strengthen the capacity of local partners to effectively lead, manage and implement interventions towards the goal of malaria elimination. It will also strengthen the malaria surveillance system to better inform and target interventions, and to monitor progress. Defeat Malaria will engage communities and promote the involvement of the private sector. Defeat Malaria will work with the NMCP and key partners to achieve the following objectives: Objective 1: Achieve and maintain universal coverage of at-risk populations with proven vector control and case management interventions, while promoting the testing of new tools and approaches. Objective 2: Strengthen the malaria surveillance system to comprehensively monitor progress and inform the deployment and targeting of appropriate responses and strategies. Objective 3: Enhance technical and operational capacity of the NMCP and other health service providers at all levels of service provision. Objective 4: Promote the involvement of communities, private healthcare providers, private companies and state-owned enterprises in malaria control and elimination initiatives.

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Partners American Refugee Committee (ARC), Myanmar Health Assistant Association (MHAA), Myanmar Nurses and Midwifery Association (MNMA), and Jhpiego attended and participated in the meetings conducted for Defeat Malaria in Nay Pyi Taw and Yangon. In addition, partners conducted meetings with respective State and regional level persons on project start-up and implementation activities, analyses on coverage gaps and overlaps with respective Township Health Departments and malaria focal persons. They negotiated with township authorities, local and village level leaders on recruitment of volunteers, and discussed and assessed the status of former CAP-Malaria Village Malaria Workers (VMWs) and Private Providers (PPs). All partners are currently recruiting required human resources for the project implementation. Activity outcomes are reported in respective activity updates. Field staff also contacted former CAP-Malaria VMWs/PPs and village-leaders to assess if they still want to participate during Defeat Malaria. If not, replacements are identified. Field teams also collected a consensus on transportation allowances for health center meetings. 3. IMPLEMENTATION PROGRESS

3.1 Quarterly Summary

FY17 Q1 saw continued start-up of Defeat Malaria actvities. Together with Dr. Mya Sapal Ngon, the USAID Agreement Officer’s Representative (AOR), Defeat Malaria worked with the State Public Health Director (SPHD) at Hpa-an, Kayin State, to explore areas of collaboration for Defeat Malaria activities and to inform them ARC is Defeat Malaria’s implementing partner for Kayin State. Discussions were also held with the Kayin Department of Health and Welfare (KDHW) to explore possibilities to support KDHW and the Back Pack Health Workers Organization. ARC coordinated with the Kayin State Public Health Director and Vector Borne Disease Control (VBDC) Team Leaders on area coverage. In Kayin State and three townships in , Defeat Malaria will continue activities in areas covered by CAP-Malaria. Defeat Malaria will discuss implementation in detail once we receive approval of the work plan from the Minstry of Health and Sports (MoHS). On November 7, 2016, a meeting for the dissemination of the “Defeat Malaria Year 1 Work Plan” was conducted in Naypyidaw. The objective was to disseminate the “Defeat Malaria Year 1 Work Plan” and obtaine guidance and inputs from the VBDC and Disease Control, Department of Public Health (DOPH), MoHS. And, if necessary, to revise the work plan according to suggestions/guidance. The final objective was to get a consensus on the Defeat Malaria Year 1 Work Plan. The Director of Communicable Disease, Deputy Director of Malaria (Program Manager) and Central VBDC, Rakhine State, Kayin State, Taninthayi Region Health Directors, VBDC Leaders and Implementation Partners attended the meeting. In addition, the PMI Regional Malaria Advisor, USAID Malaria Advisor, USAID AOR and representatives from WHO, 3MDG, UNOPS attended. According to workshop recommendations, the work plan was revised on November 17, 2016 and presented to the Director of Communicable Diseases and the Program Manager for consensus. The work plan was then provided to the International Health Relationship Department for final approval.

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On November 11, 2016, ARC’s Project Manager and Field Operation Coordinator discussed with the Regional Artemisinin Initiative (RAI) and Save the Children Deputy Project Manager project villages to avoid overlapping in Hlaingbwe and Kawkayeik townships, Kayin State. Defeat Malaria’s Monitoring and Evaluation (M&E) Technical Advisor attended the Orientation Workshop on M&E Formats for Implementing Partners conducted by the NMCP in Nay Pyi Taw. The NMCP gave guidance on reporting timelines, flow, and a new reporting format to harmonize among all partners. Meeting objectives were: o To orient implementing partners on the data collection tools, flow of reports and timelines. o To familiarize partners with the existing data management system. o To improve/upgrade the existing data management system through the feedback from implementing partners. According to meeting outputs, all IPs will need to support this endeavor of NMCP for complete and timely reporting information for action and IPs will be oriented on that data management system 3.1.1. Geographic Area and Service Coverage Table 1: Defeat Malaria Geographic Coverage and VMW coverage* (October 2016 – December 2016) Covered No. of Organiza- Villages Covered Covered VMWs No. Township tion including Households Population already Worksites recruited Tanintharyi 1 60 5,130 22,545 29 2 56 5,896 33,715 34 3 Launglon 32 4,356 21,568 13 4 Myeik 49 5,869 30,799 25 URC 5 57 4,466 22,437 35 6 Thayet 43 5,855 30,221 15 7 48 7,647 31,947 10 8 Ann 61 3,203 14,818 51 Rakhine 9 Kyaukpyu 50 5,902 24,865 50 10 URC Ramree 88 8,112 35,648 39 11 Toungup 76 6,300 26,782 47 12 Gwa 50 4,366 14,246 50 MNMA 13 Thandwe 50 3,459 12,648 50 TOTAL 720 70,561 322,239 448 *Includes townships with already recruited and trained VMWs, and starting case detection, management activities, and VMW monthly meetings. Defeat Malaria plans to cover 1,974 villages/worksites in 3 States and Regions. The current number of villages and worksites at the end of December 2016 is 970 (nearly 50%). This is because most of the villages in planned townships are already occupied by other implementing partners, not yet receiving official approval from MOHS, some States/Regions cannot yet start activities without official approval. Defeat Malaria is working VBDC officials to ensure 5 Last Updated: January 30, 2017 Defeat Malaria Activity Quarterly Report (FY17Q1)

