U.S. President's Malaria Initiative Impact Malaria Project ...

IM Annual Report October 2020 – September 2021

U.S. President’s Malaria Initiative

Impact Malaria Project

Annual Performance Report

Project Year 4: Fiscal Year 2021

October 1, 2020 - September 30, 2021

Contract #: 7200AA18C00014

Submitted: November 12, 2021

Resubmitted: February 8, 2022

Approved: February 17, 2022 Funding for this report was provided by the U.S. President’s Malaria Initiative. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID or the United States government.

IM Annual Report October 2020 – September 2021

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IM Annual Report October 2019 – September 2020 i

Table of Contents

Acronyms.......................................................................................................................................................................... 1

Executive Summary .................................................................................................................................................. 10

Background .................................................................................................................................................................... 13

IM Project Year 4 Achievements ........................................................................................................................ 19

Objective 1: Improving access to high quality malaria diagnosis, malaria treatment, and prevention and management of malaria in pregnancy...................................................................................................................... 19

Objective 2: Improve quality of access to other malaria drug-based approaches and provide support to pilot/scale-up newer malaria drug-based approaches ......................................................................................... 62

Objective 3: In support of objectives 1 & 2, provide global technical leadership, support operational research, and advance program learning ............................................................................................................... 72

Monitoring and Evaluation ..................................................................................................................................... 85

Gender ............................................................................................................................................................................. 90

Communication ........................................................................................................................................................... 93

Project Management ................................................................................................................................................ 96

Environmental Monitoring and Mitigation Plan ........................................................................................ 102

Lessons Learned ........................................................................................................................................................ 103

COVID-19 ..................................................................................................................................................................... 104

Addendum 1: IM HQ Core Team Organigramme .................................................................................. 105

Addendum 2: IM Country Achievements ..................................................................................................... 107 Benin ............................................................................................................................................................................. 110

Bureau for Africa ....................................................................................................................................................... 123

Bureau for Latin America and the Caribbean..................................................................................................... 125

Burkina Faso ............................................................................................................................................................... 129

Cambodia .................................................................................................................................................................... 145

Cameroon ................................................................................................................................................................... 150

Côte d’Ivoire .............................................................................................................................................................. 195

Democratic Republic of the Congo ...................................................................................................................... 225

Ghana ........................................................................................................................................................................... 253

Kenya ............................................................................................................................................................................ 291

Lao People’s Democratic Republic ....................................................................................................................... 315

Madagascar .................................................................................................................................................................. 328

Malawi .......................................................................................................................................................................... 359

Mali ............................................................................................................................................................................... 376

Niger ............................................................................................................................................................................ 412

Rwanda ........................................................................................................................................................................ 435

IM Annual Report October 2019 – September 2020 ii

Senegal ......................................................................................................................................................................... 451

Sierra Leone ............................................................................................................................................................... 457

Tanzania ....................................................................................................................................................................... 482

Zambia ......................................................................................................................................................................... 506

IM Annual Report October 2020 – September 2021 1

Acronyms

AC Agents Communautaires

ACPR Adequate Clinical and Parasitological Response ACT Artemisinin-based Combination Therapies AFR Africa Regional Bureau AL Artemether lumefantrine ALMA African Leaders Malaria Alliance aMDRT Advanced MDRT AMFm Affordable Medicines Facility-Malaria AMM Adjusted Male Median ANC Antenatal Care API Annual Parasite Incidence APMEN Asia Pacific Malaria Elimination Network AQ Amodiaquine ARC Artesunate Rectal Capsule ASAQ Artesunate-amodiaquine ASLM African Society for Laboratory Medicine As-Pyr Artesunate-pyronaridine combination ASTMH American Society of Tropical Medicine and Hygiene BA Breakthrough ACTION bMDRT Basic Malaria Diagnostics Refresher Training BTC Biotechnology Center CAC Coordinateurs d’Activités Communautaires, Community Activity Coordinators CARAMAL Community Access to Rectal Artesunate for Malaria CCMm Community Case Management of malaria CD Community Distributors CDC Centers for Disease Control and Prevention CDEC Ministry of Health Community Development, Gender, Elderly and Children CERMES Centre de Recherche Médicale et Sanitaire, Center for Medical and Health Research CHA Community Health Assistant CHAI Clinton Health Access Initiative CHMES Continuous Medical Education Sessions CHMT County Health Management Teams CHO Community Health Officer CHOGM Commonwealth Heads of Government Meeting CHPS Community-Based Health Planning and Services CHRR Centre Hospitalier de Référence Régionale, Regional Reference Hospital Center CHTF Child Health Task Force CHU Centre Hospitalier Universitaire, University Hospital Center CHU Community Health Units CHV Community Health Volunteer CHD Centre Hospitalier de District, District Hospital Center


CHR Centre Hospitalier Régional, Regional Hospital Center CHW Community Health Worker CLU Clinical Laboratory Unit CM Case Management CMCC County Malaria Control Coordinators CME Centre Mère Enfant, Mother Child Center CMPE Centre for Malariology, Parasitology and Entomology CMWG Case Management Working Group CNM Center for Parasitology, Entomology and Malaria Control CNRFP Centre National de Recherche et de Formation sur le Paludisme, National Center for

Research and Training on Malaria COE Committee of Experts COP Chief of Party CPHRL Central Public Health Reference Laboratory CSB Centre de Santé de Base, Basic Health Center CHR Centre Hospitalier Régional, Regional Hospital Center CHRD Centre Hospitalier de Référence de District, District Reference Hospital Center COVID-19 Coronavirus Disease 2019 CQ Chloroquine CQI Clinical Quality Improvement CRS Catholic Relief Services CSB Centre de Santé de Base, Basic Health Center C-SCHMTs County and Sub-County Health Management Teams CSCom Centres de santé communautaire, Community Health Centers CSI Centre de Santé Intégré, Integrated Health Center CSO Civil Society Organization CSRefs Centres de santé de reference, Referral Health Centers CST Country Support Team CTO Clinical Training Officers C Cycle DCDC Department of Communicable Disease Control DCHS Division of Community Health Services DCR Deputy Country Representative DDL Data Development Library DEPSI Direction des Etudes, de la Planification et du Système d'Information,

Studies, Planning and Information System Department DFH Directorate of Family Health DGHPH Directorate General of Health and Public Hygiene DGSR Direction Générale de la Santé de la Reproduction, General Directorate of

Reproductive Health DH District Hospital DHA-PPQ Dihydroartemisinin-piperaquine DHIMS District Health Information Management System DHIMS2 District Health Information Management System – 2


DHIS2 District Health Information System 2 DHMIS2 District Health Management Information Software2 DHMT District Health Management Team DHO District Health Office DHS Demographic and Health Surveys DIP District Implementation Plan DIIS Direction de l’Informatique et de l’Information Sanitaire, Department of Information

Technology and Health Information DLS Direction des Laboratoires de Santé, DLS, Directorate of Health Laboratories DNMP Division of National Malaria Control Program DO District Officers DOS Direction de l’Organisation des Soins, Directorate of the Organization of Health DOT Directly Observed Treatment DOT3 Directly Observed Therapy during three days of treatment DQM Department of Quality Management DRC Democratic Republic of the Congo DRCH Directorate of Reproductive and Child Health DRS Direction Régional de la Santé Regions, Regional Health Directorate DRSP Direction Régionale de la Santé Publique, Regional Public Health Directorate DSC Direction de la Santé Communautaire, Community Health Directorate DSF Direction de Santé Familiale, Family Health Department DQA Data Quality Assessment DQM Department of Quality Management DRMH Division of Reproductive and Maternal Health DRSP Direction Régionale de la Santé Publique, Regional Directorate of Public Health DSME Direction de la Santé de la Mère et de l’Enfant, Mother and Child Health Directorate DTC Directeurs Techniques de Centre, Heads of Health Center DVSSER Direction de la Veille Sanitaire, de la Surveillance Epidémiologique et ripostes,

Department of Health Watch, Epidemiological Surveillance and Response EA Enumeration Area ECAMM External Competency Assessment in Malaria Microscopy EDS Electronic Data Systems EHT Environmental Health Technologist eLMIS Electronic Logistics Management Information EMMP Environmental Mitigation and Monitoring Plan EPI Expanded Program on Immunization EPR Epidemic Preparedness and Response EQA External Quality Assurance ETF Early Treatment Failure EV Enrollment Violation FDA Food and Drugs Authority FHD Family Health Division FIF Facility Improvement Funds


FY Fiscal Year G6PD Glucose-6-phosphate dehydrogenase GANC Group ANC GHS Ghana Health Service GHSC-PSM Global Health Supply Chain-Procurement and Supply Management GMS Greater Mekong Sub-region GOK Government of Kenya GON Government of Niger HB Hemoglobinometer HBHI High Burden to High Impact HBMm Home-Based Management of Malaria HEAT Hostile Environment Awareness Training HD Health District HDMT Health District Management Team HF Health Facility HFCA Health Facility Catchment Area HGR Hôpitaux généraux de référence, General Referral Hospitals Hgb Hemoglobin HIO Health Information Officers HMIS Health Management Information Systems HNQIS Health Network Quality Improvement System HQ Headquarters HRIO Health Records and Information Officers HRP2 Histidine-rich Protein 2 HSA Health System Accelerator HSA Health Surveillance Assistant HTI Health Training Institutions HW Health worker iCCM Integrated Community Case Management ICD Institutional Care Division ID Species identification IDSR Integrated disease surveillance and response IM PMI Impact Malaria IMaD Improving Malaria Diagnostics Project IMC Improving Malaria Care IMCI Integrated Management of Childhood Illnesses INRB Institut National de Recherches Biomédicales, National Institute of Biomedical Research INSP Institut National de Sante Publique, National Institute of Public Health INVIMA Instituto Nacional de Vigilancia de Medicamentos y Alimentos, National Institute for

Medical and Food Regulation in Colombia IPC Infection Prevention and Control IPCI Institut Pasteur de Côte d’Ivoire, Pasteur Institute of Côte d’Ivoire IPD In-patient departments


IPM Institut Pasteur de Madagascar, Pasteur Institute of Madagascar IPTp Intermittent Preventive Treatment in pregnancy IQA Internal Quality Assurance IRB Institutional Review Board IRS Indoor Residual Spraying ISS Integrated Supportive Supervision IT Information Technology ITN Insecticide-Treated Mosquito Net IU/Gm International Units per Gram JHSPH Johns Hopkins University School of Public Health JHU Johns Hopkins University JOOTRH Jaramogi Oginga Odinga Teaching and Referral Hospital JPPM Joint Partner Planning Meeting KCRH Kakamega County Referral Hospital KEMSA Kenya Medical Supplies Authority Kg Kilogram KHIS Kenya Health Information System KHRC Kintampo Health Research Centre KM Knowledge Management KMS Kenya Malaria Strategy KMTS Kenya Medical Training College LAC Latin America and the Caribbean LBMA Laboratoire de Biologie Moléculaire Appliquée, Applied Molecular Biology Laboratory LDHO Lusaka District Health Office LLIN Long-Lasting Insecticidal Nets LLW Lessons Learned Workshop LQAS Lot Quality Assurance Sampling LTFU Lost-to-follow-up M&E Monitoring and Evaluation MBS Malaria Behavior Survey MCCH Maternal, Child, and Community Health MCDI Medical Care Development International MCGL MOMENTUM Country Governance and Leadership MCH Maternal and Child Health MCHA Maternal and Child Health Aid MDA Mass drug administration MDRT Malaria Diagnostics Refresher Trainings MEDS Missions for Essential Medicines and Supplies MERA Malaria Elimination Readiness Assessment MERG Monitoring and Evaluation Reference Group MFO Malaria Field Officers Mg Milligram MIP Malaria in Pregnancy


MIPWG Malaria in Pregnancy Working Group MIS Malaria Indicator Survey MLS Medical Laboratory Scientists MM Malaria Microscopy MMV Medicines for Malaria Venture MNH Maternal and Neonatal Health MOFA Ministry of Foreign Affairs MOH Ministry of Health MoHS Ministry of Health and Sanitation MOP Malaria Operational Plan MOPDD/RBC Malaria and Other Parasitic Diseases Division/Rwanda Biomedical Center MOU Memorandum of Understanding MPR Malaria Program Review mRDT Malaria Rapid Diagnostic Test MRR Malaria Rapid Reporting MRTC Malaria Research and Training Center MSB Malaria Slides Bank MSDQI Malaria Service Delivery and Quality Improvement N/A Not Applicable NGO Non-Governmental Organization nECAMM National External Competency Assessment for Malaria Microscopy nCAMM National Competency Assessment for Malaria Microscopy NHIA National Health Insurance Agency NMCP National Malaria Control Program NMEC National Malaria Elimination Program NMEP National Malaria Elimination Strategic Plan NMP National Malaria Program NMSP National Malaria Strategic Plan NPHL National Public Health Laboratory NPRL National Public Health Reference Laboratory NPSP Nouvelle Pharmacie de la Santé Publique, New Public Health Pharmacy NSP National Strategic Plan ONSE Organized Network of Services for Everyone OPD Outpatient Department OTSS+ Outreach, Training, and Supportive Supervision Plus OR Operational Research PAHO Pan-American Health Organization PAMO Program for Advanced Malaria Outcomes PAMS Provincial Anti-Malaria Stations PARMA PMI-supported Antimalarial Resistance Monitoring in Africa PBF Performance-Based Financing PBO Piperonyl butoxide PC Parasite Counting


PCDC Provincial Centers of Disease Control PCR Polymerase Chain Reaction PD Parasite Detection PDR People’s Democratic Republic PDSA Plan-Do-Study-Act PECADOM+ Prise en Charge à Domicile+, Home-based management of malaria+ P. falciparum Plasmodium falciparum PfK13 Plasmodium falciparum Kelch 13 PHC Primary Health Care PHIM Public Health Institute of Malawi PHU Peripheral Health Units PHO Provincial Health Offices PI Principal Investigator PI Parasite Identification PM Project Management PMI President’s Malaria Initiative PNLP Programme National de Lutte contre le Paludisme, National Malaria Control Program PMP Performance Monitoring Plan PNSC Politique National de la Santé Communautaire, National Community Health Policy PNSME Programme National de la Santé de la Mère et de l’Enfant, National Mother and Child

Health Program POC Point of Care PO-RALG President’s Office Regional Administration and Local Government PPE Personal Protective Equipment PPM Public Private Mix PPMED Policy, Planning, Monitoring, and Evaluation Decision PQ Primaquine PSI Population Services International PSM Procurement and Supply Management PT Proficiency Testing PTF Partenaire technique et financier, Technical and financial partner PTFU Post-training follow-up PTS Proficiency Testing Scheme P. vivax Plasmodium vivax PY Project Year Q Quarter QA Quality Assurance QA-QC Quality Assurance and Quality Control QC Quality Control QI Quality Improvement QIT Quality Improvement Teams QOC Quality of Care R Round


RAI3E Regional Artemisinin-resistance Initiative 3 RBM Roll Back Malaria RCD Reactive Case Detection RCH Reproductive and Child Health R/CHMT Regional and Council Health Management Teams RDQA Routine Data Quality Assessment RDT Rapid Diagnostic Tests Reco Relais Communautaire, Community Relay RFP Request for Proposals RH Reproductive Health RHA Regional Health Administration RHFPP Reproductive Health and Family Planning Program RHMT Regional Health Management Team RISE Reaching Impact, Saturation and Epidemic Control RHD Reproductive Health Department RMA Rapport Mensuel d’Activité, Monthly Activity Report RMNCH Reproductive, Maternal, Neonatal, and Child Health RNEC Rwanda National Ethics Committee RNHRC Rwanda National Health Research Committee RSA Rapid Situation Assessment RTA Regional Technical Advisors RTSL Resolve to Safe Lives SBC Social and Behavior Change SBCWG Social and Behavior Change Working Group SCPC Strategic Communications Partner Committee SDHIR Sub-Directorate of Health Institutions and Regulation SDRH Sub-Directorate of Reproductive Health SDSP Service de Santé de District Publique, Public District Health Service SEC Soins essentiels dans la communauté, Essential Care in the Community SIMR Surveillance Intégrée De La Maladie Et La Riposte, Integrated Disease Surveillance &

Response SMC Seasonal Malaria Chemoprevention SME Surveillance, Monitoring, and Evaluation SMERG Surveillance, Monitoring, and Evaluation Reference Group SMS Short Message Service SOMAGO Société Malienne de Gynécologie Obstétrique, Malian Obstetric Gynecology Society SOP Standard Operating Procedure SPH School of Public Health SP Sulfadoxine pyrimethamine SP-AQ Sulfadoxine pyrimethamine-amodiaquine SP&DQ Surveillance practice and data quality SSA sub-Saharan Africa SSGI Services de Santé à Grand Impact, High-Impact Health Services


SST Single screen and treat SSV Supportive Supervision Visits TES Therapeutic Efficacy Study TOR Terms of Reference TOT Training of Trainers TQ Tafenoquine TSS Technical Support Supervision TSQ Training, Supervision, and Quality Assurance T3 Test, Treat, Track TWG Technical Working Group UCAD Université Cheikh Anta Diop UCSF University of California, San Francisco UCT University of Cape Town UNFPA United Nations Population Fund U.S. United States USAID United States Agency for International Development USTTB Université des Techniques et des Technologies de Bamako, University of Sciences,

Techniques and Technologies of Bamako VHC Village Health Clinics WHO World Health Organization WHO GMP World Health Organization's Global Malaria Program WT Withdrawn WMD World Malaria Day ZAMEP Zanzibar Malaria Elimination Programme ZMSWM Zero Malaria Starts with Me


Executive Summary The U.S. President’s Malaria Initiative (PMI) Impact Malaria (IM) project, funded by the United States Agency for International Development (USAID) through PMI, is a five-year (February 13, 2018 – February 12, 2023) service delivery project providing global technical leadership to fight malaria and save lives. IM supports countries in their efforts to strengthen malaria diagnosis, treatment, and drug-based prevention in health facility and community settings through implementation and technical support, as well as operational research (OR). During the reporting period, IM worked in 18 countries and had two regional buy-ins, in Latin America and the Caribbean (LAC) and sub-Saharan Africa (SSA). IM also closed out and transitioned activities to a new PMI bilateral mechanism in Côte d’Ivoire. This annual report describes accomplishments and results toward achieving IM objectives during project year four (PY4), from October 1, 2020, through September 30, 2021. In PY4, IM supported Ministries of Health and their partners to measurably improve the quality of and access to malaria case management (CM), prevention and treatment of malaria in pregnancy (MIP), and drug-based approaches, through country-led initiatives and innovations, which informed and advanced global technical learning and evidence. The cornerstone of the IM quality improvement (QI) approach is Outreach, Training, and Supportive Supervision Plus (OTSS+), a facility-level quality improvement approach aimed at improving health facility (HF) and provider competency through supportive supervision, troubleshooting, coaching, and on-the-job training in 11 IM supported countries. IM has worked with countries to learn from their implementation experiences with OTSS+ processes and tools, which has informed IM’s QI framework and draft guide on what to do before, during, and after the OTSS+ visits. Despite the challenges presented by the Coronavirus Disease 2019 (COVID-19) pandemic, IM successfully supported 10 countries to organize multiple rounds of OTSS+ (Malawi is launching its first IM-supported OTSS round in 2022), following national policies and guidelines for personal protection and infection prevention and control. By the end of the current project reporting period, countries had completed between two and seven rounds of OTSS+ conducting 6,137 OTSS+ visits in 2,715 public and private health facilities. OTSS+ was supplemented in selected countries with other QI approaches, including mentorship, peer-to-peer learning, and targeted classroom training for providers. IM also supported all 11 OTSS+ countries to update their malaria case management and MIP guidelines and training curricula to align with global policies and best practices. These efforts were highlighted in the draft report of IM’s mid-term evaluation. Below are additional PY4 highlights of country achievements that were supported by IM. These achievements include: ● Supported national malaria control programs (NMCP) in four countries to implement their seasonal

malaria chemoprevention (SMC) campaigns, training 42,773 SMC actors. Validated results of 2020 SMC campaigns showed that more than four million children under the age of 5 years were reached with SMC with IM support. In Mali, a further 168,103 five- to ten-year-old children were also reached. Preliminary results from the first three cycles of the 2021 SMC campaign indicate that more


than five million children under the age of 5 years were reached by IM. Final validated results will be available in early 2022.

● Supported independent monitoring surveys in Burkina Faso, Cameroon, Mali, and Niger that documented high coverage of and adherence to SMC in IM-supported areas.

● Continued support to six countries, including Cameroon, Côte d’Ivoire, Mali, Niger, Rwanda, and Sierra Leone, to scale up and improve the quality of integrated community case management (iCCM); thus, expanding the population covered by iCCM from 2,549,941 in Project Year 3 (PY3) to 3,411,334 in Project Year 4 (PY4), including previously unserved communities, in coordination with NMCPs, other donors, and primary health counterparts.

● Supported countries to expand OTSS+ support to more than 2,700 facilities in 11 countries, exceeding 6,000 facility visits since project launch. Almost all countries demonstrated high or improving competency in management of uncomplicated malaria.

● Worked with NMCPs to strengthen provider quality of care for severe malaria at the inpatient level; including support for 3,975 providers to receive at least one training that covered severe malaria case management, 3,439 OTSS+ visits using the inpatient/severe malaria module and launching severe malaria champions programs in Niger and Cameroon.

● Worked with the NMCP in Sierra Leone to roll out artesunate rectal capsules (ARC) as a pre-referral intervention at the peripheral facility level across 14 districts, training 2,452 providers in danger sign recognition, ARC administration, effective referral practices, and record-keeping.

● Developed innovative complementary efforts to improve provider quality of care at the inpatient level to supplement OTSS+, including five to ten day in-hospital trainings for targeted health workers and follow-up mentorship visits, in Kenya and Ghana.

● Collaborated with Breakthrough ACTION (BA) to explore and identify where the addition of certain social and behavior change (SBC) elements may add the best value to supportive supervision trainings.

● Designed an innovative approach to using OTSS+ data to explore how provider and facility performance may relate to the overall quality of MIP care.

● Conducted basic and advanced malaria diagnostics refresher trainings (MDRTs) in Cameroon, Côte d’Ivoire, the Democratic Republic of the Congo (DRC), Ghana, Kenya, Madagascar, Malawi, Mali, Sierra Leone, Tanzania (Mainland and Zanzibar), and Zambia. IM supported MDRTs to improve skills in malaria microscopy and malaria rapid diagnostic tests (mRDTs) of laboratory technicians. A total of 452 participants attended a basic MDRT (bMDRT) and 104 participants attended an advanced MDRT (aMDRT).

● Supported Cameroon, Madagascar, Niger, Sierra Leone, and Tanzania to procure malaria slides from certified sources to build a slide bank where none previously existed or to supplement an existing slide bank.

● Supported MIP strengthening activities in eleven countries: Cameroon, Côte d’Ivoire, Ghana, Kenya, Malawi, Mali, Niger, Rwanda, Sierra Leone, Tanzania, and Zambia. These included on-going support for national MIP technical working groups in seven countries as well as training and OTSS+ in six countries.

● In Cameroon, DRC, and Ghana, IM received USAID funding to support the COVID-19 response. This support included integrating infection prevention and control, personal protection measures and biosafety into the malaria clinical and laboratory OTSS+ checklists, as well as the clinical assessment, management, and triage of suspected COVID-19 cases at front-line facilities.


IM also supported research and global learning achievements during the project reporting period. Achievements include: ● Implemented the IM Learning Agenda to ensure that the lessons learned through the project are well

documented and disseminated to the global malaria community. ● Supported OR activities including: 1) Group Antenatal Care (ANC) and ANC surveillance in Benin;

2) Mass drug administration (MDA) in Senegal; 3) Feasibility, and accuracy of point-of-care Glucose-6-phosphate dehydrogenase (G6PD) testing in Cambodia, and 4) Enhanced ANC services in Mali.

● Supported the planning and implementation of Therapeutic Efficacy Studies (TES) for first-line treatment of Plasmodium falciparum (P. falciparum) in nine countries and for radical cure treatment of Plasmodium vivax (P. vivax) in LAC.

● Provided Secretariat support for the Roll Back Malaria Partnership to End Malaria (RBM) MIP Working Group (MIPWG) and completed and disseminated a guide for addressing MIP indicator measurement challenges associated with intermittent preventive treatment of malaria for pregnant women (IPTp) measurement.

● Co-chaired a global technical webinar with the USAID Maternal and Child Health Division and the World Health Organization (WHO), in January 2021, to disseminate a MIPWG M&E brief – to standardize the M&E of MIP services across malaria-endemic countries.

● Supported the SMC Alliance Monitoring and Evaluation (M&E) Subgroup to develop an SMC M&E Toolkit.


Background

The U.S. President’s Malaria Initiative (PMI) Impact Malaria (IM) project is PMI’s flagship global service delivery project, dedicated to improving the quality of malaria diagnosis, treatment, and malaria in pregnancy (MIP) services and supporting health providers in the countries IM serves. IM also supports implementation of drug-based prevention approaches and operational research (OR) in targeted countries. IM works to support National Malaria Control Programs (NMCP) from the national to health facility (HF) and community levels to advance malaria service delivery. Geographic Scope PMI focuses its work to fight malaria and save lives in 27 countries across sub-Saharan Africa (SSA) and the Greater Mekong Subregion (GMS) of Asia. IM is poised to provide support in any of those countries, as needed. During the reporting period, IM worked in 18 countries and had two regional buy-ins, in Latin America and the Caribbean (LAC) and SSA. IM also closed out and transitioned activities to a new PMI mechanism in Côte d’Ivoire. IM country buy-ins

● Benin ● Burkina Faso ● Cambodia ● Cameroon ● Democratic Republic of

the Congo (DRC) ● Ghana

● Kenya ● Lao People’s Democratic

Republic (PDR) ● Madagascar ● Malawi ● Mali ● Niger

● Rwanda ● Senegal ● Sierra Leone ● Tanzania ● Zambia

Regional buy-ins

● Latin America and Caribbean Regional Bureau ● Africa Regional Bureau (AFR)

Figure 1: Map of IM’s Geographic Focus Areas

IM buy-ins transitioned to bi-lateral mechanism

• Côte d’Ivoire


Technical Scope

The IM technical strategy is centered on the following three objectives: ● Objective 1: Strengthen the quality of and access to malaria case management and

prevention of malaria during pregnancy ο Get the right diagnostics and treatment to more patients with suspected and confirmed

malaria ο Increase the provision of intermittent preventive treatment of malaria for pregnant

women (IPTp) ● Objective 2: Improve the quality of and access to other malaria drug-based

approaches and provide support to pilot and scale up newer malaria drug-based approaches

ο Deploy innovative approaches, including seasonal malaria chemoprevention (SMC), mass drug administration (MDA), or other drug-based approaches, as appropriate

● In support of Objectives 1 and 2, provide global technical leadership, support OR, and advance program learning

ο Work at sub-national, national, and global levels to bolster the linkage of country systems with global policies and dialogue

ο Strengthen malaria health systems and the rigorous use of data for decision-making Figure 2 depicts the interrelatedness of IM objectives. IM support to improving implementation on-the-ground and research activities in the countries it serves generates the lessons learned and results that contribute to advancing global technical learning and strengthening malaria health systems, which are then translated into country-level improvements in implementation.

Figure 2: IM Objectives


Objective 1: Strengthen the quality of and access to malaria case management and prevention of malaria during pregnancy IM works to close gaps in malaria diagnosis and treatment, and the prevention and treatment of MIP, through the project’s Quality Improvement (QI) model (Figure 3). Accurate diagnosis, appropriate treatment and referral, and timely reporting and tracking of malaria cases are the cornerstones of malaria service delivery. However, several barriers limit access to high-quality malaria services including inadequate health provider competencies and practices, slow or ineffective uptake of new global guidance, and shortages of commodities and supplies. IM supports NMCPs in their efforts to fight malaria and save lives through improving the quality of health service delivery for those most at risk of severe malaria and death, especially children and pregnant women.

Figure 3: IM Quality Improvement Model

The backbone of the IM approach to QI includes: ● Ensuring national guidelines align with global best practices ● Supporting countries to implement guidelines, targeting providers at facility and community

levels ● Equipping providers with the required tools, knowledge, and skills ● Supporting countries to monitor and improve the quality of malaria service delivery

The World Health Organization (WHO) defines QI as an approach to improve service systems and processes, through the routine use of health and program data, to meet patient and program needs. IM’s QI approach builds capacity of NMCPs to improve the skills and performance of health workers (HW) at all levels of the health system in the delivery of quality malaria services in line with national guidelines and policies. This QI approach aims to: ● Improve the quality of case management of uncomplicated and severe malaria, including in pregnant

women, encompassing assessment, diagnosis, treatment, referral, and counseling ● Improve the quality of prevention and counseling for MIP through ANC services, including

administration of three or more doses of IPTp and distribution of insecticide-treated mosquito nets (ITN)


● Collect, analyze, and use available data for decision-making in a timely manner that supports the first two aims

The cornerstone of the IM QI approach is Outreach, Training, and Supportive Supervision Plus (OTSS+), a facility-level activity aimed at improving health facility (HF) and provider competency through competency-based supportive supervision, troubleshooting, coaching, and on-the-job training. Central to the success of OTSS+ is that supportive supervision and training take place at the HF. Rather than pulling providers and staff away from their facility and patients into classrooms, supervisors conduct outreach through in-person visits to observe providers interacting with patients; to understand the gaps in knowledge and skills, and challenges faced by providers; and then to tailor on-the-job training, troubleshooting, and coaching. Coaching occurs during follow-up supervisory visits. Action planning at the end of each visit outlines specific areas where facilities can act to improve the quality of the services they deliver. Other elements of IM’s QI approach include mentorship, peer-to-peer learning, and targeted classroom training for providers. These approaches are deployed to complement and build on each other. For example, mentorship is most often targeted to those providers and facilities with poor performance during OTSS+ visits.

Objective 2: Improve quality of and access to other malaria drug-based approaches and provide support to pilot and scale up newer malaria drug-based approaches Under this objective, IM supports NMCPs and partners in Burkina Faso, Cameroon, Mali, and Niger to implement SMC campaigns as well as an MDA OR study in Senegal. In all targeted countries, IM has provided full technical, financial, and operational support to the NMCP in priority areas of the country. This includes: 1) Recruiting, training, and paying thousands of community distributors (CD) and supervisors to deliver SMC with high coverage and adherence; 2) Improving record-keeping, and 3) supporting other aspects of the campaigns, from procurement of high-quality supplies to implementing independent monitoring surveys to validating coverage and adherence.

IM support to improve the quality of SMC focuses on: 1) Implementation, such as supporting town criers, community leaders, and other social and behavior

change (SBC) efforts to improve uptake and adherence to the full treatment regimen 2) Confirmation that SMC staff have supplies to protect themselves from Coronavirus Disease 2019

(COVID-19) 3) Adjustment of programs based on lessons learned and sharing those lessons with other countries,

e.g., splitting up distributor pairs to reduce person to person contact in Cameroon 4) Collecting and using data to monitor progress and identify areas for improvement, e.g., introducing

and harmonizing methods for independent rapid monitoring surveys, digitizing campaign data collection, standardizing reporting procedures by developing the global standard monitoring and evaluation (M&E) toolkit and supporting countries to analyze and use their data to inform future campaigns

Operationally IM focuses on efficiency, including constantly working to streamline payment of SMC staff using mobile money, payment agents, or hybrid systems, which has reduced payment delays and boosted morale and performance.


Success Story: Malaria-Free Children Keep Families Healthy “Through the door-to-door strategy, we can see how satisfied the parents are with our work. Aside from the health aspect, we saw how the seasonal malaria chemoprevention (SMC) campaign also affects the economic power of a household,” said Yahaya Assoumane. Yahaya along with his colleague Ramatou Mahamadou are two community health workers that form an SMC campaign distribution team in the Koré Mairoua district of Tibiri, Niger. The NMCP in Niger implements SMC campaigns, with support from PMI through PMI Impact Malaria, to protect children under the age of five years, the most vulnerable age group, from malaria infection during the rainy season when malaria transmission rates are high. Yahaya and Ramatou are one distribution team of hundreds across Niger that make SMC campaigns happen. Before the COVID-19 pandemic, parents would come to health centers or designated distribution sites to get preventative malaria medicines for their children. Now, to eliminate large gatherings, distribution teams, like Yahaya and Ramatou, come to them. They go house to house to distribute preventative malaria medicines to children and give information to parents on proper dosing and administration. Yahaya and Ramatou can reach up to 80 children at their homes in a single day during SMC campaigns. To date, IM supported SMC campaigns in Niger have reached over 1.2 million children in each of the first three of four cycles required for malaria protection. Yahaya and Ramatou recently visited the home of Farida Amadou, a mother of three, two of whom are under the age of five years. Farida told them, “I am very happy that my children received this treatment and I saw how important these drugs were, because last year thanks be to God my children did not get malaria.” Farida also shared how IM-supported SMC campaigns, in keeping her children healthy, benefit her whole family. As Farida explains, “...if the children do not get sick, we will be able to carry out our farming activities and save our resources, which are already insufficient. The SMC saves us time and improves our health; our children are healthy, and we all have time to cultivate our fields more in order to have enough to provide for them.”

Yahaya Assoumane and Ramatou Mahamadou visit Farida Amadou and her children at home during door-to-door outreach for SMC.

Photo credit: IM Niger


Objective 3: In support of Objectives 1 and 2, provide global technical leadership, support OR, and advance program learning IM support to improving implementation on-the-ground in the countries it serves generates the lessons learned and results that contribute to advancing global technical learning and translate into country-level improvements in policy, guidance, program implementation, and monitoring. IM also supports design, planning, and implementation of the OR studies prioritized by PMI. IM currently supports OR activities in the areas of 1) Group Antenatal Care (GANC) and Antenatal Care (ANC) surveillance in Benin; 2) MDA in Senegal; 3) Feasibility and accuracy of point-of-care Glucose-6-phosphate dehydrogenase (G6PD) testing in Cambodia, and 4) Enhanced ANC services in Mali. IM also supports planning and implementation of therapeutic efficacy studies (TES) for first-line treatment of Plasmodium falciparum (P. falciparum) in eight countries and for radical cure treatment of Plasmodium vivax (P. vivax) in Latin America. IM has also developed a learning agenda to support that the lessons learned through the project are well documented and disseminated to the global malaria community. IM also supports and contributes to several RBM Partnership to End Malaria (RBM) Technical Working Groups (TWG), including the Case Management Working Group (CMWG), Malaria in Pregnancy Working Group (MIPWG), Surveillance, Monitoring and Evaluation Reference Group (SMERG), and Social and Behavior Change Working Group (SBCWG). The IM Senior Technical Advisor co-chairs the CMWG and IM serves as the Secretariat for the MIPWG. Furthermore, IM plays a leadership role in SMC Alliance, including convening and providing secretariat support to the M&E Subgroup, and has helped organize the Severe Malaria Stakeholders Meeting. With support from USAID Africa Bureau funding, IM is collaborating with the Child Health Task Force (CHTF) on several activities focused on institutionalization of integrated community case management (iCCM).


IM Project Year 4 Achievements Objective 1: Strengthen the quality of and access to malaria case management and prevention of malaria during pregnancy Strengthening malaria case management IM supported case management strengthening in Cameroon, Côte d’Ivoire, DRC, Ghana, Kenya, Madagascar, Malawi, Mali, Niger, Rwanda, Sierra Leone, Tanzania, and Zambia in project year (PY) 4 (Figure 4).

IM monitors its case management and QI activities using the indicators in the table below. Table 1: Case Management Program Indicators

Outcome   Intermediate Outcome   Output ● % of uncomplicated

malaria cases receiving first-line antimalarial treatment according to national guidelines

● % of severe malaria cases that were appropriately managed according to national guidelines

● % of observed HWs demonstrating competency in management of uncomplicated malaria

● % of observed HWs demonstrating compliance to treatment according to WHO guidelines for cases with positive malaria test results

●  % of targeted HWs trained in the management of severe malaria

● % of targeted HWs trained in malaria case management with artemisinin-based combination therapies (ACTs)

Figure 4: Countries supported by IM for case management strengthening


Outcome   Intermediate Outcome   Output ● % Children under the age

of 5 appropriately treated for fever according to iCCM or country algorithms by community health workers (CHW)

● % of observed HWs demonstrating adherence to negative test results according to global standards

● % of observed HWs demonstrating competency in management of severe malaria

● % of supervised facilities that meet standards, including appropriate materials, documentation, and qualified staff, for quality malaria case management

● % of targeted health facilities that receive a supervisory visit

● % of IM-supported countries with national guidelines for malaria treatment that meet global standards

During the project reporting period, IM has continued to support NMCPs to build on the capacity built over the last three years to improve and sustain quality malaria case management services in 13 countries (Figure 4). With IM support, all 13 supported countries have updated their guidelines and their training curricula to align with global guidance. At the service delivery level, IM supported NCMPs to build on the architecture of the health delivery system at district level to support a continuum of malaria case management services from the community to district hospitals. While the focus has been on the primary level of the health system for the proper assessment of fever, diagnosis, and treatment of uncomplicated malaria as well as appropriate referral of those with danger signs, IM also supported NMCPs to build on support initiated in the previous reporting period to reinforce the proper management of severe malaria cases at inpatient facilities. Along the continuum of malaria case management services, IM supported integrated training of health providers in clinical case management, performance, and interpretation of malaria rapid diagnostic tests (mRDTs), as well as prevention and treatment of MIP using up-to-date training curricula and materials. IM also built on a robust infrastructure for supportive supervision through the OTSS+ approach in 11 of the 13 countries to improve and sustain quality service delivery using a pool of clinical supervisors at central, regional, and district levels whom IM has helped to train. Rwanda has developed their own supportive supervision approach and Tanzania implements Malaria Service Delivery Quality Improvement (MSDQI), which was based on an older version of OTSS, also incorporates a data quality assessment component. OTSS+ uses a standard integrated package of streamlined and revamped outpatient and inpatient competency-based checklists built into electronic tools that IM developed in previous project years. Collection of OTSS+ data through these digital tools was essential in establishing a data-driven process to plan supervision visits and provide real-time data analysis, feedback, and action planning during OTSS+ visits. As of last year, 10 of II OTSS+ countries have adopted and adapted these supervision checklists (Table 2). Malawi was still finalizing these checklists at the end of PY4.


Table 2: Country adaptation and adoption of OTSS+ tools

Countries Previous reporting period Current reporting period

Status Digitization Status Status Cameroon

Adaptation and adoption of the full package of OTSS+ checklists * Launch of OTSS+ with this package

Implemented clinical and Laboratory OTSS+ using KoBoCollect Digitization into the Health Network Quality Improvement System (HNQIS) completed

Used HNQIS for Laboratory and Clinical OTSS+, integrated COVID-19 elements in checklists

Côte d’Ivoire Adaptation and adoption of the full package of OTSS+ checklists Launch of OTSS+ with this package

Digitized checklists in KoBoCollect digital platform

Used KoBoCollect for data collection of Laboratory and Clinical OTSS+

DRC Adapted and adopted the clinical OTSS+ package Continued to implement supportive supervision with Laboratory OTSS+ checklist

Implemented Laboratory OTSS+ using HNQIS Clinical OTSS+ HNQIS checklist adopted

Used HNQIS for Laboratory and Clinical OTSS+

Ghana Clinical OTSS continued to be implemented using electronic data systems (EDS) Transitioned Laboratory OTSS+ checklist to HNQIS Transitioned Integrated Supportive Supervision (ISS)tool into HNQIS

Used HNQIS for Laboratory OTSS+ ISS tool transitioned into HNQIS (launched during the current reporting period)

Used HNQIS for Laboratory OTSS+ Used EDS for Clinical OTSS+ ISS also digitized in HNQIS

Kenya Laboratory supervision using the Ministry of Health (MOH) Laboratory checklist commenced

Initiated the digitization of the MOH supervision checklist into HNQIS, which is undergoing final review and revisions. Mentorship checklist digitized using REDCap software. (Note: OTSS+ checklists are administered during mentorship visits. The supervision checklist is an inventory checklist developed prior to IM.)

Pilot testing ongoing for the MOH supervision checklist using HNQIS


Countries Previous reporting period Current reporting period

Status Digitization Status Status Madagascar Adopted Laboratory OTSS+

package and has implemented multiple lab OTSS+ rounds Adapted and adopted the OTSS+ clinical checklists and launched one round of clinical OTSS+

Laboratory OTSS+ checklist transitioned into HNQIS Clinical OTSS+ checklist transitioned into HNQIS


Malawi Malawi added to the IM portfolio October 2020

Malawi added to the IM portfolio October 2020

OTSS+ checklists reviewed and adapted to country context Digitization of checklists to begin in PY5

Mali Aligned existing checklists with updated OTSS+ package (including adopting MIP module)

Implemented OTSS+ using KoBoCollect Clinical and Laboratory OTSS+ checklists transitioning into HNQIS (to be completed and rolled out during PY5)

Used HNQIS for Laboratory and Clinical OTSS+ (New IM regions in Mali)

Niger Adaptation, adoption, and launch of OTSS+ clinical checklist

Implemented OTSS+ using KoBoCollect Global OTSS+ HNQIS checklist adapted and adopted

Used HNQIS for Clinical OTSS+

Sierra Leone Tool refined tool to include elements of OTSS+ checklist

Data entered in Excel database and OTSS+ process refined during PY3 Clinical OTSS+ checklists transitioned into HNQIS


Zambia Continued use of OTSS checklist adopted through previous project Used EDS tool for digital data collection Adopted MIP OTSS+ checklist

Transitioned MIP OTSS+ checklist into EDS

Transitioned EDS to advanced EDS (HNQIS)

* Full package of OTSS+ checklists includes: facility inventory, OPD checklist, inpatient checklist, ANC/MIP checklist, and lab checklist **Supervision checklists and tools for Rwanda and Tanzania were developed and digitized by other partners prior to IM.

With this clearly defined approach for QI, through last year, IM focused on refining and standardizing IM’s quality assurance (QA) approaches for malaria clinical case management, expanded the number of HWs trained in case management, increased OTSS+ visits, and monitored progress across all countries.


Refined and standardized IM’s QI approaches and tools During the current reporting period, IM continuously monitored new global policies on malaria case management by participating in and contributing to RBM and WHO meetings and webinars to assess whether changes to IM QI approaches were needed. IM’s QI approach remains fully aligned with global guidance on capacity building of HWs for malaria case management, and key indicators for monitoring service delivery quality. This alignment was highlighted in the draft report of IM’s mid-project evaluation. IM has also been working with countries to learn from their implementation experiences with OTSS+ processes and tools, which is informing IM’s QI framework and draft guide on what to do before, during and after the OTSS+ visits. All countries made progress in the institutionalization of OTSS+ planning, management, and implementation follow-up within district health offices. To better harmonize and sustain the implementation of OTSS+, in the current reporting period, IM developed a draft OTSS+ guide that presents key steps for the implementation of the checklists and in the use and interpretation of the data collected. This guide will be finalized and disseminated in the next project reporting period. In Cameroon, DRC, and Ghana, IM received United States Agency for International Development (USAID) funding to support the COVID-19 response. This support was integrated into the clinical and laboratory OTSS+ checklists of modules to monitor the adherence to and performance of enhanced infection control, biosafety, and personal protection procedures, as well as the clinical assessment, management, and triage of suspected COVID-19 cases at front-line facilities. These modules are now fully integrated into the OTSS+ checklists in Cameroon and DRC. Expanded the number of trained HWs in case management Last year, IM continued to support training in supported countries based on guidelines and curricula updated in previous years. Topics for these training courses included the prevention and treatment of MIP, clinical case management of fever, and performance and interpretation of mRDTs. The courses were targeted to physicians, nurses, midwives, and other clinical staff working in primary health facilities. In most countries, the number of people trained fell somewhat short of the target, in large part because the COVID-19 pandemic interrupted or delayed training schedules and participation (Figure 5).


Figure 5: Percentage of targeted HWs trained in integrated case management, MIP, and severe malaria Expanded OTSS+ visits IM continued to support the expansion of OTSS+ visits in 11 countries. Five countries (DRC, Ghana, Kenya, Mali, Zambia) had supported OTSS through predecessor projects. Four countries (Cameroon, Côte d’Ivoire, Niger, and Sierra Leone) first launched OTSS+ during IM. An additional two countries (Malawi and Tanzania) recently were added to IM’s portfolio and had been implementing OTSS approaches adopted during predecessor projects. Despite the challenges faced by these countries in the current reporting period from the COVID-19 pandemic, IM successfully supported countries to organize multiple rounds of OTSS+, following national policies and guidelines for personal protection and infection prevention and control (IPC). By the end of the current project reporting period, the five countries with established programs completed between two and seven rounds of OTSS+ since the launch of the project. Countries with the recent addition of OTSS+ implementation moved past the start-up challenges experienced in the previous project reporting period and implemented two to four OTSS+ rounds during the last two years (Tables 3 and 4). Since the launch of IM, 6,137 OTSS+ visits have been conducted in 2,715 facilities in the 11 target countries.


Table 3: Timing of OTSS+ rounds, by country

*DRC added clinical OTSS+ to its ongoing lab OTSS+ during PY4. Tanzania implements an alternative supportive

supervision approach (MSDQI) and is not included in this table (see country report for more details).

Table 4: Number of OTSS+ visits in IM-supported countries


Success Story: Ensuring Availability of Medicines to Treat Malaria, Pharmacist Goes the Distance to Support Remote Communities in Zambia

With poor road conditions, the Kafue River is the most direct and reliable way to reach the Ngabwe District, a collection of isolated homesteads separated by forests, marshlands, rivers, and streams in Zambia’s Central Province. Due to its terrain, mosquito borne illnesses, like malaria, pose a serious health threat to the small-scale farming and fishing communities that call this area home—the Ngabwe District reported 240 malaria cases per 1,000 people in 2020. The medicine and supplies that are necessary to treat malaria effectively have a difficult journey to reach the remote health facilities in Ngabwe that provide care to its communities.

Kandadu Chibosha is a provincial pharmacist who works in Ngabwe as part of an integrated Outreach, Training, and Supportive Supervision (OTSS+) team. With PMI Impact Malaria’s support to Zambia’s Provincial Health Office (PHO) pharmacy unit, pharmacists, like Kandadu, participated in OTSS+ visits to health facilities from March to June 2021. During the visits, Kandadu helped health care workers and pharmacy staff in the management of malaria commodity stocks at the health facility. He also spot-checked drug availability and delivered essential medicines and supplies.