coverage in areas with gaps. 3.1.2. Summary of key activities (Services)  To increase uptake of malaria preventive services and use of malaria diagnosis and treatment in target areas o A total of 1,095 long-lasting insecticidal nets (LLINs) were distributed in as requested by the Regional Malaria Control Programme, covering 18 worksites, 500 households and 1,272 people. o 1,472 people (786 male and 686 female) were reached by interpersonal communication (IPC) activities, including 118 migrants. o In 13 townships, 5,370 people were tested for malaria with rapid diagnostic tests (RDTs) through a network of 448 volunteers and private providers. o 272 malaria patients (212 Pf , 58 Pv and 2 Pfmixed) were treated. 97.42% among them were treated according to National Treatment Guidelines. o 236 newly recruited VMWs/PPs (92 male and 144 female) were trained on both malaria diagnosis and case management. VMWs/PPs continuing from CAP-Malaria will be trained in FY17Q2.  To strengthen the malaria surveillance system for increasing use of strategic information for decision making at national and local levels

o Build local capacity of health care providers and volunteers, as well as project staff to maintain quality malaria services and malaria information . Orientation training to Defeat Malaria staff on the M&E system . How to use existing CAP-Malaria strategic information as a baseline in Defeat Malaria (based on the CAP-Malaria end line survey and project achievements)  To enhance technical and operational capacity of the NMCP and other health service providers at all levels of service provision. o Logistic and technical support to NMCP on Planning and Implementing Partners mapping.  To promote the involvement of communities and private sector in malaria control and elimination initiatives. o Met with the Karen Department of Health and Welfare to explore possible areas of collaboration and service gaps of KDHW. o Advocacy meeting with village leaders and villagers on Defeat Malaria, their roles, and selection of village volunteers. Conducted seven advocacy meetings with 466 people (147 male and 319 female) (District level and Township level). Objective 1: Achieve and maintain universal coverage of at-risk populations with proven vector control and case management interventions, while promoting the testing of new tools and approaches. 1. Ensure the distribution of LLINs, diagnostics, and quality-assured medicines to the beneficiary populations, health services and collaborating VMWs in the targeted areas Township coverage areas were updated based on discussion with respective Township Health Departments and commodity storage and distribution points were established. Monthly 6 Last Updated: January 30, 2017 Defeat Malaria Activity Quarterly Report (FY17Q1)

monitoring and supervision of stock management of VMWs/PPs during monthly meetings will be conducted after distribution, which will start in FY17Q2, to optimize coverage and promote use of proven vector control interventions. LLIN distribution and monitoring of net coverage and utilization Table 2: LLIN distribution at worksites in (October 2016 to December 2016) Indicator Results # of Worksites 18 # of Households (HHs) present 500 # of HHs covered 500 # of Population present 1,272 # of Population covered. 1,272 Total LLINs Distributed 1,095 % of HHs having LLIN 100.0% % of Population covered 100.0% Net Ownership (Pop per LLIN) 1.16

During October – December 2016, 18 work sites in Thayetchaung Townships received 1,095 LLINs covering a population of 1,272 from 500 households. Table 3: Monitoring net coverage and utilization in Tanintharyi Region (October 2016 to December 2016) Township Indicator Launglon Yebyu Total # of villages 11 10 21 HH Number 132 120 252 # Of HH Members 782 605 1,387 # Of Migrants in HH 0 1 1 Total # of Bed Nets in Your House 376 308 684 # of Ordinary Nets 126 86 212 # of LLINs Received Within 3yrs 250 222 472 Population Per LLIN 3.13 2.73 2.94 # of People Slept in Your House Previous Night 718 528 1246 Including Visitors # of People Slept Under Bed Nets in Your House 544 378 922 Previous Night Including Visitors % of People Slept Under Bed Nets 75.8% 71.6% 74.0% Under Ordinary Nets 207 80 287 Under LLINs 337 298 635 % of People Slept Under LLINs 46.9% 56.4% 51.0% % of People Slept Under Ordinary Nets 28.8% 15.2% 23.0% # of Migrants Slept in Your House Last Night Including 0 2 2 Visitors # of Migrants Slept Under Bed Nets in Your House 0 2 2 Previous Night Including Visitors Under Ordinary Nets 0 0 0 Under LLINs 0 2 2 % of migrants Slept Under LLINs last night 0 100.0% 100.0%

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In Decmeber 2016, monitoring of LLIN coverage and utilization was conducted in project villages in Launglon and Yebyu townships in Tanintharyi Region, where LLINs were distributed during CAP-Malaria. Populations per LLIN were 3.13 and 2.73, respectively, in Launglon and Yebyu and did not meet the 2:1 ratio. Top-up distribution to increase coverage will be done in January 2017. LLIN utilization was about 50% in both townships and promotion of LLIN utilization will be emphasized through Behavior Change Communication (BCC) during LLIN top-up distribution. Interpersonal Communication VMWs and private providers provided IPC. Figure 1 shows the total number of people, disaggregated by gender, reached through IPC on malaria preventive messages such as taking treatment with 24 hours after onset of fever, sleeping under a LLIN, etc. A total of 1,472 people (786 male and 686 female) were covered by IPC. Among them, 118 were migrants. PPs reacged 284 people. Figure 1: Number of people, disagreggated by gender, reached through IPC by VMWs and PPs in Tanintharyi Region and Rakhine State Townships (October - December 2016)

Toungup 128 78 Thandwe 31 Ramree 87 98 Kyaukpyu 80 57 Gwa 58 60 Ann 230 201 Yebyu 72 Thayetchaung 17 12 Palaw 31 23 Myeik 38 68 Launglon 513 Kyunsu 63 50 Dawei 39 23 0 50 100 150 200 250 300 350 400 450

Male Female

Table 4: Number of people reached through interpersonal communication (IPC) by Private Providers (October 2016 to December 2016)

Individual IPC by Private Providers

Sr No. Township Migrants Male Female Total included

Tanintharyi 1 Dawei 2 1 3 0 2 Kyunsu 21 20 41 0 3 Myeik 22 35 57 3 4 Palaw 1 4 5 3 5 Thayetchaung 13 8 21 3 Sub-total 59 68 127 9 Southern Rakhine 8 Last Updated: January 30, 2017 Defeat Malaria Activity Quarterly Report (FY17Q1)

Individual IPC by Private Providers

Sr No. Township Migrants Male Female Total included

1 Ann 45 35 80 2 2 Kyaukpyu 8 6 14 0 3 Ramree 2 3 5 0 4 Toungup 41 17 58 4 Sub-total 96 61 157 6 Grand Total 155 129 284 15

2. Ensure early diagnosis and appropriate treatment of all clinical malaria cases. Case finding and management Case detection was done through various approaches such as mobile teams, screening points, and VMWs and PPs in Tanintharyi Region and Southern Rakhine State. A total of 5,370 people were tested and 272 positive cases were found to be positive (212 Pf, 58 Pv and 2 mixed). The Test Positivity Rate (TPR) is 5.07%. Table 5: Summary of case finding and management (October 2016 to December 2016)

No. of No. # Approaches positive Pf Pv Mixed TPR% tested cases

1 Mobile Teams 121 3 3 0 0 2.48%

2 Screening Points 0 0 0 0 0 0%

3 VMWs 3,860 198 156 40 2 5.13%

4 PPs 1,389 71 53 18 0 5.11%

5 Total 5,370 272 212 58 2 5.07%

From October 2016 to December 2016, 51 positive cases (19 Pf and 32 Pv) were found among 2,527 tested in Tanintharyi Region and 221 positive cases out of 2,843 tested were positive in Southern Rakhine State. TPRs were 2.02% in Tanintharyi and 7.77% in Southern Rakhine State. Case finding and management activities were not yet started in Northern Rakhine and Kayin States. Table 6: Summary of case finding and management by State/Region (October 2016 to December 2016)

No. of No. # State/Region positive Pf Pv Mixed TPR% tested cases

1 Tanintharyi 2,527 51 19 32 0 2.02%

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No. of No. # State/Region positive Pf Pv Mixed TPR% tested cases

2 Southern Rakhine 2,843 221 193 26 2 7.77%

3 Northern Rakhine 0 0 0 0 0 0%

4 Kayin 0 0 0 0 0 0%

5 Total 5,370 272 212 58 2 5.07%

There was a high number of positive malaria cases in Rakhine State where transmission is intense and there were service gaps between CAP-Malaria and Defeat Malaria. Imported cases also contributed to the high number of positive cases. In Rakhine State, about 87% of total positive cases were P falciparum. Because of the high Pf case load, rapid and aggressive reduction of positive cases is required to prevent development of artemesinin resistant Pf in Rakhine State. Directly Observed Treatment of Pf and Mixed Cases During this reporting period, directly observed therapy (DOT) activities were implemented in townships where case finding and management was conducted. DOT is provided by either VMWs or PPs, but not all Pf and Mixed positive cases are enrolled in DOT. Enrollment depends on accessibility, occupation (migrants) and social factor of female VMWs/PPs. Some people enrolled in DOT may need to travel before completion of the 6 doses. In this case, VMWs instruct patients on how to properly complete the course of treatment. If >5 Pf or mixed cases are detected during mobile case finding activities in hard- to-reach hot spots and villages, where neither VMWs nor PPs exist, a mobile-team staff may stay in the village to provide DOT provided the team can spare a team member. Otherwise, mobile teams offer DOT on the first dose only. From October to December 2016, 214 Pf and mixed (78.7%) infections were detected among a total of 272 positive cases,. Among these, 123 cases (57.5%) were enrolled in DOT. All enrolled Pf and mixed cases completed DOT (100%). While 100% of patients enrolled in DOT completed the full course, overall, only only 57.5% of Pf and mixed cases were enrolled in DOT. Table 7: Summary of Directly Observed Treatment (DOT) (October 2016 to December 2016)