To reach the Chilwa Islands and Ngabwe rural health centers, located on an island on the Kafue River, Kandadu parked his vehicle on one side of the Kafue. Using a pontoon and then a canoe, he crossed the river and made his way through neighboring swamps. After safely crossing, he walked for another hour on the last stretch to the health centers. It’s an arduous and potentially hazardous journey, but it’s worth the effort as Kandadu says, “My passion is to see that every facility has drugs available for all diseases; therefore, the fear of crossing the river on the canoe to reach the two facilities does not apply. What applies is arriving safely, taking the safety precautions on the canoe and delivering the malaria commodities and other essential drugs to the most difficult to reach facilities.”

The OTSS+ visits build the skills of health workers and pharmacy staff to manage stock and maintain required levels of essential malaria supplies and drugs, complementing the USAID and PMI supported Global Health Supply Chain-Procurement and Supply Management (GHSC-PSM) project, which provides commodity procurement, supply, and systems strengthening. The investments are paying off.

As Kandadu notes, “Before the introduction of commodity logistic supply chain in Zambia, it used to be very difficult to support availability of essential drugs at facilities that are far-fetched all year round. I enjoy seeing patients receive the right treatment with the correct diagnosis.” Through IM and other global PMI projects such as GHSC-PSM, health care workers like Kandadu in Zambia help to ensure consistent malaria care can be provided to those who may be the hardest to reach.

Kandadu Chibosha crosses the Kafue River by canoe to get to Ngabwe health center.

Photo Credit, IM Zambia


Monitored OTSS+ results across countries

In the current project reporting period, IM has maintained regular and close monitoring of OTSS+ results across countries to identify cross-country challenges in the quality of clinical case management and bottlenecks in data analysis. With almost all IM countries adopting a standard outpatient department (OPD) checklist, IM has been able to perform cross-country analyses of the competency of HWs in the management of uncomplicated malaria, the correct classification of malaria, and adherence to negative test results. Although IM has developed a standard checklist for chart reviews of inpatients with severe malaria, not all OTSS+ countries have implemented it and those that adopted the checklist have used different data collection approaches, some mixing observations with record reviews. Therefore, cross-country analyses of these data have not been possible. Furthermore, only a small percentage of facilities receiving OTSS+ visits have inpatient units where the severe malaria checklist can be applied. In the current reporting period, IM worked with countries to implement a more standardized approach to monitoring management of severe malaria, with a particular focus on assessing the appropriateness of the referral of OPD patients with danger signs and on the inpatient treatment of severe cases at district hospitals. IM also launched the severe malaria champions program and began landscaping ancillary approaches to improve the quality of severe malaria management. Progressed on quality improvement of case management services through OTSS+

Measuring provider competency in the management of uncomplicated malaria is assessed by scoring provider performance of a series of key steps. The steps include history taking, physical exam, use and interpretation of test results, and appropriate prescription of treatment. A high percentage of HWs scored at or above the competency threshold of 90% in PMI countries with longstanding OTSS+ programs (Figure 6). The exception was Mali, where IM moved its implementation area during the current

reporting period to new regions that had not previously implemented OTSS+. Figure 6: Percentage of observed HWs demonstrating competency in the management of uncomplicated malaria, by country, in countries previously implementing OTSS+ programs


Figure 7: Percentage of observed HWs demonstrating competency in management of uncomplicated malaria, by country, in countries with the recent addition of OTSS+ programs Three countries newly implementing OTSS+ under IM, including Côte d’Ivoire, Madagascar, and Niger, greatly improved competency in the management of uncomplicated malaria over three successive OTSS+ rounds (Figure 7). Competency was also high in Rwanda, where the first round of IM-supported clinical supportive supervision was conducted. In contrast, competency remained largely unchanged or declined in Cameroon, DRC, and Sierra Leone. Further analysis of data from these countries suggest that drug shortages and turnover of trained personnel were important contributing factors to the lack of progress. In addition, IM Sierra Leone doubled its geographic scope between OTSS+ Rounds 1 and 2, with five new districts added in Round 2 that had not previously received any case management support from the project. The small overall increase in results for this indicator between the two rounds was largely driven by the addition of these new districts. IM will continue to work with these countries to address these issues and provide them with support to improve the results. Most IM countries implementing OTSS+ demonstrated high or improved competency in the correct classification of malaria as uncomplicated or severe, which requires correctly identifying patients with danger signs and making appropriate referral or treatment (Figures 8 and 9).


Figure 8: Percentage of observed HWs demonstrating competency in correctly classifying malaria cases in countries previously implementing OTSS+ programs

Figure 9: Percentage of observed HWs demonstrating competency in correctly classifying malaria cases in countries with the recent addition of OTSS+ programs Adherence to negative test results remained above 80% in almost all OTSS+ countries (Figures 10 and 11). Notably, Cameroon documented a sizeable improvement in Round 3 compared to previous rounds. DRC demonstrated improvement, almost reaching the 80% target. Mali fell just short of the target in the fourth round.


Figure 10: Percentage of observed HWs demonstrating adherence to negative test results according to global standards by IM country in countries previously implementing OTSS+ programs

Figure 11: Percentage of observed HWs demonstrating adherence to negative test results according to global standards in countries with the recent addition of OTSS+ programs Examination of Health Management Information Systems (HMIS) data from districts supported by IM (Figures 12 and 13) demonstrated that most patients with fever were tested for malaria and most of the patients with a positive test were treated with ACTs.


Figure 12: Number of suspected malaria cases, suspected malaria cases tested for malaria, confirmed malaria cases, and malaria cases treated with an ACT, in countries previously implementing OTSS+ programs, Source: HMIS data

Figure 13: Number of suspected malaria cases, suspected malaria cases tested for malaria, confirmed malaria cases, and malaria cases treated with an ACT in countries with the recent addition of OTSS+ programs, Source: HMIS data


Success Story: OTSS+ Improves Health Care Provider Performance in Diagnosing, Treating, and Preventing Malaria in Côte d’Ivoire

Brice Kouadiou has been a nurse in Côte d’Ivoire for nearly 10 years. Despite his training and experience, he noted, “I didn’t realize that I was providing care that was sometimes not up to standard.” Brice provides preventive and curative care, including malaria services, for about 90 patients every month at the Bocassi health facility, which serves over 4,000 community members in the Bougouanou health district. Bocassi facility is one of 242 health facilities in Côte d’Ivoire that has received Outreach, Training, and Supportive Supervision Plus (OTSS+) visits supported by the NMCP with technical assistance provided by PMI through its flagship malaria service delivery project, PMI Impact Malaria. OTSS+ is an approach designed to provide continuous quality improvement support to health care providers in the diagnosis, treatment, and prevention of malaria. Through OTSS+ visits at the facilities where they work, health care providers, like Brice, receive on-the-job training, coaching, and supportive supervision from trained supervisors to bolster their diagnostic and clinical skills in managing malaria cases and provide preventive malaria services for pregnant women. Health facilities receive multiple “rounds” of OTSS+ visits to continuously monitor provider progress in meeting established guidelines and standards for malaria services and provide ongoing feedback for health care providers. The Bocassi health facility, where Brice works, received three rounds of OTSS+ visits between July 2020 and March 2021. Performance scores improved in diagnosis malaria using rapid diagnostic tests from 94.7% to 100%; treating uncomplicated malaria from 72.6%, to 96.7%; and preventing malaria in pregnancy scores improved from 67.4%, to 100%, over the three rounds. While the numbers speak for themselves, Brice emphasizes the value of the coaching approach afforded by OTSS+ when he says, “With the regular coaching visits from Mr. Soro (IM OTSS+ Supervisor) and the OTSS+ supervision, I have improved a lot. OTSS+ supervision has changed my usual practices, helping me to comply with the application of standards and guidelines in the care of patients suffering from malaria.”

Strengthened provider and supervisor SBC In the current reporting period, IM and Breakthrough ACTION (BA) held several collaborative meetings at the headquarters (HQ) level to explore and better determine ways in which to incorporate and strengthen elements of provider SBC within the framework of supportive supervision visits as part of the

Brice Kouadiou, nurse from the Bocassi health, tests a child with fever for malaria using a rapid diagnostic test. Photo: IM Côte d’Ivoire


IM OTSS+ approach. IM Kenya joined these meetings to provide BA with more context and a clearer understanding of IM’s integrated clinical malaria supportive supervision approach on the ground. These sessions helped to inform design considerations for BA’s Provider Behavior Change Diagnostic Tool. BA reviewed the OTSS+ checklists and training modules, applying a behavioral lens and the Malaria Service Provider Ecosystem, which highlights determinants and influencers of provider behaviors. IM and BA jointly agreed that materials to build supervisor communication skills in conducting performance feedback sessions and mentorship visits would complement the OTSS+ training package. BA provided modules and job aids on providing effective feedback, environmental scans, and conversation starters to help supervisors get a better sense of providers’ personal histories and work environment, as well as how to build empathy. These tools reinforced supervisor skills by better understanding the issues affecting providers due to more comfortable communication environments. Collaboratively, IM and BA determined where the addition of certain SBC elements may add the best value to the supportive supervision trainings, which will be integrated into the upcoming OTSS+ e-learning modules in the next project reporting period. Supported Effective Severe Malaria Management Approximately 94% of the estimated 409,000 malaria deaths in 2019 occurred in SSA1. To reduce malaria deaths, IM supports NMCPs and other MOH departments to enhance effective severe malaria management in eleven countries. In these countries, the percentages of deaths attributable to malaria in children under the age of 5 range from 6% percent in Madagascar to 23% in Sierra Leone and Ghana2 (Figure 14). In recognition of the varied malaria-related gaps and challenges existing across its portfolio, IM supports country governments to implement a range of interventions for improving severe malaria management by increasing access to services, maximizing efficiency of systems, and improving the quality of care (Table 5). Severe malaria interventions along the continuum of care are supported by IM, with a focus on bolstering the quality of inpatient, outpatient, and community-level care, and strengthening referral systems.

1 WHO Global Malaria Program. 2020. World Malaria Report 2020. https://www.who.int/publications/i/item/9789240015791 2 Institute for Health Metrics and Evaluation. 2019. Global Burden of Disease Results Tool. http://ghdx.healthdata.org/gbd-results-tool

Figure 14: Percentage of deaths attributable to malaria in children under the age of 5 in IM countries

https://www.who.int/publications/i/item/9789240015791

http://ghdx.healthdata.org/gbd-results-tool


Table 5: IM’s approach to supporting effective severe malaria management Access Efficiency of Systems Quality of Care

● Extending care to communities through support for iCCM

● Including private facilities where appropriate

● Advocating for and collaborating to improve commodity availability

● Reducing gender, financial, and acceptability barriers

● Updating and operationalizing policies and guidelines

● Strengthening data systems and data use at national and sub-national levels

● Using provider quality improvement technology at scale

● Bolstering referral systems

● Updating and disseminating policies and guidelines

● Organizing pre-service and continuing education

● Developing job aids and adapting existing tools

● Conducting facility-based training, supportive supervision, and mentoring

● Reinforcing adherence to guidelines

Bolstered provider quality of care at the inpatient level As part of its broader clinical case management support package, IM works with NMCPs to strengthen provider quality of care for severe malaria at the inpatient level. In the current reporting period, IM supported 3,975 providers to receive at least one training that covered severe malaria case management. Training included danger sign recognition, classification of cases, use of diagnostic testing, effective referral, and counseling. In addition, 3,439 OTSS+ visits using the inpatient/severe malaria module were conducted during this project year. Across most IM-supported countries, trends in the percentage of HWs demonstrating competency in correctly classifying cases as uncomplicated malaria versus severe malaria improved or remained high (Figures 8 and 9). There is a clear distinction between countries that have longstanding OTSS+ programs, compared to those who launched OTSS+ during the IM project. In Ghana, Kenya, and Zambia, provider competency in correct classification remains above 90%. Cameroon, Côte d’Ivoire, Madagascar, Niger, and Rwanda all demonstrated large improvements in average competency over successive rounds of OTSS+. In Sierra Leone, the second round of OTSS+ was conducted using HNQIS and was expanded from five to 10 districts. Competency in correct classification of uncomplicated malaria versus severe malaria was commensurate with expected scores for this indicator in other new PMI countries. In the current project reporting period, the availability of OTSS+ data collected during these supervisory visits enabled IM to conduct a secondary analysis to address some of the concerns of possible over-classification of severe malaria (recording severe malaria in patients who do not show danger signs) and prescription of injectable artesunate to non-severe cases. IM quantified appropriate treatment practices for uncomplicated malaria across five countries using OTTS+ data. As shown in Figure 15, the recommended ACT was provided in more than 90% of all cases of uncomplicated malaria. In DRC and Mali, a small percentage (9% and 7%, respectively) of uncomplicated cases were not provided an ACT,


although IM does not collect information on other treatment provided in those cases. Further investigation would be needed to examine whether any of these cases received injectable artesunate.

* Preliminary data from CQI pilot in the province of Haut Katanga, DRC

Figure 15: Quantifying inappropriate treatment for uncomplicated malaria During PY4, IM supported innovative complementary efforts to improve provider quality of care at the inpatient level to supplement OTSS+. In Kenya and Ghana, five- to ten-day in-hospital trainings were provided to targeted HWs from lower performing facilities and followed up with mentorship visits that reinforced the initial training in a clinical setting. IM Ghana supported the NMCP to train 2,151 district-level providers, including medical officers, physicians, physician assistants and public health nurses. IM Kenya supported the NMCP to conduct training for 64 physicians, clinical officers, and nurses in IM-supported counties. In response to travel and gathering restrictions due to the COVID-19 pandemic, IM Kenya also supported the NMCP to conduct 19 virtual continuing medical education (CME) sessions on severe malaria for 709 HWs across 28 sub-counties in the current reporting period. The virtual format of these CME sessions also made it possible for HWs from outside target counties to participate. In PY4, IM supported the NMCP to introduce a 15-day hands-on training in severe malaria for clinicians at district hospitals in Cameroon and Niger. This training aimed at building the competencies of selected clinicians so that they are designated as “champions” in the management of the complications of severe malaria. The training provided them with the skills to mentor their respective hospital colleagues in the management of severe malaria. During this reporting period, 55 clinicians from 30 hospitals were trained to be Champions in their respective facilities in the two countries, with plans to expand the program in both countries during the next reporting period.


Success Story: Improving Severe Malaria Management Through On-the-Job Training in

Madagascar Meet Gabriel, a nurse who treats malaria patients at a military hospital in the far north of Madagascar. In the past, the hospital did not follow the latest severe malaria treatment guidelines and did not stock injectable artesunate, the WHO-recommended treatment for life-threatening severe malaria. Through several IM-supported Outreach, Training, and Supportive Supervision (OTSS+) visits, Gabriel and his colleagues at the hospital received on-the-job training and supportive supervision on the most up-to-date severe malaria treatment guidelines and the management of malaria drug inventories to avoid stock outs of critical medicines, like injectable artesunate. Today, Gabriel is a champion for injectable artesunate and trains his peers at the hospital on best practices to treat severe malaria. The on-the-job training and supportive supervision are having an impact—during a recent OTSS+ visit, the hospital’s severe malaria case management score was 73% compared to only 15% at the first OTSS+ visit.

After receiving training and supportive supervision through OTSS+, Gabriel teaches his colleagues about injectable artesunate and how best to treat severe malaria. Photo Credit: IM Madagascar

Improved community-level quality of care and strengthening referral systems for severe malaria IM supports NMCPs to enhance quality of care at the community level and to strengthen referral systems. From the launch of the project, IM has supported 13,546 CHWs to receive training that included danger sign recognition and effective referral practices. During the current reporting period, IM supported the NMCP in Sierra Leone to roll out artesunate rectal capsules (ARC) as a pre-referral intervention at the peripheral facility level across 14 districts. Approximately 2,452 providers were trained in danger sign recognition, ARC administration, effective referral practices, and record-keeping. Average pre- and post-training test scores for severe malaria


management and referral increased from 56% to 86%. Following the ARC intervention roll-out, a rapid record review assessment was supported by IM to quantify appropriate ARC administration and referral practices, and to document outcomes of patients receiving ARC (Figure 16). In total, 109 (90%) of the 121 identified patients for whom ARC was clinically indicated, received it. Providers recommended referral in 100% of those patients who were administered ARC. Ambulances were the primary mode of transportation and used for 75% of referrals. Referral forms were received by the district hospital in 96% of cases. These results indicated that ARC roll-out in Sierra Leone improved quality severe malaria care and referral at front-line facilities. IM will continue to use OTSS+ and mentorship at targeted facilities to maintain this high quality of care.

Figure 16: Severe malaria continuum of care in records reviewed in facilities implementing ARC in Sierra Leone In previous project years, IM supported NMCPs in Ghana and Kenya to implement CHW internships to improve CHW competencies in management of sick children, with a particular focus on improving management and referral of severe malaria. This internship placed selected CHWs in a five-day rotation at district hospitals to learn from a team of clinicians, followed by continuous in-service mentorship for two-months by the clinicians as part of a supportive supervision process. In the current project reporting period, IM built from these experiences to develop a draft standardized curriculum for CHW internship implementation. The draft will be finalized and piloted in the next project year. Improved access to and quality of iCCM During the current project reporting period, IM continued to provide a package of support to six countries (Cameroon, Côte d’Ivoire, Mali, Niger, Rwanda, and Sierra Leone) to scale up and improve iCCM quality. Over the last three years of the project, IM has continued to build on the systems components promoted by WHO and the UNICEF to promote institutionalization of iCCM in these countries. All six countries have iCCM policies grounded in their Primary Health Care (PHC) national guidelines. Treatment guidelines for case management at community level are well defined and CHW community activities are integrated in the health system at district and health area levels. All countries have coordination mechanisms for iCCM at central, regional, and district levels and have built on partnerships with and resources from different donors and civil society organizations. Their supply chains for medicines and commodities are part of the national supply chain for essential medicines, while their data reporting systems are part of their local and national HMIS. In addition, all countries have developed the capacity


of district and health area staff to conduct training and supervision and have been keen to involve communities in social mobilization and support. Despite these advances, IM-supported countries still facing challenges with the implementation and institutionalization of iCCM. Some lacked essential commodities, particularly non-malaria medicines. Government incentive policies for CHWs were not uniformly implemented. SBC activities to promote the use of services were insufficient, as was community support for the referral of severely ill children. Most countries had not implemented a counter-referral system for children who returned to the community after management at a higher-level facility. Some countries also lacked a QI framework, with performance indicators and improvement strategies built into a competency evaluation system for CHWs. During the current reporting period, IM expanded iCCM services to additional previously unserved communities and continued efforts to improve the quality of services in coordination with other donors, NMCPs, and PHC counterparts. At the global level, IM initiated work to develop a global toolkit on institutionalization of iCCM in collaboration with the CHTF, which will be completed in the next project reporting period. Further details can be found in the Africa Bureau Annex. Expanded iCCM to previously unserved populations During the current project reporting period, IM, in coordination with other partners, supported Cameroon, Côte d’Ivoire, Mali, Niger, and Rwanda MOHs to expand the population covered by iCCM from 2,549,941 to 3,411,334. For this expansion, the government with community participation hired new CHWs and IM has helped to build their capacity through training and regular supervision. Figure 17 provides a country breakdown of populations covered. IM provided support along the continuum of health services from community to higher-level facilities.

Figure 17: Population covered by iCCM in IM-supported countries Improved the quality of iCCM through capacity building of CHWs


In the current reporting period, IM supported the training of 936 new CHWs using national iCCM curricula adapted and revamped in the previous project reporting period. In Cameroon, SBC training was integrated into this curriculum in collaboration with BA. After their training, each CHW was provided with SBC materials and tools to perform their activities. IM also supported health area and district staff to supervise targeted CHWs and conduct regular check-ins with CHWs at health facilities. These activities provided the opportunity to continually improve CHW knowledge and skills, collect and review iCCM data, and troubleshoot problem areas (e.g., stock-outs of medicines and diagnostics). During the current project reporting period, IM built on existing national supervision tools that focus primarily on monitoring of commodity stock status as well as data quality and management, developed a competency-based checklist and piloted it in Cameroon and Mali. Feedback from those pilots is expected during the next project reporting period, which will likely lead to refinement, adoption and wider implementation of the checklist.

Success Story: Inspired to Serve Her Neighbors, a Community Health Worker Trains to Bring Care Closer to Her Community in Rwanda

When Beatha Mukabucyana’s children fell sick with malaria, a community health worker treated them at home in her village. “The quick and efficient health services provided to me in my time of need motivated me to become a community health worker myself.” she said. Ms. Mukabucyana, a 46-year-old mother of eleven, serves the Karambi Village of the Nyamasheke District, Rwanda, as a community health worker. But she didn't feel confident treating for malaria because she lacked training in handling suspected malaria cases. “At such times, I felt helpless,” she added. That changed when Ms. Mukabucyana participated in a four-day training program on integrated community case management supported by PMI through the PMI Impact Malaria project. Integrated community case management (iCCM) is a strategy to extend the management of childhood illness beyond health facilities so that more children have access to lifesaving treatments. iCCM relies on community health workers to deliver care for childhood illnesses, including malaria. During the training, Ms. Mukabucyana learned to confidently diagnose and treat malaria cases. While visiting families in her community, she sees up to 20 suspected cases of malaria per month, four to ten of which test positive for malaria. Before, her community had to travel long distances to receive the care they needed. “I used to be disheartened seeing sick children and their parents walking long distances to seek care,” she said.

Bethea Mukabucyana and Athanase Ntihinyurwa, head of Kamonyi Health Center. Photo credit: IM Rwanda


Now, Ms. Mukabucyana brings health care services to their doorsteps. She joins a network of over 58,000 community health workers across Rwanda that not only make health care services for children more convenient for the communities they serve but can help alleviate the burden placed on sometimes already stretched health facilities. Athanase Ntihinyurwa, head of Kamonyi Health Center, one of the regional health centers, shared that community health workers have helped reduce the number of malaria cases handled by the health center. From January to June 2021, the health center treated 63 positive cases of malaria while community health workers treated 687 malaria cases directly in the community. Proper training plays a critical role in ensuring that Ms. Mukabucyana and other community health workers can deliver quality and timely care to their neighbors and extend the reach of health systems beyond brick-and-mortar health facilities.

Improved the quality of iCCM service delivery IM has monitored community service delivery data throughout implementation in IM-supported countries. During the current reporting period, a high percentage of fever cases seen by IM-supported CHWs were tested for malaria with an mRDT (Figure 18). Of those that tested positive, a very high proportion of patients across all countries were treated by the CHW with ACTs. The rarity of cases of severe illness and HMIS data limitations prevent reporting of cases with danger signs referred to a HF. This has limited insights into a key aspect of the continuum of care delivered through iCCM programs. The competency-based checklist, newly developed during the current reporting period may provide further information on the appropriateness of patient referrals.


Figure 18: Number of suspected malaria cases, suspected malaria cases tested for malaria, confirmed malaria cases, and malaria cases treated with an ACT through iCCM, Source: HMIS data Bolstered malaria case management in the private sector In many malaria-endemic countries, the private sector plays an important role in the health system, often extending malaria services to areas not reached by public sector health services. In some PMI countries, as much as 40% to 70% of treatment for febrile children is sought in the private sector. Although the private sector is often referred to as a discrete entity, it is diverse, including a range of providers from large hospitals to small clinics, pharmacies, and drug sellers. They may be formally registered and regulated or informally established and unauthorized, and operating a non-profit or for-profit business model.3 Because private sector outlets are often closest to communities, located in the patient's village or in peri-urban areas, they are frequently the first place for seeking treatment. However, in most settings where the private sector is an important source of health care, private health services are often not included in MOH and NMCP strategies as a channel to deliver high-quality services.

3 Wadge, H. et al. 2017. Evaluating the impact of private providers on health and health systems. London, UK: Imperial College London. https://assets.cdcgroup.com/wp-content/uploads/2017/06/25150846/Impact-of-private-providers-on-health-and-health-systems.pdf

https://assets.cdcgroup.com/wp-content/uploads/2017/06/25150846/Impact-of-private-providers-on-health-and-health-systems.pdf


The global malaria community has learned much about the feasibility of supporting quality malaria case management services in the private sector from initiatives such as the Affordable Medicines Facility-Malaria (AMFm) and the UNITAID-funded Private Sector Rapid Diagnostic Test (RDT) Project, ACTwatch, and various country-specific activities. In 2019, WHO hosted a Technical consultation on the engagement of the private sector for malaria case management4 that reviewed those experiences and focused on barriers to engagement with private sector providers, including legal and regulatory barriers and supply chain constraints. Based on the recommendations from this meeting, PMI requested that IM collaborate with WHO to develop an Operational Handbook for Malaria Case Management in the Private Sector, including a desk review. In the current project reporting period, the desk review was completed, and a first draft of the Handbook was developed that builds on the outcomes of the WHO consultation, as well as previous work by the RBM CMWG, and the Roadmap for Optimizing Private Sector Malaria Rapid Diagnostic Testing5. In the next reporting period, IM will draft and field test the Handbook in three countries in SSA. Learnings from the workshops will be incorporated into the final version of the Handbook prior to its publication and dissemination. In selected countries, IM has extended its OTSS+ support to private sector facilities, particularly private hospitals and clinics. Across Cameroon, Ghana, Madagascar, and Sierra Leone, 232 private sector facilities have received at least one clinical OTSS+ visit during the current project reporting period. An additional 397 private sector facilities received a laboratory OTSS+ visit in Cameroon, DRC, Ghana, Kenya, Madagascar, Sierra Leone, and Zambia. In addition, 203 private sector facilities in Cameroon, Ghana, Sierra Leone, and Zambia benefited from MIP OTSS+ support since the beginning of the project. IM also includes private sector providers in its classroom training for clinicians. Across Cameroon, Côte d’Ivoire, Ghana, Madagascar, Mali, and Zambia, 202 private sector providers received training in malaria case management. An additional 154 laboratory professionals received laboratory training in Cameroon, Côte d’Ivoire, DRC, Madagascar, Sierra Leone, and Zambia and 329 private sector providers from Côte d’Ivoire, Ghana, Mali, Sierra Leone, and Zambia received training in MIP service delivery. Improving Access to High-Quality Malaria Diagnosis During this reporting period, IM supported improved access to high quality malaria diagnosis across 12 countries, including Cameroon, Côte d’Ivoire, DRC, Ghana, Kenya, Madagascar, Malawi, Mali, Niger, Sierra Leone, Tanzania, and Zambia (Figure 19).

4 WHO Global Malaria Program. 2019. Technical Consultation on Engagement of the Private Sector Malaria Case Management. https://www.who.int/malaria/mpac/mpac-october2019-session6-report-case-management-private-sector.pdf?ua=1 5 Population Services International. 2019. A Roadmap for Optimizing Private Sector Malaria Rapid Diagnostic Testing. https://www.psi.org/publication/a-roadmap-for-optimizing-private-sector-malaria-rapid-diagnostic-testing/

https://www.who.int/malaria/mpac/mpac-october2019-session6-report-case-management-private-sector.pdf?ua=1

https://www.psi.org/publication/a-roadmap-for-optimizing-private-sector-malaria-rapid-diagnostic-testing/


Figure 19: IM-supported countries receiving laboratory technical support   IM’s objective is to improve access to high quality malaria diagnostic services by focusing on increasing the proportion of: persons tested before treatment at service delivery points; HWs who competently perform diagnostic tests; and febrile cases correctly classified. Table 6 represents IM’s diagnosis indicators used to track performance throughout the year. Table 6: Diagnosis Program Indicators

Outcome   Intermediate Outcome   Outputs   ● % of reported malaria cases

confirmed with a diagnostic test   

●  % of patients with suspected malaria who received a parasitological test

● % of supervised facilities that meet standards (including appropriate materials, documentation, and qualified staff) for quality diagnosis of malaria 

● % of HWs demonstrating competency in malaria microscopy  

● % of HWs demonstrating competency in mRDTs  

● % of observed HWs demonstrating competency in correctly classifying cases as not malaria, uncomplicated malaria, and severe malaria   

● % Targeted countries with national guidelines for malaria diagnosis that meet global standards  

● % Targeted countries with national malaria diagnostic supervision tools that adhere to global standards  

● % of designated supervisors trained in supervision of malaria diagnostics 

● % of targeted HWs trained in malaria diagnostics 

● % of supervised facilities with at least one provider trained in malaria diagnosis  


During the current reporting period, IM continued supporting the implementation of QA systems for malaria microscopy, mRDTs, and the diagnosis of uncomplicated and severe malaria in IM countries. IM provided technical support to improve malaria diagnosis at different levels of the health system, with tailoring of the mix and priority of activities across the different countries. At national level, IM provided support to strengthen policies on malaria diagnosis, national reference laboratories, and units that host national slide banks, as well as groups of core trainers and supervisors. IM provided support in updating national diagnostic policies and guidelines to align with global guidance, updating training curricula and materials, developing national slide banks, and improving supervisory and mentoring skills.    At the provincial, district, and HF levels, IM supported the implementation of QI activities for malaria diagnostic testing (malaria microscopy and mRDTs), external quality assurance (EQA), proficiency testing (PT), and internal quality assurance (IQA). IM also supported strengthening competencies for malaria microscopy and mRDTs through malaria diagnostic refresher trainings (MDRT) and OTSS+ visits. Table 7 below presents activities carried out in the current reporting period. Table 7: IM current reporting period laboratory strengthening activities by country Activity    Country   

Malaria microscopy QA manuals updated 

Malawi, Tanzania (Mainland and Zanzibar), and Kenya 

MDRTs conducted (basic and advanced) 

Côte d’Ivoire, DRC, Cameroon, Ghana, Kenya, Madagascar, Malawi, Mali, Sierra Leone, Tanzania (Mainland and Zanzibar), and Zambia  

OTSS+ supervisors 

trained

Cameroon, Côte d’Ivoire, DRC, Ghana, Kenya, Malawi, Madagascar, Mali, Sierra Leone, Tanzania (Mainland and Zanzibar), and Zambia  

Laboratory OTSS+ visits   

Cameroon, Côte d’Ivoire, DRC, Ghana, Kenya, Malawi, Madagascar, Mali, Sierra Leone, Tanzania (Mainland and Zanzibar), and Zambia  

Supported updates to diagnosis policy, guidelines, and job aids During the current project reporting period, IM supported NMCPs in Kenya, Malawi, and Tanzania (Mainland and Zanzibar) to bring malaria diagnosis policy, guidelines, QA manuals, and job aids into alignment with current global diagnostic guidance.  IM also supported the review of biosafety guidelines for CHWs in Kenya.  Supported the review of diagnostic curriculum and training materials The pre-service curricula in many training institutions often does not build sufficient skills in malaria microscopy. This leads to HWs having inadequate diagnostic skills when working in health


facilities. Recent graduates must therefore go through refresher training to achieve the desired competency level. Previous reviews of pre-service training curricula completed in Kenya showed a lack of alignment with most recent updates of national malaria case management guidelines. These curricula did not include updated information on mRDTs. To bridge the gap between pre-service education and in-service training courses, IM supported the review of pre-service curricula and refresher training materials in both the DRC and Kenya. In DRC, IM also supported the NMCP to revise the malaria case management content within the curricula of higher-level institutions that train doctors, nurses, and midwives. Reinforced malaria diagnostic refresher training IM supported MDRTs to improve microscopy skills of laboratory technicians in parasite detection (PD), species identification (ID), and parasite counting (PC), as well as their competency for performing and interpreting mRDTs. Microscopy competencies were assessed during each training through pre- and post-tests. IM prioritized competency in PD (achieving a score of >80% per WHO recommendation) at all health facilities, while also building competency in ID (score >80%) and PC (score >40%) at referral level. During the current reporting period, IM conducted basic and advanced MDRTs in Côte d’Ivoire, DRC, Cameroon, Ghana, Kenya, Madagascar, Malawi, Mali, Sierra Leone, Tanzania (Mainland and Zanzibar), and Zambia.   The criteria used by NMCPs to select participants for MDRTs was dependent on the baseline level of microscopy expertise among laboratory technicians and whether participants had previously been trained. Technicians who had not previously attended MDRT began with a basic MDRT (bMDRT). Those that demonstrated high performance in bMDRT proceeded to advanced MDRT (aMDRT). Those that performed best at aMDRT were selected to move on to National External Competency Assessment in Malaria Microscopy (nECAMM). MDRT trainers were finally selected from those who earned a level A or level B during nECAMM.  In most countries, IM support was prioritized to training peripheral laboratory technicians who had not received previous MDRT.  MDRT participants improved in PD, with most trainees in several countries achieving a score >80% at the end of training (Figure 20). Lower PD competencies were seen in Sierra Leone, which just launched laboratory OTSS+ this year and may be an indication of insufficient pre-service training. In Tanzania, lower PD competencies were at least partially attributed to the quality of the training microscopes. Improvements in average PD scores were seen among all participants, even those who did not reach the minimum competency threshold (Figure 21).


Figure 20: Percentage of laboratory technicians achieving competency level of 80% in parasite detection during bMDRT

Figure 21: Pre- and post-test average scores in Parasite Detection during bMDRT in 2021

Success Story: Building a Cadre of Skilled Malaria Microscopists in the DRC and Malawi Christine Kabedi looks through the lens of her microscope. She adjusts the handle to magnify her view and fixes her eyes. Once the sample is in clear view, she starts counting parasites. Christine is a microscopist at the provincial reference laboratory in Kananga, Democratic Republic of the Congo (DRC). She analyzes patient blood samples to determine if there is a malaria infection, what type of malaria parasite is responsible, and the severity of the infection. Christine’s work plays a pivotal role in diagnosing malaria in patients, tracking treatment progress, and uncovering antimalarial


treatment failures. Yet she struggled with parasite counting and often found herself discouraged and frustrated when trying to analyze blood samples. Malaria microscopy is no easy task, and microscopy skills require constant practice and refreshing. PMI through IM supports the NMCP in DRC to strengthen microscopists’ skills by providing training and supervision. Christine recently participated in a microscopy refresher training. Her test scores in identifying parasites improved from 25% pre-training to 100% post-training and she finished the training at the top of her class. As a result, Christine was selected to participate in the next higher-level training to become a microscopy supervisor. “Being among the best, I was again selected for the national malaria microscopy accreditation course. At the end of this course, I was ranked among the best with the level B according to the WHO certification.” Christine is now a nationally accredited microscopist. “I have become an expert in malaria microscopy, and a supervisor and trainer … I share my knowledge with all those who need it in my health facility and during supervision to increase the critical mass of microscopists capable of improving the quality of microscopy in my province.”

Patrick Kadangwe is a microscopist at the Kasungu district hospital laboratory in Malawi. Like Christine, he also struggled in his work. “It had been slightly over ten years since I attended a malaria microscopy refresher training,” said Patrick. He worried his skills were not up to date. Through the support of PMI and IM, Patrick recently attended a malaria microscopy training to refresh his skillset. “There are many technical aspects that I gained during these sessions including parasite identification and parasite counting, which is key to severe malaria case management,” he noted about the refresher training. Skilled microscopists are critical in ensuring patients with malaria infections receive appropriate treatment to prevent severe illness and even death. With PMI support through IM, NMCPs in the DRC and Malawi have trained 113 malaria microscopists, like Patrick and

Christine, to strengthen their microscopy skill sets and add to a growing network of dedicated experts that can correctly identify malaria infections. As Christine emphasizes, “malaria microscopy has become my passion.’’

Supported malaria slide banks and proficiency testing Malaria slide banks are a source for well characterized and high-quality reference slides used to train and assess competencies during MDRTs, PT, nECAMM, and other activities related to malaria microscopy. Panels of well-characterized slides of known composition are needed for PT of malaria

Patrick Kadangwe, a malaria microscopist at Kasungu district hospital laboratory. Photo credit: IM Malawi

Christine Kabedi training to become a microscopy supervisor, Katoka Health Zone, Kananga, Kasai Central Province. Photo credit: IM Democratic Republic of the Congo


microscopy. PT is used to identify health facilities or microscopists that need more support to improve their competency, and thereby to better allocate resources and confirm that poor-performing staff are not left behind. IM conducted regular PT during OTSS+ on-site visits which allowed for immediate on-the-job training if poor performance was detected. PT programs have also been set up by a growing number of PMI-supported countries, including Ghana, Sierra Leone, DRC, Malawi, and Zanzibar.   IM supported Cameroon, Madagascar, Niger, Sierra Leone, and Tanzania to procure malaria slides from certified sources to build a slide bank where none previously existed or to supplement an existing slide bank. This included replacing broken and misplaced slides and increasing the species composition and parasite density ranges of those banks. In Zambia, IM supported the National Malaria Elimination Program (NMEC) to locally recruit non-P. falciparum-infected donors for the preparation of standardized slides to add to their existing slide bank. IM also supported the NMCPs in Tanzania (Mainland and Zanzibar) to conduct training on the slide bank database, in preparation for arrival of the newly procured slides. Reinforced Laboratory Outreach, Training, and Supportive Supervision Plus OTSS+ builds on MDRT to improve and sustain the competency of laboratory technicians in quality malaria diagnostic testing. During the current project reporting period, IM implemented laboratory OTSS+ in Cameroon, Côte d’Ivoire, DRC, Ghana, Kenya, Malawi, Madagascar, Mali, Sierra Leone, Tanzania (Mainland and Zanzibar), and Zambia. Figure 22 presents the percentage of HWs demonstrating competency in malaria microscopy, assessed during the microscopy observation component of OTSS+ rounds in eight countries (Cameroon, Côte d’Ivoire, DRC, Ghana, Madagascar, Mali, Sierra Leone, and Zambia). Malawi and Tanzania had not completed lab OTSS+ during this reporting period and Kenya measures this competency using different indicators. Countries that have been implementing Laboratory OTSS+ and MDRT through previous PMI-supported projects, including DRC, Ghana, and Zambia, performed better than countries that launched OTSS+ and MDRT during IM, including Cameroon, Côte d’Ivoire, and Sierra Leone (Figure 22). In Mali, OTSS+ was implemented in new provinces in Round 3 which appears as a drop in competency compared to previous rounds. Similarly, targeting OTSS+ visits to low-performing HF in later rounds, as Zambia has done, resulted in a measured decline in competency. Figures 23, 24, and 25 present the average competency scores for specific diagnostic skills, including parasite detection, slide staining, and slide preparation.


Figure 22: Percentage of HWs demonstrating competency in malaria microscopy  

Figure 23: Parasite Detection average scores by OTSS+ round

Figure 24: Slide staining average scores, by OTSS+ round


Figure 25: Slide Preparation average scores by OTSS+ round The proper use of mRDTs is another critical skill needed for quality malaria diagnostic services. Figure 26 presents the percentage of HWs demonstrating competency under observation in the use of mRDTs during OTSS+ visits.

Figure 26: Percentage of HWs demonstrating competency under observation in using mRDTs


Success Story: Rapid Diagnostic Testing for Malaria is More Important Than Ever During

the COVID-19 Pandemic “COVID-19 and malaria have similar symptoms, like fever, fatigue, headache and sometimes difficulty breathing,” notes Regina Akweley Kluise, Deputy Director of Nursing Services in Akuapem North District in Ghana. Malaria is a major health risk in Ghana, with over 4.9 million diagnosed cases and over 11,000 deaths in 2019 alone. With the added threat of COVID-19, the World Health Organization (WHO) advised high-malaria burden countries, like Ghana, to tailor interventions and maintain the availability of essential health supplies, like malaria rapid diagnostic tests. Regina, who also works as a trained, district-level quality assurance health supervisor, knows that now, amid the COVID-19 pandemic, it is more important than ever to correctly diagnosis the cause of fevers to ensure patients get the right treatment. PMI, through its flagship malaria service delivery project PMI Impact Malaria (IM), supports the NMCP in Ghana to provide high quality malaria case management services in 867 health facilities in seven regions with high malaria burden. This support includes on-the-job training in line with WHO’s test, treat, and track strategy for malaria. With additional funding from USAID, IM supported the NMCP in the development and roll out of COVID-19 case management and laboratory guidelines. Regina recently attended a two-day training supported by IM on how to supervise, train, and coach health workers in diagnosing and treating malaria in the facilities where they work. Following the training, Regina donned a face mask and other COVID-19 precautionary measures while visiting the Tetteh Quarshie Memorial Hospital. There, she provided on-site support to hospital outpatient nurses as part of IM’s Outreach, Training and Supportive Supervision Plus (OTSS+) approach to improving health worker skills in diagnosing and treating malaria. Regina and her team noted some of the nurses weren’t quite confident in using rapid diagnostic tests for malaria and supplies were low. Regina took the opportunity to provide an on-the-job refresher training for the nurses on performing rapid malaria diagnostic tests and monitoring and maintaining stock levels.

Regina Kluise conducts a refresher training for outpatient department nurses on using malaria rapid diagnostic tests at the Tetteh Quarshie Memorial Hospital in Mampong Auapem, Eastern Region. Photo Credit: Emmanuel Attramah, IM Ghana

https://www.who.int/news/item/23-04-2020-who-urges-countries-to-move-quickly-to-save-lives-from-malaria-in-sub-saharan-africa

https://www.who.int/news/item/23-04-2020-who-urges-countries-to-move-quickly-to-save-lives-from-malaria-in-sub-saharan-africa

https://www.who.int/news/item/01-06-2020-maintaining-essential-health-services-new-operational-guidance-for-the-covid-19-context


Thanks to training, coaching, and support by quality assurance supervisors like Regina, nearly 90% of all health workers in 867 targeted health facilities across Ghana can effectively use rapid malaria tests and correctly diagnosis malaria. In addition, there have been no test stockouts at Tetteh Quarshie Memorial Hospital in over a year. With COVID-19 and malaria sharing similar symptom profiles, WHO warned deaths from malaria could increase if the diseases were misdiagnosed. Regina adds, “…we had to increase malaria rapid diagnostic tests use at the hospitals and health centers.” Her role in ensuring health care workers have malaria rapid diagnostic tests available and the skills to use them confidently and correctly is critical in heading off this added threat, and in getting patients the correct therapy they need in treating the cause of fevers.

Identified malaria diagnosis implementation challenges related to the COVID-19 pandemic The COVID-19 pandemic continued to present implementation challenges, particularly due to travel restrictions to and from IM countries. As a result, participants from Sierra Leone and Zambia could not travel to attend an External Competency Assessment in Malaria Microscopy (ECAMM) in Senegal or Kenya. Planned travel by participants from Madagascar was also delayed. However, IM was able to provide international technical support from the regionally based technical advisors to Côte D’Ivoire, DRC, Malawi, and Tanzania. Improving Access to High-Quality Prevention and Management of malaria during pregnancy IM supports improved access to high quality interventions to prevent and treat MIP. These include IPTp, ITNs, and appropriate case management of MIP. IM aims to increase the percentage of pregnant women receiving three or more doses of IPTp and an ITN through the ANC platform, as well as the identification and testing of mothers with suspected malaria, for correct classification, treatment, or referral of those who test positive.

Regina Kluise and outpatient department nurses with their malaria rapid diagnostic test records and inventory books at the Tetteh Quarshie Memorial Hospital. Photo Credit: Emmanuel Attramah, IM Ghana


Figure 27: Countries receiving support from IM for MIP During the current project reporting period, IM supported MIP strengthening activities in eleven countries: Cameroon, Côte d’Ivoire, Ghana, Kenya, Malawi, Mali, Niger, Rwanda, Sierra Leone, and Tanzania, as well as in Zambia, where only OTSS+ is supported (Figure 27). IM additionally supported a G-ANC and ANC surveillance study in Benin, where the project carried out a baseline household survey and launched both components of the study after making protocol adjustments in response to the COVID-19 pandemic. The IM strategies for improving MIP service delivery in targeted IM countries include national-level coordination; support for policy change and implementation; promotion of increased ANC attendance; quality improvement for MIP prevention and treatment; supply chain coordination with key stakeholders; and strengthened routine monitoring and evaluation, including use of data for decision-making. These MIP service delivery improvement strategies are summarized in Figure 28. MIP interventions are tailored to country needs and priorities and implemented through an integrated approach to service delivery with other IM technical areas.


Figure 28: IM strategies for improving MIP service delivery IM’s indicators for MIP are used to track performance through the year (Table 8). Table 8: MIP Program Indicators Outcome  Intermediate Outcome  Outputs  ● % Pregnant

women who received three or more doses of IPTp 

● % Observed HWs demonstrating competency in the prevention of MIP 

● % Observed HWs demonstrating competency in the treatment of MIP 

● % Pregnant women who receive one dose of IPTp 

● % Pregnant women who receive two doses of IPTp 

● % Pregnant women who receive three doses of IPTp 

● % Pregnant women who receive four or more doses of IPTp 

● % Pregnant women who receive an ITN during routine ANC 

● % Targeted countries with national guidelines for the prevention and treatment of MIP that meet global standards 

● % Targeted HWs trained in MIP, including IPTp, ITNs, and case management of MIP 

National MIP TWGs are key platforms to establish and maintain coordination, discuss policy change, monitor progress, review lessons learned, and address challenges to the implementation of MIP interventions between MOH malaria and reproductive health (RH) units. IM continued to support national MIP TWGs in Cameroon, Côte d’Ivoire, Ghana, Kenya, Mali, Niger, and Sierra Leone. IM also began


support to existing MIP TWGs in Malawi and Tanzania during the current reporting period. In addition to national level working groups, Côte d’Ivoire and Kenya continued to support sub-national TWGs. Across countries, COVID-19 continued to disrupt some scheduled TWG meetings, while others were held virtually. MIP TWGs engaged other key stakeholders within and outside of the government, such as academic and research institutions and development partners to coordinate and implement MIP programming. National TWGs also provided a direct link from country stakeholders to the RBM MIPWG, creating avenues for the dissemination of global guidance, as well as sharing country experiences, successes, and challenges. Specific topics discussed in country TWGs included reviewing data quality audit results; exploring the coverage of pregnant women with ITNs delivered through ANC; updating OR activities; discussing community IPTp pilots; and developing strategies to improve IPTp3 uptake. Table 9. Status of MIP guidelines and MIP technical WG in targeted IM countries

Country 

MIP guidelines

aligned with global

standards 

Considerations  Functional MIP TWG 

Cameroon 

Y The malaria TWG has adopted IPTp initiation at 13 weeks. An addendum to the guidelines is being developed and the information has been shared with all facilities.

N

Malaria TWG is addressing all

thematic areas,

including MIP

Côte d’Ivoire 

N  Guidelines do not list IPTp initiation at 13 weeks/beginning of 2nd trimester 

N 

Central group did not meet in PY4;

lower-level TWGs have met

Ghana  Y  Ghana’s guidelines are aligned with global standards

Y 

Kenya  Y Guidelines revised to include the WHO-

recommended eight ANC contacts for IPTp scheduling. 

Y 

Malawi Y Guidelines now aligned to WHO

recommendations, IPTp initiation at 13 weeks with eight recommended ANC contacts

Y


Country 

MIP guidelines

aligned with global

standards 

Considerations  Functional MIP TWG 

Mali 

Y  MIP training manual is aligned to WHO recommendations, IPTp initiation at 13 weeks, and eight ANC contacts. National guidelines reflect WHO recommendations for MIP.

Y 

Niger 

N  IPTp not begun at 13 weeks; quinine used in the first trimester for severe malaria 

N

High-level “core” group has met, not

full TWG 

Sierra Leone 

Y  MIP guidelines are up to date. The TWG works closely with the NMCP to resolve stock-outs of malaria commodities and is involved in designing and acting as trainers for IM’s mentorship work to reach all ANC providers in project districts.

Y 

Rwanda 

Y  Guidelines are aligned to WHO recommendations (artesunate for the treatment of severe malaria during the first trimester). Rwanda does not implement IPTp.

N 

MIP addressed under Malaria TWG 

Tanzania

Y Implements IPTp in conjunction with single screen and treat at first ANC visit (ANC1), starting as early as possible in the second trimester.

N

Expected to be scheduled for Q1 the next reporting

period

During the current reporting period, IM continued to support MIP service delivery through training and OTSS+ in Cameroon, Côte d’Ivoire, Mali, Niger, Sierra Leone, and Zambia. IM also reinforced Rwanda’s supportive supervision process, which uses an adapted OTSS+ MIP supervision checklist. In the current reporting period, IM Mali was redeployed to the regions of Kayes and Koulikoro, and the District of Bamako and conducted a baseline rapid situation assessment; trained health providers on MIP; and conducted two rounds of OTSS+ in the new geographic focus areas. IM also began support of Malaria Service Delivery and Quality Improvement (MSDQI) in Tanzania, which will contribute to the project-wide learning around MIP service delivery and Malawi began preparations to launch OTSS+ with the MIP module in the next reporting period, including adapting the checklist to national context and validating


checklists. In some countries, OTSS+ is supplemented with mentorship between OTSS+ visits to address gaps identified during the OTSS+ visits. The most recent data from OTSS+ and other project-supported supportive supervision indicated that average competency scores in MIP prevention ranged from 68% in Cameroon to 98% in Côte d’Ivoire, and 73% in Cameroon to 94% in Kenya, for competency in the treatment of MIP. Average scores improved from the baseline in Côte d’Ivoire, Ghana, Mali, and Niger for MIP prevention and in Cameroon, Côte d’Ivoire, Ghana, Kenya, Mali, and Niger for MIP treatment. Trends in the percentage of HWs scoring as competent (>90%) in MIP prevention looked somewhat different (Figures 29). Ghana and Kenya had the highest percentage of providers deemed competent and do so consistently, while Côte d’Ivoire and Niger demonstrated consistent gains across measurements. Data on the percentage of providers scoring competent in MIP treatment followed a similar pattern, with Ghana and Kenya scoring consistently competent and Côte d’Ivoire and Niger showing improvements over time (Figure 30). Because the same facilities were not always visited during each OTSS+ round (except in Côte d’Ivoire and Niger), caution should be taken when making inferences about whether the quality of service was improving in specific facilities between rounds.

Figure 29: Percentage of observed HWs demonstrating competency in the prevention of MIP


Figure 30: Percentage of observed HWs demonstrating competency in the treatment of MIP In addition to OTSS+ data, the project also reviewed routine health systems data to monitor and guide programs. While coverage of IPTp1 exceeded 80% in Côte d’Ivoire, Malawi, Niger, and Sierra Leone (Tanzania does not collect information on IPT1), coverage of IPTp3 was lower than 80% across most countries, except Tanzania (Figure 31). When IM compared IPTp3 coverage with ANC4 coverage - assuming that by a fourth ANC visit, a provider would have had adequate opportunity to provide three doses of IPTp - gaps in coverage were apparent. In Ghana, Kenya, Malawi, and Tanzania, ANC4 coverage is notably higher than IPTp3 coverage, indicating that there were many missed opportunities to reach pregnant women at ANC with IPTp (Figure 32). Conversely, in Mali and Niger, IPTp3 coverage exceeded ANC4 coverage, indicating that women were likely beginning ANC later and are of late enough gestational age to initiate IPTp at their first ANC visit. In these countries, programming should focus on encouraging early ANC attendance to provide women with an ITN and begin IPTp as early as possible to support the mother and unborn child to be continually protected against malaria.

Figure 31: Percentage of pregnant women receiving IPTp1, 2, and 3, Oct 2020 - Sept 2021


Figure 32: Comparison of IPTp3 uptake and ANC4 attendance to identify missed opportunities or late initiation, Q1 versus Q4 2021 Ghana, Malawi, Sierra Leone, and Tanzania had relatively high and stable distribution of ITNs to pregnant women via ANC during the current reporting period; however, other countries were unable to achieve or maintain high coverage levels (Figure 33). In Kenya, ITN coverage exceeded 100% during the reporting period because ITN stocks were replenished following a period of insufficient supply in the previous reporting period. Therefore, clients who had not received ITNs during first ANC late in the previous reporting period were issued an ITN during visits during the current reporting period. While providers had little control over ITN supplies, there was anecdotal information from several countries that adherence to routine distribution policies were not uniform, which can be addressed through OTSS+. Unfortunately, HMIS data on screening and case management for MIP were not available in many countries, which prevented the tracking of trends.

Figure 33: ITN distribution via ANC, Q1-Q4 2021


In addition to OTSS+, country-tailored innovative practices and approaches continued to guide IM’s comprehensive approach to improving the quality of and access to MIP services. For example, in Malawi, the IM team designed an assessment methodology and tool to better understand whether ITNs have reached pregnant women through ANC and maternity services as planned. The assessment will be implemented in three districts early in the next project reporting period. In Côte d’Ivoire, IM supported stratégie avancée, or ANC outreach services, in five districts for seven months. During this time, 22% of all ANC1 visits and 39% of IPTp3 doses were delivered through this outreach approach. The Benin G-ANC and ANC surveillance OR, which was launched during the current project reporting period, has shed critical light on the feasibility of implementing these interventions through routine ANC clinics. A baseline survey was conducted early in the current project reporting period, followed by provider training shortly thereafter. The ANC surveillance data collection began at 40 HFs in December 2020, and the G-ANC recruitment began at 20 health facilities in March 2021. Although recruitment has encountered on-going challenges, the study team has proactively strived to address these challenges and continue study enrollment. In Ghana, routine service delivery data has been used as the source of data for measuring IPTp coverage. In line with WHO guidelines for measuring IPTp coverage using HMIS data, the indicator is calculated by expressing the number of pregnant women receiving each dose of IPTp as a percentage of the number of pregnant women appearing for their first ANC visit (ANC registrants). However, IPTp coverage reported from routine HMIS data continued to be lower than the coverage recorded through population-based surveys. Recognizing this as a concern for the Ghana Health Service (GHS), IM Ghana began a systematic review of the current method of calculating of IPTp coverage from HMIS data to investigate reasons for the discrepancy and to optimize methods used for IPTp coverage calculation in the current reporting period. Results are expected during the next project reporting period. In Mali in the current project reporting period, IM supported two studies, conducted by the Malaria Research and Training Center (MRTC). One study is to find innovative strategies to increase the uptake of IPTp through enhanced ANC service delivery. The second study is assessing the impact of an outreach approach for delivering ANC services on ANC and IPTp coverage. Study implementation began during the current reporting period, and the results will be available in the next project reporting period. Across countries, IM developed an innovative approach to using OTSS+ data to explore how provider and facility performance may relate to the overall quality of MIP care through the MIP quality of care assessment. This assessment was conducted to better understand factors affecting MIP service delivery and is nearing completion. During the current project reporting period, the research questions were developed, data cleaned, Institutional Review Board (IRB) approval obtained, and preliminary descriptive statistics produced. The regression analysis is underway and on schedule to be completed early in the next project reporting period, after which a manuscript will be developed for publication and findings will be disseminated through the RBM MIPWG and other international forums. As part of an effort to standardize MIP M&E guidance, the IM HQ team during the current reporting period completed and disseminated a summary guide on how to address MIP indicator measurement


challenges – especially those associated with IPTp measurement. The guide, which was disseminated to MIP and M&E teams across IM countries, is in use in IM-supported countries. Its content is being incorporated into country-level trainings, OTSS+ checklists, and M&E visits to resolve the measurement challenges observed in documenting and aggregating facility IPTp data. Following this project-wide dissemination, IM co-chaired a global technical webinar with the USAID Maternal and Child Health Division and WHO, held in January 2021, to disseminate an RBM MIP M&E brief – global technical guidance to standardize the M&E of MIP services across malaria-endemic countries. Through the webinar, IM provided guidance on how the brief can be practically applied by Malaria and Reproductive Health programs and stakeholders in their countries, to improve the accuracy, tracking, and use of the MIP indicators.

Success Story: Healthy Moms-to-Be Mean Healthy Families, Preventing Malaria in Pregnancy in Mali

“Every morning I took my tô (traditional Malian okra-based dish) before going to the field and, in the evening, I watered my garden and harvested my crops – all without a malaria problem. Often, I even carried bags of rice and baskets of tomatoes without any assistance.” Djeneba Kone was expecting her fifth child. She stayed healthy and able to tend to her fields and provide for her family throughout her pregnancy by proactively seeking and receiving preventive malaria care. Pregnancy reduces a woman’s immunity to malaria, making her more susceptible to malaria infection and increasing the risk of anemia, severe illness, and death. For her unborn child, maternal malaria is associated with premature delivery and low birth weight, a leading cause of newborn deaths.

During her pregnancy, Djeneba visited her local community health center in Soké, Mali, for routine checkups, or antenatal care. During each of four separate checkups and under the supervision of a maternity health worker, she took antimalaria pills to protect herself from malaria as part of the intervention known as intermittent preventive treatment of malaria in pregnancy, or IPTp. PMI Impact Malaria supports Mali’s NMCP and Reproductive Health Sub-Directorate to make IPTp and other preventive malaria services available to expecting mothers, like Djeneba. IM supported the NMCP to revamp the malaria in pregnancy (MIP) training package, incorporating global standards recommended by WHO, and trained over 400 health providers from across Mali to deliver MIP, including IPTp. With these preventive efforts, more women like Djeneba can experience a malaria-free pregnancy, safely welcoming the newest addition to their families and continuing to care for their families who depend on them.

Djeneba Kone with her healthy child. Photo Credit: Cheick Traore, IM Mali.


Objective 2: Improve the quality of and access to other malaria drug-based approaches and provide support to pilot and scale up newer malaria drug-based approaches During the current project reporting period, IM supported NMCPs in four countries to implement their SMC campaigns. IM supported implementation in Burkina Faso (27% of SMC districts), Cameroon (100% of SMC districts), Mali (20% of SMC districts) and Niger (29% of the national target, for 4.9 million children under the age of 5 in two regions). IM supported NMCPs in these countries to conduct microplanning; procure distribution supplies; recruit, train, and provide compensation to campaign workers; support data collection; and monitor and improve the quality of these campaigns. IM collaborated closely with the other implementing partners, including BA and PMI Measure Malaria, through SMC TWGs at the country level, and with the SMC Alliance at the global level. In the reporting period, IM conducted a review of lessons learned from 2020 SMC campaigns and initiated and supported the SMC Alliance M&E Subgroup to develop an SMC M&E Toolkit. Supported a review of the preliminary results of the first three cycles of the 2021 SMC campaign

During the current reporting period, IM supported the training of 42,773 SMC actors, including 39,432 CDs in Burkina Faso, Cameroon, Mali, and Niger. Across the four countries, families continued to accept SMC and coverage of SMC remained high. Based on administrative data, coverage in the first cycles of the 2021 campaign was 105% in Burkina Faso, 97% in Cameroon, 103% in Mali, and 98% in Niger (Figure 34). The number of children targeted in Burkina Faso, Mali, and Niger was based on census data whereas in Cameroon a household enumeration exercise was done before cycles 1 and 3, and there may be out-of-region or even cross-border children treated during the campaigns, pushing administrative coverage close to or above 100%. In Niger, a 10% contingency of buffer stock was included every year, to cover all children in the intervention zone on the days of the campaign, per national guidelines. Overall, the four countries combined treated more than five million children in the first three cycles in the IM-supported zones.

Figure 34: Proportion of targeted children reached in the first 3 cycles in 2021, Source: Administrative data


Success Story: SMC Prevents Malaria in Children in Burkina Faso

This is Angela Kabore, three years old and the youngest of four children in her family. She’s the pride and joy of her father, a clothing merchant at the local market, and her mother, a donut seller in front of the elementary school in their village of Signoghin, in the Pouytenga district of Burkina Faso. Angela is one of 45,000 children under the age of five years in the Pouytenga district that has been receiving preventive antimalarial medicines since July as part of the NMCP’s annual seasonal chemoprevention (SMC) campaign, supported by PMI through the PMI Impact Malaria project. SMC is a door-to-door intervention to protect children from malaria infection during the rainy season when transmission rates are high. As Angela’s mother explains, "For the past three months, Issa, the [SMC] community distributor, has been coming to our house to give my daughter medication. He gives us advice on how to avoid malaria by using mosquito nets and keeping the yard clean. He also follows-up on the use of mosquito nets by family members.” Mr. Moise Sibone is the nurse in charge of the Natenga primary health center. Mr. Sibone and his team of seven health care providers provide malaria prevention and treatment services to the communities of five villages, including Angela’s, surrounding the health center. This year the health center partnered with community distributors, like Issa, and district Ministry of Health staff to follow-up with 12 children, including Angela, during the course of this year’s SMC campaign. Mr. Sibone describes the objective of the monitoring conducted by the local health center staff is to "reassure parents of the effectiveness of SMC if the treatment is properly done." Mr. Sibone and his team monitored the occurrence of adverse events and reinforced proper dosage regimen for the preventative medicines used in SMC. According to Mr. Sibone, since July, none of the 12 children have fallen ill with malaria, a testament to the effectiveness of the SMC intervention. This year, with PMI’s support through IM, more than 800,000 children, like Angela, will benefit from the SMC campaign across 19 districts of the Centre-Est, Centre-Ouest, and Sud-Ouest regions of Burkina Faso.

Validated results of the 2020 SMC campaign In 2020, more than four million children under the age of 5 were reached by IM, according to the administrative data which was self-reported by CDs (Figure 35). In Mali, a further 168,103 five- to ten-year-old children were also reached.

Angela Kabore, recipient of SMC in Signoghin, Burkina

Faso. Photo credit: IM Burkina Faso.


Figure 35: Proportion of targeted children reached in each cycle in 2020, Source: Administrative data In 2020, Mali and Niger had a single target for the entire campaign, derived from available census data, and the country’s administrative SMC coverage data, reached very close to or exceeded 100%. As available census data were often outdated, using these figures did not provide adequate information about which children may have been missed. In contrast, Cameroon adjusted its denominator upward each cycle, as younger children aged into the target group and additional children were identified. This gave a better indication of the targeted children who may not have been reached in each cycle. Cameroon’s unique approach also combined household enumeration with social mobilization before each cycle. Other IM-supported countries have considered this approach, with the main barrier to adoption being the added cost. Monitored coverage and adherence Because the tally sheets used by CDs to report the numbers of children treated do not include the names of individual children, the only way to know whether children were treated during all four cycles is to use household surveys. In 2020, for the first time, IM supported Cameroon, Mali, and DRC to conduct rapid independent household monitoring surveys after the first and fourth SMC cycles, or in the case of Cameroon after every cycle. The monitoring surveys included questions on coverage, adherence to the full treatment regimens including the doses of amodiaquine (AQ) to be taken on Day 2 and Day 3 of each cycle, and how caregivers found out about the campaign, among other topics. These included whether it was the caregiver or CD who administered the first dose, why the child did not receive a first or subsequent doses if they did not. There are two ways of determining the proportion of children reached in all four cycles or the proportion who adhered: through caregiver verbal declaration and verification of proof, including a correctly completed SMC card, empty blister pack, or in Cameroon only, a marked finger.


Figure 36: Proportion of targeted children who were reached in all four cycles in 2020, Source: Surveys

Figure 37: Proportion of targeted children who took second and third doses during each cycle in 2020, Source: Surveys In Figures 36 and 37 above, there was a gap between what caregivers reported verbally, and what they could demonstrate as proof. In the same monitoring survey, IM Niger explored why families could not show proof of SMC treatment. They found that for 65% of the parents who could not show proof, the SMC card was incorrectly completed, and the remainder had lost or discarded the SMC card.


In Mali, the NMCP believed that caregiver declarations were closer to the truth because of known challenges with literacy and the fact that SMC cards may have been locked away safely while parents were out of the house tending the fields at the time when the survey monitors passed. Older siblings or grandparents who care for the children during the day may have been able to report accurately whether the child was treated but may not have had access to important family documents.

Success Story: Religious Leaders Play Key Role in Community Health in Mali “In the past, I would take about 10 children per month to the health center for malaria treatment,” lamented Thierno Souleymane, a Muslim religious leader, or imam, and teacher in the Nioro du Sahel district in western Mali. Imam Souleymane teaches the Koran to more than 60 students, half of whom are under the age of five years and are among the most vulnerable to succumbing to malaria infection. If a student showed up to the classroom with malaria symptoms or illness, Imam Souleymane would bring them to a health facility for proper care and treatment. Religious leaders in Mali, like Imam Souleymane, are trusted sources of health information in their communities and play an important role in the success of health intervention efforts, such as the NMCP’s seasonal malaria chemoprevention (SMC) campaigns, supported by PMI through PMI Impact Malaria. SMC campaigns provide children under five years of age with preventive malaria medication, known as “SPAQ”, during the rainy season when the threat of malaria infections rise. Imams are often consulted for coordination and planning of SMC activities in their communities and relied upon to reinforce awareness and messages about proper adherence to the administration schedule of SPAQ. Imam Souleymane has witnessed first-hand the benefits of preventive measures, such as SMC, on the health of his students. As he remarks, “I’ve noticed that, as of four years ago when the administration of SPAQ started, I’ve not had to take a single child to the health center due to malaria.” In 2021, over one million children in Mali will receive SMC through IM-supported campaigns. Working with religious leaders, such as Imam Souleymane, helps to ensure the success of SMC campaigns and the overall health of their communities. As Imam Souleymane says, “without health, nothing is possible.”

Despite declared adherence being high, in 2020 IM Cameroon, at the request of NMCP, initiated a pilot program known as Household Leaders. A respected head of a household in the target population (i.e., with at least one child targeted for SMC) volunteered to visit five neighboring households in the evenings of the campaign cycles to check if medicines had been given on Days 2 and 3. The volunteer was not

Imam Thierno Souleymane holding antimalarial medicine. Photo credit: IM Mali


remunerated, so the only cost was the training for the volunteers. Cameroon scaled up this approach nationwide in their 2021 SMC round. Verbal declaration of adherence only improved marginally, but the gap between verbal declaration and proof narrowed considerably, especially for empty blister packs (Table 10). Table 10: Comparison of proof and oral declaration for SMC in target and control groups in Cameroon

Survey regions

Group Oral declaration Finger mark

SMC card

Empty blister shown

Proof (finger mark or campaign card or empty blister)

North Target 96.7% 0.0% 40.0% 80.0% 82.0%

Control 95.5% 2.3% 30.5% 61.2% 69.9% Far North

Target 97.4% 13.4% 55.2% 90.7% 90.7% Control 96.6% 5.8% 47.5% 77.5% 88.6%

Total Target 97.1% 7.6% 48.5% 86.0% 86.9% Control 96.2% 4.6% 41.8% 72.1% 82.3%

Despite the best efforts of IM Cameroon to promote gender parity, 100% of household leaders who volunteered to be part of the program were men, as men are officially the “Heads of Household” in Cameroon. Therefore, in the current reporting period, IM Cameroon launched a Women Leaders approach for the third SMC cycle in September 2021. The leaders of the network of women’s associations were trained to provide additional sensitization on the importance of administering the medicine on Days 2 and 3 over the appropriate five-day period coinciding with the campaign. Whether this additional approach improves adherence will be assessed in the next reporting period.


Success Story: Empowering Women as Stewards of Health in Their Communities in Cameroon

Nabame Madi Louise is a mother of four living in the health area of Bidzard in the Figuil Health District in the North of Cameroon. Her children, like many others in her community that are under 5 years of age, are at high risk of contracting malaria during the rainy season in the North. For the past four years, Mrs. Madi has worked among 16,000 community mobilizers and distributors in implementing Cameroon’s annual seasonal malaria chemoprevention (SMC) campaigns. SMC campaigns, rolled out by the NMCP and supported by PMI through its flagship malaria service delivery project PMI Impact Malaria, are an effective measure in preventing malaria in children. Mrs. Madi explains her role in the campaigns: “My assignment is to visit the households, [count the number of] eligible children, and come back to administer the medicines as protection from malaria during the rainy season. Besides distributing medicines, I also raise awareness and sensitize visited households on adherence to the SMC treatment.” By September 2021, thanks to the dedication and hard work of Mrs. Madi and many community mobilizers and distributors, more than 1.8 million children under 5 years of age received preventive malaria medicine in each of 3 of 4 cycles completed so far during this year’s SMC campaign supported by PMI and IM. Mrs. Madi adds, "I really like working in SMC because it allows me to contribute to the health of the population of my village.” There’s an added benefit of her work with the SMC campaigns. Mrs. Madi explains: “SMC activities have also raised my profile in my community as parents rely on my advice for their children's health. The way others look at me has changed, starting with my husband and some more educated people than me. They come to me for advice.”

Nabame Madi Louise, SMC community mobilizer and distributor, Bidzard,

Cameroon. Photo credit: IM Cameroon


According to members of her community, Mrs. Madi is one of the most respected SMC mobilizers and distributors, but she is the only female SMC worker in Bidzard. Mrs. Madi knows the important leadership roles women can play in ensuring the health of their communities. Their involvement in SMC campaigns is a positive step in that direction. She adds, “Today, I am advocating that more women be involved in health activities because we are the ones who take care of our children. And this also helps to value us in the community.”

Improved the collection and quality of SMC administrative data During the current project reporting period, IM Cameroon piloted electronic data collection in the fourth cycle of the 2020 campaign. Fifty tablet computers were given to SMC data focal points at the health district level. Real-time data completeness was 93% on Days 1, 2, and 3 in the pilot districts in the North Region. In contrast, completeness declined from 58% on Day 1 to 46% on Day 2 and 17% on Day 3 in non-pilot districts. The approach also was determined to be successful for improving data quality, allowing data entry errors to be spotted and corrected at the end of each day. As a result, the NMCP requested IM to scale up tablet-based electronic data entry to all 446 aires de santé (health areas) targeted for SMC in 2021. In the first cycle, though, the influx of data into the District Health Information System 2 (DHIS2) database caused the system to become unstable, as there were too many validation rules (e.g., data point X must be smaller than data point Y). To address this, many of the problematic validation rules were removed from the software before the second cycle. In addition, there has been population movement from month to month, with entire villages emptied because of Boko Haram activities. The Cameroon NMCP has also consciously tried to avoid reporting administrative coverage over 100%, so one of their policies is that if the number of patients treated in any health area exceeds the number targeted, the target is updated to the number of people treated. In the current project reporting period, IM Cameroon worked with PMI Measure Malaria to conduct a Data Quality Audit of the first cycle of the 2021 campaign. The methodology had two parts: 1) a comparison of data in source documents and data reported through the electronic system; and 2) a qualitative evaluation of the strengths and weaknesses of the data collection and reporting systems. Source documents evaluated were: OPD registers; distribution registers; summary and tally sheets for distribution, social mobilization, and enumeration; and stock sheets. The results demonstrated that

Nabame Madi Louise visits a mother and her child at their home to distribute preventative antimalarials during the SMC

campaign. Photo credit: IM Cameroon


the North Region exceeded the 90% target for accuracy (Figure 38), and the Far North Region was close to the target (Figure 39).

Figure 38: Adequacy of source documents, first cycle of the SMC campaign, North, Cameroon (34 sites)

Figure 39: Adequacy of source documents, first cycle of the SMC campaign, Far North, Cameroon (18 sites) The on-going COVID-19 pandemic necessitated maintaining the modifications in the SMC delivery strategy adopted in 2020 to keep both HWs and families safe. Mali and Niger fully adopted a door-to-door strategy, rather than mixed with fixed-site distributions, as they did in 2019, to eliminate the crowds that might exacerbate transmission of COVID-19. All IM countries asked HWs to use face coverings and recommended that the first dose of sulfadoxine pyrimethamine-amodiaquine (SP-AQ) be administered by the family member under the observation of the distributor. Updated messaging efforts informed communities about COVID-19 infection and explained the reason for these changes in the distribution and administration approach. Additional messages promoted SMC and use of malaria services. Training


and supervision of SMC distributors used social distancing approaches. Cameroon shifted to single mobilizer-distributors (rather than pairs) as a COVID precaution in 2020 to reduce the number of contacts per distributor. This was popular with the distributors, who were able to spend more time with the households and call back more often. The shift to mobilizer-distributors was retained for the 2021 campaign. Supported development of an SMC M&E Toolkit in collaboration with the SMC Alliance During the current reporting period, IM organized and served as the Secretariat for the M&E Subgroup of the SMC Alliance. It supported the development of a Terms of Reference (TOR) for the group, which was completed in January 2021. The primary goal of the Subgroup has been to discuss and agree on a minimum set of core standardized metrics for reporting coverage and adherence. The Subgroup has been discussing and agreeing how to consistently track the indicators and develop or adapt existing tools to be used across countries, implementing partners, and funding streams. IM supported the development of a Performance Framework with standardized metrics, which was shared with country stakeholders by email and via a webinar ahead of the 2021 SMC campaign. The draft Performance Framework will be shared through a series of country consultations which began in September 2021 to determine the feasibility of collecting the proposed core standardized metrics. The Performance Framework has also included a core indicator on data quality: the proportion of health staff trained as focal data managers. The result is calculated as the number of health staff trained as data managers for SMC divided by total number of health staff enrolled in the SMC campaign for data management. Three further optional data quality indicators are: 1) Proportion of final micro-plans that include a data quality plan (including Standard Operating Procedures (SOP)); 2) Proportion of health facilities with SMC reporting tools; and 3) Proportion of complete SMC reports received on time. Subsequently, a country feedback collection guide and a diagram showing factors that influence effectiveness of SMC were developed by the Subgroup to improve the Performance Framework. The Subgroup, with IM as Secretariat, continued working on other elements of the SMC M&E Toolkit, including a standardized end of campaign report outline and an updated pharmacovigilance chapter. Data collection tools used by CDs (from tally sheets to adverse event monitoring forms) were gathered and reviewed to draw out best practices and provide examples for countries experiencing challenges or who were new to SMC. Guidance on independent monitoring surveys was also enriched. These efforts will continue in the next reporting period.


Objective 3: In support of Objectives 1 and 2, provide global technical leadership, support OR, and advance program learning Global Technical Leadership As stated previously in Figure 2, IM’s impact will come from supporting countries to implement up-to-date global guidance and best practices and share lessons learned from our country programs with the global malaria community. IM has done this through engagement in RBM TWGs and by implementing cutting-edge OR as prioritized by PMI. In the current project reporting period, IM has brought its country experience and lessons learned to contribute to the development of global guidance on malaria case management, MIP, and SMC that together will lead to accelerating progress toward reducing malaria mortality and ultimately toward elimination. Global Engagement Supported the RBM Malaria in Pregnancy Working Group During the current reporting period, IM continued to perform the Secretariat role for the MIPWG, promoting global- and national-level coordination; and disseminating updated guidelines, research, and tools to advance the MIP agenda. Specifically, during two technical webinars , IM staff presented to the WHO and USAID/PMI on the topics of community engagement and MIP M&E indicators; and coordinated the dissemination of the updated MIP M&E brief. With support from IM, the MIPWG successfully launched the Global Call to Action to increase IPTp coverage during a media briefing hosted by RBM and helped to drive the on-going campaign through use of targeted MIP messaging around key events such as International Women’s Day, World Malaria Day, and the International Day of the Girl Child. These efforts included an op-ed by the First Lady of Ghana, a gender-focused social media toolkit, and a video on the importance of IPTp, produced in collaboration with the UN Foundation, that was released on Mother’s Day. IM also provided technical support for the development of an information toolkit that will further engage First Ladies and be used for continued promotion of the Call to Action during the next reporting period. IM also played a key role in country engagement interviews or “listening sessions” with NMCP and RH representatives from 14 countries, the findings of which will be used to improve global support for national-level MIP efforts and to inform 2022 MIPWG workplanning. In addition, through the MIPWG Secretariat, IM continued to host bi-monthly teleconferences featuring partner presentations on a variety of topics to promote learning across the global community. Due to COVID-19, the annual MIPWG meeting was postponed and held virtually in September 2021. Supported the RBM Case Management Working Group The annual meeting of the CMWG, which was planned for the current project reporting period, was further postponed because of the COVID-19 pandemic. It is tentatively planned for June 2022. To fill the gap of the postponed meeting, IM supported the CMWG to host a webinar presentation from WHO on the status of resistance to malaria treatments. A second webinar to review the results of the UNITAID-funded Community Access to Rectal Artesunate for Malaria (CARAMAL) study was postponed until


October 2021. IM also supported the CMWG to make a proposal to the SMERG to convene a joint task force, in coordination with WHO, to review and update current global indicators for malaria case management. Participated in the RBM Surveillance, Monitoring, and Evaluation Reference Group IM participated in the 32nd SMERG meeting from May 18-20, 2021, the second meeting to take place virtually due to the COVID-19 pandemic. This meeting’s focus was on streamlining the SMERG to fully embody its role in enhancing surveillance, monitoring, and evaluation systems in malaria endemic and elimination countries or regions. The key topics discussed centered around the SMERG’s role in supporting and harmonizing partners’ efforts during a public health emergency; actions to better coordinate M&E efforts for malaria control and elimination; and coordination and documentation of strategies aimed at improving malaria surveillance and data use. RBM WGs and SMERG taskforces also took this opportunity to report on their accomplishments, challenges, and proposed way forward. As members of the CMWG and the SMC Alliance M&E WG, IM contributed to updates from those groups to the SMERG membership. IM further supported the establishment of the new SMERG Surveillance Practice and Data Quality committee, which was created, based on recommendations from the previous SMERG meeting to better streamline surveillance and data quality improvements efforts. The SMERG Secretariat compiled proposals and ideas raised during the three-day meeting and requested members to prioritize. IM-indicated support for various ideas including a review of the WHO malaria surveillance, monitoring, and evaluation manual, and the CMWG proposal to review malaria case management indicators. IM will continue to engage with SMERG and collaborate with implementers on issues related to measurement and research in malaria case management and service delivery. Participated in ASTMH The Annual Meeting of the American Society of Tropical Medicine and Hygiene (ASTMH) was held virtually because of the COVID-19 pandemic. IM gave two oral (from DRC and Kenya) and four poster (from Ghana, Kenya, Mali and one multi-country) presentations during the meeting in November 2020. IM also co-hosted a symposium on severe malaria, presenting early results from the ARC pilot in Sierra Leone. IM supported eight headquarters staff to participate in the meeting and sponsored one IM country staff person per country to participate. For ASTMH 2021, IM prepared and submitted 14 abstracts for the meeting, which were all accepted, one for an oral presentation and the remainder as posters, to be presented at the virtual meeting in November 2021. Participated in the RBM Strategic Communications Partner Committee In the current project reporting period, IM joined all RBM Strategic Communications Partner Committee (SCPC) planning calls and attended the virtual annual meeting held in February 2021. This year’s annual meeting, made virtual due to the impact of the COVID-19 pandemic, focused on the efforts and events throughout the previous year to amplify timely guidance and critical messaging for countries to safely continue life-saving malaria prevention and treatment efforts and to avoid losing ground on malaria


control and elimination during the pandemic. This year was especially important to keep malaria high on the global agenda to reinforce continued progress toward control and elimination. Throughout the meeting, IM participated in discussions aligning the global community around key messages to catalyze action and inform campaign adjustments to adhere to COVID-19 precautions as directed by WHO; to reinforce country and regional contributions and leadership; to highlight the critical efforts of frontline HWs, and to amplify the value of the malaria infrastructure in strengthening health systems against pandemics. As one of the few implementing partners in the group, IM has been able to share examples of country-driven work in malaria service delivery to bolster the linkage of global dialogue with country systems. Organizations represented through the SCPC have played a key role in sharing and amplifying IM’s content on these topics, including the success story blog posts, webinars, learning briefs, and COVID-19 e-learning modules. Engaged with the RBM SBC Working Group IM participated in the RBM SBC Working Group Virtual Forums held on October 21-22, 2020, and September 1-2, 2021. The Virtual Forums were held in lieu of the Working Group’s Annual Meetings, to maintain the momentum gained as a global malaria SBC community during and beyond COVID-19. The Virtual Forum: Maintaining Momentum was an opportunity for SBC professionals to speak about emerging issues, share common challenges, and highlight successes among peers. During the Forum, updates and promising practices on malaria SBC in the context of the COVID-19 pandemic were shared as well as an update on progress towards workstream deliverable: CHW malaria SBC Package. During PY4, 1M provided inputs on, and review of, the technical content of service delivery modules of the RBM SBCWG Toolkit for CHWs, including “Malaria Prevention, Testing, and Treatment Messaging” and “Barriers and Facilitators to Change.” IM also provided technical contributions on gender transformative service delivery to empower CHWs to support clients’ informed decision-making and address gender and socio-cultural barriers to service uptake. IM provided technical inputs on the CHW toolkit and recommendations that related to SMC (including adverse drug reactions); MIP; MDA; and malaria care-seeking, testing, and malaria treatment. Supported the SMC Alliance IM took on an expanded role in the SMC Alliance during the current reporting period. As previously mentioned, IM served as the Secretariat and key partner in the SMC Alliance M&E Subgroup. Through this, IM supported the development of a performance framework for country SMC campaigns and has worked to develop an M&E toolkit with a set of standardized tools and indicators built on best practices and lessons learned from countries. IM participated in the SMC Alliance virtual annual meeting in March 2021, during which IM updated the Alliance on the M&E Subgroup’s plans and chaired the first panel discussion on issues in monitoring and evaluating the quality of SMC implementation, with NMCP managers from Benin, Cameroon, Guinea, Senegal, and Togo. IM is also a member of the Core Group of the Alliance, updating the Core Group on the M&E Subgroup’s activities at monthly meetings. The M&E Subgroup has been meeting more than once a month, and smaller subgroups have been meeting to work on specific sections of the Toolkit.


Collaborated with the Child Health Task Force With support from the USAID Africa Bureau, IM collaborated with the CHTF Institutionalizing iCCM Subgroup on a series of activities to support a regional agenda for scaling up and institutionalizing country iCCM programs. IM secured the services of a knowledge management expert, who is supporting the CHTF to develop an iCCM webpage on the CHTF website and organize iCCM tools available through the website, so they are more accessible to users. IM also commissioned an expert in iCCM to conduct two assessments: 1) An assessment of the implementation of country iCCM CHW compensation schemes, which will assess how they are structured and their effectiveness in delivering compensation to CHWs; and 2) A deep dive of three countries with national scale iCCM programs to assess factors that led to the successful scale-up of these programs and major bottlenecks and lessons learned from implementation. Work on the website redesign and the two assessments was initiated in the current reporting period and will be completed in the next project reporting period. In the current reporting period, IM also launched a collaborative effort with Population Services International’s (PSI) Health Systems Accelerator group to support the CHTF to develop a toolkit for iCCM institutionalization. Key staff and consultants were identified, with a planned launch of the work in November 2021. Participated in the Severe Malaria Stakeholders Meeting Due to the on-going COVID-19 pandemic, the Severe Malaria Stakeholders Meeting was cancelled during this project reporting period. However, IM supported severe malaria activities which will be reported on during the upcoming project year’s meeting. In Sierra Leone, IM supported a rapid record review assessment of the roll-out of ARC across five districts to quantify appropriate ARC administration and referral practices, and to document health outcomes of patients receiving ARC. Findings from this assessment can be found in the Sierra Leone section of this document and will be presented as a poster during the 2021 ASTMH meeting. In collaboration with Medicines for Malaria Ventures (MMV), IM also developed an assessment to capture information on appropriate ARC administration, as well as appropriate referral facility level oral ACT prescription, after completion of injectable treatment, in six IM-supported countries. Provided ad hoc support for WHO, RBM, and global malaria partner engagement IM has participated in several forums and discussions with global partners, in addition to the meetings listed above, including global advisory groups developing guidance on malaria service delivery in the context of the COVID-19 pandemic. IM supports the Secretariat for the MIPWG and the IM Technical Director serves as Co-Chair of the CMWG. When feasible, IM staff participated in RBM WG coordination calls, to share experiences and progress with a broad range of RBM partners. Operational Research Benin Group ANC Study The IM Benin team conducted the baseline household survey in 2,472 households in the Atlantique Department, from November to December 2020, in which 51% of households included at least one


recently pregnant woman. Baseline results revealed that while 58% of pregnant women attended at least four ANC visits, only 36% of pregnant women received at least three doses of IPTp, with over 30% of pregnant women initiating ANC in the third month of gestation. The most common reason cited for a pregnant woman not to attend ANC was cost. The most common reason cited to not take IPTp was that it was not offered by the provider. Subsequently, the study team trained health providers at all 40 intervention and control health facilities in tablet-enabled data collection for malaria intervention coverage, with a brief CommCare survey that was conducted along with mRDT administration during ANC1. Study team members trained providers at the 40 study sites to the purpose and goals of the IM OR study, and briefed them on Benin’s most up-to-date quality standards for ANC. From February to March 2021, IM trained 54 midwives and other ANC providers across 20 intervention sites as G-ANC facilitators. Those trained in turn began enrolling pregnant women to participate in ANC cohorts. Facilitators then carried out G-ANC meetings by cohort under the study team’s supervision. During the period under review, midwives formed 65 cohorts with the active participation of 653 pregnant women, and 23 of these cohorts completed the five-meeting G-ANC series, approximately 36% of the enrollment target. The aim for PY5 is to continue to rapidly scale up G-ANC enrollment and conduct qualitative research assessing the acceptability and feasibility of G-ANC and ANC surveillance interventions. More details on the Benin G-ANC study can be found in the Benin Country Addendum. Conducted the Senegal MDA study In the current reporting period, IM conducted a cross-sectional survey to assess baseline malaria prevalence in the study villages. A total of 2,352 participants from 487 households were surveyed from 60 study villages. Malaria parasite prevalence was measured using blood smear microscopy and polymerase chain reaction (PCR). Demographic and epidemiological data were collected through standardized questionnaires. Data from the survey was used to inform the MDA intervention and to provide baseline epidemiological information and prevalence of drug resistance markers for the study. IM also supported District Medical Teams to expand coverage of Prise en Charge à Domicile+, (PECADOM+), Senegal’s proactive community malaria case management program, across study villages. Under the coordination of the district medical team and with the support of head nurses, IM recruited 42 new CHWs to conduct pro-active weekly household screenings of clinical malaria cases in study villages. A total of 104 CHWs were trained on study procedures and collection of high-quality malaria morbidity data. In collaboration with the NMCP and local health and administrative leaders, IM conducted community engagement campaigns to inform participants and stakeholders of the MDA campaign. During the current reporting period, IM also implemented all three rounds of the planned MDA campaign. In June 2021, IM implemented the first round of MDA in 30 study villages, with support from CHWs, health post nurses, the NMCP, and PMI. MDA was delivered by 241 CHWs and 57 local supervisors who treated approximately 8,129 participants with all three doses of dihydroartemisinin-piperaquine (DHA-PPQ) and single low-dose primaquine (PQ). Overall crude coverage of the first round


of MDA was high (83%) and the refusal rate was low (1%). Findings from the acceptability study found that community sensitization campaigns resulted in high coverage. Through passive pharmacovigilance, 46 of the study participants reported having experienced an adverse event. Most adverse events were transient, and included headache, vomiting, abdominal pain, and fever. Similar adverse events were found through the active pharmacovigilance system. The second MDA round was conducted August 6-9, 2021, and an 87% coverage rate was achieved, with a refusal rate of 2%. The third and final round of MDA was implemented September 18-21, 2021. Results from the third round are pending. More details on the Senegal MDA study can be found in the Senegal Country Addendum. Supported the Cambodia G6PD point of care testing feasibility study IM has also been supporting Cambodia’s Center for Parasitology, Entomology and Malaria Control (CNM) to conduct a study to evaluate the accuracy and reliability of a novel point of care (POC) assay used for detecting G6PD deficiency. Individuals who are G6PD deficient experience adverse health reactions to PQ and tafenoquine (TQ), drugs capable of achieving radical cure of P. vivax infections. The ability to accurately identify G6PD deficient individuals would allow for the appropriate prescription of drugs like PQ at the POC and facilitate elimination of P. vivax, while ensuring the safety of patients with G6PD deficiency. To assess the performance of the POC assay, a study was designed in two phases in the Kampong Speu Province. In the first phase, the protocol dictated that 1,000 non-pregnant adults from across 30 villages chosen by systematic random selection should be targeted for enrollment. In Phase two, the protocol indicated that an additional 1,000 adults and children over the age of 5, presenting with febrile illness to seven health centers in areas with high P. vivax transmission, should be enrolled. During the current reporting period, IM completed enrollment for Phase one and nearly completed enrollment for Phase two. During Phase one, 1,001 people were enrolled according to schedule. Delays related to COVID-19 pushed Phase two into the dry season, which slowed the rate of enrollment. However, enrollment rapidly increased with the commencement of the rainy season. Ultimately, 966 people were enrolled in Phase two. Preliminary results suggest that the correlation between the POC assay and gold-standard spectrophotometry was good and the POC assay effectively identified severe G6PD deficiency. Control of storage temperatures and regular use of controls was noted as critical, as field conditions may lead to destabilization of the POC assay. Preliminary results from Phase two will be presented at the annual ASTMH meeting and subsequently submitted as a manuscript for peer review. More details on this study can be found in the Cambodia Country Addendum.


Success Story: Using a Surveillance Approach and Treating “Incurable Malaria” to Achieve Elimination in the Greater Mekong Subregion

Cambodia, China, Laos, Myanmar, Thailand, and Vietnam have made major strides in eliminating malaria disease within their borders. The countries, collectively known as the Greater Mekong Subregion (GMS), are working together towards a shared goal of total malaria elimination by 2030. Reaching this goal depends on careful monitoring and tracking of malaria cases as well as proper treatment that eliminates the parasite that causes malaria. IM supports the NMCPs in Cambodia and Laos in working toward this elimination goal. In Laos, the development of an effective nationwide surveillance system is key for elimination efforts. IM supported Laos to train health providers on the “1-3-7” approach, where all confirmed malaria cases are reported within 1 day, cases are investigated within 3 days, and necessary follow-up actions are implemented within 7 days. Dr. Khiewsomphone Doungnoukhan has worked as a medical doctor in the Ka Tua health center in Lao Ngam District for three years. He was selected to participate in a 1-3-7 training. Before the training he was not familiar with the up-to-date malarial elimination guidelines and only knew that he had to report a malaria case within 24 hours. Now, he feels confident with the entire process and improved his ability to report, investigate, and respond to malaria cases in line with national guidelines. Dr. Doungnoukhan also learned how to distinguish the different parasite species that cause malaria and the importance of testing for glucose-6-phosphate dehydrogenase (G6PD) deficiency before prescribing medication for Plasmodium vivax (P. vivax) – the strain of malaria most prevalent in the GMS region. G6PD deficiency affects around 400 million people globally. Diagnosing G6PD deficiency is important in areas where P. vivax malaria infections are widespread. The drug of choice for treating P. vivax malaria infections is primaquine. Primaquine can completely rid the P. vivax parasite from a patient’s body, which clinicians call “radical cure”. But it can also cause serious and severe reactions in patients with G6PD deficiency. Without a quick and easy way to diagnose G6PD deficiency, many health care providers are hesitant to prescribe primaquine for malaria. They fear causing potential life-threatening adverse reactions, yet no treatment is not an option and treatment with drugs other than primaquine that don’t eliminate the malaria parasite leaves patients at risk of recurrent malaria infections and impedes progress towards malaria elimination. In Cambodia, IM provides support to the National Center for Parasitology, Entomology and Malaria Control (CNM) and Institut Pastuer du Cambodge in conducting a study testing the performance of a novel point-of-care test for detecting G6PD deficiency and assessing its severity.

Dr. Khiewsomphone Doungnoukhan, from the Ka Tua health center in Lao Ngam District. Photo credit: IM Laos PDR

https://www.vivaxmalaria.org/diagnosis-treatment/g6pd-deficiency/g6pd-global-prevalence


Samphors is a midwife at the Preychumpou Mean Ang Health Center in the Kampong Speu Province of Cambodia. She works hand-in-hand with Village Malaria Workers to encourage community members to seek care at the health center when they are experiencing malaria symptoms. As part of the IM-supported study, Samphors is one of fifteen people across Cambodia trained on how to use the new G6PD point-of-care test.

“I wanted to become a health provider because I love to help people in our community, in our country,” said Samphors. With the ability to test for G6PD deficiency at her health center, Samphors can find out right away if a malaria patient has G6PD deficiency and safely prescribe the most appropriate medicine to treat her malaria patients from what used to be known as “incurable malaria,” or P. Vivax infection. Testing patients for G6PD at the point-of-care saves precious time that would otherwise be lost by sending blood samples to a lab and waiting to hear back before beginning treatment. By investing in training for frontline health workers like Dr. Doungnoukhan and Samphors, IM supports partner countries to implement surveillance processes and testing to overcome obstacles like G6PD deficiency to move towards malaria elimination. Achieving a malaria-free region brings the world closer to eradicating humanity’s oldest disease, and a world without malaria.

Therapeutic Efficacy Studies In the current reporting period, IM supported NMCPs in nine countries (Burkina Faso, Cameroon, Côte d’Ivoire, DRC, Kenya, Mali, Niger, Rwanda, and Sierra Leone) to conduct TES. Studies supported by IM vary in logistical and technical complexity. In all but one country (Niger), the TES are multi-arm studies where the efficacies of two or more drugs are being evaluated. The studies are being implemented in between two and six sites in each country, with each site often recruiting at multiple health facilities and extending recruitment efforts into HF catchment area communities, as well (Figure 40).