Total Pf % of % of No. of and Total Total completed completed covered No. of DOT Mixed Pf+Mixed Pf+Mixed DOT DOT Villages implemented # Township positive enrolled of among among the and Villages and in under complete Total Pf patient Worksit Worksites project DOT DOT and Mixed under es areas positive DOT Tanintharyi 0% Dawei 60 0 0 0 0 0% 0% 2 Kyunsu 56 3 14 5 5 35.7% 100.0% 3 Launglon 32 0 0 0 0 0% 0% 4 Myeik 49 1 1 1 1 100.0% 100.0% 5 Palaw 57 1 3 1 1 33.3% 100.0% 6 Thayetchaung 43 1 1 1 1 100.0% 100.0%

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Total Pf % of % of No. of and Total Total completed completed covered No. of DOT Mixed Pf+Mixed Pf+Mixed DOT DOT Villages implemented # Township positive enrolled of among among the and Villages and in under complete Total Pf patient Worksit Worksites project DOT DOT and Mixed under es areas positive DOT 7 Yebyu 48 0 0 0 0 0% 0% Total 345 6 19 8 8 42.10% 100.0% Rakhine (South) 1 Ann 61 22 144 83 83 57.64% 100.0% 2 Gwa 50 0 2 0 0 0% 0% 3 Kyaukpyu 50 0 0 0 0 0% 0% 4 Ramree 88 0 4 0 0 0% 0% 5 Thandwe 50 0 0 0 0 0% 0% 6 Toungup 76 5 45 32 32 71.1% 100.0% Sub-total 375 27 195 115 115 58.97% 100.0%

Grand Total 720 33 214 123 123 57.48% 100.0%

Table 8: Clinical Audit on case treatment according to National Treatment Guidelines (October -December 2016).

Total (+) % of (+) cases Total % of Total (+) cases Total (+) patients treated referred treated found in cases treated who was # Township according cases in cases reporting in reporting treated to NTGs in reporting among (+) month month according reporting month cases to NTGs month

Tanintharyi 1 Dawei 7 7 7 0 100.0% 100.0% 2 Kyunsu 25 25 25 0 100.0% 100.0% 3 Myeik 2 1 1 1 50.0% 100.0% 4 Palaw 8 8 7 0 100.0% 87.5% Thayetcha 5 9 9 9 0 100.0% 100.0% ung Sub-total 51 50 49 1 98.0% 98.0% Southern Rakine 1 Ann 160 160 159 0 100.0% 99.4% 2 Gwa 7 7 4 0 100.0% 57.1% 3 Ramree 1 1 1 0 100.0% 100.0% 4 Thandwe 4 4 4 0 100.0% 100.0% 5 Toungup 49 49 47 0 100.0% 95.9% Sub-total 221 221 215 0 100.0% 97.3% Grand Total 272 271 264 1 99.6% 97.4% Clinical audit was done in 10 townships of Rakhine State and Tanintharyi Region. About 97.4% of treated cases were complied according to National Treatment Guideline. Monthly meetings of VMWs and PPs

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Monthly meetings with existing VMWs and PPs (formerly CAP-Malaria) were conducted starting November 2016 in existing project areas (previous CAP-Malaria townships) to monitor performance, collect and verify data, replenish materials and drugs, and discuss case management and migrant activities in their community. Timely reporting is important and monitored monthly. Among rep

Figure 2: Status of timely reports from VMWs and PPs (October 2016 to December 2016).

100% 100% 100% 100% 100% 100% 100% 100% 99% 100% 100% 100% 100% 100% 100.0% 90% 97.1% 97.4% 97.4% 95.6% 97.4% 96.0% 94.3% 92.0% 92.4% 80% 87.9% 81.6% 70%

60% 66.0% 50%

40%

30%

20%

10%

0%

% of those reporting who reported on time % Reporting

3. Strengthen and expand the network of VMWs to improve access to basic diagnostics and treatment services (RDTs and ACTs), particularly for high-risk and hard-to- reach populations. Capacity Building: Diagnosis and Case Management From October 2016 to December 2016, 236 health workers including 194 VMWs (73 males, 121 females) and PPs (19 males, 23 females) were trained on case management with artemisinin-based combination therapies (ACTs) and on malaria diagnostics (RDTs). All were new trainings lasting for 3 days. Table 9: Number of VMWs and PPs trained on case management with ACT (October 2016 to December 2016)

Village Malaria Workers Private Providers Grand # Townships M F Sub-total M F Sub-total Total Tanintharyi

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Village Malaria Workers Private Providers Grand # Townships M F Sub-total M F Sub-total Total 1 Kyunsu 2 24 26 6 3 9 35 2 Launglon 6 19 25 - - - 25 3 Myeik 2 19 21 1 6 7 28 4 Thayetchaung 2 7 9 - 5 5 14 Total 12 69 81 7 14 21 102 Southern Rakhine 1 Ann 24 16 40 4 2 6 46 2 Kyaukpyu 26 14 40 - 6 6 46 3 Toungup 11 22 33 8 1 9 42 Total 61 52 113 12 9 21 134 Grand Total 73 121 194 19 23 42 236

Table 10: Number of VMWs and PPs trained on diagnosis (October 2016 to December 2016)

Village Malaria Workers Private Providers Grand # Townships M F Sub-total M F Sub-total Total Tanintharyi 1 Kyunsu 2 24 26 6 3 9 35 2 Launglon 6 19 25 - - - 25 3 Myeik 2 19 21 1 6 7 28 4 Thayetchaung 2 7 9 - 5 5 14 Total 12 69 81 7 14 21 102 Southern Rakhine 1 Ann 24 16 40 4 2 6 46 2 Kyaukpyu 26 14 40 - 6 6 46 3 Toungup 11 22 33 8 1 9 42 Total 61 52 113 12 9 21 134 Grand Total 73 121 194 19 23 42 236

VMW supervision Following table shows number of VMW/PP supervised and monitored between October 2016 to December 2016. During supervision visits, case registers were checked for data quality, completeness and validity. No stock out was found during these visits. Table 81: Number of VMW/PP supervised and monitored (October 2016 to December 2016)

Number of # of visits to # of visits Total # of VMWs and # Township VMWs/PPs Posts VMWs to PPs PPs supervised

Southern Rakhine 1 Ann 51 16 4 20 2 Kyaukpyu 50 13 2 15 3 Ramree 39 4 0 4 4 Toungup 47 2 10 12 Total 187 35 16 51 13 Last Updated: January 30, 2017 Defeat Malaria Activity Quarterly Report (FY17Q1)

Grand Total 187 35 16 51

Monitoring on stock out of RDTs and first line antimalarials (ACTs) To provider better malaria service to community, Defeat Malaria monitored on whether stock out of commodity mainly on RDT and first line antimalarial (ACT) at service delivery points regularly by checking commodity balance of VMW/PP at monthly meeting and at the time of monitoring visits. If a service delivery point run out of RDT or ACT or had any expired commodity for one week or longer during last 3 months, that kind of service deliver point faced stock out experience. During this reporting period, total 89 VMW/PP were monitored on stock out of commodity not only at monthly meeting but also at the time of monitoring visits and all monitored VMW/PP responded they experienced no stock out of any commodity. Coordination Meetings The “National Malaria Partner Mapping Workshop” was organized by NMCP on 11th October and 8th - 9th November 2016 in Nay Pyi Taw. Follow-up meetings will be conducted at the State/Region and Township levels. Main objectives of the meeting were to identify the services of each malaria implementing partner, detect any duplication and overlap or service gaps in interventions and ensure geographical coverage while implementing operation activities. Defeat Malaria’s COP, Deputy Chief of Party (DCOP) and Senior Technical Director participated. Defeat Malaria provided logistic and technical support for this meeting. The “Regional Coordintion Meeting on Malaria” was conducted on October 7, 2016 in Dawei. Defeat Malaria’s Regional Field Diector attended the meeting and introduced the project and the village-based malaria situation of Dawei and Kyunsu townships. He also discussed the service gap assessment in with the NMCP Team Leader who provided VMW data of all IPs for verification.

The “Coordination and Planning Meeting with Malaria Partners and Township Medical Officers” organized by the Tanintharyi Regional Health Director was held on December 26, 2016 in . Defeat Malaria’s Regional Field Director presented CAP-Malaria’s 2016 achievements and future plans for Defeat Malaria. At the request of the Thayetchaung Malaria Supervisor and Township Medical Officer, LLIN distribution was conducted in 7 migrant worksites. Eight hundred and fifty (850) LLINs were distributed to achieve coverage of 348 HH and 996 populations.

“Township Level Migrant Mapping Meeting” organized by NMCP was held on 24th Oct 2016 in Thayetchaung township. Township administrative officer, Township Medical Officer (Thayetchaung township), Malaria Team Leader (Tanintharyi Regional VBDC) and Regional Field Director of Defeat Malaria project attended the meeting. After the mapping, it was detected that 800 LLINs are needed to get complete coverage to migrants there. NMCP requested to distribute those 800 LLINs to migrants in Thayetchaung township. 4. Conduct operational research to pilot promising new tools and approaches to reduce malaria transmission as directed by PMI, in consultation with the NMCP No activity during this reporting period (October to December 2016).