Samphors tests a patient for G6PD deficiency using a point-of-care test and examines at the results. Photo credit: IM Cambodia

Samphors tests a patient for G6PD deficiency using a point-of-care test and examines at the results. Photo credit: IM Cambodia


Figure 40: Patient enrollment status at IM-supported TES sites Through close engagement with NMCPs, PMI, and other study stakeholders, IM helped coordinate TES implementation across the study spectrum, from the development and IRB approval of the study protocol; procurement of the study supplies; preparation of the study sites; launch of patient recruitment; QA of study procedures; conducting of laboratory testing; quality control of laboratory procedures; data analyses; and report writing. In the current reporting period, patient enrollment was launched in Burkina Faso, Cameroon (Centre Region), Côte d’Ivoire, DRC, Kenya, Niger, and Rwanda. Enrollment has since been completed in Niger, Cameroon (Centre Region), Côte d’Ivoire, and DRC; and is ongoing in the other countries. Table 11 shows the most recent status of IM-support TES studies. New or expanded studies were planned during the current project reporting period. IM supported the Sierra Leone NMCP to develop the protocol and obtain IRB approval for the country’s first PMI-supported TES. In Cameroon, IM assessed patient enrollment at the six study facilities, identifying the need to end recruitment at two poor performing facilities. Additionally, IM is supporting the Cameroon NMCP to expand their current TES in the Centre Region to a site in the North Region which will be implemented in the next reporting period. In the current reporting period, IM entered into a service agreement with the University of Cape Town (UCT) for the analysis of Day 7 lumefantrine levels in TES patients in Burkina Faso, DRC, Kenya, and Rwanda. Ahead of study launch in each of these studies, UCT shipped pre-treated filter papers required for the collection of blood spots from patients in the lumefantrine arms to each study team. IM will continue to collaborate with UCT to ship samples from the studies to South Africa and to oversee the completion of sample analysis by UCT. Most TES studies that were recruiting patients during the current project reporting period experienced challenges with patient enrollment. Study investigators noted fewer patients seeking care for fever at


health facilities, in part due to COVID-19-related community fears and restrictions on movement. Other factors affecting enrollment included the success of ITN distribution and SMC campaigns. To respond to these enrollment challenges, IM supported NMCPs to extend TES recruitment activities to the community level. In Cameroon, Côte d’Ivoire, Kenya, Mali, and Rwanda, additional messages about the studies were disseminated at the community level to encourage care seeking and participation in the study. In Kenya and Rwanda, CHWs were trained to screen and refer cases to TES study sites. Security concerns in Burkina Faso led the study team to provide overnight accommodation for patients to establish the proper treatment and monitoring of participants in the artemether lumefantrine (AL) arm. This allowed patients seeking care in the afternoons to also be enrolled into the study. These innovative strategies have proven effective in addressing the unforeseen challenges presented to the study teams. IM has shared these best practices with other countries implementing TES and plans to use these practices in the coming year. IM also coordinated regular check-ins with all study stakeholders to share status updates, identify bottlenecks, and problem-solve to support completion of deliverables per WHO recommendations and within appropriate timelines. Table 11. Status of TES studies supported by IM in the previous reporting period Country Tested Drugs Study Stages Achieved

AL ASAQ

DHA-PPQ

As-Pyr

Protocol Developed

IRB Approval Received

Enrollment Launched

Enrollment Completed

PCR Genotyping

Molecular Markers of Resistance

Final Report

Burkina Faso

X* X X X X X

Cameroon Centre Region

X X X X X X

Cameroon North Region

X X X

Côte d’Ivoire

X X X X X X

DRC X* X X X X X Kenya X* X X X X Mali X X X X X Niger X X X X X X X Rwanda X* X X X X Sierra Leone

X X X X

* = lumefantrine analysis at UCT

Advance Program Learning The IM Learning Agenda was developed in PY3 in consultation with PMI and organized around a set of learning questions on IM’s four key intervention areas: QA, iCCM, MIP, and SMC. The Learning Agenda seeks to generate evidence and insights that will enable the project to refine its approaches, while


contributing to the body of knowledge on the most effective and efficient ways to deliver malaria services, documenting what happens when theory is tested in practice across different contexts. Through a variety of methodologies, the Learning Agenda will produce (or contribute to) practical outputs, including country-level analyses of technical and data reviews, cross-cutting and technical area-specific analyses, an OTSS+ independent evaluation, CHW internship curriculum, iCCM Toolkit, and assessment of the effectiveness of OTSS+ approach on MIP service delivery, and more consistent and accurate methods of measuring coverage and adherence to SMC. These new tools will also consider virtual and distance solutions, both to respond to the COVID-19 pandemic, and to identify improvements in scalability and effectiveness of its interventions. Table 12 outlines the list of learning questions, the core workplan activities underway to address these questions, and the status of those activities. Table 12: IM Learning Agenda questions, activities, and status

Learning Agenda Question Activity Output Status QA1 Do the fundamental elements

of the OTSS+ approach achieve their intended effect? What are the contributing success factors? What aspects of OTSS provide the most benefit, and to what areas?

Technical Reviews Conduct independent evaluation of the OTSS approach

Country-level analyses

Technical Reviews ongoing in all OTSS+ countries. Evaluation team from Tropical Health LLC contracted to conduct OTSS+ independent evaluation. Kick off meeting held with IM team. Evaluation to be completed in PY5.

QA2 Can lessons learned from countries with histories of a staged approach to OTSS be applied to newer OTSS countries?

Cross country and global level analyses Conduct independent evaluation of the OTSS approach

Cross-cutting and technical area-specific analyses

Thematic Deep Dives conducted on case management, MIP, lab diagnosis, severe malaria, and SMC and presented to PMI during PY4. OTSS+ evaluation launched. To be completed in PY5.

QA3 Are there more cost-effective approaches than the current approach to OTSS?


Learning Agenda Question Activity Output Status -What are the essential components of the OTSS package and which components can be removed or streamlined? -Would a lighter OTSS approach achieve similar effect(s)? -Can virtual or distance-based QA approaches be implemented effectively? If so, are these approaches scalable? Is this something that can be monitored? -What are the implications for sustainability, continuity, and institutionalization of OTSS?

Conduct independent evaluation of the OTSS approach

Evaluation Report and OTSS Manual

OTSS+ evaluation launched. To be completed in PY5. QA4 Does OTSS+ improve data

reporting completeness and quality at the facility level? What are the factors that lead to this improvement?

QA5 Is OTSS+ facilitating timely data use? If so, at what level and by whom? Does electronic data collection and availability facilitate data use?

QA6 Is there a way to use OTSS+ data to try to attribute causes of poor quality of care?

iCCM1 How do feasible CHW support practices improve a CHW's ability to manage a fever case?

Develop a standardized curriculum for implementing CHW Internships

CHW internship curriculum

Curriculum drafted. To be finalized and disseminated in PY5. iCCM2 How do feasible CHW support

practices improve a CHW’s ability to identify danger signs?

iCCM3 What are the “success factors” for achieving iCCM at scale?

Develop and disseminate tools to support implementation of iCCM

iCCM Toolkit

PSI Health Systems Accelerator Dept leading development of the toolkit. Draft methodology developed. Toolkit to be completed in PY5.


Learning Agenda Question Activity Output Status MIP1 What are the reasons why

ANC providers do not provide IPTp during visits? Review of MIP Quality

of Care (QOC)

Brief on the effectiveness of OTSS approach on MIP service delivery

MIP QOC analysis underway. To be completed in early PY5. Brief to be developed after analysis is complete.

MIP2 Is DOT necessary for IPTp uptake?

Review of MIP QOC Conduct independent evaluation of the OTSS approach

Brief on the effectiveness of OTSS approach on MIP service delivery Evaluation Report and OTSS Manual

As above, brief to be developed after completion of MIP QOC analysis. OTSS+ evaluation launched. To be completed in PY5.

MIP3 What are the facility-level causes of the gap between ANC 4 coverage and IPTp 3 uptake, and can IM support facilities to close the gap through using a tool that goes beyond OTSS+?

MIP4 Can CHWs supported by IM be leveraged to generate demand at the community level for early and frequent ANC?

Develop guidance on promotion of ANC and IPTp for CHWs

Guidance and tools for CHWs

Tools under development. To be completed in PY5.

SMC1 How can IM contribute to the development of standardized measurement of SMC coverage and adherence?

Develop and test standardized methodology for determining SMC coverage and adherence

Updated guidance by SMC Task Force

Coverage and adherence survey methods adopted by M&E Subgroup of SMC Alliance. Surveys implemented in all IM SMC countries in PY4.

SMC2 What are the best practices in improving data collection at the source and ensuring high quality and optimal data management across all touchpoints?

Develop a systematic approach to monitoring the quality of SMC administrative data

Updated guidance by SMC task force

Draft M&E toolkit developed by M&E Subgroup of SMC Alliance. To be finalized and disseminated in PY5.

SMC3 How can technology optimize service delivery and cost-effectiveness?

Determine country needs and develop appropriate technological solutions to improve SMC campaign efficiency and reduce the risk of COVID-19

IT and distance solutions

Country-tailored IT approaches adopted in IM SMC countries, e.g. SMC administrative data integrated in DHIS2 system in Cameroon


Monitoring and Evaluation Finalizing and digitizing OTSS+ checklists and building capacity for roll-out In the previous project reporting period, IM digitized most country OTSS+ checklists using the DHIS2-based Android app, HNQIS, and supported the analysis of OTSS+ data collected with HNQIS through automatic DHIS2 dashboards in the IM Data Hub, IM’s DHIS2-based project monitoring system. IM also developed and refined training materials for end-user trainings and trainings of trainers (TOT) for HNQIS for OTSS+ in both English and French, focusing on delivery through virtual formats. In the current project reporting period, IM continued to support NMCPs to use the HNQIS and data visualization tools in the IM Data Hub, configuring new checklists, and updating already configured checklists. IM configured the global OTSS+ checklist, as well as 31 adapted checklists for Zambia as part of activities to transition from the EDS application that has been used since it was launched by the MalariaCare project. IM also digitized eight OTSS+ checklists for COVID-19 and biosafety for DRC and Cameroon, some of which were integrated into existing OTSS+ malaria checklists. By the end of the reporting period, IM maintained a total of 138 OTSS+ checklists in the IM Data Hub across nine countries (Cameroon, DRC, Ghana, Kenya, Madagascar, Mali, Niger, Sierra Leone, and Zambia). During the current reporting period, IM also supported country stakeholders to develop basic OTSS+ dashboards into the IM Data Hub in advance of the first round of OTSS+, using HNQIS to enable teams to monitor data submissions. IM then supported these country stakeholders to refine the dashboards into advanced versions that are tailored to country needs. Examples of tailoring include custom indicators that the country are interested in monitoring (in addition to the core IM indicators) and setting multiple thresholds for Performance Monitoring Plan (PMP) indicators to allow monitoring against global and local standards. A total of nine advanced dashboards have been developed during the current project reporting period, five for Clinical OTSS+ and four for Laboratory OTSS+. IM has started to develop dashboards that update automatically based on the geographical access permitted by the account, which has allowed countries to maintain fewer dashboards, while enabling individual users to view performance for their sub-national areas and facilities. The team continued to work closely with country programs to refine these dashboards based on country and local needs. IM responded to 44 requests through the IM Data Hub for support from the IM Helpdesk in the current reporting period, five of which are still underway, in addition to 28 requests submitted via email. These requests typically included support to resolve software bugs, fix issues with checklists, or resolve issues encountered during OTSS+ visits.


Refining and expanding IM’s project monitoring system (Data Hub) The IM Data Hub captures global and country-level PMP indicators, including data from HMIS, OTSS+, training, and SMC campaigns. IM uses Data Hub to increase and improve data-driven decision-making and learning by project staff, NMCPs, and other partners. Users increasingly accessed the IM Data Hub during the current project reporting period, peaking at more than 4,650 views in April 2021 (Figure 41). Most views were to generate pivot tables, which IM refined across PMP and OTSS+ dashboards, to automatically highlight strong, average, and poor performance across indicators. During the current reporting period, IM added two new countries into the IM Data Hub (Laos and Malawi), bringing the total to nine countries reporting data into the IM Data Hub (Figure 42). The number of organizational units increased every year, with a 29% increase in the current reporting period.

Figure 41: Number of views of data visualizations from the IM Data Hub, by month and visualization format

Figure 42: Number of organizational units managed in the IM Data Hub


Ghana maintained 41.5% of reporting units (n= 9,633), while the recently onboarded Malawi had the least number of reporting units at 94 (0.4%) (Figure 43).

Figure 43: Number of organizational units per country The onboarding of sub-national reporting units into the IM Data Hub varied across countries. Whereas some countries set up their reporting units once during onboarding into the IM Data Hub, other countries continuously added units based on changes or expansion of geographic and technical scope. The cumulative number of organizational units onboarded into the IM Data Hub for the supported countries is shown in Figure 44 below.

Figure 44: Cumulative number of IM Data Hub organizational units per country project year As countries increasingly used the IM Data Hub for PMP reporting and to manage OTSS+ data through the HNQIS application, the number of users of the IM Data Hub greatly increased in the current project reporting period (Figure 45). Users include data generators (e.g., supervisors reporting data through HNQIS, IM M&E staff entering PMP data) and data users, most commonly accessing OTSS+ dashboards, (e.g., in-country M&E teams, NMCPs, sub-national health teams, and PMI country teams).


Figure 45: Number of user accounts in the IM Data Hub per project year Integration of existing supportive supervision data into the IM Data Hub To enable monitoring of trends in OTSS+ data from the beginning of the project, IM migrated OTSS+ data into the IM Data Hub that were collected and stored using other tools and applications, such as KoBoCollect and Microsoft Access. This required mapping these datasets to align them with the current format of the digital OTSS+ checklists, as early rounds of OTSS+ in some IM countries used earlier versions of the checklist that do not fully align in content and format with the current OTSS+ checklists. In the previous reporting period, these data had been imported for DRC and Madagascar. During the current reporting period, migration of these data was completed for Mali, Niger, and Sierra Leone. Technical support for the Electronic Data System IM continued to provide technical support to Ghana and Zambia that used the EDS systems they adopted during the PMI MalariaCare project. In Zambia, IM supported the NMEC to digitize an MIP checklist, migrate data and metadata to the IM Data Hub, and pilot the Zambia OTSS+ checklists in HNQIS, and make edits based on feedback from partners and field supervisors. During the current project reporting period, IM added activities in Malawi that also used EDS to collect its OTSS+ data. Although no technical support with EDS was requested by Malawi in the current reporting period, IM was requested by the NMCP to begin planning a transition from EDS to HNQIS to be implemented in the next project reporting period. Review and revision of global PMP Indicators In October 2020, IM received approval from PMI for a revised list of IM global PMP indicators, which was developed during the previous project reporting period. In the current reporting period, IM supported its countries to implement the changes to the PMP, circulating the revised global IM PMP indicator table, orienting IM country teams, and updating the IM Data Hub and data collection platforms to reflect the changes.


M&E support to strengthen capacity for the analysis and use of data and foster cross-country and project learning During the current reporting period, IM continued to provide support to build the capacity of IM country and HQ teams to access, visualize, analyze, and use project data. Key activities included supporting monthly M&E country team meetings highlighting key areas related to indicators, data quality, data analysis, and data visualization; and supporting thematic technical deep dives. IM also created and led webinars for the M&E country teams focused on (1) triangulation of different data sources and considerations for reporting; (2) guidance adopting and reporting on the updated global PMP indicators; (3) OTSS+ data analysis and visualization (seven sessions focusing on each of the OTSS+ checklists), use, and visualization across all global OTSS+ checklists. All webinars and meetings provided space for sharing of cross-country learnings, cross-country capacity building, and guidance on furthering the use of data. All presentations were shared with country and HQ teams in both French and English. In the current reporting period, a Wednesday Webinar M&E series presented topics including data visualization; preparing for and monitoring OTSS+ activities; the use of digital tools for OTSS+ (experiences from Côte d’Ivoire and Sierra Leone); preparation for and support of lessons learned workshops (LLW) in DRC and Madagascar; and looking beyond the numbers at qualitative data to support reporting and data use. Finally, in the current project reporting period, IM created and led four Global M&E Learning webinars for country IM M&E teams. The learning series were an opportunity to create an on-going system of learning; strengthen capacities across countries; and provide a space to share knowledge, evidence, and experience to better support country teams. The series covered topics including data visualization, LLWs, preparing and monitoring OTSS+ activities, M&E activity documentation, and best practices.


Gender

Gender Assessments in Cameroon and Kenya During the previous project reporting period, IM Kenya and IM Cameroon developed protocols for gender analyses to examine gender-related barriers to early ANC initiation, ANC continuation, IPTp use, ITN use (in Kenya), and care-seeking for children with fever (in Cameroon). These studies received ethical clearance from the Johns Hopkins University School of Public Health and in-country ethical review boards in the previous reporting period but were unable to be conducted due to COVID-19 restrictions in both countries. During the current project reporting period, both countries were able to conduct their assessments. The studies used a qualitative methodology, including focus group discussions and key informant interviews to engage 276 participants across the two countries within the categories of mothers of children under the age of 5; fathers of children under the age of 5 (who were not partners of selected women); CHWs; and facility HWs. The Kenya study also engaged older women, known to be strong influencers of pregnancy related behaviors. Illustrative study findings and recommendations are seen in Table 13 below. Table 13: Illustrative gender analysis findings from Kenya and Cameroon

Findings Recommendations ANC initiation and continuation

● Women and their partners have complete and correct information about how, when, and why to seek ANC services.

● Male partners (in both countries) and mothers-in-law (in Kenya) influence whether a woman attends ANC or seeks traditional care, or no care at all, as well as the timing for when she begins to seek care.

● Male partners grant permission to begin ANC and provide transport fare.

● Women fear judgement or mistreatment from providers, and male partners may forbid ANC attendance due to worries about provider abuse.

● Male partners forbid wives from seeking care from predominantly male providers as it is culturally inappropriate (Cameroon).

● Discord within the couple may keep men from supporting their partners, or

● Engage influencers and those with decision-making power over women’s actions

● Help providers build their own skills in interpersonal communications and empathy to create a strong client-provider relationship.

● Explicitly address abusive behaviors in all provider training curricula.

● Prioritize the integration of couples’ communication interventions into malaria programming.

● Build the capacity of health providers in couples counseling, to facilitate partner participation in ANC.

● Advocate for revisions to provider TOR to remove barriers to recruitment and retention of female providers (Cameroon).

● Delink HIV testing with other critical care, if possible (Kenya).


Findings Recommendations women from telling their partners that they are pregnant (Kenya).

● Fear of HIV testing (for both partners) is a barrier to care seeking (Kenya).

● Once a woman begins ANC, she will most likely continue if she is treated kindly by the provider.

IPTp uptake ● In Kenya, women and their

partners understand the benefits of IPTp to prevent malaria in pregnancy.

● Women found the major barrier to be physical discomfort from taking IPTp, while other respondents disregarded this concern, and believed that women should take IPTp anyway due to the benefits. (Kenya)

● Providers view Directly Observed Treatment (DOT) as a benefit for women to be protected, but women see this practice as coercive. It discourages some women from returning to care, because they feel they will be forced to take IPTp against their will (Kenya).

● If a provider treats a woman with respect and kindness during administration of the first dose, the woman will return and take future doses.

● In Cameroon, participants do not differentiate between IPTp and other medications, so identified barriers associated with stock-outs in facilities leading to clients needing to purchase the medicine at pharmacies.

● Providers should support clients by giving them the opportunity to voice their concerns, listen with empathy and respect, and address any questions they may have.

● Malaria programs should focus on providers’ and clients’ conflicting views about DOT. Providers can explain to clients the reason behind the use of DOT, but also must acknowledge clients’ discomfort at feeling like they do not have control of their own health choices.

● Conduct IPTp awareness-raising campaigns in Cameroon. These campaigns should include information about why and how to use IPTp and incorporate learnings from Kenya in terms of how to communicate about issues related to physical discomfort and client choice.

● Confirm that IPTp is included in supply chain activities to address stock-outs.

The study reports were shared with government counterparts and partners, including BA. In Kenya, key recommendations were integrated into IM’s country workplans, and the team collaborated with BA to determine how other recommendations could be integrated into partner activities. In Cameroon, a validation and strategic planning workshop was conducted to integrate results into the NMCP and IM Cameroon’s workplans. Findings will be presented as a poster at the ASTMH conference in November 2021, and IM Kenya has begun to develop a manuscript for submission, to be completed in the next reporting period.


Additional Gender Activities At global and country levels, IM continues to integrate gender content into assessments, training curricula, provider, and supervisory tools, and workplans. In the current project reporting period, IM supported the NMCP in Mali to complete its Gender and Malaria training module (begun in the previous reporting period after IM oriented its team and NMCP partners on gender determinants of malaria service uptake) and conducted a TOT for NMCP master trainers on the module. IM conducted an extended gender orientation for the IM Ghana team to prepare them to pilot the Gender Marker tool. Following this, IM met with technical and M&E team members to assess the program using the tool and evaluate the usefulness of the tool for future use by IM country programs. The process resulted in recommended adaptations to the tool, including changing scoring from a checkbox to a point system, to be able to identify areas for improvement more easily, as well as revising the tool’s guidance document to include examples for use with health service delivery programs (as the current guidance only refers to community-based interventions). An unexpected benefit of the use of the Gender Marker tool was that it provided a forum for the IM Ghana team to capture gender sensitive adaptations being conducted within the project, which had not previously been shared, such as the examples in the box below:

Gender sensitive adaptations within IM Ghana

● IM Ghana found that it was challenging for midwives at the regional hospitals to attend full-day trainings. They noted that this was because many midwives had to leave quickly in the afternoon to be home when their children got home from school. IM Ghana met this need by scheduling multiple half-day trainings.

● When female providers travel to attend trainings, they often travel with young children and nannies. IM Ghana trainings established catering plans that included food for these extra attendees and provided regular breaks to allow participants to breastfeed.

IM also conducted two gender-focused Wednesday Webinars for the wider IM community: an adapted Gender Deep Dive in November 2020, and a presentation on the results of the Kenya and Cameroon gender analyses in September 2021. Externally, IM supported the RBM SBCWG in the development of its SBC CHW Toolkit, including the integration of gender-specific determinants of malaria behaviors, and strategies and messaging for CHWs to help clients address these determinants. In addition, IM presented the results of the Kenya and Cameroon gender analyses at the RBM MIPWG annual meeting as a “Hot Topic in MIP.”


Communication

IM centered its external communication strategy and activities on two overarching goals: (1) Promote IM impact, evidence, and leadership in support of the advancement of technical and operational excellence in global malaria service delivery, and (2) Support PMI in developing the tools needed to sustain support from U.S. policymakers. To achieve these goals, IM focused on three key communications objectives in the current reporting period:

1. Guide and support the communications needs of IM team members to help strengthen IM’s capacity to provide high quality technical and implementation support in IM focus countries.

2. Distill, package, and share IM’s country-led evidence and stories, including successes, lessons learned, best practices, and insights, to demonstrate impact and advance key learnings.

3. Grow IM’s visibility through global engagement and thought leadership across our focus areas to reinforce the linkage of global dialogue with country systems and accelerate malaria service delivery improvements.

Guided by these objectives, IM completed the following activities in the current reporting period. Enhanced IM Website IM’s website is a primary channel to promote project visibility and enable easy access to products that convey IM’s impact and technical leadership. During the reporting period, IM regularly edited and added country pages and technical content so that the website reflected accurate and up-to-date IM content. IM also launched its Resource Library on the IM website. Specifically:

● Launched a publicly available resource library to house all of IM’s deliverables and products such as maps, webinars, briefs, reports, and videos. With over 60 resources in the library, users could easily filter their search by country, resource type, and focus area.

● Added approximately 190 malaria service delivery photos to IM’s online photo library, all with full captions and demonstrating proper COVID-19 safety precautions among health providers. As part of this activity, IM conducted photography sessions in Sierra Leone and Cameroon. Flickr shows that IM’s photo library has had over 260,900 views since its creation in December 2018. These photos have been used in PMI’s new website, PMI and USAID social media accounts, PMI’s annual report, PMI’s 2021-2026 Strategic Plan, and by partners in the global malaria community.

● IM launched digital country pages for Tanzania and Malawi on IM’s website, representing IM’s most recent country buy-ins, to enhance the visibility and clarity of IM’s country-driven activities and impact. In addition to these digital resources, and for easy access, IM packaged this content as country briefs available on the IM website Resource Library alongside 10 country briefs in French for francophone countries, bringing the total number of IM-supported country briefs to 27. IM country briefs concisely convey intervention areas and progress to date.

● IM conceptualized and began designing an interactive map for the IM website. The map will showcase up to date, featured implementation data, findings from research and/or technical


support, and human-centered feature stories and blog posts for each IM-supported country. The interactive map will provide easy access to country-related content through a click on the map.

Created Blog Posts

The IM team wrote blog posts to highlight the impact of IM support, showcase country successes, and demonstrate leadership and expertise in malaria service delivery. The success stories illustrated interesting characters, results, and innovative and novel ways of providing services while conveying four priority themes: data, collaboration, the journey to self-reliance, and adaptations to maintain malaria service delivery during the COVID-19 pandemic. IM also wrote blog posts that shared learning and evidence from IM’s country-driven activities, with the aim of sharing knowledge with the malaria and global health community to advance malaria service delivery. Specifically:

● Published six human-focused success stories with compelling photography and strong data points to show the impact of IM’s country-driven support for improving malaria diagnosis and treatment and protecting children and pregnant women from malaria infection. The stories highlighted work in Cameroon, Côte d’Ivoire, Ghana, Madagascar, Mali, Niger, Sierra Leone, and Zambia.

● Authored and posted seven blog posts on IM’s website highlighting IM’s OTSS+ approach, the importance of speeding up and scaling up IPTp coverage, key lessons learned from responding to COVID-19 in Cameroon, the DRC, and Ghana, and the launch of IM’s publicly available COVID-19 eLearning modules for health providers.

● Wrote and posted two “letters from the director” on IM’s website for the release of the 2020 World Malaria Report and World Malaria Day 2021. The letters described the progress achieved in the fight against malaria and PMI’s role among global partners in those efforts, and shared timely IM content.

● Participated in PMI’s Malaria Frontline Hero campaign, collecting information and quotes from CHWs, microscopists, midwives, and others to demonstrate their impact on keeping their communities safe, as well as the life-saving contributions of PMI. Three of IM’s frontline heroes were featured across the USAID Medium blog as well as PMI and USAID Twitter accounts.

Created Briefs and Case Studies

IM developed a variety of publications, including a set of country briefs to summarize epidemiological data, map out IM’s geographic presence, clarify priority malaria service delivery activities, and convey key achievements to date. IM countries were able to regularly reference and distribute these briefs when working with in-country stakeholders. Efforts to support these resources included:

● Amplification to external audiences of a Quality Improvement Technical Brief in English and French. The brief outlined IM’s novel four-pronged approach to improving malaria service quality at all levels of the health system. This approach includes mentorship, peer-to-peer learning, targeted classroom trainings, and OTSS+, as the main pillar. The technical brief has provided standardized language to be helpful for the IM team, NMCPs and country stakeholders. It also includes a real-life example of the life-saving impact of IM’s QI work in Madagascar.

● Partnering with the RBM MIPWG to amplify a Malaria in Pregnancy Monitoring and Evaluation Brief in English, French, and Portuguese. The brief provided practical tips and recommended


indicators for tracking progress toward meeting national and global targets for preventing and managing MIP.

● Collaborated with the SMC M&E Subgroup and SMC Alliance to host a webinar for NMCPs, explaining and soliciting feedback on the SMC M&E Toolkit developed by the WHO Global Malaria Program.

Produced multimedia content

IM produced multimedia content to highlight project impact and accountability and demonstrate technical leadership through the sharing of learning and evidence. These activities included:

● Planning and managing videography in Cameroon at multiple health facilities to highlight the OTSS+ model in malaria prevention, diagnosis, and treatment. Planning involved the creation of a script and storyboard, coordination with the IM Cameroon team for logistics and identifying subjects and locations for the film; and management of the creative and editing processes for the forthcoming final project.

● Regularly sharing content via IM Twitter and LinkedIn accounts, as well as through several IM mailings, to greatly increase the reach and visibility of all IM content produced and to disseminate key messages and priorities for advancing malaria service delivery. Across platforms, IM content has had more than 625,000 total views in the global health community. During the reporting period, IM’s Twitter following grew 50% and IM’s LinkedIn following grew 74%. Additionally, IM made it a priority to support the broader malaria community by consistently amplifying posts from PMI and other malaria and global health partners.

Facilitated Strong Team Communication

IM supported internal communications and fostered the ability for staff to access, develop, and share information about IM’s impact and learning. This included editing internal products and reviewing final deliverables to develop high-quality products; providing communications technical support to country teams and IM consortium members; updating and developing templates and guidance briefs for branding and marking, language and visual style, photography, storytelling, presentations, and conveying data and technical information. Additional activities included:

● Hosted 20+ biweekly internal knowledge-sharing webinars for IM staff and IM consortium partner colleagues. Webinars have reached up to 66 colleagues per session. The on-going internal webinar series featured malaria service delivery technical updates, highlighted IM country programmatic achievements and lessons learned, and explored cross-cutting topics important to IM project activities, such as evidence-based gender approaches and SBC.

● Drafted and sent bi-weekly “In the Know” mailings from IM’s Project Director to the IM consortium, providing timely project updates and reminders about key priorities.

● Supported the Program Management team to host IM’s Annual Meeting, to prepare presentations, reinforce proper branding throughout, and provided technical remote meeting support. The Annual Meeting is an opportunity for the IM team to hear updates from PMI and high-level updates from the Project Director, and for teammates to share timely and informative content among the IM consortium. Sessions included Publications writing 101, Data analysis and use, MIP interventions, OTSS+, and iCCM.


Project Management Engagement with PMI IM continued close collaboration with the PMI team during the reporting period, through weekly check-in calls with the IM COR team and IM’s Senior Management Team. These calls focused on project progress and performance, contractual matters including waivers and approvals, and the project’s financial management. Additionally, IM’s Core Team met with the PMI IM team twice monthly to provide country and technical updates on alternating meeting dates. IM Chiefs of Party (COP) from six countries including Cameroon, DRC, Ghana, Kenya, Madagascar, and Rwanda have presented to the PMI team during the country update meetings to provide in-depth project snapshots on activities being supported in their respective countries. Core workplan specific updates were also presented to the PMI team throughout the year. IM focused technical updates on the presentation of deep dives into topics including severe malaria, clinical case management, laboratory, SMC, MIP, and discussions about the Data Development Library (DDL). In addition to routine engagement with PMI, IM held a publications workshop in September 2021 to discuss publication priorities as the project nears its end. As an outcome of the meeting, a prioritized list of publication topics was agreed on. IM also participated in an external mid-term evaluation of the IM project during the reporting period. IM engaged with external evaluators hired by PMI, to provide contextual information, key informant contacts, project documentation, and to participate in interviews as requested by the external evaluation team. Additionally, IM shared its learnings and experiences with a broader PMI audience through participation in the PMI All Hands meeting in June 2021, where IM provided a project overview, discussed the global status of malaria service delivery, and shared high-level results from OTSS+, iCCM, and SMC interventions. IM in-country teams continued to engage PMI staff at USAID Missions through, at a minimum, monthly calls or in-person meetings. IM COPs have the agency to make decisions regarding workplan activities and remain flexible in meeting the needs and request of the mission, provided activities are within scope and available budget. IM country teams submitted quarterly progress reports to their relevant missions throughout the reporting period and the reports have been uploaded to a Google drive accessible to PMI IM team. In addition, IM country teams participated in annual Malaria Operational Plan preparation and meetings, provided requested information to mission counterparts, shared operational and implementation insights as appropriate, and participated in meetings as requested. Project Coordination During the reporting period, IM organized and held the project’s third annual meeting in July 2021. The four-day meeting was held virtually due to COVID-19 international travel restrictions. This permitted the project to extend participation beyond IM COPs and included technical, M&E, and finance staff located at country level. Meeting attendance and participation was high throughout the week, with 164 individuals attending the opening ceremony. The meeting provided an opportunity for the IM team to convene, exchange ideas, and learn from one another with several sessions focused on IM’s technical pillars, the sharing of lessons learned across IM countries, brainstorming how best to reinforce the sustainability of IM’s work, and the dissemination of project learnings. Outputs from the meeting included a list of potential


publication topics for IM-supported countries, a community of practice where COPs can exchange ideas and brainstorm solutions to complex challenges, and staff updated on the global state of the art for IM’s technical pillar areas including laboratory and diagnostics, clinical case management, MIP, SMC, and severe malaria. Participants also received relevant updates relating to M&E, financial management, and contractual requirements of the project. Country Support Team (CST) check-in calls continued to be held monthly with each in-country IM team. The CSTs consist of IM HQ support staff, including program, technical, financial, and M&E staff members. Teams reviewed progress against deliverables and workplan activities to identify and troubleshoot bottlenecks or obstacles, as well as determine needs for technical support in-country. The group reviews financial monthly reports and clarifies any anomalies or rates of expenditures. Success stories are shared as well as best practices and cross-cutting issues affecting IM country programs. To complement the team meetings, the IM Country Operations Director continued to hold monthly one-on-one supervisory calls with IM COPs and the IM Project Director held meetings with IM COPs to provide project-wide updates. IM continued to use the “Wednesday Webinar” series, which had been restarted during the previous project reporting period, to promote the internal sharing of information and project-wide learnings. “Wednesday Webinars” are open to all IM staff, made available in English and French, and feature presentations and discussions led by both IM HQ team members and IM in-country field staff. A total of 17 internal webinars were featured during the reporting period on topics including gender and malaria service delivery; IM’s COVID-19 response in Cameroon, DRC, and Ghana; a review of provider behavior change models and tools, 2020 SMC campaign results; the ARC roll-out and assessment in Sierra Leone; a diagnostics overview; review of the malaria landscape in LAC; and many more. In addition to the “Wednesday Webinar” series, IM’s compliance team held a nine-part compliance training, in both English and French, for IM and PSI staff based both in Washington, DC, and across IM countries on a variety of subjects, including prior approvals, staffing, travel, procurement, and subcontract management. These training sessions were designed to be interactive and provide all staff with the latest guidance for the project to remain compliant in every aspect of the work. Finally, the IM Core Team facilitated south-to-south learning across specific implementation areas on a regular basis and as needed to allow in-country teams an avenue to connect and share challenges, lessons learned, and best practices. Unfortunately, planned supervisory trips from the Senior Management Team were interrupted due to the COVID-19 pandemic and associated international travel restrictions. IM has used an iterative approach to project management, continuously updating tools and standards of practice based on the changing context in which they are used. In the current project reporting period, IM further refined the project’s Project Management (PM) tracker, which was developed to track the status of procurements, subcontracting, staffing, and travel for each IM country. Additional refinements made included more detailed tracking of information technology approvals across countries. IM rolled out the PM tracker to subcontractors and the process has helped improve transparency of approvals across the project. IM also reviewed its workplan development and reporting guidance, making updates to more efficiently support the development and timely submission of these key project deliverables. During this reporting period, IM also revamped the project’s knowledge management (KM) approach. IM’s KM Officer developed and implemented several systems and tools to build the project’s KM capacity.


These included the streamlining of permissions and file access on Microsoft SharePoint®, development of an automated travel request and tracking system to be rolled out during the next reporting period, development of a project specific landing page that houses and makes available the project’s standards of practice, guidance documents, and project resources to all partners, and the development of a KM governance plan to also be rolled out during the following reporting period. This suite of tools has and will continue to improve IM staff ability to access project information, documents, and resources and to navigate the project’s compliance needs. To measure uptake of these tools, IM has developed an internal quarterly KM metrics report that is shared with the internal team and is used to pinpoint further areas for improvement across the project. Internally, IM continued to hold weekly all-staff meetings for PSI and subcontractor staff to update the IM team on project developments and activities, including updates on country activities, technical developments and initiatives, compliance, finance, communications, knowledge management, and recruitment. IM’s Technical Team met on a weekly basis to discuss technical strategies and interventions to achieve project objectives. Technical Team meetings include participation from IM HQ Technical Advisors and staff as well as technical experts and staff from IM subcontractors. IM additionally hosts weekly Operational Team meetings centered on improving efficiencies and communication, sharing lessons learned, and reinforcing contract compliance. Finally, IM holds weekly Finance and Compliance Team meetings to troubleshoot any challenges the teams are facing around project finance or compliance issues and develop actionable plans for resolving these challenges in a timely manner. Subcontractor Management PSI, as the prime IM contractor, is accountable for ensuring that subcontractors spend project funds appropriately and in compliance with USAID rules and regulations governing the project to accomplish project objectives. Currently, PSI has four subcontractors under IM that are US-based organizations – Akros, Jhpiego Corporation, Medical Care Development International (MCDI), and the University of California, San Francisco (UCSF)—and locally-based subcontractors in Burkina Faso, Cambodia, Cameroon, Côte d’Ivoire, DRC, Ghana, Mali, Senegal, and South Africa. During the reporting period, IM’s finance team has continued monthly monitoring of compliance and financial performance of subcontractors. Monitoring efforts include detailed reviews of invoices and supporting documentation to confirm that all costs are allowable and allocable to the project and that they are supported with the necessary PMI approvals, as applicable. Due to COVID-19 related travel restrictions, in-person planned subcontractor monitoring visits to Jhpiego, MCDI, and UCSF headquarters were not feasible; however, the compliance and finance teams were able to conduct these virtually in accordance with PSI policy. In addition, the IM Associate Project Director and Project Management Lead conduct meetings with each US-based IM subcontractor. IM meets with senior representatives of Jhpiego, MCDI, and UCSF on a biweekly basis to provide on-going project updates; confirm that contractual obligations are being met and activities are progressing as planned; discuss and resolve any issues that arise. These meetings maintain an open flow of information and maintain an important feedback loop to the IM HQ Core team and the Project Director. Staffing IM has assembled a team of programmatic and technical professionals from its subcontractor organizations. Led by PSI, they work as one team to bring together demonstrated experience in the


delivery of quality malaria services—moving countries closer to malaria elimination. The IM HQ Team, working across subcontractors, maintains close communication and collaboration daily as needed to support country programs, in addition to regularly scheduled bi-weekly partner senior management meetings.

Key staff members leading the project team were selected based on their proven leadership and expertise in the field of malaria control. Key staff positions include:

Senior Project Director, Mr. Ricki Orford. The IM Project Director provides vision, leadership, guidance, and overall management for the technical, strategic, and financial integrity of IM. He serves as the primary point of contact with PMI and works to establish strategic relationships with global organizations and agencies working toward malaria elimination.

Senior Technical Advisor, Dr. Lawrence Barat. The Senior Technical Advisor is responsible for providing technical leadership on all aspects of malaria service delivery, quality improvement, drug-based approaches, operations research, and learning. The Senior Technical Advisor reinforces IM strategies and technical outputs to be based on up-to-date evidence and state-of-the-art practices in line with PMI guidance. IM continued to staff up during the reporting period to respond to the project’s growth in size and complexity in line with the approved Core workplan staffing plan. New staff hired to support the project during the reporting period included a LAC Technical Advisor, M&E Officer, Compliance Officer, Kenya-based Management Information Systems Officer, and a Kenya-based Digital Health Program Manager. Additional staff added during the reporting period have enabled the project to provide strong technical and systems support. IM also recruited and filled positions that became vacant during the year. A consultant to increase engagement with small businesses was not hired as initially planned in the approved Core workplan; however, IM was able to more than triple small business engagement compared to the previous year through several strategies. These included ensuring a preference for U.S. registered small businesses in procurements, attendance at USAID’s 13th Annual U.S. Small Business Conference in June 2021, improving the flow of subcontractor reporting on small businesses, and identification of services to transition to small businesses, such as editing services and translation. Skills Building IM continued to build on the previous years’ efforts by investing in the people who support the project. IM’s Country Operations Director conducted a virtual Project Management Training in March 2021 for staff based in Kenya and Zambia and a second virtual training in May 2021 with the support of the IM Program Manager and Program Coordinator for staff based in Ghana, Malawi, Sierra Leone, and Tanzania. The training is based on the internationally recognized Project Management for Development Professionals course and has provided basic knowledge and skills to manage a project throughout its life cycle. This training was also conducted in the two previous project reporting periods for IM HQ Core staff. By expanding it to the country teams, IM promoted a common understanding of project management and established a shared vocabulary around management tools and methodologies. The training takes participants through the life cycle of a project including project design, start up, planning, implementation, and control, monitoring and evaluation, and close out.


IM also participated in PSI’s annual malaria technical workshop, which was held virtually from March 29-30, 2021. IM presented and participated in discussions around SMC, OTSS+, iCCM, and severe malaria, among other topics. Participation helped inform IM’s work and support IM to remain in tune with the global malaria landscape. Due to COVID-19 limitations on travel and in-person trainings, participation in other planned trainings such as the PSI Finance Expedition for IM’s finance and compliance staff, the adult learning techniques training to enhance team training skills, and the multi-day hostile environment awareness training was not possible. Coordination among PMI Flagship Projects During the reporting period, there were six USAID global flagship projects supported by PMI, at various stages of implementation including IM, the PMI VectorLink Project, PMI MEASURE Malaria, Breakthrough Action (BA), Global Health Supply Chain Program-Procurement, Supply Management (GHSC-PSM), and PMI Insights. Each project’s mandate is clearly defined and close collaboration between projects provides the opportunity to amplify synergies and avoid duplication. IM and BA had a robust set of activities in the current reporting period, including collaborative efforts to strengthen SBC among providers and supervisors as described earlier. In addition, BA conducted a webinar open to all IM staff providing an overview of Provider Behavior Change Models and Tools as part of IM’s Wednesday Webinar learning series platform. The webinar described and shared resources for strengthening the links between SBC, service delivery programs developed by BA, the Circle of Care model, and the Service Communication I-Kit. The webinar included a deep dive into the jointly developed resource by BA and IM, “A Blueprint for Applying Behavioral Insights to Malaria Service Delivery.” The Blueprint serves as a guide to explore factors that influence provider behaviors specific to malaria service delivery; develop appropriate, targeted activities to address those factors; and conduct M&E of interventions. During the current reporting period, IM and BA built upon their previous collaboration in the co-development of “A Blueprint for Applying Behavioral Insights to Malaria Service Delivery.” Program implementers expressed the need for tools that help them sift through the potential determinants of a given provider behavior and focus on those that are most influential in their context. Representatives from IM HQ and country teams in Kenya, Niger, and Sierra Leone joined USAID, Center for Disease Control and Prevention (CDC), and other implementing partners to participate in and provide technical inputs to the Provider Behavior Change Tools Intent and Co-Design Workshops convened by BA. The workshops served to inform the development of BA’s Provider Behavior Change Diagnostic Tool, a companion to the Blueprint, to diagnose areas where facility-based provider behavior change, or enhanced provider support has been needed. In the next reporting period, BA will pilot the tool in Kenya, in collaboration with IM. During the current project reporting period, IM also attended a workshop hosted by BA that featured the analysis of data sets from Guinea, Uganda, and Tanzania, regarding the key variables that influence service delivery and categorized the biographic variables involved such as attitudes, norms, demographics, training, and knowledge of guidelines. The workshop also featured analysis from Guinea and Uganda regarding the


segmentation of providers into four groups: high performers, pragmatics, over-confidents, and laggards. By looking at the commonalities and variables within segments and comparing between segments and variables, recommendations can be developed for quality improvement based on provider behaviors. IM has also continued its regular collaboration and close coordination with GHSC-PSM in the current project reporting period, through regular check-ins between IM’s Project Director and Senior Technical Advisor and GHSC-PSM’s Task Order Director and Integrated Supply Chain Manager monthly. These efforts have resulted in improved communication and coordination on issues facing both projects, including supply chain challenges and their potential impact on malaria service delivery activities. Among the issues addressed were suppliers and supply chains for mRDTs, availability of injectable artesunate, stock status of key malaria commodities in the context of supply disruptions from the COVID-19 pandemic and forecasting and delivery timing for SMC treatments. In the current reporting period, IM also developed a strong collaborative relationship with the PMI Insights Project, PMI’s flagship project for Operational Research (OR). IM and PMI Insights are coordinating closely on two related assessments: 1) the IM-commissioned Independent Evaluation of the OTSS+ Approach, which will be conducted by an IM subcontractor, Tropical Health, and 2) a PMI-supported assessment of supervision best practices and lessons learned, which will be conducted by PMI Insights. A series of discussions were held to reinforce that the methods for the two assessments are complementary and draft methods for the two activities have been shared among the partners.


Environmental Monitoring and Mitigation Plan IM developed a detailed Environmental Mitigation and Monitoring Plan (EMMP) near the project’s inception, based on findings and recommendations in the USAID Africa Bureau's Programmatic Environmental Assessment for Insecticide-Treated Materials in USAID Activities in SSA. This plan has intended to allow the IM prime contractor, PSI, and its subcontractors to carefully monitor and manage waste generated during training activities or activities for any adverse health or environmental factors. All activities have been designed to manage and monitor potential risks and adherence to the initial environmental examination, included in the contract. The EMMP data provided in the Indicator Table below has been compiled from across IM countries from the period October 1, 2020 – September 30, 2021. Table 14: Environmental Monitoring and Mitigation Plan Indicator Table

Indicator Diagnosis Case

Management OR and TES

Number of countries with SOPs developed on waste management, or have developed SOPs with components of waste management

12 7 9

Number of countries with training sessions that have components of waste management

13 11 9

Number of countries with guidelines developed or reviewed that have components of waste management

12 7 10

Total number of HWs trained in waste management (any training that included a component on waste management)

2028 13,557 465

Disposal records maintained 1 1

3


Lessons Learned

● Countries that adopted OTSS+ during IM have seen rapid improvement in key service delivery indicators, while other competencies have lagged. Common challenges noted across countries in documented areas of weakness are the ongoing turnover of health facility staff and the lack of essential commodities. More comprehensive solutions are needed to address these health workforce and supply chain challenges.

● Both low- and high-tech innovations enabled IM to continue to scale up activities and

expand its portfolio despite the COVID-19 pandemic and instability in some IM targeted areas, leading IM-supported countries to continue to meet and sometimes exceed implementation and quality improvement targets. Such innovations included:

o Splitting up SMC distributor teams in Cameroon, so that each distributor can focus on a smaller number of households, reducing the number of contacts and travel distances.

o Using virtual and hybrid approaches to classroom training, such as in DRC where NMCP and IM technical staff provided video lectures to lab trainees in the regions when travel was restricted, while regional staff managed the practical training

o Developing WhatsApp groups to mentor hospital clinicians on severe malaria management in Kenya and coaching and troubleshooting clinicians and lab staff at frontline health facilities in DRC.

o Expanding recruitment of patients for TES to additional facilities and into the community to address low enrollment related partially to reluctance to seek care at health facilities

o Decentralizing supervision and oversight of campaign staff, reducing the need for national and international staff to travel through conflict zones.

o Countries have stated that they plan to maintain many of these innovations after this current pandemic has passed, as they often reduce travel requirements, increase opportunities for contact between HWs and supervisors, and save resources.

● Efforts during PY3 and PY4 to build and populate IM’s Data Hub and scale-up digital

data collection are now paying dividends. Countries now have ready and timely access to project data and data dashboards that enable them to refine their technical and implementation approaches and better target underperforming facilities and providers. Access to these data has also empowered countries to document and share with PMI and the global malaria community lessons learned on progress made on its technical interventions and best practices for program implementation.

● IM’s technical approach and implementation platform facilitated countries’ response

to the COVID-19 pandemic and could serve as a platform for response to future public health emergencies. The IM-supported COVID-19 response in Cameroon, DRC, and Ghana was largely built off its existing OTSS+ and iCCM platforms. Supervision for IPC, personal protection, and biosafety practices related to COVID-19 were integrated into existing OTSS+ clinical and laboratory checklists. IM also integrated messaging related to prevention and detection of COVID-19 into training and supervision provided to its existing cadre of CHWs supported on iCCM.


COVID-19

In response to the global COVID-19 pandemic, during the previous reporting period USAID missions in Cameroon, DRC, and Ghana requested IM support for the respective MOH responses to the pandemic. Each country developed objectives and workplans in accordance with respective priorities to fill gaps and complement the work of other partners, focusing on areas within IM’s existing geographic coverage and scopes of work. IM continued implementation of COVID-19 activities during the current project reporting period in DRC and Ghana, through March 2021 and in Cameroon until August 2021.

Requested support outlined in the scope included development of guidelines and tools for the detection and management of COVID-19 infections; IPC for clinics and laboratories; and training of HWs and laboratory technicians on these new guidelines and best practices for safe service delivery during the pandemic. Malaria-focused IM activities were also adapted in countries to respond to the pandemic, including integrating COVID-19 considerations into OTSS+ checklists. In Cameroon, IM leveraged its PMI-supported work on iCCM to provide COVID-19 training to its supported CHWs. This allowed for easier access and rapid mobilization, while also being more time-efficient for trainers and participants. Further details on country-specific activities and accomplishments can be found in individual country reports.

In addition to the country-specific activities, IM completed the development of a series of e-learning modules during the current reporting period to enable information on WHO and CDC-recommended best practices to be quickly and safely accessible to clinical and laboratory HWs in the participating countries and beyond. After reviewing the available guidance that was emerging and evolving in the early stages of the pandemic, IM developed the following six training modules, in English and French, in a user-friendly format:

1. COVID-19 and the Role of Health Workers 2. Safety, Hygiene, and Personal Protective Equipment (PPE) 3. COVID-19 Care Pathway: Triage, Treatment, and Discontinuation of Care Pathway 4. Collecting, Handling and Transporting COVID-19 Specimens 5. COVID-19 Facility-level Protocols and Management 6. Conducting Routine Laboratory Work During COVID-19

These modules were shared with IM country programs and were made available through the IM website (https://impactmalaria.org/covid-19) in November 2020. They use an interactive, yet low-bandwidth platform that can be viewed on a tablet or smartphone, and once downloaded, can also be used offline. These e-learning modules will be particularly useful as training and reference materials for HWs who cannot access training in COVID-19 or as refresher tools for those who do receive such trainings. It also includes reference sheets and tips that can be downloaded and printed as reminders and job aids.

IM continued to use a dedicated team in the current reporting period to support the additional COVID-19 activities across the three countries. This team, including consultants and staff, was able to provide high-level support in the areas of laboratory, case management, and operations. Weekly meetings continued to be held with each IM COVID-19 country team so that activities were closely tracked and that any issues arising were managed in a timely manner. This dedicated team also provided guidance in the close-out of country activities, including for routine reporting and the disposition of materials, in addition to providing technical inputs to approaches and materials, such as the centrally developed COVID-19 e-learning modules.


Addendum 1: IM HQ Core Team Organigramme

PMI Impact Malaria, Sierra Leone, 2021


Addendum 2: IM Country Achievements

PMI Impact Malaria, Sierra Leone, 2021

110 IM Benin October 2020 – September 2021

Benin Background In Benin, IM focuses on MIP OR, in particular for ANC. In collaboration with the NMCP and PMI, IM Benin has been conducting a study of G-ANC in the Atlantique department entitled, “Assessing the Impact of G-ANC on IPTp uptake in Benin and the Feasibility and Acceptability of Pregnant Women as a Sentinel Surveillance Population.” G-ANC is a service delivery model where women with pregnancies of similar gestational age are brought together for ANC services, incorporating information sharing and peer support. This model 1) Provides selected aspects of clinical care to women in the group at the same time during group visits; 2) Creates a support group of women at a similar stage in pregnancy; and 3) Improves the quality of care and engagement of women in the ANC process—with the aim of leading to better retention in care. Initial studies have suggested that G-ANC improves uptake of IPTp1, however, the effect has not been evaluated at the community level. This is the first time that G-ANC has been implemented in Benin, and the study is also assessing its feasibility and acceptability in Benin. In parallel, the study provides a platform to pilot the surveillance of malaria trends using a population of women attending ANC1. Recent data from Kenya2,3,4 have suggested that malaria parasite prevalence among pregnant women correlates with the prevalence among children under the age of 5 and could be used to track parasitemia trends over time. The very high coverage of ANC in Benin suggests that pregnant women may be a representative sentinel population to track coverage over time of malaria control indicators, as well as prevalence. However, as pregnant women represent only approximately five percent of the overall population, it is important to demonstrate that the trends in malaria prevalence and in household-level coverage of interventions reported by pregnant women—such as use of ITNs—are representative of population-level coverage with these same interventions. Feasibility of data collection during ANC1 will be assessed, as the first ANC visit can be quite long, and data collection may overwhelm health workers’ workload. Benin was chosen as the site for this study, as the coverage of early ANC is high, with 83% of women receiving ANC from a trained provider, and a median initiation of ANC is in the fourth month. ANC4

1 Grenier L, Suhowatsky S, Kabue MM, Noguchi LM, Mohan D, Karnad SR, et al. (2019) Impact of group antenatal care (G-ANC) versus individual antenatal care (ANC) on quality of care, ANC attendance and facility-based delivery: A pragmatic cluster-randomized controlled trial in Kenya and Nigeria. PLoS ONE 14(10): e0222177. https://doi.org/10.1371/journal.pone.0222177 2 Hellewell J., Walker P., Ghani A., Rao B., Churcher T.S., Using ante-natal clinic prevalence data to monitor temporal changes in malaria incidence in a humanitarian setting in the Democratic Republic of Congo. Malaria Journal. 2018;17(1):312 3 van Eijk A.M., Hill J., Noor A.M., Snow R.W., ter Kuile F.O. (2015) Prevalence of malaria infection in pregnant women compared with children for tracking malaria transmission in sub-Saharan Africa: a systematic review and meta-analysis. The Lancet Global Health. 2015;3(10):e617-e628. 4 Samuels A.M., Kwambai T.K., Seda B., et al. Antenatal clinic surveillance for malaria accurately reflects community malaria infection prevalence in a high transmission setting in western Kenya. The American Journal of Tropical Medicine and Hygiene. 2018; 99(4S) :(Abstract 47).

Figure 1: IM Benin Project Focus Area


coverage, however, is sub-optimal in Atlantique department, at just 63%. Despite the relatively early initiation of ANC in Benin, only 34.2% and 13.7% received IPTp2 and IPTp3, respectively.5,6 Benin is divided into 12 departments. The Atlantique department was selected to avoid confounding factors with other USAID-funded efforts to improve ANC. Selection factors for participating health facilities in Atlantique favored ANC clinics with more than one provider and having sufficient clients who were not spread out over a very large geographical area.

Strategic Approach The study is a cluster-randomized, controlled trial involving 40 health facilities in three zones of the Atlantique department. The G-ANC intervention uses a five-visit G-ANC model, with meetings one month apart, which equates to a minimum of six scheduled ANC visits during pregnancy. Intervention facilities have been encouraged to organize a sufficient number of G-ANC cohorts to enroll at least 50% of pregnant women attending ANC1 in the intervention. Malaria surveillance during ANC1 will continue to be conducted on a routine basis at all intervention and control facilities. Data for ANC surveillance is collected via CommCare on a tablet provided to each participating facility and is monitored in real time. Both interventions are expected to run 18 months. An identical study was planned in Tanzania, but due to COVID-19 considerations and delays, the study there will include only the component for malaria surveillance during ANC. Study Objectives: 1. Conduct baseline and endline household surveys to collect population-level data 2. Enroll women of similar gestational age in G-ANC and support intervention facilities to conduct G-

ANC as an alternative service delivery model 3. Collect surveillance data on malaria indicators at ANC clinics 4. Conduct qualitative research with ANC and G-ANC participants and stakeholders 5. Compare data from different sources to determine generalizability of the ANC data 6. Assess the feasibility and effectiveness of G-ANC in Benin—specifically for achieving IPTp coverage

at the community level and more generally as an alternative service delivery model for ANC Study objectives 4 and 5 will be carried out in the next reporting period.

5 Institut National de la Statistique et de l’Analyse Économique INSAE and ICF. (2019). Enquête Démographique et de Santé au Bénin, 2017-2018. Cotonou, Bénin and Rockville, Maryland, USA: INSAE and ICF. 6 Institut National de la Statistique et de l'Analyse Économique, ICF (2019). République Du Bénin Cinquième Enquête Démographique et de Santé au Bénin (EDSB-V) 2017-2018. Cotonou, Bénin: INSAE/Benin and ICF; 2019.

Figure 2: Benin G-ANC Study Setting: 40 facilities in Atlantique Department


Key Accomplishments Key accomplishment #1: Conducted Baseline Household Survey with 2,472 Households (Study objective #1) IM Benin supported the NMCP to submit the study protocol during the previous reporting period. It received approval by Benin’s National Ethics Committee on August 12, 2020. This was done in collaboration with the study co-principal investigator (co-PI), who is the director of the Benin NMCP. Under approved protocol, the study will compare household survey data collected at baseline and endline with routine data collected through ANC surveillance to determine if there was a significant community-level effect of G-ANC on IPTp uptake. The household survey data will also be used to determine if and how malaria prevalence and household coverage of interventions, including IPTp, reported by pregnant women at ANC1, correlated with coverage among the population in general. IM Benin carried out a baseline household survey in 40 selected clusters in the Atlantique department. The survey was implemented from November 2 – December 12, 2020. Data collectors began by enumerating all households in each cluster, using the CDC Sampling application7. Households with women who had a live birth in the last 12 months were identified during enumeration, and two categories of survey respondents were then randomized to select equal numbers of each category for survey administration. The two categories were: 1) Households with women who had given birth in the last twelve months, and 2) Households with an eligible survey respondent of either gender, 15 years of age or older.

7 The CDC Sampling app is a software in beta version that has been used for household listing (i.e. enumeration) and creation of a simple random sample from all eligible households for the purpose of conducting surveys. It is free for download on Android mobile devices. Prior to its application in Benin, it was used for CDC studies in Zambia and Malawi.

Figure 3: A data collector obtains written informed consent from a participant in the baseline household survey. Photo credit: Alao Manzidatou, IM


Table 1: Characteristics of respondents for baseline household survey in 40 clusters, Atlantique Department Number

Surveyed Percentage Age in Years

Mean Minimum Maximum Men 339 13.7% 40.40 16 85 Women 2,133 86.3% 31.19 16 83 Respondents of either gender aged 15 or older

1,213 49.1% 38.21 16 85

Women aged 15 or older who gave birth in the last 12 months

1,259 50.9% 26.92 16 48

Overall 2,472 100% 32.45 16 85

To remain compliant with national guidelines for malaria diagnosis and case management, CHWs performed mRDTs and administered ACTs to all children who tested positive during the baseline survey. The participation of CHWs was important as study Data Collectors were not formally accredited by the MOH to perform case management tasks. CHWs also helped Data Collectors delimit enumeration area (EA) boundaries during survey enumeration and to gain the trust of community members to open their doors to Data Collectors and participate in the survey. In some cases, too few or no CHWs were in place in the selected EAs, most notably in Ouidah. As an alternative, IM Benin requested the support of qualified health personnel from the health center in the cluster to perform those CHW roles for the study.

From a target of 2,520 interviews, the IM survey team conducted a total of 2,472 interviews (Table 1). Key findings were that 28.6% of children under the age of 5 tested positive by mRDT (Figure 4). In addition, while 88% of women who had given birth in the past year received at least one dose of IPTp, only 69% had received two doses, and only 40% had received three doses. The baseline findings did not change the planned study implementation.

Figure 4: Percentage of children under the age of 5, who tested positive by mRDT at baseline (N = 1,431)


Key Accomplishment #2: Trained health workers on data collection using CommCare and initiated malaria indicator data collection at first ANC visit (Study objective #3) In December 2020, following the completion of the baseline household survey, IM Benin conducted three training sessions with 40 midwives and health aides plus six zonal-level staff at the 40 study sites to begin using tablets loaded with the CommCare application to collect data on malaria intervention coverage from pregnant women at first antenatal care visit (ANC1). Training participants received tablets to take back to their respective health facilities and began routine ANC surveillance immediately upon their return. After ANC surveillance training, IM Benin conducted study orientation visits at each of the 40 participating health facilities to provide on-site coaching and troubleshooting of tablets. For real-time QA of ANC surveillance data, IM Benin developed an interactive dashboard using PowerBI8 to visualize interactive data exported from CommCare. During quarterly supervision visits to control sites, IM Benin compared data from different sources, including DHIS2; ANC registers; and labor and delivery records to determine the completeness of ANC surveillance data collected on a routine basis by providers for the study. As of August 2021, ANC surveillance efforts were capturing 53% of ANC1 clients attending ANC at targeted facilities. According to the PowerBI ANC surveillance dashboard, among ANC1 clients approached to participate in ANC surveillance, 99.4% agreed to participate. Of those, 71% of pregnant women who were interviewed also consented to being tested with an mRDT after answering all survey questions. Among the 12,000 pregnant women surveyed, 9,847 (82%) were tested for malaria via mRDT, with a test positivity rate of 25%. The average proportion of children under 5 sleeping under an ITN the

8 PowerBi is a Microsoft business intelligence tool, accessible via: https://powerbi.microsoft.com/en-us/.

Figure 5: During the baseline household survey, a community health worker in Atlantique department tests a child for malaria as an Impact Malaria data collector looks on. Photo credit: Manzidatou Alao, IM

Figure 6: Job aids for the study were translated into French and validated for use in Benin by the Benin MOH’s Maternal and Child Health Directorate

https://powerbi.microsoft.com/en-us/


previous night was 94.5%. The proportion of pregnant women sleeping under an ITN the previous night was 82.5%. Among the 8,786 children under 5 whose recently pregnant mothers were surveyed, 15% had experienced a fever in the preceding two weeks. ANC surveillance presented a series of challenges after its launch in December 2020. Not all trained providers were routinely surveying all their ANC1 clients and submitting the data to CommCare. IM Benin followed up with a number of intervention and control sites but were unable to provide constant on-site supervision of all 40 participating health facilities. As of July 2021, IM Benin developed the ability to remotely track activity on the tablets used to enter routine ANC surveillance data. The IM Benin team gained the ability to detect when tablets were offline and for how long they had been offline. Technical staff provided subsequent troubleshooting in response to the findings by calling or visiting health facilities whose tablets were offline. Of the 40 tablets in use, the number offline has ranged from as little as two to over half at any given time (Figure 7). The challenges that resulted in tablets being offline included staff turnover, challenges with SIM card registration, and lack of electricity at eight out of 40 study sites (20%).

Key Accomplishment #3: Trained 54 facilitators from the 20 intervention facilities on the G-ANC model in collaboration with partners in West Africa From February 15 to March 5, 2021, short-term technical advisors from Senegal and the United States led three G-ANC training sessions. The two midwife-trainers from Senegal had extensive experience

63% 65%70% 73%

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18%13%

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3%Jul-21 Jul-21 Jul-21 Jul-21 Aug-21 Aug-21 Aug-21 Aug-21 Sep-21

Connection active on day of monitoring Connection active 1 to 5 days prior

Connection active 5 to 10 days prior Trend

Trend

Figure 7: Trends in online status of tables used for ANC surveillance (N=40


conducting G-ANC in an implementation research context.9 They trained 51 frontline health providers, including 34 midwives and nurses; 17 health aides from intervention sites; and three midwifery supervisors responsible for monitoring and supervision of maternal and neonatal services in each of the participating health zones. This provided a total of 54 individuals trained in G-ANC meeting facilitation. The IM Benin team noted that ideally three providers per G-ANC site would have been trained, but sites were short-staffed.

The objectives of the G-ANC trainings sessions were to prepare health facility personnel to:

● Facilitate G-ANC meetings ● Prepare schedules for G-ANC meetings, plan cohorts to enroll eligible women (e.g., calculate the

ranges for the expected dates of delivery) ● Demonstrate the approach to conduct self-assessments including how to use the Microlife digital

blood pressure devices ● Complete required reports and records ● Describe key elements of the G-ANC study in Benin conducted by the Benin NMCP and CDC,

including ANC monitoring Trainers provided the following feedback after the trainings:

● Midwives who participated in the trainings were receptive to G-ANC, as indicated by their questions and descriptions of the current situation and challenges of ANC in Benin. The participants arrived on time each day and actively participated in the training sessions.

● During the first set of trainings, it became clear that language presented an obstacle. Midwives understood spoken French and could speak, but they lacked the experience and skills for reading. French was even more difficult for the nursing assistants. For the second group, IM Benin encouraged participants to speak in Fon, the local language, while practicing conducting meetings. Facilitators often speak local languages during G-ANC group meetings. IM Benin staff joined the small groups to check participants’ progress in following the guide. Participants read the guide at home and circled or highlighted the sentences they could say during the G-ANC meetings. The IM Benin staff led the third training mainly in Fon because more of the participants were nursing assistants.

9 McKinnon, B., and Sall., Vandermorris, A., Traoré, M., Lamesse-Diedhiou, F. McLaughlin, K., and Bassani, D. (2020). Feasibility and preliminary effectiveness of group antenatal care in Senegalese health posts: a pilot implementation trial. Health Policy and Planning. 10.1093/heapol/czz178.

Figure 8: Pregnant women enrolled in G-ANC take turns measuring one another’s blood pressure during a group meeting, Photo credit: Manzidatou Alao, IM


● The IM Benin team identified topics during the first training which were difficult for the participants. This allowed facilitators to develop and provide more detailed explanations in the second and third training sessions.

● At the end of the training, most participants were ready to plan and host G-ANC meetings, and each health facility had at least one trained midwife for the implementation of the G-ANC.

● The trainers from Senegal expressed concern about the ability of health facility staff to manage the administrative and logistical tasks necessary to enroll women into G-ANC and to conduct the overall study, including, describing the G-ANC study, determining eligibility, obtaining written consent, calling women, and filling out study forms were viewed as time-consuming. This highlighted a potential risk that the newly trained providers may become discouraged by the time needed to implement G-ANC, which could compromise the quality of the study. In contrast, the Senegal G-ANC study design included research assistants at each facility for the study-related work. As a result of this concern, IM Benin requested to add five Research Assistant positions to the study team that had not previously been considered in the staffing plan.

Key accomplishment #4: Initiated the enrollment of pregnant women in G-ANC cohorts and meetings (Study objective #2) IM Benin provided almost all G-ANC materials and supplies to the intervention facilities from April to June 2021. These included printed G-ANC materials, including the meeting guide for facilitators, self-assessment cards, enrollment and scheduling tools, the G-ANC cohort tracker, and gestational age pregnancy wheels, as well as supplies to conduct G-ANC, including privacy screens, tents, and Microlife blood pressure devices. From March 2021, IM Benin staff supported providers trained in G-ANC to schedule meetings and begin enrollment. Table 2 below has summarized progress through September 2021 for each health facility to form cohorts and conduct meetings:

● All 20 intervention sites started holding G-ANC meetings, with 212 meetings carried out, and 94 of those meetings directly observed by the IM Benin team.

● Twenty-three cohorts of pregnant women have completed all five meetings in the G-ANC series. ● A total of 65 cohorts have been formed; representing approximately 36% of the minimum target

of 180 cohorts expected to be formed over the first six months of G-ANC implementation. ● Only one facility formed cohorts at the anticipated pace. Four of the lowest-performing facilities

were among the five facilities with the highest recorded ANC1 caseloads in 2019 and 2020. During the start-up phase of G-ANC, an average of 9% of pregnant women attending ANC at the 20 intervention facilities were successfully placed in cohorts and attended at least one group meeting. Nevertheless, researchers sought to increase the study enrollment rate to include at least 50% of all


pregnant women arriving for ANC at the intervention health facilities to have a measurable impact on IPTp uptake and other outcomes of interest. As can be ascertained from Table 2, in the future, the achievement of providing G-ANC to 653 women during the period under review will need to be accelerated so that 613 additional women are newly enrolled in cohorts every month, in parallel with the continuation of existing cohorts, for an average recruitment of 31 additional pregnant women per health facility per month. Achieving the enrollment targets will be a challenge and may require additional months to be added to the G-ANC implementation timeline in the study to compensate for the delays and reduced health facility utilization due to COVID-19. One step being undertaken to improve G-ANC coverage among pregnant women presenting for ANC at participating clinics is the organization of quarterly accountability meetings between the IM Benin team, the health zone leadership, and health facility staff to review key performance indicators and develop solutions to any challenges encountered. Other remedial activities include the hiring of five midwives to serve as Research Assistants, who will be responsible for supporting the trained G-ANC providers to screen, obtain written informed consent, and place meeting reminder calls to pregnant women who have agreed to participate in the study. It is expected that the additional temporary staff will relieve some of the administrative burden associated with conducting operational research on a novel clinical service delivery method. In addition, IM Benin will reinforce the involvement of the central level maternal and child health directorate (DSME) and NMCP, responsible for ANC and MIP, respectively.

Key accomplishment #5: Conducted on-site supervision and mentoring of health personnel The IM Benin team has four members who have been conducting on-site supervision and mentoring. Three team members were focused on the clinical aspects of ANC surveillance and G-ANC and one supported data collection and M&E. For G-ANC, from the end of the G-ANC trainings in March, the IM Benin team frequently visited facilities to provide support for both interventions. The team made a site visit schedule and updated it based on information gathered by phone from the sites. For example, the team prioritized site visits to observe meetings and visit facilities, which were slow to form cohorts and start meetings. On days when a G-ANC meeting was being held and a team member visited, the team member attended the meeting and completed the meeting observation checklist using a standardized tool included in the G-ANC facilitation manual. The observation checklist noted in detail whether or not the meeting started on time and with the correct number of participants, whether the proper methodology was used, and whether the appropriate meeting

Figure 9: Health facility personnel participate in a G-ANC and ANC surveillance study orientation that IM Benin staff carried out on-site. Photo credit: Manzidatou Alao, IM


steps had been followed in sequence. By the end of September 2021, 94 meetings were observed out of 212 meetings, indicating that 44% of meetings were held under direct supervision. For the ANC surveillance component of the study, supervision by the IM Benin team and health zone authorities was conducted quarterly, with continued on-site coaching, training, and troubleshooting of tablets. Additional visits were made to a few health facilities that had difficulties with their tablets that could not be resolved from a distance.

Challenges and Solutions Challenges Solutions G-ANC training: Trainees in the first G-ANC training session had challenges in reading and comprehending the manual in French.

The IM Benin team successfully conducted the second training session, partially in the Fon language, and conducted the third training session entirely in Fon, to support all participants to understand the concepts and facilitate meetings.

G-ANC enrollment: Several issues have limited enrollment into G-ANC, which then limited the ability to fill cohorts. In a few sites, women attending ANC1 lived outside of the intervention clusters and were therefore not eligible for G-ANC. In some cases, pregnant women could not commit to paying the fees associated with the series of G-ANC sessions without consulting their spouses. Some health facility staff misunderstood the gestational age guidance and were only enrolling women who were close to 20 weeks at ANC1 versus. assigning all women under 24 weeks to a cohort as indicated. Many facilities have not been completing the enrollment log, which is intended to capture the reasons women did not join G-ANC.

IM Benin actively followed up, through regular phone calls and site visits with the intervention sites, to track the formation and troubleshooting of cohorts. The team discovered which facilities were slow on enrollment and then visited these facilities to provide on-site support. By August 2021, most sites were actively enrolling women, but still not at the rate expected.

G-ANC implementation: Competing tasks, such as vaccination campaigns and mandatory trainings diverted health workers’ time away from conducting G-ANC at intervention sites from March-May 2021 and/or caused G-ANC meetings to be rescheduled.

Midwives called enrolled women in advance to notify them when their meeting time had changed due to an unforeseen scheduling conflict at the health center. The study team also worked with health zone coordinating physicians and midwifery supervisors to organize G-ANC meetings and other required MOH commitments far enough in advance to avoid overlap.

G-ANC implementation: Some health personnel who had been trained on G-ANC were transferred to other health facilities outside of the study area in June and July 2021.

The IM Benin team developed a plan to provide on-the-job training of new health workers on the G-ANC approach, versus a group-based training. For some facilities, new providers will need to


Challenges Solutions visit neighboring intervention sites to observe how G-ANC meetings are conducted.

ANC surveillance data collection: Tablet-enabled data entry waned after a few months of ANC surveillance due to a combination of factors: (1) lack of electricity to recharge the tablets at the health center; (2) lack of a system for sharing the tablet, so that one HF staff would take the tablet home with them so that it would be unavailable for data entry when that person was off-duty.

The study teamed implemented a remote monitoring system for determining which tablets at the 40 study sites were online versus offline. The team then followed up with sites where the tablets were offline to understand the reasons why data entry was not occurring and to provide troubleshooting and technical support. Where tablet sharing was the problem, HF staff worked with the IM team to establish a system using a “sign-out” sheet similar to what was used for other shared health equipment.

Lessons Learned ● G-ANC has been slower to be adopted at

the scale desired, despite active support and on-site mentoring by the IM Benin team. Some of the delays were due to external factors, such as providers being pulled from the facilities for other work and staff transfers. Other factors leading to slow adoption include staff shortages; heavy existing workloads; perceived burden of additional study tasks at ANC1, including both ANC surveillance and G-ANC, and confusion over enrollment process. The combination of the two study elements, which relies on additional tasks at ANC1 might be too complex in settings with limited ANC staffing.

● On the demand side, as in many other countries, pregnant women in the study area of Benin commonly seek ANC outside the HF catchment area where they live for a variety of reasons. Some prefer to go to the facility in the catchment area where their parents or extended family live, where others are of the same ethnicity, or where the health care providers have a good reputation. Many women have also indicated that they prefer to be seen at health facilities that are further away to hide their pregnancies from the community where they live. Finally, facilities often are not located in the center of the catchment area, leading some pregnant women to attend ANC in adjacent areas. G-ANC providers were instructed to only enroll women living in the facility catchment area in study

Figure 10: A midwife at Avame Health Center, a G-ANC intervention site, conducts the individual portion of the consultation with a pregnant woman. Photo credit: Manzidatou Alao, IM


cohorts, so as not to “contaminate” the study control areas. ANC consultations in Benin are not provided free-of-charge; while SP and ITNs are distributed for free, the maternal health cards and ANC consultations have a cost. This cost may serve as a disincentive to some women to attend one or more ANC visits, unless they are experiencing symptoms or discomfort.

● Although G-ANC implementation has been slower than expected, several providers, health zone coordinators, or others in the health system have emerged as G-ANC “champions,” meaning that they fully embraced G-ANC in both its approach and implementation, contributing to higher levels of study enrollment at their respective health facilities. As the study progresses, IM Benin will continue to identify G-ANC champions and will empower them to share experiences with providers at other study sites in order to motivate actors in the health system to adopt and sustain the G-ANC approach.

● With increased high-level commitment, the MoH could drive additional accountability at the health zone and facility levels to adopt the new interventions and implement the study, as this has been an effective approach in other G-ANC settings.

● The development of the manual and meeting cards in French presented a challenge to G-ANC meeting facilitation by those midwives and health aides with limited proficiency in French. Translating materials into the Fon language would have also posed a challenge because it is not commonly read. To date, G-ANC meetings have been carried out exclusively in Fon language, with written materials in French. The lesson learned for future projects was to assess language preference for participants in advance of the training and prepare sessions and materials to cover the basic principles of G-ANC in Fon with standardized terminology.


Table 2: Detailed information on G-ANC intervention progress

Health Zone

Health Facility

Number of cohorts

expected (March-

September 2021)

Total number of cohorts formed (March-

September 2021)

ANC1 monthly caseload (Source: DHIS2 2020

average CPN1)

Number of

meetings carried

out with all

cohorts

Number of meetings

supervised

Number of pregnant women

enrolled in all cohorts formed

Number of G-ANC

participants present at

first organized meeting

AS

14-CS 5-10 2 41 7 4 22 21

18-CS 5-10 2 33 4 3 20 20

11-CS 15 6 117 21 8 83 82

13-CS 15 3 131 9 6 33 32

15-CS 15 2 69 7 6 20 17

Health Zone Sub-

total 1 15 390 48 27 178 172

ATZ

40-CS 15 3 137 10 4 33 31

38-CS 5-10 2 47 7 4 34 20

34-CS 5-10 6 47 24 10 85 75

35-CS 10-15 3 62 15 4 48 32

24-CS 5 1 31 1 1 7 4

31-CS 10 4 62 14 3 57 33

39-CS 15 2 87 6 4 21 11

25-CS 10 3 40 11 5 32 32

Health Zone Sub-

total 2 24 512 88 35 317 238

OKT

47-CS 10 5 46 14 4 53 45

41-CS 10-15 4 60 12 5 60 44

50-CS 5 3 29 10 4 32 25

48-CS 10 4 63 11 6 68 54

49-CS 5-10 2 54 6 5 28 17

45-CS 5-10 4 30 9 2 20 20

42-CS 5-10 4 41 14 6 50 38

Health Zone Sub-

total 3 26 324 76 32 311 243

Total 180-220 65 1226 212 94 806 653

123 IM Bureau for Africa October 2020 – September 2021

Bureau for Africa

Background Sub-Saharan Africa remains the region with the highest under-five mortality rate in the world.1,2 In 2019, 53 percent of all under-five deaths (2.8 million) occurred in sub-Saharan Africa and the African region overall had an average under-five mortality rate of 76 deaths per 1,000 live births.3,4 In African countries, the top killers of children are malaria, diarrhea, pneumonia, and neonatal causes.5,6 The appropriate treatment of childhood pneumonia, diarrhea, and malaria is one of the most powerful interventions to reduce mortality;7 however, in most high-mortality countries, facility-based services alone do not provide adequate access to treatment. As a result, those who are poor often receive care too late or not at all. Recognizing that health services need to be brought closer to home, many countries in the African region use Community Health Workers CHWs) who can use simple methods to identify and treat most children who have the conditions mentioned above. This approach, called integrated community case management (iCCM) 8, has been adopted in 28 countries to improve child health and survival. For iCCM to successfully improve child health and survival, a deep understanding is needed of what works, the main challenges to implementation, and the determinants for success. With the support of USAID Africa Bureau funding, IM is supporting the documentation of key challenges and lessons learned for institutionalizing and achieving scale for iCCM programs and to identify determinants of success. IM is also supporting the development of a toolkit for countries to institutionalize iCCM programs and to examine the implementation of CHW compensation schemes. This work is being carried out in collaboration with the Child Health Task Force (CHTF) Institutionalizing iCCM Subgroup.

Key Accomplishments

Key Accomplishment #1: Supported the Child Health Task Force to improve the organization and dissemination of available resources for iCCM implementation and institutionalization During the current reporting period, IM secured the services of a consultant who is providing expertise in knowledge management to map the current suite of available iCCM tools on the CHTF website. Under this activity, the consultant began reaching out to each organization that produced the tools currently

1 UNICEF (2021). UNICEF Data: Monitoring the situation of children and women, August 2021. Retrieved October 29, 2021, from https://data.unicef.org/topic/child-survival/under-five-mortality/ 2 United Nations Inter-Agency Group for Child Mortality Estimation (2020). Report 2020: Levels & Trends in Child Mortality Estimates. Retrieved October 29, 2021, from https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/unpd_2020_levels-and-trends-in-child-mortality-igme-.pdf 3 UNICEF (2021). 4 UN Inter-Agency Group for Child Mortality Estimation (2020). 5 UNICEF (2021). 6 UN Inter-Agency Group for Child Mortality Estimation (2020). 7 Bryce, J., et al. (2010). LiST as a Catalyst in Program Planning: Experiences from Burkina Faso, Ghana, and Malawi. International Journal of Epidemiology, vol. 39, no. 1, 2010, pp. i40–i47. 8 In the iCCM approach, CHWs have specific tasks: 1. Identifies and refers children with danger signs to a health facility; 2. Treats or refers pneumonia, diarrhea, and fever; 3. Identifies and refers children with severe malnutrition; 4. Refers children with other problems that need medical attention; and 5. Advises caregivers on home care for all sick children.

https://data.unicef.org/topic/child-survival/under-five-mortality/

https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/unpd_2020_levels-and-trends-in-child-mortality-igme-.pdf

https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/unpd_2020_levels-and-trends-in-child-mortality-igme-.pdf

124 IM Bureau for Africa October 2020 – September 2021

being hosted on the CHTF website to acquire the most up-to-date versions of those tools. IM also began to identify the appropriate tools to continue hosting the website and developed a plan for a new iCCM tools webpage. The consultant will finalize the tools database and support the webpage development during the next reporting period. Key Accomplishment #2: Laid the groundwork to assess CHW compensation schemes and best practices, lessons learned, and key challenges from selected countries who have developed sustainable, national iCCM programs During the current reporting period, IM drafted a scope of work for the recruitment of a consultant to complete two assessments. The first is an assessment of CHW compensation schemes. The second is an assessment identifying best practices, lessons learned, and the key challenges from three African countries that have developed sustainable, national scale iCCM programs. In collaboration with the CHTF, IM has secured the services of an experienced consultant with expertise in iCCM and health systems who began work in August 2021. Additionally, IM organized a meeting with the CHTF, PMI, and USAID Africa Bureau to discuss the scope of work for these assessments, along with key questions and audiences for each assessment. The CHTF has agreed to convene an advisory group drawn from the CHTF and PMI/USAID representatives to support this and other IM activities supported by the USAID Africa Bureau. The consultant has started the initial design work for these two assessments, developing a draft concept note for the compensation assessment which has been circulated to key stakeholders for review. During the next reporting period, the consultant will complete the assessment design, conduct the assessments, and produce a final report for each activity. Key Accomplishment #3: Identified a team to develop a toolkit for iCCM institutionalization, in coordination with the CHTF During the current reporting period, IM disseminated a Request for Proposals (RFP) on the PSI website for the development of a toolkit for iCCM institutionalization. IM identified the necessary skills and capacity within the PSI Health Systems Accelerator (HSA) team which has expertise in iCCM, child health, and health systems and financing. After agreement on the SOW, IM requested the HSA team to lead toolkit development, in collaboration with IM, the CHTF, and USAID Africa Bureau. The toolkit will be developed during the next reporting period.

Challenges and Solutions Challenge Solution There are many stakeholders in iCCM, and the activities proposed need broad buy-in that necessitates a collaborative approach to the proposed activities.

IM has collaborated with the CHTF and supported the formation of an iCCM subgroup to bring together a range of stakeholders, ensure there is broad buy-in for activities and their products, and gather feedback on work in progress from experts in the field.

125 IM Bureau for Latin American and the Caribbean October 2020 – September 2021

Bureau for Latin America and the Caribbean Background USAID supports malaria activities at the regional level in Latin America and the Caribbean (LAC). IM received funding to work with the Pan American Health Organization (PAHO) on two key activities: 1) Assess the efficacy of a high-dose radical cure regimen for P. vivax malaria; and 2) Support the development of safety policies on the use of P. vivax radical cure regimens. IM supports MOHs/NMCPs to conduct this work in collaboration with USAID, PMI, CDC, local organizations, and aligned with global P. vivax malaria consortia, networks, and programs. P. vivax malaria is the most common type of malaria in LAC, and recent progress on malaria elimination in the region has stalled as the number of P. vivax infections are increasing in many countries.1 P. vivax infections are characterized by relapses of malaria arising from persistent liver stages of the parasite (hypnozoites), which can be prevented by using 8-aminoquinoline drugs, primaquine (PQ) or tafenoquine (TQ).2 P. vivax relapses arising from dormant hypnozoites contribute significantly to P. vivax malaria. In most LAC countries, the first-line treatment recommended for P. vivax malaria is schizonticidal treatment and radical cure with chloroquine (CQ) + low dose PQ (3.5 milligrams (mg)/ kilogram (kg)).1,3 This regimen has not changed in more than 60 years. The WHO recommends increasing PQ doses in East Asia and Oceania, where P. vivax strains relapse frequently and low dose PQ has been less effective in preventing relapses.3 However, currently there is insufficient evidence for a similar policy recommendation in LAC countries. There are recent developments in the radical cure for P. vivax malaria in LAC. Recent clinical trials assessing TQ4,5 led to official regulatory approval for its use as a radical cure in Brazil and Peru, and as an investigational drug in Colombia.6 Furthermore, recent evidence from a clinical study in Brazil showed that a higher dose of PQ (7 mg/kg over 14 days) was superior in preventing relapses compared to a lower dose of PQ (3.5 mg/kg over 7 days). In 2019, the PAHO Malaria Technical Advisory Group recommended gathering more evidence from an additional country in LAC to inform regional policies.7 While recent developments using 8-aminoquinoline drugs as a radical cure are promising, their use is also associated with acute hemolytic anemia in individuals with glucose-6-phosphate dehydrogenase (G6PD) enzyme deficiency, a genetically X-linked disorder with varying frequency by region and ethnic groups.2

1 WHO (2020). World Malaria Report. 2 Chu C.S., White N,J. (2021). The prevention and treatment of Plasmodium vivax malaria. PLoS Medicine 18(4): e1003561. Retrieved September 20, 2021, from: https://doi.org/10.1371/journal.pmed.1003561 3 WHO (2021). Guidelines for malaria. Geneva: World Health Organization; 2021 (WHO/UCN/ GMP/2021.01). License: CC BY-NC-SA 3.0 IGO. Retrieved February 16, 2021, from: https://www.who.int/publications/i/item/guidelines-for-malaria 4 Lacerda M. et al. (2019). Single-Dose Tafenoquine to Prevent Relapse of Plasmodium vivax Malaria, New England Journal of Medicine, ;380:215-28. Retrieved September 20, 2021, from: https://www.nejm.org/doi/full/10.1056/NEJMoa1710775 5 Llanos-Cuenta A. et al. (2019). Tafenoquine versus Primaquine to Prevent Relapse of Plasmodium vivax Malaria. New England Journal of Medicine 2019; 380:229-241. Retrieved September 20, 2021, from: https://www.nejm.org/doi/full/10.1056/NEJMoa1802537?query=recirc_curatedRelated_article 6 INVIMA (2018). Acta No. 2 de 2019. https://www.invima.gov.co/documents/20143/1194435/Acta-No-02-de-2019-SEMNNIMB.pdf/01789faf-b63e-5f39-4ea2-211dcd3fec73?t=1559854655327 7 PAHO (2019). Fourth Meeting of the malaria technical advisory group to the Pan American Health Organization. Retrieved September 20, 2021, from: https://www3.paho.org/hq/index.php?option=com_docman&view=download&alias=50391-fourth-malaria-technical-advisory-group-meeting-report-may-washington-dc&category_slug=malaria-technical-advisory-group&Itemid=270&lang=en

https://doi.org/10.1371/journal.pmed.1003561

https://www.who.int/publications/i/item/guidelines-for-malaria

https://www.who.int/publications/i/item/guidelines-for-malaria

https://www.nejm.org/doi/full/10.1056/NEJMoa1710775

https://www.nejm.org/doi/full/10.1056/NEJMoa1802537?query=recirc_curatedRelated_article

https://www.invima.gov.co/documents/20143/1194435/Acta-No-02-de-2019-SEMNNIMB.pdf/01789faf-b63e-5f39-4ea2-211dcd3fec73?t=1559854655327

https://www.invima.gov.co/documents/20143/1194435/Acta-No-02-de-2019-SEMNNIMB.pdf/01789faf-b63e-5f39-4ea2-211dcd3fec73?t=1559854655327

https://www3.paho.org/hq/index.php?option=com_docman&view=download&alias=50391-fourth-malaria-technical-advisory-group-meeting-report-may-washington-dc&category_slug=malaria-technical-advisory-group&Itemid=270&lang=en

https://www3.paho.org/hq/index.php?option=com_docman&view=download&alias=50391-fourth-malaria-technical-advisory-group-meeting-report-may-washington-dc&category_slug=malaria-technical-advisory-group&Itemid=270&lang=en


Limited evidence suggests a low prevalence of G6PD deficiency in LAC countries, though G6PD testing is rare. Operationally, NMCPs implement pharmacovigilance by practicing early recognition of hemolysis signs and recommending the discontinuation of PQ doses to prevent more severe outcomes. It is anticipated that a limited range of treatment options for a radical cure of P. vivax (low-dose PQ, high-dose PQ, and TQ) will be available throughout the region in the near future; and each option is associated with different G6PD deficiency-related risks for hemolysis. Furthermore, varied G6PD testing approaches will be available, including point of care qualitative testing, point of care quantitative testing, and no testing in areas with very low G6PD deficiency. Therefore, when deciding on a radical cure treatment and G6PD testing, the risk of hemolysis and benefits of decreased relapses and cost need to be assessed, though clear approaches for such an assessment are not yet available. Several countries in LAC have begun implementing or are interested in drug-based interventions such as either focal or targeted, or total/blanket mass drug administration as well as reactive and proactive case detection to accelerate malaria elimination. Where interventions target asymptomatic individuals, NMCPs will need to assess their risks and benefits before implementing them. In addition, a higher level of pharmacovigilance regarding G6PD-deficiency may be required. In addition to planning for an assessment of the efficacy of a high-dose radical cure regimen for P. vivax malaria, IM is working with PAHO, USAID, and partners to develop and pilot a risk-benefit framework that will help countries with the safe administration of PQ. To achieve this, IM has participated in regular planning and coordination meetings with national and regional stakeholders, including VivAccess (now renamed PAVE)-the initiative to support countries in the elimination of P. vivax malaria, the Asia Pacific Malaria Elimination Network (APMEN), Medicines for Malaria Venture (MMV), and PATH, to align USAID-supported LAC activities with their P. vivax malaria programs in LAC and globally. IM LAC also provided technical inputs and reviewed PAHO’s draft policy documents on the use of drug-based interventions (mass drug administration and reactive/proactive case detection) for P. vivax malaria in LAC. By the end of this reporting period, IM had built on strong coordination and complementarity with targeted NMCPs, partners, and global groups, programs, and initiatives for P. vivax malaria. In collaboration with those groups, IM will develop, validate, and strengthen local capacities with the risk-benefit framework that will guide countries on safer approaches for the radical cure of P. vivax malaria and other drug-based interventions.

Key Accomplishments

Objective 3: Provide global technical leadership, support operational research, and advance program learning Key Accomplishment #1: Prepared the assessment of the efficacy of a high-dose radical cure regimen for P. vivax malaria Following results from a Brazilian clinical study that showed that a double dose of PQ was superior in preventing relapses compared to a lower dose of PQ, IM participated in meetings aimed at selecting the field site for the assessment of the efficacy of high-dose PQ. IM participated in discussions with the Peruvian


NMCP, PMI, the USAID LAC Bureau, CDC, and PAHO, to review Peru as a potential site. However, Peru completed the registration of TQ in January 2021 and its NMCP intends to use it for the radical cure of P. vivax malaria. IM then initiated conversations to assess the possibility of conducting the assessment in Colombia and consulted with key decision-makers from Colombia to receive inputs and support for the field activities. With PAHO and the USAID LAC Bureau, and in consideration of sample sizes, feasibility, and epidemiological contexts that have relevance to other LAC countries, IM proposed Colombia as the appropriate site for field activities. The USAID LAC Bureau, in coordination with the USAID Colombia Mission, coordinated a kick-off meeting with the Colombian MOH to discuss the proposed IM activities. In April 2021, IM met with the malaria advisory group in Colombia (Grupo Funcional Malaria), MOH, and PAHO Colombia about the assessment. Additionally, a coordination meeting with the Instituto Nacional de Vigilancia de Medicamentos y Alimentos (INVIMA, National Institute for Medical and Food regulation in Colombia), PAHO, and MOH was conducted to discuss the requirements and approval timelines. IM then developed and shared the protocol for technical input from partners, PAHO, PMI, CDC, the USAID LAC Bureau, and the USAID Colombia Mission. Between April and June 2021, IM LAC organized further discussions with PAHO, PMI, CDC, and the USAID LAC bureau and refined the protocol. In preparation for the assessment, IM completed procurement of G6PD tests and readers in August 2021. A request for proposals to identify an implementing partner for the assessment was issued in June 2021. Following an evaluation of submissions, IM initiated negotiations with the selected candidate to conduct the assessment. Once the subcontract is finalized in the next project year, ethical clearances will be obtained and the study launched. Key Accomplishment #2: Supported the development of safety policies on the use of P. Vivax radical cure regimens Beginning in March 2021, IM LAC conducted a literature review of published and unpublished data regarding G6PD deficiency in LAC countries. The three key objectives of the review were: 1) to describe the prevalence of G6PD deficiency at the national and sub-national levels in LAC, 2) to describe the reported genetic variants in LAC of the G6PD gene; 3) to estimate the proportion of individuals with deficient, intermediate, and normal activity that would be reported by the qualitative and quantitative tests available, and the proportion of people that should be excluded from treatment with 8-aminoquinolones. Findings from the review were being analyzed at the time of writing of this report. IM then presented the LAC portfolio of activities to MMV and PATH’s P. vivax malaria projects. Both organizations provided updates on the PAVE program. IM drafted a protocol on the methodology for the risk-benefit assessment and shared it with partners in September 2021. Planning has begun for a consultative meeting with key stakeholders to review the methodology. Based on this work to date, IM submitted a scientific abstract to the Annual Meeting of the American Society of Tropical Medicine and Hygiene entitled “Epidemiology of Glucose-6-Phosphate Dehydrogenase (G6PD) in Latin America and the Caribbean: A systematic review and meta-analysis to inform Plasmodium vivax radical cure.”


Challenges and Solutions Challenges Solutions Colombia’s socio-political and economic context

IM is following guidance on security from the USAID Colombia and the USAID LAC Bureau. Risk mitigation activities will be in place before initiating field activities. IM will establish a monthly debrief with USAID Colombia while conducting field activities.

Third wave of the COVID-19 pandemic and restrictions

IM is following guidance from the Colombian MOH and is monitoring the situation with partners. The study team will adhere to all local and national guidelines for prevention of COVID-19.