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Objective 2: Strengthen the malaria surveillance system to comprehensively monitor progress and better inform the deployment and targeting of appropriate responses and strategies. 1. Strengthen the malaria surveillance system, improve data management capacity at all levels of the health system, from village to central level, and support appropriate information technology to facilitate data collection, reporting, and use in both public and private sectors. Activities will start in Y1Q4. 2. Support the implementation and regular updating of the new village-based malaria stratification framework, mapping high-risk areas and populations and use of data to better plan and target control interventions. Activities will start in Y2Q3. 3. In elimination areas, pilot test and scale-up a system for rapid detection and notification of malaria cases, case and contact investigations, and prompt deployment of appropriate response interventions. Activities will start in Year 2. 4. Conduct entomological monitoring in representative sentinel sites to monitor vector bionomics, behavior, insecticide resistance and potential breeding sites. Additional entomological surveys may be carried out in areas identified as foci or hot-spots at the request of PMI and the NMCP to guide program planning and implementation. No Activity Activities will start in Y1Q2. Objective 3: Enhance technical and operational capacity of the National Malaria Control Program (NMCP) and other health service providers at all levels of service provision. 1. Improve skills and job performance of staff involved in malaria control, particularly on epidemiology, surveillance, entomology and vector control, through supportive supervision and training at peripheral and national levels. From November 23-26, 2016, Defeat Malaria’s Deputy Chief of Party (DCOP) and Technical Advisor joined a workshop on the Finalization of Standard Operating Procedures (SOPs) in RAI areas and Evidence-Based Decision Making conducted by the NMCP in Nay Pyi Taw. The DCOP provided technical inputs, facilitated the workshop and finalized the SOPs especially on Case Investigation and Foci Investigation by DCOP. 2. Strengthen the quality of malaria parasitological diagnosis through a Quality Assurance/Quality Control program addressing all diagnostics methods used in the targeted areas: microscopy, RDTs and other potential new techniques. Activities will start in Y1Q2.

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Objective 4: Promote the involvement of communities, private healthcare providers, private companies and state-owned enterprises in malaria control and elimination initiatives. 1. Build the organizational and technical capacity of CBOs and ethnic organizations. From October 4-5, 2016, a meeting was held to discuss the Defeat Malaria Project Year 1 Work Plan among Defeat Malaria partners at the Reno Hotel Yangon. The objective was to inform partners of the PMI M&E plan and requirements, discuss and agree on procedures and tools for data collection, analysis and reporting, and to analyze and agree on the M&E plan for the first year of Defeat Malaria. Staff presented and discussed with partners the PMI requirements and guidelines for the M&E plan, annual work plan, standardization of terminology, current M&E procedures of different partners, detailed facts on targeted MMPs, PPs to be recruited, capacity building activities, research areas, and requirements on environmental monitoring and mitigation plan (EMMP), human trafficking and harassment.

Dr. Mya Sapai Ngon (USAID AOR), Dr. David Sintasath (Regional PMI Malaria Advisor), Dr. Feliciano Monti (PMI Malaria Advisor - Myanmar), Dr. Neeraj Kak (URC HQ), URC staff and representatives from all implementing partners attended the meeting.

2. Strengthen BCC and community mobilization activities to promote the sustained use of preventive methods, the timely use of community and facility-based health services, the adherence to prescribed treatment, and the collaboration in the testing of new tools and approaches. Total number of 284 people, including 155 male and 129 female were covered with interpersonal communication by informal private providers engagement (see objective 1, Table 4). BCC messages were emphasized on CAP-Malaria endline survey findings like regular use of LLIN when and where-ever they slept, washing and drying practice of LLIN, use of LLINs in proper ways, taking treatment within 24 hours from the onsetof fever. 3. Strengthen and expand training, supportive supervision, and provision of diagnostics and quality-assured antimalarial drugs to private health care providers involved in the management of malaria cases. Activities will start in Y1Q2. 4. Promote engagement of private companies and state-owned enterprises in malaria control and elimination activities through Corporate Social Responsibility (CSR) initiatives. Activities will start in Y1Q2. 4. CHALLENGES AND OPPORTUNITIES  Start-up (village level) - The project plans to cover 1,974 villages in three States and Regions. From October -December 2016, the project has initiated activities in 720 villages and worksites. Project area coverage is nearly 37%. To achieve the target, respective Township, State and Region Level Health Authorities will be engaged to initiate project implementation.  Delay in Northern Rakhine – In new project areas of Nothern Rakhine State, there is a delay in start-up due to unstable conditions. With close guidance from local

16 Last Updated: January 30, 2017 Defeat Malaria Activity Quarterly Report (FY17Q1)

administrative authorities, local health departments will be taken for initiation of project activities.  Difficulty in finding malaria cases –Starting from practicing aggressive and universal coverage of prevention and case management by all implementing partners, malaria prevalence reduced in most of the geographical areas. This led to low detection of positive malaria cases. Most of the new expansion villages have a low malaria caseload. Through negotiation and collaboration with State/Regional Health Departments/VBDC, Defeat Malaria will work beyond target areas and establish a village-based strategy and introduce intensified case finding activities. In areas where malaria prevalence is low or zero, it is necessary to adapt to the changing epidemiology and utilize appropriate approaches. In these areas, it is difficult to see impact and important to sustain a low or no malaria status in such area. Sometimes it is more costly to sustain low status or prevent reintroduction.  Existence of parasite reservoir among uniform services – In areas of high malaria transmission, such as Ann Township in Rakhine State, there is no proper case finding, management or vector control measures among uniform services. Uniform services may serve as a parasite reservoir and a source of infection to re-introduce malaria in areas where infection rates are very low or zero.