There has been a general decrease of malaria cases in several target areas in Colombia. This reduction of cases could complicate IM’s efforts to assess the efficacy of a high-dose radical cure regimen for P. vivax.

IM is regularly monitoring malaria data from MOH (weekly bulletins) and will adjust plans, as feasible. To help increase the recruitment of patients into the study, active case detection will be conducted in areas where higher numbers of malaria cases are expected.

129 IM Burkina Faso October 2020 – September 2021

Burkina Faso Background Burkina Faso’s entire population of about 22.7 million people1 is vulnerable to malaria. Malaria transmission in the country peaks during the rainy season, from June through October, with variations based on geographic zones. The malaria parasite species P. falciparum causes most infections. Malaria continues to be a leading cause of illness and death in Burkina Faso, with an estimated 10.3 million cases and 3,499 deaths in 2018. Malaria accounts for 39% of consultations with a health provider and 20% of deaths, according to the MOH 2020 Statistical Book of Burkina Faso. The national health system has a pyramid structure with malaria activities organized across all three levels: (1) the central level responsible for developing strategies, mobilizing resources, coordinating partners, monitoring implementation, and evaluating performance, (2) the intermediate level comprised of 13 health regions and eight regional hospitals, and (3) the peripheral level comprised of 70 health districts as well as district hospitals, medical centers, and primary health posts. IM Burkina Faso has supported two activities: an SMC campaign and a TES. SMC context: Since 2014, the NMCP and its partners have been implementing SMC to contribute to reducing morbidity and mortality especially among children under the age of 5 years. Within the expansion of this intervention, PMI, through the Improving Malaria Care (IMC) project, increased the number of SMC-supported districts from two in 2017 (Boromo and Dano) to 12 for 2018–2020. These include: Dano, Boromo, Sabou, Ténado, Pama, Manni, Saponé, Kombissiri, Bittou, Garango, Pouytenga, and Zabre districts. From 2017 to 2020, the SMC campaigns in the 12 PMI districts reached 1,344,319 children aged 3–59 months. In 2020, the IMC project met or exceeded most of the targets for children receiving SMC. These

1 Institute for Health Metrics and Evaluation (2019).

Figure 1: IM Burkina Faso Geographic Scope


results contributed to the decrease in the national malaria mortality rate for children under the age of 5 from 2.0% in 2014 to 1.4% by 2020. TES context: In 2005, the Burkina Faso NMCP adopted the use of ACTs for the management of uncomplicated malaria. Two drugs were recommended for first-line treatment, artesunate-amodiaquine (ASAQ) or AL. In 2016, national malaria treatment guidelines were revised to include DHA-PPQ as a third option for first-line treatment. With the introduction of SMC administering SP-AQ in all health districts of Burkina Faso, ASAQ is no longer recommended for the treatment of uncomplicated malaria in the country. A TES in 2017-18 showed that the AL combination did not meet the 90% acceptable PCR-adjusted therapeutic efficacy threshold recommended by the WHO. Data from previous studies in Burkina Faso showed a similar trend. However, molecular testing did not identify mutations related to artemisinin resistance in the Plasmodium falciparum Kelch 13 (PfK-13) gene. PMI requested that IM support repeat TES studies in the same study site to determine whether the results of the previous study could be reproduced. To determine whether poor absorption of lumefantrine might be affecting efficacy, the TES includes a lumefantrine analysis. Previous TES demonstrated adequate efficacy of the DHA-PPQ combination. The DHA-PPQ and artesunate-pyronaridine (AS-Pyr) combinations could be potential alternatives to AL in Burkina Faso if the results of the 2021 TES are consistent with previous TES, showing a decrease in AL therapeutic efficacy.

Key Accomplishments – Seasonal Malaria Chemoprevention Objective 2: Improve the quality of and access to other malaria drug-based approaches and provide support to pilot and scale up newer malaria drug-based approaches Key Accomplishment #1: Supported the NMCP to review SMC tools and complete timely, efficient, and comprehensive preparation for the 2021 SMC campaign NMCP objectives for the SMC campaign in Burkina Faso included:

1. Contribute to reducing malaria morbidity and mortality, particularly among children under five, in 19 districts. Results expected at the end of the 2021 SMC campaign are: At least 800,000 children under 5 received the full regimen of SMC treatment

2. Decrease the number of malaria cases and deaths compared to the previous year. To achieve these objectives, IM Burkina Faso supported the NMCP to plan and implement the SMC campaign in 19 districts within PMI’s three priority regions (Figure 2):

● Centre-Est (seven districts): Ouargaye, Pouytenga, Koupéla, Garango, Tenkodogo, Zabré, and Bittou

● Centre-Ouest (seven districts): Réo, Sapouy, Koudougou, Léo, Nanoro, Sabou, and Tenado ● Sud-Ouest (five districts): Dano, Gaoua, Diébougou, Batié, and Kampti


To align with the WHO’s High Burden to High Impact (HBHI) approach, the NMCP added an additional fifth SMC cycle to 19 of the 70 districts, including seven in the PMI-supported areas – two districts in the Centre-Ouest and five districts in the Sud-Ouest. The NMCP also targeted Directly Observed Therapy during three days of treatment (DOT3) in all the five districts of the Sud-Ouest region, which have the highest incidence of malaria.

Figure 2: Map of SMC Intervention Regions in Burkina Faso in 2021, by partner

Table 1: 2021 SMC Campaign targets, disaggregated by age 3-11 months 12-59 months 3-59 months

Cycle 0 (June) 42,912 219,755 262,667

Cycle 1 (July) 127,918 653,464 781,382

Cycle 2 (August) 133,775 666,073 799,848

Cycle 3 (September) 141,915 677,051 818,966

The SMC campaign in Burkina Faso was led by the NMCP who coordinated implementation across several organizations including: the Global Fund (22 health districts (HD)), Malaria Consortium (27 HDs), PMI (19 HDs), and UNICEF jointly with Malaria Consortium (2 HDs) (Figure 2). For efficient and synergistic collaboration during implementation, the NMCP organized a preparatory meeting that brought together all MOH stakeholders as well as technical and financial partners. This meeting allowed the MOH’s vision for the 2021 campaign to be outlined and innovations to be discussed, such as the implementation of a “cycle zero” in June 2021 in 19 districts according to the HBHI stratification, the digitization of data collection via a pilot initiative in the Tougan HD, and the DOT3 pilot in 12 districts.

Cycle zero is a fifth SMC cycle, implemented only in certain districts but timed to begin before the first cycle, hence the decision to call it a “cycle zero”. It is a response to the finding that the rainy season starts


earlier in some districts than in others, and that rather than start the whole country early – which may risk ending the campaign too early in some districts, - a tailored approach should be implemented according to the number of cycles and start dates as weather patterns indicate for each district. The dates of the cycles were scheduled as follows: first cycle or Cycle Zero (C0) from June 8 to 11, the second cycle or C1 from July 7 to 10, the third or C2 from August 5 to 8, the fourth or C3 from September 3 to 6, and the fifth or C4 scheduled from October 2 to 5, 2021. As it does at the start of every annual campaign, the NMCP organized a workshop, held in March 2021, to review the tools of the SMC campaign, with a focus on safe implementation in the context of COVID-19. The following tools were reviewed:

● Communication tools (banner, radio and TV spots, flyers, messages to parents) ● Training tools ● Supervision tools ● Commodities management tools (stock sheet, distribution statement, pharmacovigilance sheet) ● SP-AQ administration and data management tools (tally sheet, SMC card, monitoring and summary

sheet, reference card)

To implement the campaign with quality products, supply chain actors were brought together for an update on the conditions of storage of products and to discuss the availability of warehouses meeting standards in each HD. Each HF selected mobilizers (town criers) and community distributors (CD) within the communities to train them for the campaign. The CDs are mostly CHWs in urban centers, semi-urban areas, and rural areas. They are often high school students on vacation and other dynamic young men and women. The basic condition to be a CD was to be in good health (temperature <=37.5 degrees and no clinical sign of respiratory disease). Key Accomplishment #2: Supported the provision of data from PMI districts to complete microplanning and quantification exercises across each of the 19 districts and the 3 regions Using the SMC campaign roadmap developed by the NMCP and its partners, an Excel-based tool was sent to the Direction Regional de la Santé (DRS, Regional Health Directorate) and district health management teams (DHMT) to estimate their campaign needs prior to the microplanning workshop. IM staff participated in a workshop to review the SMC campaign tools, including data collection materials, training modules, and communication materials. This workshop was organized and led by the NMCP with all partners involved in the campaign. Starting in March 2021, microplanning workshops were held in each of the 19 PMI districts with support from the three DRS. The workshops involved 66 participants in total and consisted of a thorough review of DRS and HD microplans, including the planned activities, quantities, and budgetary elements in accordance with the outline sent to them by the NMCP. The district-level micro-planning workshops included both the DHMT members and head nurses, who supervise the CDs during the campaign. Additional planning activities included the development and execution of memoranda of understanding with every DRS and DHMT for the management of financial resources. This facilitated the local


management of financial resources for activities. IM also procured all materials and supplies needed for the campaign, aside from the SP-AQ, which included jerry cans, disposable spoons, cups, chalks, bags, waterproof bags for the CDs and infection prevention supplies to protect SMC campaign staff against COVID-19. All supplies were then distributed to the districts ahead of the SMC launch for each HD’s first cycle. Prior to the first phase of the campaign, each regional and district team organized an advocacy meeting with local authorities to inform them about the SMC campaign, its strategy, and to gain their support among the communities. Twenty-two workshops were organized and attended by 448 participants. Communication activities were carried out through the local media and town criers who visited neighborhoods, markets, and villages to inform the population of the campaign for children under the age of 5 years. Key Accomplishment #3: Supported the successful implementation of four out of five cycles of the 2021 SMC Campaign This year a fifth or “zero” cycle was introduced in June following the recommendation of the stratification done per the HBHI framework. Community distributors proceeded from door-to-door for household-based outreach, field-to-field in some rural areas where children are with their parents in the field for agricultural activities, and in fixed sites for children who are brought to health facilities for SMC and to screen for malnutrition, provide SP-AQ to caregivers of eligible children, observe the administration of the first dose of SP-AQ in monthly cycles of four days (June to October). Regular supervision visits were conducted by the IM team. Adaptations to delivery methodology due to COVID-19 In the context of COVID-19, the following prevention measures were followed by all actors in compliance with national guidelines:

● As soon as the CDs were selected, their temperature was taken. During the training sessions, the number of sessions was increased to reduce the number of participants in each session.

● Each distributor was equipped with a cloth face covering and hand sanitizer for hand hygiene before and after screening eligible children for malnutrition. The SP-AQ was administered by mothers and caregivers to eligible children and directly observed by the CDs to avoid contact between the distributors and the children.

● Medication was administered to children with household utensils. For children outside the household, disposable cups and spoons were used.

● Each CD team had a trash bag for the collection of waste, including single-use utensils used, which was disposed of at the HFs.

● Not all children 3 - 59 months received SMC treatment. Some children were considered ineligible for the following reasons:

o Children allergic to sulfa drugs, for example cotrimoxazole or Bactrim, and including SP o Children allergic to AQ o Sick children

● Children with severe acute malnutrition were also considered ineligible. These children were referred to the health centers by the CDs for evaluation and management by health personnel.


Supervision of the SMC campaign IM provided technical support to the NMCP to supervise CDs and monitor adherence to protocols as they provided services and to motivate CDs to improve performance. During the implementation of the SMC campaign, supervision was organized via a cascade approach from central to community level.

● Supervisors at central level: A team from the central level visited a DRS and then one or more districts to assess the overall organization of the campaign from microplanning to resource allocation, supervision, and data collection. Supervisors then visited health centers and community distributors to check whether the activities and social mobilization were going well and that commodities were available.

● Regional and health district supervisors: Like the central level team, a DRS team visited a health district to assess the implementation of the campaign, while providing logistical support to HD supervisors to better cover the health centers. These teams supervised the actors at the health center level and the CDs.

● Debriefing/reporting of supervision visits during SMC cycles: Each evening, supervisors participated in a debriefing meeting to share information on the progress of the campaign, weaknesses, and recommendations. It is during this meeting that the next day's supervision schedule was adjusted. On the second day, supervisors conducted a quick survey of approximately ten compounds to assess coverage and application of campaign guidelines.

Monitoring and evaluation Monitoring and evaluation activities were laid out in the NMCP’s SMC Roadmap and included: 1) routine data collection; 2) independent monitoring; and 3) rapid surveys. Administrative data collected during SMC Cycles 0–3 During each day of the campaign, data was collected, processed, and transmitted to a higher level to determine administrative coverage. The CDs collected the primary data using tally sheets and, at the end of the day, each head nurse verified and validated the data from each CD team and then filled out the daily summary sheet for all his/her CD teams. This enabled them to estimate the coverage of the area of responsibility. These data were then transmitted to the district level, which in turn compiled the data from each health center to determine district-level coverage before transmitting them to the regional level. The person responsible for data management at the regional level synthesized the data for his or her region and transmitted it to the NMCP, which presented the overall situation for the country by health district and by day. Administrative data showed coverage above 100%. Factors that contributed to this included: 1) population movement (because of insecurity, or mining and commercial activities) which affected the estimated denominator in each area measured and 2) administering the SP-AQ to children over the age of 59 months by mistake. End-of-cycle independent monitoring surveys End-of-cycle independent monitoring surveys were organized after the first and fourth cycles. For each, surveyors were recruited among non-health care providers (mainly primary school teachers). Once recruited these surveyors were trained at the regional level by a team including the NMCP, partners, and regional trainers. The training aimed to give them an overview of SMC and how to appropriately use the


independent monitoring data collection tools to collect data. Each team of surveyors had two days to collect data from 60 households. During data collection, surveyors were supervised by the NMCP and partners. Data were then entered by the NMCP in a national database from which analysis was done and key findings shared. The second independent monitoring survey acted as an end of campaign survey. During the supervision at facility level, a checklist was used to assess HF efforts to apply SMC guidelines. After the July cycle, the findings of the independent monitoring included:

● Percentage of targeted households visited: 99.88% ● Percentage of children aged 3-59 months who received treatment among those present (parental

report): 97.72% Percentage of children treated, with evidence of their treatment: 85.09%2

Household surveys Apart from the independent monitoring household survey, on Day 2 of each cycle, the NMCP recommended that supervisors conduct a rapid assessment to evaluate the proportion of eligible children who received the treatment and how they were informed about the SMC campaign. These results were discussed during the daily debriefing meetings and used to adjust the SMC campaign implementation. These surveys helped identify areas which had not been covered or had low coverage and consequently the DM team could recommend to the CDs to either return or deploy more CDs to the area to reach more households.

Figure 3: Percentage of children treated during 2021 SMC Campaign, by age (C0 – C3) Results of Cycles 0 – 3 of the SMC Campaign By June 2021, all seven targeted PMI-funded districts completed Cycle 0 out of a total of the 19 districts nationwide which had cycle 0 added. In July and August, all 19 PMI-supported districts completed Cycle 1, Cycle 2, and Cycle 3. In the Sud-Ouest region, all five districts were carrying out the DOT3 approach with the CDs. A combination of door-to-door distribution for household and fixed sites in health facilities was used.

2 This result is lower than expected, due to a lack of cards for recording treatment.


Figure 4: 2021 SMC Campaign Coverage, Results per district, per cycle (C0-C3)

Table 2: 2021 SMC Campaign Coverage, Results per cycle (C0-C3)

Cycle Number of districts Coverage C0 7 districts 105.57% C1 19 districts 105.32% C2 19 districts 104.84% C3 19 districts 103.45%

Management/referral of febrile children During the drug administration phase, febrile children, malnourished children, or children who experienced side effects after administration were referred to HFs. This referral was made by the CDs by means of a completed referral form. For the first four cycles, a total of 16,097 children were referred to HFs. Of those children referred, 538 (3.3%) cases of minor side effects were recorded in the districts during the four cycles, and one severe case was reported. This was a child in the Bittou health district, who unfortunately received two doses the same day due to lack of communication between the child's parents. This caused lethargy which was successfully managed at the local HF. The following graph shows the occurrence of minor side effects over the course of the first four cycles.


Figure 5: Percentage of children treated with minor adverse effects recorded during the 2021 SMC Campaign, per cycle (C0-C3)

Key Accomplishment #4: Developed, advocated for, and implemented an NMCP-endorsed evaluation protocol to see if direct observed treatment by CDs of eligible children taking the three-day SP-AQ treatment regimen (DOT3) will improve adherence During the 2021 SMC campaign, IM supported the NMCP to implement the DOT3 approach in the five districts of the Sud-Ouest region. The IM team advocated an evaluation of this DOT3 approach to see whether three days of directly observed treatment improves adherence. A concept note was developed and shared with the NMCP, which agreed to revise its independent monitoring tools to include supplementary questions related to the DOT3 evaluation. This tool was used in July 2021 to collect data on the impact of DOT3 on SP-AQ treatment adherence. A rapid analysis of these data revealed:

● Percentage of children administered at home: 99.16% ● Percentage of children administered in the presence of CDs: 100% on Day 1; 100% on Day 2; 99%

on Day 3 ● Percentage of cards filled out by the CD on Day 1, Day 2, and Day 3: 93.77% ● Percentage of children with good compliance with the treatment (maintained proper intervals of

administration): 98.87%

Table 3: Percentage of children who received DOT3 by CDs in Diebougou and Kampti (Intervention districts) versus Leo and Tenado (Control districts)

Indicators Diebougou Leo Kampti Tenado

% of parents who observed home treatment, corroborated by parent’s report

100% 100% 97% 65%

% of parents who followed home treatment, with evidence

17% 100% 42% 97%

% of parents who know the appropriate response to vomiting

92% 95% 96% 98%

% of parents who know the disease being prevented

93% 83% 99% 100%


Further analysis of the collected data during the independent monitoring survey will be used to inform future decision-making regarding this intervention.

Key Accomplishments – Therapeutic Efficacy Study In the current reporting period, IM supported the NMCP to carry out a TES to assess the therapeutic efficacy of AL, the first-line treatment, and alternative ACTs. The results of this TES will enable the NMCP and the Burkina Faso MOH to assess the current national policy for the first-line treatment of uncomplicated P. falciparum malaria and make an informed decision on whether it should be updated. Primary Objectives

● To measure the clinical and parasitological efficacy of AL, DHA-PPQ and As-Pyr in patients aged six months to less than 12 years old suffering from uncomplicated P. falciparum malaria; determining the proportion of subjects with early therapeutic failure, late clinical failure, late parasitological failure, or adequate clinical and parasitological response

● To distinguish between recrudescence and re-infection through PCR testing. Secondary Objectives

● To assess the incidence of adverse events. ● To determine the polymorphism of molecular markers of resistance to AL, DHA-PPQ, and As-

Pyr ● To determine the blood concentration of AL (in the AL arm) ● To determine the rate of histidine-rich protein 2 (HRP2) gene deletions

By September 2020, IM had fully executed the subcontract for the implementation of the TES with its local partner, the Centre National de Recherche et de Formation sur le Paludisme (CNRFP, National Center for Research and Training on Malaria), as well as procured all the required supplies such as Whatman 903 filter papers, pre-treated filter papers and microvettes. However, as the malaria transmission season had almost ended, the CNRFP in consultation with IM and the TES Steering Committee, decided to postpone the launch of data collection to the next transmission season, which began in June 2021.

Since launching the TES in June 2021 at the three sites in Niangoloko, Nanoro, and Gourcy, IM achieved the following:

● Created a Steering Committee composed of representatives from the NMCP, WHO Country Office, local research agencies not directly involved in the study, including the Health Sciences Research Institute and the Nouna Center for Health Research, and the PMI Burkina Faso mission to review the protocol and study materials, and to conduct site visits

● Implemented and coordinated study activities ● Enrolled more than half of the identified number of patients with a targeted completion of patient

enrollment by November 2021 ● Identified a local partner to manage funds for site visits by the Steering Committee, recruited a

consultant to monitor the study on behalf of the Steering Committee, and conducted the first site visit by the Steering Committee

● Conducted independent quality control of the slides


As of September 29, 2021, the enrollment of patients, out of the targeted of 1080, is listed in Table 4. The target date for completion of the TES is July 2022. Table 4: Patient enrolled in TES in three study sites through September 29, 2021 Niangoloko Gourcy Nanoro AL 153 162 61

DHA-PPQ 78 81 31 AS-PYR 77 80 30 TOTAL 308 323 122


Challenges and Solutions – SMC Challenges Solutions

District teams did not receive COVID-19 prevention supplies for the SMC campaign

DHMTs encouraged their nurses to use their regular stocks.

Insufficient numbers of SMC cards DHMTs provided support to make copies. SP-AQ stock-outs in some districts due to insecurity

DHMTs provide additional stocks.

Operational coverage over 100% due to an inaccurate estimate of the denominator (target)

Organize a census or household enumeration to improve the denominator and set a more accurate target for next year.

The youngest children (<12 months) were often with their mother in the fields, so the CD missed them during the home visit

The CD revisited later in the evening when mothers had returned home from their farms.

Challenges and Solutions – TES Challenges Solutions

Delay in starting enrollment at the Nanoro site due to lower rates of compensation of field staff per patient enrolled than in the other two sites

The CNRFP, as the Prime subcontractor, worked with their subcontractor, UCRN, to identify additional resources to raise the reimbursement rate and subsequently the enrollment rate increased.

Slow enrollment rate in Niangoloko The CNRFP, in consultation with IM and the Steering Committee, extended the enrollment to a satellite site within the Niangoloko district, and informed the Ethics Committee of the expanded definition of the study site.

Challenges enrolling patients who attend health facilities in the afternoons due, among other factors, to the randomization protocol. All patients randomly assigned to the AL arm of the study need their second, fourth, and sixth AL doses directly administered, which would be challenging to do later in the evening due to the security situation.

The CNRFP, in consultation with IM and the Steering Committee, provided a revised approach that allowed children and caregivers to stay overnight to support the proper treatment and monitoring of participants in the AL arm. This allowed patients seeking care in the afternoons to be enrolled into the study, without changing the randomization protocol.

COVID-19-related travel restrictions prevented the organization of PMI-supported Antimalarial Resistance Monitoring in Africa (PARMA) training visit, as the CDC in Atlanta was not accepting visitors at the time of this report and the Université Cheikh Anta Diop (UCAD) was not listed as a site where samples might be sent in the TES consent forms. There was also a lack of

The NMCP made the decision to allocate one PARMA training spot to the CNRFP and one to another research entity so that the skills could be available more broadly in Burkina Faso. A decision on where PARMA training should occur had not been made at the time of writing,


Challenges Solutions

clarity about whether the PARMA training participants should come from the research entity, which was conducting the study and providing the samples, or whether they should come from a broader cross-section of research entities in the country.

pending the lifting of travel restrictions to the CDC in Atlanta.

Lessons Learned - SMC Lessons learned from the 2021 SMC campaign implementation thus far include:

● The rapid household survey allowed identification of areas with insufficient coverage and redeployment of teams to correct the gaps.

Lessons Learned - TES High level participation in the Steering Committee, including the NMCP Director and the WHO Malaria Lead in country has been important given the challenges noted during the last TES and the likelihood of significant findings related to the therapeutic efficacy of AL. Several decisions have been discussed and documented as good practice by the Steering Committee, including but not limited to:

● The expansion of the definition of study site to the district rather than just the named health center – and the decision to allow that change to occur even without the formal written approval of the Ethics Committee which had adjourned for the summer (oral consent was obtained from the President of the Ethics Committee).

● The decision to allow patients and their caregivers to stay overnight and provided food to allow patients to be enrolled in the afternoon into the AL arm.

● The decision of Steering Committee participants to conduct site visits in person. ● The decision of the Steering Committee to also recruit an independent consultant with the

requisite technical skills to conduct site visits to reassure stakeholders of the quality of the study. ● The decision by IM to use its diagnostics partner MCDI to conduct quality control of the slide

reading in addition to the controls provided by the implementing partner


IM Burkina Faso - SMC Indicator Table The data provided in the indicator table below are IM targets and results from the period February 1 – September 30, 2021. Among the 19 districts supported by IM, 7 districts completed four cycles (June, July, August, and Sept 2021) and 12 districts completed three cycles (July, August, and Sept 2021). The remaining cycles were completed after Sept 30, 2021. Validated data for all cycles will be available late 2021/early 2022.

Indicator Target Result Progress to

Annual Target

Comments

Objective: Implement the SMC campaign

Malaria incidence in children under 5 years in intervention areas

438 per 1,000

TBD TBD (campaign in progress) 348.78 per 1,000

Based on the cumulative number of cases of uncomplicated and severe malaria during the four SMC cycles, the incidence of malaria was greatly reduced with variable levels after each cycle (221 per 1,000 in June, 113 in July, 174 in August, and 240 per 1,000 in September)

Percentage of targeted children who received the full number of courses of SMC in a transmission season

95% TBD (campaign in progress as of the end of the reporting period)

TBD (campaign in progress as of the end of the reporting period)

Awaiting data from an independent end-of-campaign evaluation.

Percentage of targeted children who receive course of SMC in the first cycle (Cycle “Zero”)

95% C-O: 107.40% M= 49.63% F= 50.37% S-O: 104.37% M= 50.18% F= 49.82%

>100% The current level exceeds the expected target. This is due to a shortcoming in the definition of the denominator. The data are population projections used by the MOH and do not consider the actual target value in these three regions.

Percentage of targeted children who receive course of SMC in the

95% C-E: 105.49% M=49.07% F=50.93% C-O: 105.20% M= 49.69%

>100%



Annual Target

Comments

second cycle (Cycle One)

F= 50.31% S-O: 105.25% M= 50.29% F= 49.71%

Percentage of targeted children who receive course of SMC in the third cycle (Cycle Two)

95% C-E: 105.23% M=49.01% F=50.99% C-O: 104.81% M= 49.67% F= 50.33% S-O: 104.17% M= 50.34% F= 49.66%

>100%

Percentage of targeted children who receive course of SMC in the fourth cycle (Cycle Three)

95% C-E: 104.16% M=48.74% F=51.26% C-O: 102.99% M= 49.65% F= 50.35% S-O: 102.96% M= 50.23% F= 49.77%

100%

Number of SBC campaigns completed

48 radio ads 48 Town criers

48 radio ads 48 Town criers

100% These SBC campaigns were completed.

Percentage of health workers trained to deliver SMC according to national guidelines

100% 100% 100% The target was reached at the beginning of the first round. This training was conducted before the launch of the campaign.

Number of community distributors trained in SMC

TBD 16,621 N/A The number of CDs was determined based on the needs expressed to ensure sufficient



Annual Target

Comments

coverage of villages and target populations.

Percentage of IM-supported districts with annual SMC implementation plans

100% 100% 100% These data are from the supervision conducted during campaign implementation.

145 IM Cambodia October 2020 – September 2021

Cambodia Background Primaquine (PQ) has been demonstrated to block P. falciparum transmission, by killing mature gametocytes. It also prevents relapses of the persistent liver stage of P. vivax. PQ has not been widely rolled out in Cambodia, due to adverse health reactions experienced by those who have a deficiency in the glucose-6-phosphate dehydrogenase (G6PD) enzyme. Cambodia has a high percentage of individuals with severe G6PD deficiency and a high proportion of P. vivax malaria cases. Therefore, despite the potential benefit of using PQ in Cambodia’s P. vivax intensive setting, which is also nearing elimination, PQ has not been widely scaled up. Quantitative spectrophotometric analysis is the gold standard in the diagnosis of G6PD deficiency. Confirmation through this method requires access to a laboratory, with a trained technician and appropriate equipment. This approach, therefore, has not been appropriate in many settings across the country. With support from PMI, IM Cambodia has been conducting a study to test the performance of a novel point of care (POC) assay, from SD Biosensor, for detecting G6PD deficiency. Wide-scale availability of a high-performing POC assay would further support rapid and accurate G6PD deficiency testing and appropriate prescribing of PQ. Study Overview The primary study objective is to determine the accuracy and reliability of the SD Biosensor quantitative G6PD assays in the Cambodian population, as well as those for a novel qualitative assay to determine severe G6PD deficiency. Secondary objectives and outcomes 1. To determine the POC performance characteristics of the diagnostic G6PD tests under investigation,

as measured against the standard laboratory-based spectrophotometric method Measurable outcomes: Sensitivity, specificity, positive and negative predictive values of each POC test, with calculations for each performed at three separate thresholds of positivity: <30%, <70%, and <80% of the adjusted male median (AMM) enzyme activity

2. To determine the POC performance characteristics of the diagnostic G6PD tests under investigation in a population of individuals with P. vivax malaria, as measured against the standard laboratory-based spectrophotometric method

Figure 1: IM Cambodia Geographic Coverage


Measurable outcomes: Sensitivity, specificity, positive and negative predictive values of each POC test, with calculations for each performed at three separate thresholds of positivity: <30%, <70%, and <80% of the AMM

3. To assess the reproducibility of each POC G6PD assay when conducted in settings with different clinical specimens Measurable outcomes: Correlation between G6PD enzyme activity levels, in international units per gram (IU/Gm) hemoglobin, as measured in the field using a capillary blood specimen, with those measured using the same in the laboratory, obtained with an anti-coagulated venous blood specimen taken from the same participant

4. To determine the ease of use and interpretation of each POC G6PD assay under investigation

Measurable outcomes: Qualitative survey results of health workers administering assays in facility-based surveys; percent of administered assays correctly used and interpreted in facility-based surveys by expert observation using a standardized checklist

5. To provide an estimate of the prevalence of individuals, male and female, living with phenotypic G6PD deficiency in Cambodian communities included in the study population Measurable outcomes: Overall and gender-specific percentages of study participants exhibiting G6PD enzyme activity within the following ranges: <30%, 30-80%, and >80% of the AMM

6. To determine variant allele frequencies in individuals exhibiting aberrant G6PD enzyme activity Measurable outcomes: The G6PD genotype results of individuals testing at less than 80% of the AMM by spectrophotometry, and the distribution of the variant alleles found

7. To ascertain the safety for the use of a selected POC G6PD assay to guide PQ-based chemotherapy

dosed for radical cure of P. vivax malaria Measurable outcomes: Percentage of individuals with P. vivax malaria deemed capable of tolerating PQ radical cure therapy by POC G6PD assay and for whom spectrophotometry determined to have a severe or intermediate G6PD deficiency; the percentage of individuals deemed capable of tolerating PQ radical cure therapy by POC G6PD assay that experience serious adverse effects secondary to PQ administration

Figure 2: A midwife at Preychumpou Mean Ang Health Center in Kampong Speu Province takes blood from a study participant


8. To generate additional estimates of malaria prevalence in selected study sites Measurable outcomes: Molecular prevalence of P. falciparum and P. vivax malaria within the community-based cross-sectional survey in selected study sites

The study is being conducted in two phases, across approximately 30 municipality clusters in Kampong Speu Province in western Cambodia. In Phase one, adults from selected villages in Kampong Speu were randomly selected and asked to provide blood samples for testing by the novel POC device and by quantitative spectrophotometry. Those results were compared to assess concordance, and to determine if the POC assay accurately identified persons with moderate to severe G6PD deficiency. In Phase two, adults and children under the age of 5 presenting with fever have been selected from a convenience sample at health facilities with high number of reported P. vivax cases across Kampong Speu and asked to provide blood samples. Testing was conducted by health facility staff who had been trained in the use of the POC testing device. Phase two samples will also be assessed to determine whether sensitivity and specificity of the POC tests are influenced by malaria infection across symptomatic versus non-symptomatic patients. In both phases, samples for quantitative spectrophotometry were transported to Phnom Penh through a cold chain and tested at the Institute Pasteur Cambodia. Those results were compared to the POC assay results. Progress Update and Accomplishments During the project reporting period, IM Cambodia, in collaboration with its partners, completed Phase one and launched Phase two of the Cambodia OR. ● Phase one: IM Cambodia successfully implemented Phase one, including data analysis and

presentation of the preliminary results to inform progress of the study and the strategy to strengthen Phase two. o IM Cambodia conducted a training and a pilot test with eight participants. o IM Cambodia enrolled 1,000 eligible participants in Phase one. As per the study protocols, blood

samples were tested in the field using the POC assay, as well as in the Institute Pasteur Cambodia laboratory in Phnom Penh, using gold standard spectrophotometry and the POC assay.

o Preliminary results from Phase one suggested that the POC assay under study accurately identified individuals at the highest risk of hemolytic anemia induced by oral ingestion of PQ.

● Phase two: Phase two activities were launched after the analysis of Phase one data, which identified important lessons for improving the Phase two data collection. From the lessons learned in Phase one, changes were made in data collection and laboratory analysis processes to align with the solutions listed in the table below. o By September 2021, IM Cambodia enrolled 957 eligible participants in Phase two, out of the

targeted sample of 1,000. o Due to the COVID-19 outbreak in Cambodia, patient enrollment was slowed and then paused

for six weeks. IM Cambodia innovated to overcome the challenges resulting from the pandemic


to move forward with Phase two data collection. For example, among the actions undertaken, IM proactively engaged health center directors and implemented safety measures to resume data collection and more importantly to reinforce compliance with local restrictions. Additionally, IM Cambodia mobilized necessary resources to respond to the sudden needs prompted by the outbreak. Three additional facilities with high numbers of confirmed P. vivax cases were approached for inclusion in the study. Additionally, the study budget was realigned to free up funding for new test kits, as some expired during the delay period. Fieldwork resumed August 16, 2021.

o Preliminary results have indicated that the POC assay demonstrated a high negative predictive value. This has positive implications as Cambodia seeks to expand radical cure options in the national treatment guidelines. Some top-line preliminary results included:

o SD Biosensor can be used effectively to identify severe G6PD deficiency at POC. However, regular use of controls and close monitoring of test kit temperatures while in storage is important.

o Overall correlation between SD Biosensor and gold standard spectrophotometry was good, with a Pearson’s R coefficient of 0.758.

o Among males, most intermediate results on SD Biosensor were normal by spectrophotometry (83%). Among females, most intermediate results on SD Biosensor were intermediate results by spectrophotometry (56%).

o Using a threshold of four IU/Gm of Hemoglobin (Hgb), SD Biosensor would have a positive predictive value of 93% and a negative predictive value of 98% to detect severe G6PD deficiency among males.

o Given that most intermediate results on SD Biosensor among women were confirmed as intermediate by spectrophotometry, maintaining a threshold of six IU/Gm Hgb is recommended for women.

o An abstract of preliminary results has been accepted as an oral presentation for the 2021 ASTMH annual meeting.


Challenges and Solutions Phase one

Challenges Solutions In some cases, the duration between Phase one blood collection and lab analysis was beyond the recommended duration of three days following blood collection and ranged from one to five days. There were 275 samples analyzed within one day, 326 within two days, 245 within three days, 118 within four days, and 37 within five days.

In Phase two, study teams reorganized enrollment days so that laboratory analysis was conducted no later than 24 hours after field blood collection.

Phase two Challenges Solutions The COVID-19 pandemic slowed patient enrollment, eventually requiring a pause in enrollment for six weeks.

Close monitoring and constant contact with selected HF staff and directors helped to determine when fieldwork could move forward. Three additional HFs were recruited for sample collection.

Fears concerning acquiring COVID-19 greatly reduced attendance at HFs

IM Cambodia engaged health networks, including Village Malaria Workers and Mobile Malaria Workers to encourage patients with fever to seek treatment at their local HF.

The roll-out of the COVID-19 vaccination campaign engaged HF staff that would normally have been engaged in study sample collection.

IM Cambodia shifted resources to respond in a flexible manner to the situation as it evolved. Field team staff were placed on standby until HFs were ready to allow them to re-enter and support enrollment.

Lessons Learned ● Temperatures in the field can exceed the manufacturer-recommended test kit 30-degree

maximum. Therefore, regular monitoring of test kit storage conditions is necessary. ● Delayed shipment of blood samples from the study sites to the laboratory can affect G6PD values

as measured by spectrophotometry. In phase two of the study, IM Cambodia shipped samples the same day that they were taken, which appeared to have resolved the issues that arose in Phase one of the study.

● IM Cambodia noted during phase two that relying on enrolled participants to present to a study health facility was ineffective. Therefore, village malaria workers were enlisted to liaise with communities and encourage them to seek care in the facility if they had fever.

150 IM Cameroon October 2020 – September 2021

Cameroon Background To support the Republic of Cameroon to reduce malaria morbidity and mortality, IM Cameroon has been supporting the NMCP to improve malaria service delivery since 2018 in the North and Far North regions. According to data from the 2020 Cameroon DHIS2, deaths attributed to malaria in children under the age of 5 years in these regions were 45.2% and 48.3%, respectively, compared to 34.9% nationally. In line with the priorities outlined in the National Malaria Strategic Plan (NMSP) 2019-2023, IM Cameroon has focused on the provision of technical and logistical support to the NMCP to strengthen malaria case management and MIP services at facility and community levels as well as SMC. IM Cameroon activities have also supported the three main IM project objectives.

● Objective 1: Improve the quality of and access to malaria case management and prevention of malaria during pregnancy

● Objective 2: Improve the quality of and access to other malaria drug-based approaches and provide support to pilot and scale up newer malaria drug-based approaches

● Objective 3: In support of Objectives 1 and 2, provide global technical leadership, support operational research, and advance program learning.

During the previous three years of the project, IM Cameroon provided support to the NMCP to align national guidelines and training materials for MIP and malaria case management, including iCCM, with global policies. IM Cameroon also reinforced coordination and policy through the creation of a technical working group (TWG); a pool of trained health providers; and infrastructure to carry out OTSS+ visits at targeted health facilities. OTSS+ tools were adapted and adopted by the NMCP. Alongside annual support for the implementation of SMC in these two regions, IM Cameroon participated in the NMCP update of the national SMC campaign strategy during the reporting period. With the outbreak of COVID-19 in 2019, IM Cameroon helped the NMCP to build HW capacity and manage COVID-19 in targeted regions. This included integrated COVID-19, infection prevention, and personal protection related questions into the OTSS+ checklist package and integrating infection prevention and personal protection measures into SMC campaigns. During the previous project reporting period, IM Cameroon continued to build on these investments and achievements to work with the NMCP and their partners, including Breakthrough ACTION (BA) and PMI Measure Malaria. Through this coordination, IM Cameroon built a functional TWG; expanded training of health providers; reinforced supportive supervision at facility and community levels; and supported SMC planning and implementation in the North and the Far North. IM Cameroon emphasized capacity building

Figure 1: IM Cameroon Geographic Coverage


of clinicians to manage severe malaria at district hospitals; identified ways to include assessment results for a gender perspective in the NMSP; supported development of the private sector strategy and implementation of the TES in the Central Region, in collaboration with the University of Yaoundé Biotechnology Center (BTC). In doing so, IM Cameroon also focused on reinforcing coordination for and ownership of supported activities at the district level.

Geographic Focus In Cameroon, IM focused its support at central level for policy and coordination and in the North and the Far North for the OTSS+ and SMC (Figure1). In the two focus regions, IM Cameroon increased support to facility-based case management and MIP from 21 districts in the prior reporting period to 31 districts in the current reporting period. IM Cameroon also increased support for iCCM from six to 10 districts during the same timeframe. For SMC, IM Cameroon continued to cover 47 health districts of these two regions.

Key Accomplishments

Objective 1: Improve the quality of and access to malaria case management and prevention of malaria during pregnancy

Key Accomplishment #1: Supported three TWG meetings to reinforce national policy and tools for malaria case management and MIP With IM Cameroon technical support, the Cameroon MOH launched a TWG in 2020, which has served as a platform for monitoring the use of malaria case management guidelines, including MIP. During the reporting period, IM Cameroon supported three TWG meetings that brought together participants from several MOH departments and other key stakeholders.

The main outcomes of these TWG meetings included several technical considerations and decisions to bring malaria management in Cameroon in line with international standards. These included:

● Changing the national IPTp guideline for SP administration in pregnant women from 16 weeks of gestational age to 13 weeks, as recommended by WHO

● Adoption of the QA tool (Key Accomplishment #2) for malaria case management that integrates the OTSS+ framework

● Sharing of IM Cameroon’s experience in using a hands-on in-service training approach for the management of severe malaria in the North and Far North, which led to NMCP consideration to develop an implementation plan for scaling up this activity with Global Fund funding

● Review and adoption of the algorithm for the management of malaria in the context of COVID-19, based on the draft algorithm prepared by the IM Cameroon technical team

In addition, these TWG meetings provided the MOH with the opportunity to advocate for resource mobilization from partners involved in malaria activities. Despite the productive outcomes of these meetings, the NMCP and partners found it difficult to hold them on a quarterly basis, mostly due to other competing meetings. As a next step, IM Cameroon will discuss with the NMCP the possibility of combining the TWG meetings with the NMCP malaria planning and evaluation meetings at the beginning and end of each year.


Key Accomplishment #2: Supported two workshops, one in each region, to review program achievements and quality performance In collaboration with regional health delegations, IM Cameroon organized a meeting in each region to present the IM Cameroon workplan and activities for this reporting period. These two workshops were held on April 28 and 30, 2021, in Maroua and Garoua. The NMCP, Global Health Supply Chain-Procurement and Supply Management (GHSC-PSM), PMI Measure Malaria, BA, Plan Cameroon, and IM Cameroon staff attended the meetings. Meeting content focused on sharing project results to date in each region; presenting the proposed continuation of activities and integration of new ones; and reviewing the proposed timeline for implementation. Recommendations from the discussions included to:

● Emphasize the follow-up of supervised personnel to improve the quality of their services ● Improve the commodity management system to avoid stock-outs ● Accelerate the process of setting up the tablets for data collection for the 2021 SMC campaign

and proceed with simulations as soon as possible ● If necessary, approach Plan Cameroon, who has a great deal of experience in CHW management,

for guidance and sharing of lessons learned Key Accomplishment #3: Supported the NMCP to develop and adopt a QA manual for malaria case management During this past year, IM Cameroon provided support to the NMCP, in collaboration with the WHO, Global Fund, and other partners to develop a draft of the Malaria Case Management Quality Assurance Guide, adapted from WHO. Building on IM Cameroon experience in quality assurance for malaria case management and MIP in the North and Far North, the NMCP and IM Cameroon supported the alignment of this guide with the OTSS+ framework and tool, including the Health Network Quality Improvement System (HNQIS) software. IM Cameroon and the NMCP have planned to finalize the QA manual during a technical meeting planned for October 2021. As a next step, IM Cameroon will support the printing and distribution of 300 copies of this document to targeted health facilities during the next reporting period. Key Accomplishment #4: Revised the CHW supervision approach for iCCM and included revised checklists in KoboCollect IM Cameroon, in collaboration with the NMCP, conducted a review of the existing national iCCM package and identified the need for a CHW supervision framework and tools. The existing supervision approach was based on an inventory checklist that did not conform to the national supervision guidelines and had a limited focus on monitoring the competency of CHWs. IM Cameroon helped the NMCP to fill this gap by integrating a competency-based evaluation checklist into the iCCM supervision toolkit and digitizing it using KoboCollect. The draft of this new tool was shared with the NMCP. IM Cameroon will support the testing of this approach in 20 health areas in the next program year to provide practical experience for its use. Key Accomplishment #5: Expanded and reinforced the pool of trained MOH experts to carry out training and supportive supervision Since the launch of the project, IM Cameroon has supported the NMCP to develop a pool of experts in training, supervision, and quality improvement (TSQ) in malaria service delivery. Initially, these MOH TSQ experts were selected at district level to reinforce district staff. This past year, as IM Cameroon expanded


malaria service delivery to more districts, the NMCP requested the addition of TSQs at central and regional levels as well. In response to the NMCP request, IM Cameroon supported the following trainings:

● At central level, IM Cameroon supported a training of OTSS+ supervision techniques and HNQIS, with 28 senior staff, including 12 men and 16 women from different MOH departments, PMI, and PMI MEASURE Malaria, from April 30 to May 3, 2021. With these trained experts, the NMCP is planning to expand OTSS+ for malaria services to an additional eight regions in the country and provide further oversight in the North and Far North.

● At regional and district levels, IM Cameroon worked closely with the NMCP to organize a: ● TSQ training for 34 new experts in the North and Far North, in February 2021. Participants

included 24 clinical supervisors and 10 laboratory supervisors, coming from the regional health delegations and the supported districts of both regions.

● Briefing in April 2021 for existing district TSQs on the use of HNQIS in preparation of a third round of OTSS+. Participants included 37 clinicians and 10 lab technicians.

● Training in supportive supervision and HNQIS at the regional level, in August 2021. Participants included 29 new TSQs, including 19 clinical supervisors and 10 laboratory supervisors.

Key Accomplishment #6: Supported malaria case management training for 245 health providers IM Cameroon supported the NMCP to train 245 health care providers, including 180 men and 65 women, on the management of malaria according to the updated national malaria guidelines, during 10 training sessions of five days each. These training sessions were implemented in two waves. From November 2020 to January 2021, 30 participants from the Far North and 65 participants from the North were trained. From June to August 2021, 150 health providers, 50 in the North and 100 in the Far North, were trained. MOH district TSQs led these trainings with technical support from IM Cameroon and under the supervision of MOH regional facilitators. The training focused on malaria case management, MIP, use of mRDTs, stock management, waste management, and data recording. Table I: Summary of health providers trained in malaria case management in the North and Far North

Region Sex November 2020 January 2021 August 2021 Total Far North F 6 N/A 25 31

M 24 N/A 75 99 North F N/A 20 14 34

M N/A 45 36 81 Total F 6 20 39 65

M 24 45 111 180 Total 30 65 150 245

Key Accomplishment #7: Supported the training for 294 midwives and health providers working in ANC services and management of MIP In addition to the integrated training for case management and MIP, IM Cameroon also supported the NMCP and MOH Family Health Directorate to deliver specific training on MIP, which targeted 200 facilities across the two regions. This training was organized to address low IPTp coverage in these facilities and


aimed at improving the skills of midwives and other maternity and ANC providers to prevent, diagnose, and treat malaria in pregnant women, using previously developed training materials. In February 2021, seven training sessions of three days each, including three training sessions in the North and four in the Far North, were organized for 199 midwives. From June to July 2021, IM Cameroon supported four additional training sessions, including two in the North and two in the Far North for 95 midwives. Table 2: Summary of health providers trained in MIP in the North and Far North

Region Sex February 2021 June 2021 July 2021 Total Far North F 45 19 N/A 64

M 75 37 N/A 112 North F 38 N/A 12 50

M 41 N/A 27 68 Total F 83 19 12 114

M 116 37 27 180 Total 199 56 39 294

Key Accomplishment #8: Conducted three rounds of integrated clinical case management and MIP OTSS+ and one round of stand-alone MIP OTSS+ During the reporting period, IM Cameroon provided technical and logistical support to the NMCP to reinforce the capacity and skills of supervisors in the implementation of integrated clinical OTSS+ rounds. In 2019, IM Cameroon initially supported a baseline assessment to determine the readiness of targeted health facilities in malaria service delivery and to test and finalize the supervision tool. In 2020, IM Cameroon supported the first round of OTSS+ supervision in 225 health facilities. In 2021, IM Cameroon supported the NMCP to scale up the implementation of OTSS+ and to conduct three additional rounds of OTSS+ covering 265, 308, and 4581 health facilities, respectively. In addition, following the February 2021 training of 199 midwives, IM Cameroon supported a stand-alone MIP post-training supervision, which targeted 101 health facilities, including 79 in the Far North and 22 in the North region, in May 2021. IM Cameroon and the NMCP prepared an analysis of results and trends in reaching performance targets for the first three integrated clinical rounds of OTSS+ since 2020 and the stand-alone MIP round during the reporting period. As a next step, the report for the fourth round is in progress and will be presented in the next quarterly report.

1 This round was completed from September 1 to October 6, 2021—concluding after the end of the reporting period.

Figure 2: A nurse and CHW conducting an MIP educational talk with pregnant women, Kaele Health center


Trends in health worker (HW) competency in the management of uncomplicated malaria, classification of cases, adherence to negative test results, and performance of mRDTs Results from three rounds of OTSS+ showed low HW competency to manage uncomplicated malaria, at 5%, 11%, and 5%, respectively, based on the 90% threshold score from the OPD checklist (Figure 3). In examining the reasons for the decrease between Rounds two and three, IM Cameroon identified several challenges that health providers have faced to correctly follow some important steps within the OPD checklist. These included: welcoming the patients; doing a thorough clinical assessment; and counseling patients. Furthermore, sites assessed were not uniform across the rounds and many facilities experienced turnover of staff from those who had been trained. Nevertheless, overall performance was far below the 40% target set by the NMCP and IM Cameroon.

Figure 3: Percentage of observed HWs demonstrating competency in the management of uncomplicated malaria during OTSS+, Source: OTSS+ data Rounds 1-3

Figure 4: Percentage of observed HWs demonstrating competency in correctly classifying fever cases during OTSS+, Source: OTSS+ data Rounds 1-3


Despite the low competency of HWs in the overall management of uncomplicated malaria, a greater percentage of HWs were competent in correctly classifying cases during the third round (90%) compared to the first and second rounds of OTSS+, 63% and 52%, respectively (Figure 4). This exceeded the 60% performance target. Results demonstrated that HWs were increasingly able to diagnose cases of fever as non-malaria in the case of negative tests; as uncomplicated malaria for positive tests without danger signs; and as severe malaria for positive test with danger signs. The percentage of HWs adhering to negative test results increased from 5% in the first round to 92% in the second round, and remained high, with a slight decrease to 84% in the third round (Figure 5). This indicated that HWs sought other causes for fever in the absence of malaria and avoided over-treatment of malaria, with the potential for performance to approach the 100% target.

Figure 5: Percentage of observed HWs demonstrating adherence to negative malaria test results, according to global standards, during OTSS+, Source: OTSS+ data Rounds 1-3


HW competency for using mRDTs at OPDs increased from 26% in the first round to 30% in the second and 62% in the third round (Figure 6). This was above the 40% target set with the NMCP for this reporting period and it demonstrated the success of OTSS+ in supporting HWs in using mRDTs.

Trends in the competency of ANC providers for the prevention and management of MIP during integrated clinical OTSS+ rounds

HW competency in the prevention of MIP, based on the 90% threshold score from the ANC checklist, had been very low for the first two rounds of supportive supervision, at 15.8% and near 0%, respectively. This percentage rose to 28% in the third round; however, it was still short of the 40% target (Figure 7). Based on analysis of the data, providers continued to struggle to properly welcome pregnant women; implement DOT administration of SP; and provide appropriate counseling.

Figure 6: Percentage of observed health workers demonstrating correct mRDT use during OTSS+, Source: OTSS+ data Rounds 1-3


HW competency in the treatment of MIP increased steadily from 5.9% in the first round, to 12.4% in the second round, and 29% in the third round, but also fell short of the 40% target (Figure 8).

Malaria prevention indicators showed overall improvement. As shown in Figure 9, most providers shifted from lower to higher performance ranges. For example, in Round 3, all providers scored above the 0-30% performance range.

Figure 7: Percentage of observed HWs demonstrating competency in the prevention of MIP during OTSS+, Source: OTSS+ data Rounds 1-3

Figure 8: Percentage of observed HWs demonstrating competency in the treatment of MIP during OTSS+, Source: OTSS+ data, Rounds 1-3


Results of the stand-alone MIP supervision in 101 facilities where midwives were trained

Despite the dedicated training for midwives, the results of this supervision showed poor performance in the prevention and management of MIP. None of the supervised providers reached the standard score of 90% for the treatment of MIP, while only 19% did for prevention of MIP. However, 28% of supervised providers scored between 60% and 90% for malaria treatment and 78% for the prevention of MIP (Figure 10). Areas which needed additional attention included: physical examination of pregnant women; classification of malaria cases; investigation of danger signs and other possible co-morbidities; and inadequate counseling on malaria treatment and prevention. This was the first supervision for most of the providers. Subsequently, providers received refresher training on integrated malaria case management, in August 2021. In addition, more than 70% of these districts were included in the extension of OTSS+ and enrolled for Round 4 of OTSS+, which started in September 2021.

Figure 10: Percentage of observed health workers from 101 facilities demonstrating competency in prevention and treatment of MIP, Source: OTSS+ data Round 3

Figure 9: Breakdown of performance ranges on for prevention of MIP OTSS+, Source: OTSS+ data Rounds 1-3


Trends in HW competency in the management of severe malaria at in-patient departments (IPD) Across OTSS+ rounds, scores for the identification and management of severe malaria were the lowest. In Round 3, only 2% of health facilities achieved a score of 90% for the severe malaria checklist. In addition to HW inability to follow the correct steps to manage severe malaria cases, HWs and supervisors had confusion regarding the implementation of the IPD checklist; the correct definition of severe malaria based on WHO guidelines; and the use of injectable artesunate. IM Cameroon and the NMCP learned from these challenges; took steps to clarify the approach to using the IPD checklist; reinforced the correct definition and management of severe malaria through OTSS+ visits; and implemented the severe malaria champion program described below (Key Accomplishment #11).

IM Cameroon has recognized that there remains a long way to go to improve the competencies of HWs in the management of malaria cases as well as the prevention and treatment of MIP. During OTSS+ visits, supervisors provided on-site capacity building and training, and after each round of supportive supervision, IM Cameroon worked with each facility to develop action plans. IM Cameroon also supported the organization of district coordination meetings, led by district staff, to review and follow up on these action plans. The NMCP then took critical steps to address stock-outs of medicines, commodities, and documents and to plan for additional training of new staff, given the large turnover of personnel. IM Cameroon also supported mentoring visits for very low performing sites. For MIP, IM Cameroon worked with the NMCP and BA to develop specific awareness-raising messages for health providers to change their attitudes on the provision of services for pregnant women. These messages focus on building confidence and rapport with pregnant women and their partners through

Figure 11: Percentage of observed health workers demonstrating competency in the management of severe malaria during supervision, Source: OTSS+ data Rounds 1-3


hospitality, respect, consideration, and attention to local cultural and religious norms. These messages will be disseminated during the next round of OTSS+. IM Cameroon also created a WhatsApp platform to serve as an exchange interface between the TSQs in the field and the technical advisor, M&E advisor, and headquarters support team. This platform has supported the effective resolution of problems related to data reporting and discussions on technical issues encountered in the field. Outcome results for case management of uncomplicated malaria and prevention of MIP Despite the struggle to improve overall HW competencies for malaria case management and MIP, key outcome indicators showed an upward trend between January and September 2021. Most cases of fever were tested with mRDTs, and most patients diagnosed with uncomplicated malaria were treated with an ACT. Continued support for HW performance through OTSS+ will further improve these key malaria service delivery indicators.

Similarly, IM Cameroon identified a positive trend in IPTp3 and IPTp4 uptake after the training sessions in February and June/July 2021. While several factors contributed to this improvement, the strengthened capacities of health providers constituted the basis for much of the progress.

Figure 12: Cascade of care for fever in IM-supported regions in Cameroon, Source: DHIS2, January to September 2021


Key Accomplishment #9: Organized two lessons learned workshops (LLWs) for OTSS+ In April and September 2021, IM Cameroon organized workshops in each region to identify implementation lessons and review OTSS+ results. Forty-seven TSQs from the two regions, including 37 clinicians and 10 laboratory technicians, attended this workshop, including 27 in the Far North and 20 in the North, from 22 health districts. Other participants included seven IM TSQs, the regional malaria coordinators from the North and Far North, and four regional M&E officers from the NMCP and IM. The LLW was used as a mechanism to provide feedback to supervisors to improve OTSS+ implementation. During the LLW, participants reviewed the second round of OTSS+ from each district, followed by group discussions on the findings, challenges, and recommendations to address them.

Figure 13: Progression of IPTp and ITN coverage in 2021 in the North and Far North, Source: DHIS2 October 2020 to September 2021


Table 3: Findings and recommendations from the LLW Number Findings and Challenges Recommendations/Solutions 1 Low involvement of district TSQs in bi-

monthly data and activity review meetings at the health districts

IM Cameroon advocated with the Regional Health Delegates to advise district managers to include TSQs in bi-monthly meetings.

2 Post-OTSS+ follow-up not effective in some health districts

The NMCP has taken steps to finalize a clinical mentoring guide to serve as a reference for TSQs and district staff to address the follow-up of supervision action plans.

3 Lack of reference documents in health facilities, i.e., malaria case definitions and algorithms

IM Cameroon printed additional case management algorithms and flow charts with malaria case definitions and distributed them to health facilities under the guidance of the NMCP.

4 IM Cameroon limitation to remedy various issues identified during OTSS+ such as gaps in human resources, availability of materials and equipment at facility level, e.g., microscopes, scales, oxygen tanks for severe malaria

Observations from OTSS+ visits have been shared with all partners to solicit support from the MOH and other PMI implementing partners in resolving the issues.

Key Accomplishment #10: Supported the roll-out of a hands-on training program to build capacity for the management of severe malaria at district hospitals Over-diagnosis and treatment of severe malaria is a contributing factor to overall appropriate case management of malaria in Cameroon. In February 2021, IM Cameroon provided technical and logistical support to the NMCP to organize a hands-on training at teaching hospitals in Yaoundé to build capacity for the management of severe malaria for clinicians from district hospitals. This training aimed to create hospital-based champions that could reinforce the management of severe malaria and reduce malaria mortality through continuous staff mentoring and internal quality assurance. IM Cameroon worked with the NMCP and the University Hospital of Yaoundé to develop a training curriculum that focused on classroom and practical training, case reviews, and medical rounds. Training topics included the management of severe malaria complications such as coma; severe anemia; and kidney failure. The training sessions and rounds were conducted by clinical experts from different specialties.

From March to June 2021, five cohorts of six participants each participated in this training over a period of 15 days. The participants included 12 physicians and 12 senior nurses from 16 health facilities, including 12 from the North and 18 from the Far North.

Following this training, IM Cameroon provided support to the NMCP and participants to implement 16 feedback meetings—one per hospital—and disseminated the learning acquired during the training in the University Hospital of Yaoundé. A total of 367 health providers from 15 health districts and the regional referral hospitals of the North and Far North regions participated in these meetings.


Table 4: Summary of severe malaria feedback meeting participation Region F M Total

Far North 77 140 217

North 88 62 150

Total 165 202 367 IM Cameroon continued to work with the health district office and champions to maintain severe malaria case review in their respective hospitals and addressed issues of poor case reporting and lack of essential supplies. Key Accomplishment #11: Supported MDRT for laboratory technicians at central and regional levels In December 2020, IM Cameroon provided support for the MDRT of 57 lab technicians for malaria diagnosis from the central level. The NMCP organized this training, with the financial support of the Global Fund. IM Cameroon supported development of the training curriculum and materials, served as co-facilitators, and completed the assessment at the end of the training session. At the end of May 2021, IM Cameroon provided technical and logistical support to train lab technicians from 88 facilities (one technician per facility). IM Cameroon trained 48 participants in the North, through four sessions and 40 in the Far North, through three sessions (Table 5). This training covered the following concepts: malaria epidemiology, biological diagnosis of malaria, quality assurance of laboratory diagnosis, biosafety, biosecurity, waste management, drafting of standard operating procedures (SOPs), maintenance and storage of the microscope, and supervision techniques. The MDRT used both theoretical and practical approaches to learning. Table 5: Distribution of health facilities with trained laboratory technicians in the North and Far North, Source: Activity Report

Region District Number of people trained Total trained Female Male

North 14 26 14 40 Far North 21 36 12 48 Total 35 62 26 88

MDRT pre- and post-tests showed an overall improvement in participant knowledge and skills. Figure 14 below shows the average participant scores on theory, parasite detection (PD), parasite identification (ID), and parasite counting (PC).


Although performance improved, it remained below WHO standards for MDRT (Table 6). IM Cameroon noted that many participants entered the course with a low level of basic pre-service training as nearly 90% of the laboratory staff in the regions are laboratory assistants assigned to tasks for which they have not been trained. Most laboratory staff were recruited from the community and retrained in diagnostics without ever receiving formal diagnostic training. Additionally, IM Cameroon found staff who have been working for over 12 years, who had not received any in-service training. Furthermore, the poor quality of laboratory equipment and reagents did not allow for a quality diagnosis. Faced with this situation, IM Cameroon adapted the training, using adult learning theory to better transfer learning and allow for knowledge acquisition by the participants. Table 6: WHO grading scale for national level standards of MDRT

National Level Standards

Parasite detection (PD)

Species identification (ID)

Parasite counting (PC)

Level A, expert ≥ 90% ≥ 90% ≥ 50%

Level B 80% - < 90% 80% - < 90% 40% - < 50%

Level C 70% - < 80% 70% - < 80% 30% - < 40%

Level D < 70% < 70% <30%

Figure 14: Average pre- vs post-test scores of lab technicians in Th, PD, ID, and PC


Key Accomplishment #12: Supported the implementation of laboratory OTSS+ From November 30 to December 16, 2020, IM Cameroon conducted the first round of laboratory OTSS+ supervision in 17 health facilities in the North and Far North to assess and improve their skills in quality malaria diagnosis. This round of supervision focused on the laboratory OTSS+ checklist because MOH supervisors had not yet been trained on clinical OTSS+ at that time. Later, IM Cameroon worked with the NMCP to integrate these OTSS+ visits and promote team building between clinical and laboratory staff in health facilities. Table 7: Distribution of supervised health facility laboratories in the North and Far North Type of Health Facility North Far North

Regional Hospital 1 1

Regional Hospital Annex 0 2

District Hospital 7 3

Integrated Health Center 2 0

Maternity/ANC Services Hospital 0 1

Total 10 7

Of the 17 supervised health facilities, 12 were evaluated using a panel test. IM Cameroon could not conduct panel tests in the remaining five facilities due to the poor quality of the microscope in two; absence of the trained technician at the time of supervision in another two; and lack of electrical power in one facility. Of the 12 health facilities that underwent the panel test, nine achieved performance of at least 80% in parasite detection. However, only 41.6% of the technicians correctly identified the parasite species on at least one slide. Parasite counting remained the weakest area for supervisees, with technicians only able to correctly quantify parasites in 20% of slides. This was largely because, in most health facilities in Cameroon, parasites densities were not calculated using the recommended standard. Based on training results, IM Cameroon set up a WhatsApp group for trainees to provide distance mentoring until the subsequent quarterly supervision visit and has implemented ad hoc in-person visits, as needed. As a next step, IM Cameroon is planning bi-annual refresher training sessions for laboratory technicians, with the final goal of moving towards accreditation of these providers. Also, part of the causes of the low performance of the lab technician is the poor quality of lab equipment and reagents. Following these supervision visits, IM has brought these issues to the government to seek to address them.


In May 2021, IM Cameroon conducted a second round of laboratory OTSS+ that covered 19 health facilities and 54 providers. IM captured data on the performance of 17 of the health facilities as the other two had not yet been configured in HNQIS. Data collection was led by MOH OTSS+ supervisors and as this was their first time completing it on their own, they noted several challenges, including the incomplete set up lab checklist in HNQIS, the handling of the HNQIS functionality and the poor network quality in red zones. As a next step, IM Cameroon is working with lab supervisors to clean the Round 2 data and provide additional coaching for Round 3. IM will work with the MOH to develop a combined report for Rounds 2 and 3, once the analysis of the results is completed. Key Accomplishment #13: Supported the development and validation of malaria diagnosis and verification tools In July 2021, IM Cameroon supported the NMCP to develop and validate 22 diagnostic SOPs and tools as listed below. These documents allowed for quality implementation of malaria diagnosis practices and supported the overall QA for microscopy in health facilities. As part of the next steps, the tools are being formatted, printed, and made available to the facilities.

● 12 SOPs on microscopic diagnosis ● One SOP on the use of mRDTs ● Two SOPs on biosafety and waste management ● One SOP on quality control of routine slides for malaria diagnosis in health facilities ● Six tools for recording and monitoring the implementation of quality control of routine slides for

malaria diagnosis in health facilities Furthermore, IM Cameroon continued to build Cameroon’s national malaria slide bank. Validated slides were used as a benchmark for quality assurance during supervision. IM Cameroon procured four boxes of 76 slides each from the WHO certified laboratory in Dakar, Senegal, and performed the required quality checks on them before adding them to the bank. This brought the total to 380 slides in the bank.

Figure 15: Panel test results during Round 1 Lab OTSS+ supervision


Key Accomplishment #14: Supported the reinforcement and expansion of iCCM in 10 districts in the North and Far North During the reporting period, IM Cameroon continued to support implementation of the national iCCM approach in six districts where the project had already initiated activities. Building on that experience, IM Cameroon expanded to another four districts. To strengthen iCCM, IM Cameroon supported the training of trainers (TOT) and cascade of training to CHWs; procurement of relevant supplies for CHW; monthly check-in meetings for CHWs at health facilities; and CHW supervision. Supported a six-day training of 30 iCCM trainers The iCCM TOT took place in Guider, in the North region from July 3 to 7, 2021, for representatives from the health districts of Touboro, Golombe, and Tcholliré, from the North, as well as Bourha, Mada, Moutourwa, Hina, Goulfey, Tokombere, and Bogo, from the Far North. A total of 30 district management team members, four women and 26 men, attended this training on adult learning approaches in preparation of CHW training. Supported a 10-day cascaded iCCM training for 346 additional CHWs From December 2020 to January 2021, IM Cameroon supported the regional health delegations in the North and the Far North to organize training workshops for 346 CHWs from the districts of Bogo, Tcholliré, Moutourwa, Hina, and Garoua 1. The newly trained CHWs joined those trained in the previous year, for a total of 768 trained and operational CHWs. More men (284) than women (62) were trained, which reflects gender inequalities in the community workforce. To start addressing this issue, IM supported the MOH and other key partners to assess gender related issues for the use of IPTp services. A key recommendation of this study was to empower women by including them in the decision-making process for community health through women associations. IM has taken steps to support the involvement of these associations in SMC activities this year. Table 8: Summary of CHW training

Region Sex November 2020 January 2021 August 2021 Total Far North F 11 8 31 50

M 19 73 71 163 North F 12 0 12

M 104 17 121 Total F 23 8 31 62

M 123 73 88 284 Total 146 81 119 346


Procured iCCM tools and materials for the newly trained CHWs IM Cameroon provided tools and materials to CHWs and their supported health facilities to support iCCM implementation. For newly trained CHWs, IM Cameroon distributed packets of tools including case management, communication, and supervision registers. IM Cameroon also procured thermometers, flip chart message boards, medicine boxes, backpacks, badges, and jackets. In addition, IM Cameroon distributed bicycles to 768 CHWs in the health districts of Mokolo, Kaele, Guider, Ngong, Bogo, Moutourwa, Golombe, and Garoua 1. For health facilities, IM Cameroon distributed 460 electronic tablets to support data collection and reporting and 200 COVID-19 prevention kits for infection prevention. Supported monthly check-ins for 625 CHWs Monthly check-ins provided the health area chief the opportunity to review data collected by CHWs, discuss challenges and solutions to improve their activities, and replenish their stock of commodities and tools. During the reporting period, IM Cameroon covered the transport and per diem costs for monthly check-ins for 625 CHWs. This activity was implemented in eight districts, Bogo, Kaele, Moutourwa, and Mokolo, Ngong, Guider, Garoua 1, and Tcholliré. These meetings have improved the completeness of

Figure 16: A CHW using an mRDT to test a child with suspected malaria

Figure 17: CHW during a home visit to a household with a pregnant woman


CHW data included in their respective health center reports. Currently, PMI regions are leading in completeness of community data reporting in Cameroon, at 97% in the North and 96% in the Far North. Supported monthly supervision of 625 CHWs Each quarter, IM Cameroon supported MOH staff from the Far North and North to supervise CHWs from Mokolo, Kaele, Guider, Bogo, Moutourwa, Golombe, Garoua 1, and Ngong districts. The objectives of these visits were to support the continuity of community-directed interventions, including iCCM, and to assess the progress of community activities compared to the last supervision. The percentage of CHWs who received at least one supportive supervision visit during the first quarter of 2021 was very high: 96.6% in the Far North and 94.6% in the North, compared to the national average of 38.7%, according to the NMCP's semi-annual report on malaria indicators. However, determining the quality of CHW-led malaria services remained difficult to monitor with existing tools, leading IM Cameroon and the NMCP to add competency-based supervision tools to the existing inventory checklist. As of September 2021, 4,868 children > 5 years with fever were seen by the CHWs. While most of them were tested for malaria and most of the cases diagnosed with uncomplicated malaria were treated with an ACT, there still a large gap between those with fever and those tested This is due in large part to RDT stockouts. This issue has been raised to the government and supply chain partner to address this issue that has created missed opportunities.

Figure 18: Cascade of malaria case management in community Objective 2: Improve the quality of and access to other malaria drug-based approaches and provide support to pilot and scale up newer malaria drug-based approaches Key Accomplishment #1: Supported the NMCP to organize an SMC campaign review workshop At the end of November 2020, IM Cameroon supported the NMCP to organize a review workshop for the 2020 SMC campaign with all stakeholders including: PMI Cameroon, WHO, UNICEF, PMI


implementing partners, other non-governmental organizations (NGO), and relevant directorates of the MOH. During the five-day workshop, the group formulated several recommendations to improve the upcoming 2021 SMC campaign. Recommendations included to:

● Recruit additional IM Cameroon finance staff and a program manager in the Far North ● Organize weekly meetings between regional IM Cameroon teams and the Regional Malaria

Working Group during the SMC campaign period ● Clarify the roles and responsibilities of stakeholders during the initial SMC strategy development ● Designate a focal person in each district to collect all payment documents ● Consider speedboat rental for flooded areas during the rainy season ● Review the contract with the mobile money partner to include the identification of the phone

numbers of campaign actors to reduce potential fraud2 ● Share the micro-plan budget with health districts and health areas before planning at the regional

level ● Support the NMCP to develop mechanisms for searching for new funding sources by integrating

economic operators, mobile phone partners, and other actors and partners Following this workshop, IM Cameroon also supported a two-day meeting to review and discuss the external monitoring strategy that was used to evaluate the quality of SMC implementation in 2020. The objective was to assess the validity of the methodology and the results. At the end of the meeting, the following recommendations were made for the next SMC campaign:

1. Develop an operational protocol for external monitoring and data sharing 2. Consider ethical questions while validating the questionnaires 3. Obtain ethical clearance for the study 4. Hire independent consultants for external monitoring to work closely with the NMCP at the

national and regional levels for data QA 5. Use tablets for electronic data collection 6. Review and adapt the methodology to assess new activities such as the “household leaders”

approach 7. Build the capacity of the NMCP and IM Cameroon program staff in using the Lot Quality

Assurance Sampling (LQAS) methodology 8. Share the main results of the external monitoring during regional feedback meetings 9. Develop a scientific article on the External Monitoring Strategy

Key Accomplishment #2: Supported the NMCP to organize a validation and planning workshop for the 2021 SMC campaign at the central level Following the review workshop in November 2020, IM Cameroon supported an SMC 2021 campaign planning workshop in February 2021 for the NMCP and key stakeholders. The workshop aimed to validate and adopt the SMC 2021 campaign strategy, consider lessons learned from the previous year and the ongoing COVID-19 context. The workshop also focused on revising the SMC implementation guide;

2 Actors included all those playing a role in supporting the SMC campaigns, including supervisors at all levels, mobilizer-distributors, data entry clerks, and town criers.


updating management tools and the training manual; and developing a budgeted operational plan with a detailed timeline. At the end of this workshop, the participants decided to maintain the 2020 SMC strategy while considering some efficiency changes. These changes included to:

● Conduct social mobilization and identification of eligible children only in Cycles 1 and 3, instead of all cycles as in previous years

● Extend the Household Leader strategy to all districts ● Strengthen epidemiological surveillance and data quality monitoring during the SMC campaign

Several other topics were discussed, including the eligibility of some health districts for the SMC strategy, the appropriate period to conduct the campaign, the number of cycles needed depending on the amount of rainfall, and the possible expansion of the target age beyond 59 months. Summaries of these discussions were shared with Cameroon’s malaria scientific committee to review, make decisions, and provide future guidance for SMC in Cameroon. Table 9. Distribution of children targeted for SMC by region and age group

Region Children 3 to 11 months Children 12 to 59 months Total North 122,270 602,632 724,902

Far North 201,467 996,613 1,198,080

Total 323,737 1,599,245 1,922,982

Key Accomplishment #3: Supported DHIS2 configuration and quantification of materials and tools for 2021 SMC From March 3 to April 4, 2021, IM Cameroon supported the organization of a five-day workshop to review the DHIS2 platform for the 2021 SMC campaign and to adjust for the new and revised tools coming out of the validation workshop. During this meeting, participants also discussed the quantification of tools to be procured. The group quantified the tools by health area, district, and region. IM Cameroon then used this to inform their procurement and distribution of campaign supplies. The main changes to data collection tools in DHIS2 have been included in the below list.

● The Distribution Sheet introduced a variable to capture "Children not counted during the mobilization” (Cycles 1 and 3) and “Children newly registered” (Cycles 2 and 4). This was added because the social mobilization and identification of eligible children was removed for Cycles 2 and 4, described above.

● The SMC card incorporated the batch number of the SP-AQ administered to the child. ● A five-page job aid developed for the heads of the health areas was included, to support data

entry, which must be done at the health area level. All of these changes were tested and incorporated into DHIS2, and relevant data collectors were oriented on the updates.


Key Accomplishment #4: Supported SMC microplanning workshops at regional level IM Cameroon also supported the NMCP to launch the microplanning process at the regional level. This was coupled with the training of actors at regional and health district levels. During this workshop, the microplanning template was shared with health district managers who filled it in to develop their micro-plans. This included analysis of the training, supervision, mobilization, and distribution at district and health area levels. IM Cameroon provided both technical support and logistical support for this activity. Lessons learned from previous campaigns were used to inform this exercise. Key Accomplishment #5: Supported the selection and training of SMC actors Training workshops for regional and district supervisors The training of regional and district supervisors on the 2021 SMC strategy in both regions took place between June 4 to 21, 2021. Sixty-two participants, including 56 district supervisors and six regional supervisors, attended this training in the North and 116 participants, including 102 district supervisors and 14 regional supervisors, in the Far North. Training for heads of health areas and proximity supervisors By the end of July 2021, 42 out of 46 districts completed the training of heads of health areas and proximity supervisors. The four remaining districts in the Far North, Fotokol, Goulfey, Mada, and Makary, organized this training for one month later, in August, as the overall SMC campaign was also moved later to better match rainfall patterns and malaria epidemiology, as per guidance from the epidemiological surveillance technical group. Training of mobilizer-distributors IM Cameroon supported the training of 16,028 mobilizer-distributors in multiple two-day sessions. Mobilizer-distributors were responsible for going door-to-door to inform households about the campaign and registering eligible children and families for distribution. They then returned three days later for SMC administration. They no longer administered SP-AQ directly to eligible children, due to COVID-19 prevention measures but guided parents and caregivers to give the first dose of medications under their supervision. A change this past year was that mobilizer-distributors were not retrained between SMC cycles, therefore, IM Cameroon supported quality training during the initial 803 training sessions to transfer knowledge and skills for the full campaign period.

Figure 19: Three mobilizer-distributors from the health district of Guidiguis, getting ready for 2021 SMC field activities


Trained and equipped SMC data managers The updated 2021 SMC strategy stipulated that data entry should be done at the health area level. To facilitate this work, IM Cameroon acquired tablets for electronic data collection and distributed them to the health areas. The MOH health information department conducted a field visit to set up the 448 tablets, including 298 in the Far North and 150 in the North, to connect them to the DHIS2 system. The IM M&E team also supported the training of SMC data managers chaired by PMI Measure Malaria and the regional malaria coordination group. These tablets were used during this training with hands-on sessions. Key Accomplishment #6: Supported the procurement and distribution of SMC materials and tools to districts and health areas Training materials and SMC tools IM Cameroon procured all SMC campaign materials on behalf of the NMCP and initially had them delivered to Yaoundé. There, IM Cameroon supported their packaging per health district and health area, to allow for delivery directly to health centers and to avoid any implementation delay. All training materials and implementation tools were delivered at least one week before the start of the SMC campaign. Personal Protective Equipment (PPE) for COVID-19 The Global Fund, through its principal recipient, Plan Cameroon, supplied PPE for COVID-19 to be used by the SMC actors during the campaign. These materials included masks, disposable gloves, and hand sanitizer. Key Accomplishment #7: Collaborated with Breakthrough ACTION (BA) and PMI Measure Malaria to reinforce communication and M&E activities for the SMC 2021 PMI recommended sharing the responsibilities and activities with other PMI implementing partners in Cameroon for the 2021 SMC campaign. Thus, IM Cameroon collaborated with PMI Measure Malaria and BA to develop a joint implementation plan and budget. PMI Measure Malaria managed most of the M&E activities for the SMC campaign and BA managed those related to communication. IM Cameroon continued to play a central role in the SMC campaign to coordinate across PMI implementing partners for smooth implementation. Thus, IM Cameroon and BA collaborated to jointly conduct some communication activities, such as integrating women's association leaders in sensitization and scaling up the household leader strategy. IM Cameroon also worked closely with PMI Measure Malaria on routine data quality assessment (RDQA) for SMC data. Table 10: Summary of women’s association activities in the third cycle of SMC

Region Number of outreach workers trained

Number of associations reached

Number of women reached

Far North 90 636 14,710

North 53 538 9,418

Total 143 1,174 24,128


Key Accomplishment #8: Analyzed results for three rounds of the 2021 SMC campaign In 2021, the SMC target was coverage of at least 90% of children 3-59 months of age in the campaign regions receiving the four cycles of SP-AQ across the peak transmission season. In this report, IM Cameroon provided results for coverage from the first three cycles, as the fourth cycle occurred outside of this reporting period.

IM Cameroon also collaborated with PMI Measure Malaria to conduct external monitoring after SMC distribution. External monitoring consisted of a quick survey to assess the quality of the implementation and to measure adherence to second and third doses. This activity was conducted by independent experts using the LQAS methodology, and classified districts from lowest to highest performers based on established criteria.

Figure 20: Results for the 2021 SMC campaign, including children counted and children treated for Cycles 1, 2, and 3

Figure 21: A mobilizer-distributor from the Balaza health area, Bogo health district, providing an SP-AQ blister to a mother during the 2021 SMC


Table 11: External monitoring results for Cycles 1 and 2, from the independent monitoring household survey Indicators Cycle 1 Cycle 2

Proportion of targeted children reached on day 2 and 3 based only on empty blister

63% 58%

Proportion of targeted children reached on day 2 and 3 based only on the declaration of mothers of an infant or child aged 3-59 months

31% 37%

Proportion of targeted children reached on day 2 and 3 based on both the declaration and empty blister

94% 95%

Objective 3: In support of Objectives 1 and 2, provide global technical leadership, support operational research, and advance program learning

Key Accomplishment #1: Supported the implementation of a TES in the Central region as well as the preparation of the upcoming TES in the North During the project year, IM Cameroon supported the NMCP to implement a TES in six study sites in Cameroon’s Central region. In February 2021, IM Cameroon subcontracted with the BTC of the University of Yaoundé to implement the fieldwork for the TES and secured the Cameroon National Ethics Committee approval of the study protocol. Once the protocol was approved, IM Cameroon, in partnership with BTC and in close collaboration with the NMCP, trained study staff in participating districts. A total of 31 participants, 24 from the study sites and seven site supervisors from BTC, and 12 facilitators took part in the training.

IM Cameroon supported BTC and the NMCP to launch the TES at all six sites on April 5, 2021. Details of the enrollment and follow-up from April 5 to June 3, 2021, have been detailed in Table 12.

Table 12: Summary of enrollment and follow-up S/N Study sites Number

of children screened

Number of

children enrolled

ACPR ETF EV Non-compliance

to treatment guidelines

LTFU WT Number of

children being

followed

1 Mbalmayo 61 44 29 1 0 0 1 0 13

2 Soa 68 33 19 2 0 0 2 0 10

3 Akonolinga 81 33 11 0 1 1 0 1 19

4 Mfou 23 4 2 0 1 0 1 0 0

5 Mbandjock 81 3 8 1 1 0 2 1 19


S/N Study sites Number of

children screened

Number of

children enrolled

ACPR ETF EV Non-compliance

to treatment guidelines

LTFU WT Number of

children being

followed

6 Ngog-Mapubi

13 23 2 0 0 0 0 0 0

Total 327 148 71 4 3 1 6 2 61

ETF=Early treatment failure; EV=Enrollment violation; LTFU=Lost-to-follow-up; WT=Withdrawn; ACPR=Adequate Clinical and Parasitological Response

IM Cameroon, in collaboration with PMI, the BTC, and the NMCP participated in a site visit to verify TES data collection protocols and data quality, and to identify and communicate areas for improvement. Several positive points were noted during this supervision, including the familiarity of supervisors with the study protocol and tools; CHW participation in the study; the referral of patients to health facilities; and the availability of study supplies. The main area for improvement identified was the quality of the study supplies, especially the lab reagents. IM Cameroon supported the NMCP to secure high-quality supplies for the remainder of the study. The visit covered four sites, as the remaining two sites, Mfou and Ngog-Mapubi, had not yet enrolled children for the study. After further review of the performance for these two sites, both were subsequently closed for lack of enrollment. The four sites visited completed enrollment and the study team has begun data analysis and report writing. IM Cameroon also initiated the extension of the subcontract with BTC to conduct a TES in the North. The NMCP, PMI, and IM Cameroon reviewed and approved the revised study protocol. The main recommendation for this new study was to reduce the number of study sites to two and to consider adding AL and Dihydroartemisinin + piperaquine (DHA-PPQ) as study candidates. Key Accomplishment #2: Conducted gender analysis and used results to develop strategies for alleviating gender-related barriers to the uptake and provision of MIP services In January 2021, IM Cameroon hired a consultant to conduct a gender analysis to better understand gender-related barriers to the uptake and provision of malaria services, including MIP and SMC. The analysis was conducted using IM’s gender analysis framework, based on a framework developed by Jhpiego, which examines barriers and facilitators across four main domains:

● Access to assets: Natural resources, productive assets, income, information, knowledge, and social networks

● Beliefs and perceptions: Access to opportunities, mobility and decisions, and expectations about appropriate behavior

● Practices and participation: Time, space, mobility, household and community, division of labor, and participation rates in different activities and roles

● Institutions, laws, and policies: Due process, education, employment opportunities, health services, infrastructure, ownership, and inheritance rights


Currently, this report is under internal IM Cameroon review and will then be shared with PMI and prepared for broader dissemination. The findings will also be featured in a poster presentation at the November 2021 ASTMH annual meeting. In July 2021, IM Cameroon provided technical support to the NMCP and the Directorate of Family Health to organize a workshop to develop a strategy for the effective use of the gender analysis results to improve early initiation and continuation of ANC services. At the end of this meeting, the results of the study were validated by participants, and a draft action plan to address the barriers was developed. This workshop was attended by the MOH Directorate of Operational Research, the Directorate of Family Health, the Ministry of Women's and Family Promotion, the Ministry of Social Affairs, the NMCP, and partners including BA and the United Nations Population Fund (UNFPA). Next steps will be to integrate the action plan into the IM Cameroon annual workplan and to begin implementation of activities.

Challenges and Solutions


Many health care providers had a low background level of knowledge and skills in malaria services. They were assigned to tasks for which they have not been trained or have not received refresher training since their graduation.

IM Cameroon will adapt training modules to the level of health providers, using key messages to facilitate understanding, as well as regular supervision for their adherence to national guidelines.

Gaps in human resources for health, including for example that the North and Far North had the lowest coverage of health providers in the country

CHW training provided an opportunity to help relieve some of the challenges of the shortage of health providers.

Poor quality of health facility equipment and materials needed to comply with the guidelines for the management of severe malaria

IM Cameroon advocated with the MOH and other partners to equip referral facilities. Local solutions and other adaptive measures have been prioritized, as shared during training (i.e., microscope maintenance).

Persistent security issues associated with armed conflicts, particularly in the Far North, resulting in difficulties in carrying out activities and accessing these areas

IM Cameroon teams adhered to existing security standard operating procedures and collaborated with local partners (local NGOs, Civil Society Organizations (CSO), health facilities) to monitor project activities.

Low ownership and involvement of health district management teams in coordinating and monitoring malaria control activities of CHWs

IM Cameroon will pilot the new community management strategy that gives more responsibility to health districts and local communities which will be launched in three health districts. IM Cameroon will also build on



community engagement initiatives around SMC, including the household leader approach and coordination with women’s association networks and local CSOs.

Instability of the DHIS2 platform during the 2021 SMC campaign, following the extension of data entry to the health area level

IM Cameroon will work closely with the MOH Health Information System division to improve the platform's performance.

Difficulty in reporting community data in DHIS2 IM Cameroon will collaborate with UNICEF, Plan Cameroon, and the MOH-Health Information System division to set up these data in DHIS2. Currently, this activity is underway

Lessons Learned o The collaboration with other partners in the implementation of large-scale activities, such as SMC,

improved the quality of the intervention. IM Cameroon collaborated with other PMI implementing partners, including PMI Measure Malaria to improve data quality, Breakthrough ACTION to strengthen communication, and GHSC-PSM to procure SP-AQ. This leveraged the capacity of other partners and reduced activity costs.

o The decentralization of data entry into DHIS2 to health area level during the 2021 SMC campaign allowed for real-time data review and prompt feedback with corrective actions. However, this initial effort at implementing a new approach revealed the need for substantial preparation before the campaign, as system instability emerged during the first and second cycles of SMC.

o For HWs and trainees with low levels of background knowledge and skills, IM Cameroon found that adapting the training modules to the appropriate level of the learners; using key messages to facilitate their understanding; as well as reviewing information at the end of each session helped to improve the acquisition of skills and transfer of learning.

o Strengthening MOH and NMCP leadership reinforced national ownership of project achievements. All IM Cameroon activities were implemented under the leadership of the MOH.


IM Cameroon COVID-19 Response

Background After announcing the first case of COVID-19 in Cameroon on March 6, 2020, the MOH organized its response around eight pillars: coordination, surveillance, rapid response, laboratory, infection prevention control (IPC), case management, risk communication, and logistics. During outbreaks and pandemics, resources tend to be focused on responding to the health crisis, which can impede progress on other health priorities. Aware of this reality, and to take advantage of existing resources in place to become operational as soon as possible, IM Cameroon integrated COVID-19 support into project activities via existing MOH structures in the North and Far North of Cameroon. Because IM Cameroon has been supporting the NMCP in malaria case management, IM Cameroon was able to support the MOH COVID-19 response starting in May 2020, alongside other USAID implementing partners, UNICEF, and WHO.

After hosting the African Nations Championship for three weeks from January to February 2021, with 16 countries competing, and the related international travel, the country experienced a spike in cases. According to the MOH, 2,000 cases were recorded between January 26 and February 1, 2021. The government reacted to this increase by reinitiating preventive measures and calling on international partners to continue their support. IM Cameroon mobilized project savings and extended some activities to respond to the second wave of COVID-19. IM Cameroon continued active implementation of COVID-19 related activities during the reporting period until April 2021, with a final activity related to the inclusion of COVID-19 component in the laboratory OTSS+.

IM Cameroon COVID-19 Key Accomplishments

Key Accomplishment #1: Supported the NMCP to build the capacity of clinical staff to manage COVID-19 cases in the North and Far North Building on IM Cameroon’s training of 187 HWs in the previous reporting period, an additional 40 health professionals were trained (Table 13) during the current reporting period from March 22 to 31, 2021, to increase coverage in the Tcholliré district. Tcholliré district required more people to be trained due to the size and dispersed nature of the district, particularly amidst rising COVID-19 cases. The workshops used the MOH training modules that included an overview of epidemic diseases; overview, diagnosis, and treatment of COVID-19; and infection prevention with facilitation led by District Health Officers. All participants received hard copies of the training modules and COVID-19 tools.

Table 13: Clinical staff trained on management of COVID-19 in the North in March 2021 (N=40)

Region Sex Number of participants

Targeted Completed Training % Trained

North

M 31 31 100%

F 9 9 100%

Total 40 40 100%


To further support the MOH to build capacity for improved malaria case management, IM Cameroon supported the development of a differential fever case management algorithm. Seventeen participants from the MOH and partners developed the algorithm during a workshop held in Douala in November 2020. The NMCP then approved the algorithm during a second workshop in December 2020. The resulting decision tree has been printed and will be distributed in hard copy to all health facilities in the North and Far North during IM’s upcoming support visits. The tool has also been shared with other malaria partners to encourage sharing in other regions.

Key Accomplishment #2: Supported COVID-19 preparedness at the health facility level During the training of frontline health workers on the management of COVID-19 cases in July 2020, a lack of basic IPC tools at health facilities was raised. IM Cameroon explored these concerns and conducted a rapid assessment of 30 facilities in September 2020 and found that health facilities lacked even the most basic sanitation supplies. Based on the information collected, IM Cameroon designed, purchased, and distributed IPC kits to three hundred health facilities, including all those supported by IM. The MOH also requested that additional facilities in the Far North be provided with IPC kits. These areas were known to be ‘red zone’ areas where Boko Haram has operated, and often do not receive support, despite having COVID-19 recorded cases. IM Cameroon provided the regional MOH with sanitation kits, which were supplied to 86 health facilities in the red zones. However, 12 of these health facilities later closed due to insecurity, and the sanitation kits were re-distributed to regional COVID-19 management centers in both regions. A total of 618 buckets, 618 mops, 290 shovels, 618 squeegees, 618 brooms, 289 bottles of liquid detergents, 592 trash bins, 587 pairs of household gloves, 300 packets of soap, 287 cartons of bleach, and 612 buckets with taps were distributed (Table 14). This was largely completed in December 2020; however, a few facilities received their supplies through March 2021, due to logistical and security constraints.

Table 14: IPC supplies distributed in the North and Far North

Item / Health District

10L Bucket

Mop Shovel Squeegee Broom Liquid

detergent Trash bins

Household Gloves

400g soap

1l bleach

40 L bucket

with tap

Far North region Bogo 30 30 15 30 30 15 30 30 15 15 30 Maga 30 30 15 30 30 15 30 30 15 15 30

Mokolo 48 48 24 48 48 24 48 48 24 24 48 Mogode 32 32 16 32 32 16 32 32 16 16 32 Guere 28 28 14 28 28 14 28 28 14 14 28 Kaele 48 48 24 48 48 24 48 48 24 24 48

Kousseri 40 40 20 40 40 20 40 40 20 20 40 Makari 22 22 11 22 22 11 22 22 11 11 22 Mada 24 24 12 24 24 12 24 24 12 12 24

Goulfe 20 20 10 20 20 10 20 20 10 10 20 Koza 38 38 19 38 38 19 38 38 19 19 38

Regional HP

26 26 03 26 26 01 06 06 11 01 26


Item / Health District

10L Bucket

Mop Shovel Squeegee Broom Liquid

detergent Trash bins

Household Gloves

400g soap

1l bleach

40 L bucket

with tap

Sub-Total 386 386 183 386 386 181 366 366 191 181 386

North region Ngong 56 56 28 56 56 28 56 56 28 28 56

Tcholliré 64 64 33 64 64 33 64 64 33 33 64 Guider 44 44 22 44 44 22 44 44 22 22 44

Gaschiga 42 42 21 42 42 21 42 42 22 21 42 Regional

HP 26 26 03 26 26 04 20 15 04 02 20

Sub-Total 232 232 107 323 232 108 226 221 109 106 226 Total 618 618 290 618 618 289 592 587 300 287 612

Between January 25 to February 3, 2021, IM Cameroon supported representatives of the MOH COVID-19 case management response team to conduct supportive supervision visits for five COVID-19 centers in the North and nine in the Far North to assess the application of provider knowledge acquired during training and the readiness of these facilities to implement COVID-19 prevention measures. The delegation developed a detailed assessment tool that was designed to collect information to be shared with the other pillars of the COVID-19 response, including risk communications and IPC.

All participants acknowledged the usefulness of the knowledge they acquired during IM Cameroon trainings on COVID-19 case management. However, they were unable to put their knowledge into practice because they lacked basic PPE and sufficient IPC supplies to enable them to do their work safely. Furthermore, most facilities were unable to accommodate recommended social distancing guidelines and lacked COVID-19 treatments, which consist of palliative treatments given to COVID-19 positive patients per the national protocol. The treatments were supposed to be available and free to patients. As such, the situation created frustration for HWs, and at times, tension with the community. The MOH delegation witnessed these issues, and during two data sharing meetings, one in each region, enumerated the challenges and identified potential solutions to share with relevant authorities and address such as distribution of IPC supplies and COVID-19 related commodities, and expanding COVID-19 centers at the district level.

Key Accomplishment #3: Supported integration of COVID-19 considerations into existing OTSS+ checklists To reinforce the review of information on health facility preparedness and data availability, IM Cameroon supported the integration of COVID-19 considerations into the existing OTSS+ tool used to supervise clinical staff management of malaria cases. A workshop was held to review and decide on the final tools, during which the NMCP advised that COVID-19 considerations be limited to IPC. The modified tool was approved and used for the first time in April 2021.


The IM Cameroon team supported the NMCP in updating the laboratory OTSS+ checklist to include modules specific to COVID-19. Updates have allowed for the assessment of laboratory readiness in biosecurity, COVID-19 testing, and laboratory technicians’ competency in the nasopharyngeal and oropharyngeal collection of specimens during the supportive supervision. The checklist was digitized into the HNQIS tool to be ready for use in-country. The modules listed below were adapted to Cameroon’s context, approved by the NMCP in June 2021, and added to the checklist.