5. JAN-MARCH 2017 PLANNED ACTIVITIES Apart from routine monthly activities including advocacy meetings, trainings, IPC, LLIN distribution, case finding and management, DOT, VMW supervision, etc., the following activities are planned to conduct during January 2017-March 2017.  Support the NMCP to strengthen Township data management system by providing computers and training NMCP staff on data management. (Activity 2.1.1)  Support the NMCP to establish a system for detecting and responding to malaria epidemics (Training Activity 2.1.3.)  Support the NMCP to update and revise the malaria microstratification guidelines inline with malaria elimination. (Activity 2.2.2 & 2.2.3)  Entomological and epidemiological surveys (Activity - 2.3.3.)  Support NMCP on basic malariology training to newly promoted malaria assistant. (Activity 2.5.1)  Initiate Jhpiego training methodology (Activity 3.1.1. – 3.1.4)  Initiation of laboratory Quality Assurance/Quality Control (QAQC) (Activity 3.2.)  Private providers mapping and worksite mapping

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Defeat Malaria Activity Quarterly Report (FY17Q1)

6. ANNEXES

6.1 Annex 1– Performance Indicators Tracking Table

Actual Target End line Indicators Frequency Baseline (FY17 Q1) Year 1 (Year 5) IP 1: Rate of confirmed malaria cases TBD after project per 1,000 populations in Defeat Annual 8 (CAP-M PY4) N/A areas profiles are 5 Malaria project areas completed IP 2: Number of severe malaria cases 660 in 2015 (from Monthly 0 TBD TBD in Defeat Malaria project areas National M&E Plan) 0.08 in 2015 (from IP 3: Malaria Mortality Rate Monthly 0 TBD TBD National M&E Plan) 6% in 2015 (from IP 4: Annual Blood Examination Rate Annual N/A TBD 8% National M&E Plan) 80%, 40% and 10% (indigenous cases) in 2016, 2017 and 2018 IP 5: Case classification rate (in respectively; and 80% 9% in 2015 (from Not done in Defeat Malaria elimination target Monthly NA and 40% (indigenous National M&E Plan) FY2017 areas) cases) in 2019 and 2020 respectively in elimination States/Region. (from National M&E Plan) 80% in elimination States/Regions by IP 6: Foci classification (in Defeat Not done in 2020. Monthly N/A NA Malaria elimination target areas) FY2017 80%, 40% and 10% (active foci) in 2016, 2017 and 2018 respectively; and

19 Last Updated: January 30, 2017 Defeat Malaria Activity Quarterly Report (FY17Q1)

Actual Target End line Indicators Frequency Baseline (FY17 Q1) Year 1 (Year 5) 80% and 40% (active foci) in 2019 and 2020 respectively in elimination States/Region. (from National M&E Plan) Objective 1: Achieve and maintain universal coverage of at-risk populations with proven vector control and case management interventions, while promoting the testing of new tools and approaches OC 1.1 % of households in targeted areas that own at least one N/A 60% ≥ 85% insecticide treated net (ITN) 47% (in Rakhine), OC 1.1.1 % of households in targeted 60,2% (in areas that own at least one ITN for Tanintharyi), 65.6% N/A 60% ≥ 85% every two persons (in Kayin) - from CAP-M OC 1.2 % of individuals in targeted areas who slept under ITN the previous night. (disaggregate by type N/A 55% ≥ 70% of net, pregnant women, children Baseline and end line under 5 OC 1.2.1 % of local residents in CAP- M targeted areas who slept under ITN the previous night (disaggregate N/A 55% ≥ 70% by type of net, pregnant women, children under 5 OC 1.2.2 % of migrants in CAP-M targeted areas who slept under ITN the previous night (disaggregate by N/A 55% ≥ 70% type of net, pregnant women, children under 5

20 Last Updated: January 30, 2017 Defeat Malaria Activity Quarterly Report (FY17Q1)

Actual Target End line Indicators Frequency Baseline (FY17 Q1) Year 1 (Year 5) OC 1.3.1 % of supplied RDT are Monthly N/A N/A TBD 100% distributed as planned OC 1.3.2 % of supplied ACT are Monthly N/A N/A TBD 100% distributed as planned OC 1.3.3 % of service delivery points which report no stock outs of RDTs Minimum 85% (from lasting more than one week during Quarterly N/A 85% ≥ 90% CAP-M) the past 3 months (disaggregate by type of SDP) OC 1.3.4 % of service delivery points which report no stock outs of first line antimalarial medicines (ACT) Minimum 85% (from Quarterly N/A 85% ≥ 90% lasting more than one week during CAP-M) the past 3 months (disaggregate by type of SDP) OC 1.4 % of reported malaria cases in last 3 months which are confirmed 21.9% (from MARC Baseline/End line N/A TBD 25% through microscopy or RDTs. survey) (among fever cases) OC 1.5 % of patients found positive who received antimalarial treatment Minimum 95% (from Monthly 97.42% 95% ≥ 95% according to National Malaria CAP-M) Treatment Guidelines OC 1.6 % of Pf/mixed Positive cases with DOT having complete Monthly 25% (from CAP-M) 57.48% 30% ≥ 50% observation (disaggregate by sex, age, and resident status) OP 1.1 Number of insecticide treated Activity implemented 92,986 (From CAP- net purchased in any fiscal year that 1,095 200,000 NA months M PY5) were distributed (F-indicator)

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Actual Target End line Indicators Frequency Baseline (FY17 Q1) Year 1 (Year 5) OP 1.2 Number of artemisinin-based combination therapy (ACT) TBD after project treatments purchased that were Every 6 months NA 0 areas profiles are NA distributed in any fiscal year (F- completed indicator) OP 1.3 Number of RDTs purchased TBD after project in any fiscal year that were Every 6 months NA 0 areas profiles are NA distributed to health facilities (F- completed indicator)

OP 1.4. Number of individuals TBD after project reached with malaria behavior change Monthly, semiannual and 514,333 (from CAP- 1,472 areas profiles are NA messages through interpersonal annual M PY5) completed communication (counted)

OP 1.5 % of training activities for health staff and VMWs are carried Month of training TBD N/A TBD Yes out as planned OP 1.5.1 Number of health workers trained in case management with 5,155 (from CAP- Month of training 236 1,500 VMWs/PPs NA ACTs (Disaggregated by male, female, M) and profession) (F-indicator) OP 1.5.2 Number of health workers trained in malaria laboratory diagnostics (rapid diagnostic tests 5,443 (from CAP- Month of training 236 1,500 VMWs/PPs NA (RDTs) or microscopy) M) (Disaggregated by male, female, and profession) (F-indicator) OP 1.6 Number of malaria tested in 583,518 (from CAP- Monthly 5,370 NA NA Defeat Malaria target area M)

OP 1.7 Number of confirmed malaria 23,512 (from CAP- Monthly 272 NA NA cases in Defeat Malaria target area M)

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Actual Target End line Indicators Frequency Baseline (FY17 Q1) Year 1 (Year 5) OP 1.8 Number of malaria cases 23,394 (from CAP- Monthly 271 NA NA treated in Defeat Malaria target areas. M)

OP 1.9 % of VMWs/PPs received at Annually N/A 0 NA ≥ 90% least two supervisory visits per year

OP 1.10 % operational research activities and pilot testing of innovative tools and delivery approaches approved in the annual Annual N/A 0 TBD Yes work plans and by the PMI operational research committee are implemented and evaluated as planned Objective 2: Strengthen the malaria surveillance system, improve data management capacity at all levels of the health system, from village to central level, and support appropriate information technology to facilitate data collection, reporting, and use in both public and private sectors OC 2.1 % of service delivery points in targeted areas report monthly data of Monthly ≥ 80% 92.07% 85% ≥ 90% malaria cases (disaggregate by type of SDP) OC 2.1.1 % of service delivery points in targeted areas report monthly data Monthly N/A 99.90% 85% ≥ 90% of malaria cases on time (disaggregate by type of SDP) OP 2.1 Number of Basic Health Staff (BHS) and project M&E staffs trained Month of training N/A 0 TBD NA on malaria database system OP 2.2 % of project villages developed and updated for Village Annually N/A NA ≥ 90% ≥ 90% Based Stratification (VBS) annually

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Actual Target End line Indicators Frequency Baseline (FY17 Q1) Year 1 (Year 5) OP 2.3 Number of villages with zero incidence of locally contracted Not done in Semiannually N/A NA NA malaria positive cases in elimination FY2017 targeted areas (Toungup and Ramree) OP 2.3.1 Number of Not done in indigenous/introduced cases in N/A NA NA FY2017 elimination target areas OP 2.3.2 Number of imported cases Not done in N/A NA NA in elimination target areas FY2017 OP 2.3.3 Number of villages with Not done in active foci in elimination targeted Semiannually N/A NA FY2017 areas OP 2.3.4 % of positive cases notified Not done in within 24 hours (in elimination Monthly N/A NA 100% FY2017 targeted areas) OP 2.3.5 % of positive cases investigated within three days from Not done in Monthly N/A NA 100% notification (in elimination targeted FY2017 areas) OP 2.3.6 % of foci investigated and classified within three days after Not done in Monthly N/A NA 100% notification (in elimination targeted FY2017 areas) OP 2.3.7 % of foci responded within Not done in seven days after notification (in Monthly N/A NA 100% FY2017 elimination targeted areas) OP 2.3 % of sentinel sites complete planned entomological monitoring Semiannual N/A 0 TBD 90% activities

Objective 3: Enhance technical and operational capacity of the NMCP

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Actual Target End line Indicators Frequency Baseline (FY17 Q1) Year 1 (Year 5) OP 3.1 % of targeted health services Month of supervisory received at least two supervisory N/A 0 TBD ≥ 90% visits visits per year.

OP 3.2 % of the targeted laboratories Month of supervisory N/A 0 TBD ≥ 80% meeting minimum quality standards. visits

Objective 4: Promote the involvement of communities, private healthcare providers, private companies and state-owned enterprises in malaria control and elimination initiatives OP 4.1 Number of private companies and state owned enterprises in Month of implementation N/A 0 TBD NA malaria activities OP 4.2 Number of advocacy meetings with private companies and state Month of implementation N/A 0 10 NA owned enterprises in malaria activities OP 4.3 % of health education sessions conducted in the targeted areas with Monthly N/A 0 TBD TBD participation from collaborating companies and enterprises as planned OP 4.3.1 Number of participants attended at health education sessions At least one each conducted in the targeted areas with Monthly N/A 0 year in targeted areas participation from collaborating companies and enterprise

OP 4.4 % of community mobilization Monthly, Quarterly, N/A N/A 10 TBD events performed as planned Semiannual and annual

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