● Biosecurity readiness ● COVID-19 readiness ● COVID-19 nasopharyngeal observation ● COVID-19 oropharyngeal observation

Key Accomplishment #4: Supported CHWs to share accurate information about COVID-19 Building on CHW briefings held between September 7 to 14, 2020 reported in last year annual report, IM Cameroon organized additional briefings and updates for CHWs between October 3 to 13, 2020, and March 22 to 24, 2021 in additional health districts of the North (Tcholliré) and the Far North (Bogo) where IM had expanded support for COVID-19 prevention and care services. The objective of the briefing was to equip CHWs with basic COVID-19 knowledge to respond to common issues and questions, and approaches for case management at community level. This included training on how to communicate to the community that COVID-19 testing was available free of charge, the location of testing and treatment centers, and what to expect from treatment. The later set of briefings, held in in Bogo health district, included information on the COVID-19 vaccines and began addressing known concerns and vaccine resistance in Cameroon. Key messages included the safety of the vaccine, the voluntary nature of administration, and vaccine roll-out. These briefings were originally designed and planned in collaboration with BA, and materials were developed by the health regions, with facilitators provided health districts.

The briefings aimed to address questions posed by CHWs, revealing some of the beliefs that existed at the community level, and the day-to-day realities that CHWs face in talking about COVID-19 with community members. The briefings, therefore, served to correct some of these misconceptions and support CHWs to provide access to more accurate information and encourage community members to seek COVID-19 testing.

Table 15: CHWs briefed on COVID-19 management in the North and Far North during the current reporting period



North

M 98 96 98%

F 20 20 100%

T 118 116 98%

Far North

M 72 72 100%

F 8 8 100%

T 80 80 100%




Total M 170 168 99% F 28 28 100% T 198 196 99%

Key Accomplishment #5: Initiated a COVID-19 Symposium In response to the second wave of COVID-19 affecting the country, IM Cameroon supported the MOH and the University of Yaoundé to organize a half-day symposium, on March 31, entitled “Highlight on COVID-19”. The symposium was the first-of-a-kind in the country and aimed to equip health practitioners with an update on the epidemiology of the virus; the pathophysiological mechanisms; updates on prevention, diagnosis, and treatment. The symposium involved academic and other experts in the search for effective approaches in the Cameroon context. Approximately 140 participants joined the symposium in-person at the university, with appropriate preventive measures in place, and a further 40 joined online. The symposium strengthened the cooperation between the MOH and the University of Yaoundé to improve data, and operational research identifying practical solutions adapted to Cameroon. The Dean of the Medical School organized the meeting and expressed his appreciation to PMI for supporting the event.

Challenges and Solutions- COVID-19 Response Challenges Solutions

As the MOH faced many competing demands for attention, receiving responses and requested information was often delayed. Messages were not always passed on from the national, regional, and district levels as expected, which slowed implementation of COVID-19 activities.

Continuous engagement and follow-up with the MOH were necessary at all levels, as well as ensuring that IM Cameroon activities were well aligned with MOH priorities. IM Cameroon engaged a consultant who was able to proactively follow up and travel to the regions ahead of time to build relations with regional MOH colleagues and support activity preparation, while ensuring that all levels were engaged in activities.

Training participants often had competing priorities, arrived late, or were called out to work at health facilities, which disrupted their learning.

IM planned trainings outside of participants’ duty stations to reduce distractions and the ability to be called away for participants (although this increased activity costs). There was also follow-up with absent participants so that they receive and understand all information to complete their learning and maintain engagement. IM Cameroon made e-learning modules available to provide training participants another opportunity to access important information.


Lessons Learned- COVID-19 Response ● Strengthening MOH and NMCP leadership has enhanced national ownership of the project’s

activities. All activities carried out by IM Cameroon were implemented under MOH leadership. This allowed implementation of new approaches such as OTSS+, for example.

IM Cameroon Indicator Table The data provided in the indicator table below are IM Cameroon targets for the IM-focused health districts from the Far North and North regions. Results reflect activities from the period October 1, 2020, to September 30, 2021. In Cameroon, IM focused its support at central level for policy and coordination; and in the two focus regions, IM Cameroon supports facility-based case management and MIP in 31 districts, iCCM in 10 districts, and SMC in 47 health districts. During the reporting period, IM Cameroon supported three rounds of clinical OTSS+ and two rounds of laboratory OTSS+, resulting in 674 clinical OTSS+ visits and 36 laboratory OTSS+ visits. IM Cameroon also supported the training of 1,130 health workers (63 TSQs, 34 supervisors at the central level, 245 HWs in case management, 294 midwives and ANC health providers, 30 HWs in severe malaria, 88 laboratory technician, 30 iCCM trainers, and 346 CHWs). For the SMC campaign, IM Cameroon supported the training of 23,141 support persons (mobilizer-distributors, supervisors at all levels, data managers, and communication focal points, and women’s associations). Progress to Target is calculated as actual result/target*100=progress to target. This provides an indication of how much progress has been made to meeting the annual target outlined in the country workplan.

Objective # Indicator Target Result Progress to

Annual Target

Comments

Objective 1.1: Improved access to quality malaria diagnosis

Percentage of reported malaria cases confirmed with a diagnostic test

100% 99% 99%

Percentage of patients with suspected malaria who received a parasitological test

91% 98% 108%

Percentage of observed health workers demonstrating competency in correctly classifying cases as not malaria,

60%

R3: 90%

(198/220)

150%

Providers' ability to classify malaria cases has gradually become a noted skill of the observed providers. This was due to the quality of the training and post-training

R2: 52.4%

87%



Annual Target

Comments

uncomplicated malaria, and severe malaria

(88/168) follow-up of these providers.

Percentage of health workers demonstrating competency in mRDTs

90% 62% 68%

Percentage of health workers demonstrating competency in malaria microscopy

90% 75% 83%

The poor performance is due to lack of qualified lab technicians. Most of lab technicians working in these regions don’t have adequate background and are generally trained as laboratory assistants but are used as laboratory technicians due to lack of personnel. IM is using mRDT and OTSS+ opportunity to increase their performance.

Percentage of supervised facilities that meet standards (including appropriate materials, documentation, and qualified staff) for quality diagnosis of malaria

10%

R3: 5.9%

(1/17)

59%

Most supervised health facilities did not yet have complete documentation for malaria diagnosis standards, including SOPs and QA manuals. Very few laboratories had an internal quality control system in place. SOPs were developed and validated with IM Cameroon support. IM Cameroon has supported production and distribution of SOPs and the QA manual in health facilities. Through formative supervision, IM Cameroon will continue to support the implementation of

R2: 0%

(0/17)

0%



Annual Target

Comments

internal quality control for malaria diagnosis in health facility laboratories.

Percentage of supervised facilities with at least one provider trained in malaria diagnosis

100% 100% 100%

Percentage of targeted health workers trained in malaria diagnostics

10% 0% 0%

No trained provider was able to reach Level 3 performance, according to the WHO classification, i.e., 70% - < 80% in detection and identification and 30% - < 40% in quantification. This was due to low initial performance levels. Some participants had not been trained in over six to 10 years.

Percentage of designated supervisors trained in supervision of malaria diagnostics

100% 100% 100%

Percentage of targeted HFs with national guidelines for malaria diagnosis that meet global standards

20% 59% 294%

IM Cameroon supported the production of the QA manual, which is gradually being distributed to health facilities. Arrangements have begun for all health facilities to be covered by the next supervision.

Objective 1.2: Improved access to targeted

Percentage of severe malaria cases that received first-line antimalaria treatment according to national guidelines

100% 49% 49%

The issue of the misdiagnosis of severe malaria (Cameroon is one of the countries with the higher rate of severe



Annual Target

Comments

quality malaria treatment

malaria) lead to misuse of injectable artesunate and then the frequent stock-out.

Percentage of uncomplicated malaria cases that received first-line antimalarial treatment according to national guidelines

100% 99% 99%

Percentage of supervised health facilities with health workers demonstrating competency in management of severe malaria

40%

R3: 2%

(2/102)

5%

The main challenges identified for the management of severe malaria cases were the lack of respect for the malaria diagnostic processes, especially a complete physical examination and in-depth patient interviews; non-adherence with recommended dosing and treatment schedules (artesunate and artemether); and insufficient technical resources in health facilities, which did not allow for good follow-up of inpatients with severe malaria.

R2: 2.8%

(4/145)

7%

Percentage of observed health workers demonstrating competency in management of uncomplicated malaria

40%

R3: 4.5%

(10/220)

11%

Inadequate compliance was noted with malaria diagnosis steps, especially during patient examination; and inadequate communication between the provider and the patient on malaria

R2:10.5%

(18/172)

26%



Annual Target

Comments

prevention guidance, treatment seeking in case of complications

Percentage of observed health workers demonstrating compliance to treatment according to WHO guidelines for cases with positive malaria test results

40%

R3: 63.2%

(139/220)

158%

R2: 8.7%

(15/172) 22%

Percentage of observed health workers demonstrating adherence to negative test results according to global standards

100%

R3: 83.6%

(56/67)

84%

R2: 92.0%

(23/25)

92%

Percentage of supervised facilities that meet standards (including appropriate materials, documentation, and qualified staff) for quality malaria clinical management

40%

R3:18%

(55/308)

45%

This underperformance was due to the absence of guidelines for completing monthly epidemiological data collection forms, malaria case monitoring forms, standard consultation registers, and ITN distribution guidelines. Discussions have been initiated with the NMCP and PMI Measure Malaria to discuss the availability of these normative documents.

R2: 0%

(0/272)

0%

Percentage of expected malaria reports from IM-supported health facilities received

100% 99.6% 99.6%



Annual Target

Comments

Percentage of targeted health facilities that receive a supervisory visit for malaria case management and/or MIP and/or diagnosis/lab

95% 100% 105%

Percentage of health workers trained in management of severe malaria

100% 100.0% 100.0%

Percentage of health workers trained according to national guidelines in malaria case management with ACTs

100% 93% 93%

Percentage of IM-supported health facilities with national guidelines for malaria treatment that meet global standards

100%

R3:96.4% (297/308)

96.4%

R2:68%

(180/265) 68%

In R2, most of HF did receive the updated national guidelines. And this was corrected in R3

Percentage of pregnant women who received an ITN during routine ANC

80% 84.9% 106.1%

Reporting difficulties were noted in the counting of pregnant women and poor reporting practices. In practice, service provider counted the number of women who received ANC and attributed the number of ITNs distributed to the same number, even though not all women received ITNs due to stock-outs, for example.



Annual Target

Comments

Percentage of pregnant women who received four or more doses of IPTp

58% 36.6% 63.1%

Although there is a slight improvement, the performance is still low. The underperformance is mainly due to late initiation of ANC by pregnant women and insufficient communication activities. IM is working with the NMCP to launch outreach ITP activities and intensify SBCC.

Percentage of pregnant women who received three doses of IPTp

58% 48.0% 82.8%

Percentage of pregnant women who received two doses of IPTp

70% 63.0% 90.0%

Percentage of pregnant women who received one dose of IPTp

80% 78.3% 97.8%

A growing number of women were taking IPTp, especially the first and second doses.

Percentage of observed health workers demonstrating competency in treatment of MIP

40%

R3: 28%

(50/177)

71%

R2: 0%

(0/25)

0%

Percentage of observed health workers demonstrating competency in prevention of MIP

40%

R3:29%

(52/177)

73%

R2:12.4%

(11/89)

31%

Generally, IPTp remained an area in which health workers had little proficiency. The trainings



Annual Target

Comments

organized by IM contributed to gradually turning around the trend as seen in Round 3 above.

Percentage of health workers trained in IPTp

100% 92% 92%

Percentage of IM-supported countries with national guidelines for prevention and treatment of MIP that meet global standards

100% 96.4% 96.4%

Functional/active Reproductive, Maternal, Neonatal, and Child Health (RMNCH)/ MIP/ANC/Community health Working Group

100% 1 100%

Objective 2: Improved access to quality transmission -appropriate drug-based prevention and treatment approaches


90% 96% 107%

Percentage of children who participated in four cycles of SMC in 2020.

Percentage of targeted children who receive course of SMC in the first cycle

95% 97% 102%

Percentage of targeted children who receive course of SMC in the second cycle

95% 95% 100%

Percentage of targeted children who receive course of SMC in the third cycle

95% 97% 102%

Percentage of health workers trained to deliver

100% 100% 100%



Annual Target

Comments

SMC according to national guidelines

Number of community volunteers trained in SMC

23,141 23,141 100%

IM Cameroon trained mobilizer-distributors, supervisors at all levels, data managers, and communication focal points. Women’s associations also received briefings.

Percentage of IM-supported regions with annual SMC implementation plans

2 2 100%

Objective 3: Project technical leadership contributes to PMI-led global policy development and OR

Contribution to national, regional, or global guidance/policy documents related to malaria (including reproductive health [RH])

5 11 220%

Contributions to documents and workshops included:

- National Diagnostic Guideline

- Laboratory SOP validation workshops (seven),

- QA guideline for malaria

- Community Health Strategic Plan

- Validation workshop for the data from the study on gender determinants in malaria control

Number of program activity outputs disseminated to the global health community

3 1 33%

An abstract from the gender analysis was accepted to be presented at ASTMH.

Participation in targeted national, regional, or global

3 7 233% National, regional, and district TWG for iCCM,


IM Cameroon COVID-19 Response Indicator Table

Indicators Data Source

Means of Verification Total

Disaggregated Results

Men Women

Number of health professionals trained on COVID-19 case management

Training Report

Participants Attendance List 40 31 9

Number of health professionals trained on COVID-19 clinical bio security

Training Report


Number of CHWs Briefed Training Report


Number of health professionals trained on improved management of fever cases and triage

Training Report

Participants Attendance List N/A N/A N/A

Number of health facilities that have available COVID-related technical guidance documents and tools

Training Report OTSS+ Analysis 308 N/A N/A

Number of COVID-19 tools and guidelines developed, adapted, and disseminated

Project document

Produced Document 2 N/A N/A

Number of health facilities who received OTSS+ supervision visits using the COVID-19 adapted tool

OTSS+ Reports/ Data

OTSS+ Analysis 308 N/A N/A


Annual Target

Comments

level Working group(s) and/or taskforce(s)

Case management, and M&E

195 IM Côte d’Ivoire October 2020 – September 2021

Côte d’Ivoire Background Malaria remained a health concern in Côte d’Ivoire: incidence remained at 189.9 per 1,000 and the positivity rate for mRDTs and peripheral blood smears was 79% in 2019.1 To address these challenges, PMI Impact Malaria supported the Ministry of Health (MOH) from 2018 to 2021, via the National Malaria Control Program (NMCP), to improve access to quality malaria services in public and private not-for-profit health facilities, and in the community. IM supported activities in 45 of Côte d’Ivoire’s 113 districts, located in 12 of the 33 health regions in the country.

1 PMI (2020). Côte d’Ivoire Malaria Operational Plan FY2021

Health Regions Health Districts

Abidjan 1 Abobo Est, Abobo Ouest, Yopougon Est, Yopougon Ouest-Songon, and Anyama

Abidjan 2 Adjamé-Plateau-Attécoubé, Treichville-Marcory, Cocody-Bingerville, Porbouet-Vridi, and Koumassi

Grands Ponts Dabou, Grand-Lahou, and Jacqueville

Sud-Comoe Aboisso, Adiaké, Grand-Bassam, and Tiapoum

N'zi Dimbokro, Bocanda, and Kouassi-Kouassikro

Moronou Bongouanou, M'Batto, and Arrah

Iffou Daoukro, Prikro, and M'Bahiakro

Agneby-Tiassa Agboville, Tiassalé, and Sikensi

La Me Adzopé, Akoupé, Alépé, and Yakassé-Attobrou

Indenia -Djuablin Abengourou, Agnibilékro, and Béttié

Gontougo Bondoukou, Tanda, Transsuat, Sandégué, and Koun-Fao

Bounkani Bouna, Nassian, Doropo, and Tehini

12 regions 45 districts

Figure 1: IM Côte d’Ivoire

Table 1: Geographical coverage of IM Côte d’Ivoire


IM Côte d’Ivoire supported the NMCP, the Programme National de la Santé de la Mère et de l’Enfant (PNSME, National Maternal and Child Health Program) and the Direction de la Santé Communautaire (DSC, Community Health Directorate) for malaria case management and the prevention of Malaria in Pregnancy (MIP). IM Côte d'Ivoire complemented partners funded by the Global Fund and UNICEF and focused on improving malaria service delivery through two IM global project objectives. ● Objective 1: Improve the quality of and access to malaria case management and prevention of malaria

in pregnancy

● Objective 3: In support of Objective 1, provide global technical leadership, support operational research, and advance program learning

IM Côte d’Ivoire activities ended on June 30, 2021, apart from the TES which is being supported until 2022. PMI/USAID is continuing to support the country through a new bilateral project called STOP DJEKOIDJO,2 implemented by PSI. The IM Chief of Party, the Senior Technical Advisor, and the M&E Advisor have all been retained to work on STOP DJEKOIDJO.

Key Accomplishments Objective 1: Improve the quality of and access to malaria case management and prevention of malaria in pregnancy Key Accomplishment #1: Supported quality improvement in health facilities of 12 project health districts In 2020, Côte d’Ivoire’s NMCP, supported by IM, conducted OTSS+ activities, and observed health providers during their activities, using competency-based checklists, supplemented with on-site mentorship in low-performing districts. To determine performance, scores of >90% were assessed as competent, 80-90% as average, and <80% as low. IM Côte d’Ivoire observed providers in each facility and generated a facility-wide score. Scores were aggregated to determine the proportion of health facilities in a district meeting the competency thresholds. In addition to receiving their results and an analysis of areas for improvement, providers were coached as part of the OTSS+ visit. As a key output of the OTSS+ visits, the NMCP and IM OTSS+ teams shared a list of technical areas for improvement with the head of the health facility, and from this, developed an action plan with the health facility. IM conducted up to three supervisory visits to health facilities in eight health districts, with100 health facilities visited three times. OTSS+ is a supportive supervision approach that has been supported by PMI for over a decade; first via the Improving Malaria Diagnostics Project (IMaD), then Malaria Care, and now IM, as well as through bilateral projects, for example in Tanzania and Malawi. IM introduced OTSS+ in Côte d’Ivoire in 2019. During this reporting period, IM, in collaboration with the NMCP and PNSME, supported 12 health

2 Stop Djekoidjo means “Stop Malaria” in Baoulé, a widely spoken language in Côte d’Ivoire.


districts to implement clinical OTSS+. District supervisors were trained in OTSS+ and supported by the NMCP and IM supervised service providers. Since the launch of IM activities in Côte d’Ivoire, OTSS+ was scaled up to 12 districts, starting initially with one round of OTSS+ in eight districts in the previous reporting period. In the current reporting period, a second round of OTSS+ covered 11 districts (adding three new districts) and a third round covered 12 districts (with the addition of one more district). District health authorities made the choice of which facilities to visit more than once, based on performance levels observed during the first visit as well as volume of patients. For example, one facility in the Abengourou district was visited twice. Performance achieved during the first OTSS+ visit for management of uncomplicated malaria was 65.3%. This poor performance led district authorities to revisit this health facility for the second round of OTSS+. After this second visit, performance improved to 84.1%. As expected, results for management of uncomplicated malaria did not meet the 90% threshold, thus this site will be selected again during the next OTSS+ visits, until 90% performance is reached. IM Côte d’Ivoire also collaborated with the NMCP to implement mentorship activities to further support providers in the delivery of high-quality malaria services. The mentorship targeted low scoring health facilities in four districts, which were chosen after the first round of OTSS+. In selected implementation districts, trained providers received mentorship from an IM staff mentor who had been trained on mentorship approaches and the standardized IM OTSS+ competency-based checklist. Mentorship topics included MIP, uncomplicated malaria case, mRDTs, and malaria diagnosis. Mentorship visit occurred after a round of OTSS+ and no more than two weeks apart. Mentees graduated once the mentee’s score reaches 90% competency. OTSS+ and mentorship have steadily improved the performance of healthcare providers delivering malaria services in health facilities in Côte d’Ivoire. Overall, provider performance improved between OTSS+ Rounds 1 and 3, reflecting an improvement in the quality of services offered to clients, as shown below at health facilities visited three times and those visited twice. Clinical OTSS+ results of facilities in districts that received three visits over the last 2 years Eight districts carried out three OTSS+ visits each: Dimbokro, Bongouanou, Daoukro, Abengourou, Bouna, Bondoukou, Adzopé, and Dabou. Overall, data from these visits showed a marked improvement in the quality of care provided by health workers between OTSS+ Rounds 1 and 3. For health facility readiness, the percentage of facilities that met standards including appropriate materials, documentation, and qualified staff for quality malaria case management improved steadily, from a low baseline in Round 1 of 14-80% (median 82%) to 74-100% (median 100%) in Round 3, with 100% of health facilities meeting standards in two of the eight districts.


Figure 2: Percentage of HF that met facility readiness standards, including appropriate materials, documentation, and qualified staff for quality malaria case management

For competency of health workers performing mRDTs, all providers in the eight districts improved and obtained a score ≥ 90% during the third OTSS+ visit.

Figure 3: Percentage of health workers who reached the 90% threshold in realizing mRDTs For management of uncomplicated malaria, the percentage of health workers who obtained a score ≥ 90% in the management of uncomplicated malaria in Round 3 improved in seven out of eight IM Côte d’Ivoire districts (Figure 4). In Dimbokro, the eighth district that did not show improvement, the competency of health providers in managing uncomplicated malaria decreased from 64% in round 2 to 33% in round 3. This was attributed to stock-outs of mRDTs in most of the health facilities visited in Round 3, some of which were staffed by new providers. On-the-job training was provided to the new providers during OTSS+, and quality improvement action plans developed at the facilities were followed up after the supervision round by the district staff, including addressing the stock-outs of RDTs. Dimbokro is one of the four districts that benefited from mentorship in between OTSS+ rounds, which means it had a full


time Regional OTSS+ Officer (mentor) based in the district throughout the project, responsible for supporting the district health authorities to follow up the quality improvement action plans.

Figure 4: Percentage of health workers who reached the 90% threshold in managing uncomplicated malaria

Between Rounds 1 and 3, provider competency in preventing malaria in pregnancy improved in four of the eight districts; fell in Abengourou, Bouna and Dimbokro; and showed improvement from Rounds 2 to 3 in Bondoukou (Figure 5). Challenges identified included insufficient communication on preventive measures for malaria in pregnancy, and poor implementation of DOT, due to stock-outs of cups. Feedback and training were provided during the OTSS+ visit and health district authorities were encouraged to follow up closely.

Figure 5: Percentage of health workers who reached the 90% threshold demonstrating competency in prevention of MIP For the treatment of malaria in pregnant women, the third round of OTSS+ showed an improvement in provider competency (Figure 6). However, providers in Dabou and Daoukro districts did not achieve a


score ≥90%. Providers in these two districts did not properly perform a comprehensive physical examination of pregnant women with suspected malaria and did not follow national guidelines. IM Côte d’Ivoire provided feedback and training to the providers during the OTSS+ visit. In the future, it will be important for health district authorities to continue to follow up with regular OTSS+ visits, feedback, and training as needed.

Figure 6: Percentage of health workers who reached the 90% threshold in demonstrating competency in treatment of MIP

Clinical OTSS+ results of facilities in districts that received two visits Three health districts, including Anyama, Agboville, and Aboisso, carried out two rounds of OTSS+ visits. Provider performance improved between the first and second visits.

The percentage of district health facilities which met standards for quality malaria case management improved from 0-13% (median 9%) in Round 1 to 22-75% (median 30%) in Round 2.

Figure 7: Percentage of HF that met standards, including appropriate materials, documentation, and qualified staff for quality malaria case management


Health workers improved their competency in using mRDTs between the two rounds (Figure 8). Those health workers who did not achieve the desired performance (≥90%) struggled with 1) Waiting the necessary time before reading the mRDT; 2) Failing to label the patient's initials on the cassette; and 3) Not wearing gloves, among other challenges.

Figure 8: Percentage of health workers who reached the 90% threshold in using mRDTs

The treatment of uncomplicated malaria improved in the Agboville district but providers in the districts of Aboisso and Anyama still needed support to improve their competency (Figure 9). Examples of performance challenges included incorrect physical examination; non-compliance with national guidelines; and insufficient advice given by providers to patients for correctly taking medicines at home.

Figure 9: Percentage of health workers who reached the 90% threshold in uncomplicated malaria case management

Regarding the prevention of malaria during pregnancy, provider performance decreased in Round 2 of OTSS+ visits in the districts of Agboville and Anyama. In Agboville, ITNs stock-outs were observed in some health facilities in the district, alongside a failure to investigate current fever or a history of fever


during the previous two days. In the Anyama district, challenges included non-compliance with the DOT strategy and insufficient communication between some providers and pregnant women, especially on the potential adverse effects of SP.

Figure 10: Percentage of health workers who reached the 90% threshold in demonstrating competency in prevention of MIP Provider competency improved for achievement of a score of ≥ 90% in the treatment of malaria in pregnant women during the second OTSS+ visit, except in the district of Aboisso, due to non-compliance with national malaria case management guidelines and insufficient communication to pregnant women regarding the side effects of treatment.

Figure 11: Percentage of health workers who reached the 90% threshold in demonstrating competency in treatment of MIP


Results of Clinical OTSS+ in facilities that received one visit

Figure 12: OTSS+ Indicator results in the district of Cocody Bingerville The district of Cocody Bingerville received one round of clinical OTSS+ during this FY. The percentage of health facilities that met standards, including appropriate materials, documentation, and qualified staff for quality malaria case management is 18%. 55% of observed health providers met the 90% threshold in realizing mRDTs. During this supervision 9% of observed health workers reached the 90% competency in managing uncomplicated malaria and none of observed health workers reached the 90% in demonstrating competence in preventing malaria during pregnancy. There were no positive malaria cases during the supervision, health workers were not assessed on the treatment of malaria during pregnancy. Key Accomplishment #2: Supplementing OTSS+ with mentorship to improve quality of care IM supplemented OTSS+ with on-site mentorship in four health districts that had been struggling with low performance scores during a pilot phase before OTSS+ was introduced.

Eight health districts conducted three supervisory visits in 100 health facilities. Mentorship was provided between OTSS+ visits in four of the eight districts (Adzope, Bongouanou, Daoukro, and Dimbokro). After the baseline OTSS+ round, existing mentors targeted lower performing facilities in these four districts. In the mentorship districts, the average percentage of facilities scoring “competent” in the management of uncomplicated malaria increased from 37.75% [range: 33%-45%] in Round I to 80.5% [range: 33%-100%] in Round 3. In the non-mentorship districts, the average percentage of facilities scoring “competent” in the management of uncomplicated malaria increased from 39.25% [range: 17%-80%] in Round I to 77.5% [range: 68%-87%] in Round 3.

In the mentorship districts, the average percentage of facilities scoring “competent” in meeting standards for quality diagnosis of malaria increased from 44% [range: 27%-80%] in Round I to 95.25% [range: 89%-100%] in Round 3. In the non-mentorship districts, the average percentage of facilities scoring “competent” increased from 32.25% [range: 14%-50%] in Round I to 77% [range: 70%-89%] in Round 3. Both OTSS+


alone and OTSS+ plus mentorship improved some competencies, leading to a higher quality of malaria care. Further analysis will determine whether mentorship added value as a complement to OTSS+

Table 2: Comparison of the improvement from Rounds 1 to 3 in the districts where providers received mentorship and of those where providers did not

Meeting standards for quality diagnosis

of malaria Performing mRDTs

Management of uncomplicated

malaria

Preventing malaria in pregnancy

Treating malaria in pregnancy

Mentorship districts

R1 R2 R3 R1 R2 R3 R1 R2 R3 R1 R2 R3 R1 R2 R3

Adzope 27% 94% 100% 40% 88% 100% 45% 53% 89% 33% 86% 100% 100% 67% NA

Bongouanou 29% 93% 100% 20% 100% 100% 33% 93% 100% 60% 100%

100% 50% 100% 100%

Daoukro 40% 69% 92% 50% 100% 100% 33% 33% 100% 50% 100%

92% 0% 0% 33%

Dimbokro 80% 69% 89% 50% 83% 100% 40% 64% 33% 100%

92% 71% 0% NA NA

Non-mentorship districts

Abengourou 25% 38% 70% 46% 65% 100% 40% 48% 80% 55% 55% 25% 100% 33% 100%

Bondoukou 40% 44% 89% 60% 86% 100% 20% 71% 87% NA 85% 100% NA 0% 100%

Bouna 50% 80% 74% 40% 95% 100% 80% 67% 68% 50% 71% 60% 0% 71% 100%

Dabou 14% 41% 75% 29% 60% 91% 17% 35% 75% 25% 50% 78% NA 0% 0%

Key Accomplishment #3: Transitioning of OTSS+ and mentorship activities to MOH/NMCP During project close out, IM Côte d'Ivoire prioritized handing over OTSS+ and mentorship activities to MOH /NMCP to ensure sustainability. IM provided refresher training to district supervisors from the four districts that have been conducting mentorship and also trained supervisors from two additional districts, Abengourou and Agboville, from May 4-6, 2021, on mentorship approaches. Mentors in the two new districts were identified from among the OTSS+ supervisors and other healthcare providers with previous coaching/mentoring experience. The training included 22 participants across all six health districts, including 13 men and nine (9) women, mostly experienced nurses and midwives. This included one day in the classroom for theoretical presentations and interactive exchanges on clinical mentoring, followed by two days to visit health facilities for the practical phase. The training enabled new district mentors to better target and address health provider weaknesses for improvement and to reinforce continuous training of providers, especially those newly assigned to the health facilities.

Table 3: Distribution of district supervisors trained in mentoring

Health Regions Health Districts Number of mentors trained

Total M F

Indénié-Djuablin Abengourou 2 1 3

La Mé Adzopé 0 3 3

Moronou Bongouanou 2 1 3


Health Regions Health Districts Number of mentors trained

Total M F

Iffou Daoukro 3 3 6

N'Zi Dimbokro 2 1 3

Agneby-Tiassa Agboville 4 0 4

Total 13 9 22

IM Côte d'Ivoire also organized a three-day workshop from June 2 to 4, 2021 to handover OTSS+ activities to PNLP. The workshop was attended by 15 NMCP participants. The workshop included a refresher training for NMCP staff to reinforce the technical skills to carry out OTSS+ to improve quality of service provision relating to malaria at all levels of the health system. Among the topics discussed during the workshop were the role of the supervisor in improving provider performance, desired performance levels, gaps in provider performance, selection of appropriate interventions to improve provider performance and monitor and evaluate provider and facility performance. IM also shared the login credentials of the KoboCollect platform and built the capacity of the NMCP M&E staff on the development and configuration of the checklist in KoboCollect using XLS form (Microsoft Excel programming file), the deployment of the checklist on the KoboCollect platform, collection of data through KoboCollect using tablets and downloading, analysis, interpretation, and presentation of OTSS+ data. At the end of the workshop, the NMCP planned to use the tool for the supervision of sentinel sites in 36 health districts of the country, both in the PMI-supported areas and in the Global Fund-supported areas. Future technical support to the NMCP for OTSS+ will continue through the Stop Djekoidjo project.

Key Accomplishment #4: Built capacity for laboratory technicians at reference hospitals for malaria microscopy During the reporting period, IM and the NMCP continued to assist laboratory technicians in improving the quality of malaria microscopy diagnosis in reference hospitals. Trained national supervisors completed the second round of laboratory OTSS+ in 37 reference hospital laboratories from November 29-December 12, 2020. The 11 laboratories that had performed poorly during Round 1 of OTSS+, received mentorship visits from October 4-10, 2020, before Round 2 of the OTSS+ supervision. In those mentorship districts, 89-100% of facilities met the 90% score for malaria microscopy during the second visit, versus 70-89% of non-mentorship districts. Results of Laboratory OTSS+ in the 37 laboratories that received two rounds of OTSS+ Overall, IM Côte d’Ivoire noted an improvement in the performance of the 37 laboratories visited between Rounds 1 and 2, both in parasite detection and in parasite counting and species identification, with improvement of 2% to 9% between Round 1 and Round 3.


Figure 13: Average performance of the 37 visited laboratories in Rounds 1 to 2 Proficiency testing

Comparative analysis of data from the 11 laboratories that received mentorship, between Rounds 1 and 2 of OTSS+

Although improving parasite detection was the focus during mentorship visits, laboratory technicians were also coached on parasite identification and parasite counting during these visits. IM observed an improvement in performance of parasite detection by laboratory technicians in 10 laboratories between Rounds 1 and 2 (Figure14). Laboratories in Adjamé and Agnibilekrou each showed progress, with Adjame increasing from 33% to 100% and Agnibilekrou from 30% to 100%. During the mentoring, supervisors provided lab technicians with a pre-test using panel slides. The results were reviewed together with the supervisor, along with coaching on how to improve on errors noted. Lab technicians then completed a post-test reading with different slides. The improvement in scores was attributed to close coaching and explanation of the mistakes identified during the pre-test.

However, performance among laboratory technicians in the Dabou laboratory dropped from 80% to 70%, as Round 2 supervision involved a different laboratory technician than the one who was supervised during Round 1 of OTSS+. IM Côte d’Ivoire subsequently conducted a mentorship visit in this laboratory to raise the performance level of the laboratory technician supervised in Round 2.


Figure 14: Parasite detection competency HWs scores for 11 laboratories

IM Côte d’Ivoire also supported the development of a national pool of trainers, made up of qualified laboratory staff from reference hospitals and research institutes. In the future, this pool of trainers will be responsible for conducting training on malaria microscopy in reference hospital laboratories. IM supported the NMCP to identify 10 (9 men and 1 woman) national malaria microscopy trainers from qualified laboratories who were responsible for conducting training on malaria microscopy in reference hospital laboratories. The 10 laboratory technicians were trained from March 15-19, 2021, at the Institut National de Santé Publique (National Public Health Institute) in Abidjan. The objective was to reinforce the knowledge, skills, and competencies of national laboratory technicians in malaria microscopy. An IM expert and a national expert from the Institut Pasteur de Côte d’Ivoire (IPCI, Pasteur Institute of Côte d’Ivoire) led the training. The modules covered included the review of the MDRT plan; overview of the participant scoring system for parasite detection, species identification and parasite counting; calculation of sensitivity and specificity related to the reading of slides; classification of participants at different skill levels; interpretation of the data; selection of blood smears; use of pre- and post-test questionnaires; maintenance and storage of microscopes; and development of training reports. Participants were trained on the scoring system for parasite detection (PD), species identification (ID) and parasite counting (PC). Participants were assessed on their scoring skills and results showed overall progress. Participants understood how to score PC but the scoring for ID and PD was more complex (Figure 15). IM recommended regular monitoring and retraining of these national trainers, so that they maintain their acquired skills and abilities, for the benefit of other laboratory technicians.


Figure 15: Mean competency of pre-and post-test evaluation of the 10 participants during the training of trainers on lab OTSS+ scoring Malaria microscopy training of laboratory technicians in reference hospitals In general, the MDRT approach builds the capacity of laboratory technicians to diagnose malaria infections, emphasizing slide preparation, staining, and reading as well as use of malaria rapid diagnostic tests and maintenance of microscopes. In November 2019, IM worked with the MOH to train 40 laboratory technicians in two groups of 20. In February 2021, due to restrictions related to the COVID-19 pandemic, IM took a different approach, training small groups of laboratory technicians at six reference hospitals. This training was facilitated by the pool of national trainers previously trained by IM in March 2020. The curriculum and contents of the pre- and post-training tests remained the same. Six, five-day training sessions with three participants per hospital, were held and included both theoretical and practical sessions. Each participant was provided with a microscope. Slide reading was assessed for three competency areas: PD, ID, and PC. Participant pre- and post-test results for those who attended the workplace training sessions were comparable to those who participated in the classroom-based training sessions in 2019. In the onsite training, average scores for PD increased from 59% to 86%, however scores only slightly improved for ID (from 44% to 47%) and for PC (from 10% to 19%). This compared to 2019

Figure 16: On-site training of three laboratory technicians for the microscopic diagnosis of malaria, Abobo referral hospital, in Abobo East health district, April 2021.


classroom training average score improvements for PD from 53% to 85%; for ID from 40% to 55%; and for PC from 11% to 36%. Onsite training included the following benefits. Each participant had a microscope for practical work, which is not always the case when 20 trainees are in a classroom. Onsite training allowed the trainer to see the challenges specific to each laboratory visited. The trainers had more time to dedicate to each participant and to motivate the technicians to change bad habits. Onsite training costs were lower than classroom training. Onsite training also reduced contact between participants during COVID-19. This alternative approach to bMDRT resulted in improvements in key competencies for malaria microscopy and better protected participants from COVID-19. Among 18 laboratory technicians prioritized, 17 were trained, including 13 men and 4 women (94% participation) as detailed in the table below. In addition, IM Côte d’Ivoire supported the development of a national quality assurance guide for the malaria microscopy and made it available to the NMCP and reference hospital laboratories. Table 4: Distribution of the 17 laboratory technicians trained

Health Regions Health Districts Reference Hospital No. of participants Total M F

Agneby-Tiassa Tiassalé Tiassalé 2 1 3 Taabo 2 0 2

Abidjan 1 Anyama Anyama 1 2 3

Abobo Est Houphouët Boigny 3 0 3

Indénié-Djuablin Abengourou Abengourou 3 0 3

Gontougo Bondoukou Bondoukou 2 1 3

Total 6 13 4 17

Key Accomplishment #3: Supported the transfer of skills to empower district health teams to lead iCCM activities IM Côte d’Ivoire worked with the NMCP and the DSC to transfer the monitoring of community activities from local non-governmental organizations (NGOs) to 27 health district authorities. This approach was approved by the NMCP, the DSC, health districts, and PMI Côte d’Ivoire. The transition was made from July to December 2020, through the gradual reduction in the number of local NGO intervention areas. The aim was to empower district health authorities to be more directly involved in the coordination and monitoring of community activities implemented by CHWs, particularly iCCM; to take ownership of the interventions; and to reinforce their sustainability.

IM Côte d’Ivoire supported the skills transfer for overseeing community activities in 27 districts with iCCM activities. This included:


1. Providing the NMCP and the DSC with an operational document for coordinating, monitoring, and evaluating community interventions (orientation guide).

2. Training 27 district-level Coordinateurs d’Activités Communautaires (CAC, Community Activity Coordinators) on their tasks and responsibilities; iCCM activities; reporting tools; and supervision techniques, including the use of DHIS2. These training sessions were organized in August and December 2020, in Agboville and Jacqueville respectively.

3. Coaching 254 CHW supervisors (health officers) and 54 CHW coaches (experienced CHWs), on their roles, basic CHW coaching techniques, and the correct completion of reporting tools. The orientation sessions took place from September to December 2021. CHW coaches were identified from among the pool of CHWs, considering their experience and motivation. In general, CHW coaches are responsible for supporting the supervising health officers in monitoring and coaching of approximately eight CHWs. IM Côte d’Ivoire is the first partner to implement the CHW coach approach included in the National Strategic Plan for Community Health 2017-2021.

4. Allocating 50 motorcycles and 27 laptops to the districts for the monitoring, supervision, and processing of community data in DHIS2.

These actions by IM Côte d’Ivoire strengthened the monitoring of activities and supervision of CHWs directly managed by district stakeholders. From January to June 2021, IM noted:

● An increase in the frequency of CHW supervision by supervising health officers, with 1,838 CHWs supervised at least four times over the period

● Two supervisory visits by the CAC of 380 CHW supervisors (health officers) ● Improvement in the completeness and timeliness of community data entry into DHIS2, increasing

from 50% to 80% and from 40% to 75% respectively, from 2019 to 2021 ● Improved monitoring of the CHW allocation of iCCM commodities and medicines by the CACs

in connection with district pharmacists, when the products were available in the districts ● Good facilitation of coordination meetings with CHWs, including the preparation of

presentations based on community data produced by CHWs; interactive exchanges with CHWs; retraining of certain CHWs for a better understanding of the indicators and the proper completion of data collection tools; proposals for solutions in the face of challenges encountered by CHWs and supervisory health officers.

Previously, local NGOs implemented the actions listed above in support of district stakeholders, apart from the entry of community data in the DHIS2 which was carried out by district data managers.

Trends in community malaria case management data

Validated community data from DHIS2 are presented below, covering the period from October 2020 to March 2021. Data from April to June 2021 were not available at the time of writing this report.

DHIS2 data in the management of uncomplicated malaria cases showed an upward trend from Q1 to Q2 of the reporting period for suspected cases detected by CHWs. However, the reporting showed a discrepancy between the number of suspected cases and the number tested. This was mainly due to the stock-out of mRDTs, which was one of the major challenges in effective iCCM implementation. From October to December 2020, Côte d’Ivoire reported more confirmed positive malaria cases than suspected cases treated, because providers were treating patients presumptively due to a stock-out of


mRDTs. Overall, 81.15% of confirmed cases receive ACTs. Where CHWs did not have ACTs on hand, they referred patients to the health facility. It has not been possible from this data to disaggregate referrals due to stock-outs from referrals due to danger signs, the data showed that the number of referred cases exceeded the gap between positive cases identified and positive cases treated with ACT, so referrals were not all due to ACT stock-outs.

Figure 17: Community malaria case management data for October 2020 – June 2021

Figure 18: Community malaria case management data by quarter

To support the effective involvement of districts in the monitoring and coordination of community interventions after the withdrawal of local NGOs, IM Côte d’Ivoire, in collaboration with the NMCP and the DSC, organized a joint mission with the NMCP, DSC, PNSME, and Direction de l’Informatique et de


l’Information Sanitaire (DIIS, Department of Information Technology and Health Information) to monitor and supervise district stakeholders. The mission took place from May 17-22, 2021, in six districts from six health regions. The objectives of the field mission were to: (1) Assess the state of implementation of community activities; (2) Identify the challenges and obstacles to implementation; (3) Propose solutions to improve the quality and performance of interventions. To facilitate the collection of data from this mission, IM developed a checklist (questionnaire) that was reviewed and validated by stakeholders. Strengths observed during the mission included:

● District discussion of community activities during their monthly meetings ● Improvements in the completeness and timeliness of community data entered in DHIS2, with the

contribution of CACs, compared to previous years ● Supervision of CHWs by supervisory health officers, and the supervision of health workers by the

CACs ● Monitoring the supply of iCCM commodities with CHWs, per availability in the districts, by some

CACs, in conjunction with district pharmacists ● Community data pre-validated by some CACs before entering it into DHIS2, noting that pre-

validation was difficult to carry out by districts before CAC support was implemented, as the entry of all data (health and community) was the sole responsibility of the district data manager.

● Wallcharts available in some districts for monitoring community indicators with graphic representations

● CHW recognition by their communities and satisfaction expressed with the work the CHWs carry out for their populations

Areas for improvement observed in the field included: ● Weak involvement of some regional health directorates in community activities, including the

absence of focal points and the non-inclusion of community activities in regional meetings ● The unavailability of some CHWs, for example, due to resignations to spend more time on

personal work, led to a slowdown in activities, while new recruits learned iCCM approaches ● Community activity reports not consistently transmitted to the districts on time by HF managers ● Frequent stock-outs of iCCM commodities, constituting a real bottleneck for the effective

implementation of CHW activities and a source of demotivation for some CHWs in the field ● Replacement of some CHW supervisors due to MOH assignments to other structures, causing a

slowdown in activities ● Insufficient organization of internal validation of community data each month within health

facilities, and between supervisory health workers and CHWs ● Late payment of incentives to CHWs, leading to CHW demotivation and resignation in some

cases

Key Accomplishment #4: Supported outreach ANC, leading to improvements in the coverage of IPTp3 in pregnant women In Côte d’Ivoire in 2018, only 40% of pregnant women received a third dose of IPTp, compared to 81% who received IPTp1. In September 2020, IM supported the NMCP to initiate outreach ANC with the aim of improving IPTp3 coverage rates and reducing the number of pregnant women lost to follow-up after their first ANC visit. From September 2020 to March 2021, five health districts with low IPTp3 coverage


organized outreach ANC, including Adzope, Agnibilekrou, Alepe, Daoukro, and M’Batto. In each district, IM Côte d’Ivoire identified three village groupings or zones more than five kilometers from the nearest health center and with a population above 1,000 inhabitants, including Adzope, Bofafo, Lobohope, and Nyan. In each of the zones, an appropriately private and secure site was selected with beneficiary communities. For two consecutive days per month, a midwife and an assistant from the health center in that zone’s catchment area provided ANC consultations at the community site. Two local CHWs mobilized pregnant women before and during the activity. During outreach ANC, eligible pregnant women received one dose of IPTp and an ITN at first visit. Fever cases were tested by mRDT and confirmed malaria cases were treated according to national guidelines. Data was collected in the ANC register of the associated health center, and then entered into the national health information system, DHIS2. In seven months, 2,244 ANC visits were carried out in the 15 zones including 496 first ANC visits, 588 second visits, 567 third visits, and 593 fourth or more ANC visits. At these outreach ANC visits, 1,771 doses of IPTp were given to eligible pregnant women: 448 IPTp1, 509 IPTp2, 561 IPTp3 and 253 IPTp4+. Out of 2,229 ANC1 visits in the five districts, 496 (22%) were carried out during outreach ANC. Of the 1,435 IPTp3 recorded in DHIS2, 561 (39%) were administered during outreach ANC. This demonstrated that outreach services can be an important part of a comprehensive strategy to improve IPTp uptake. Key Accomplishment #5: Supported regular meetings of the decentralized MIP and iCCM Technical Working Groups Since its inception, IM Côte d’Ivoire advocated for a joint MIP and iCCM TWG, which was created in April 2019 by ministerial order. During 2020-2021, IM Côte d’Ivoire continued to support the health regions and districts to convene MIP and iCCM TWG meetings. Unlike the national Steering Committee and the national Technical Committee, which did not hold any meetings in the final project year, the health regions and districts were active in carrying out this activity. A total of 47 quarterly meetings were held: 10 at the regional level and 37 at the district level, as shown in Table 5.

Table 5: Number of MIP and iCCM TWG meetings by region and district

Health Region # Health District # Health

District # Health District #

Indénié-Djuablin 2 Dimbokro 1 Bounna 2 Agboville 1

Gontougo 2 Bocanda 1 Bondoukou 2 Tiassalé 1

Boukani 2 Bongouanou 1 Nassian 2 Sikensi 1 Sud-Comoé 1 Daoukro Tanda 2 Dabou 1

Agneby-Tiassa M’Bahiakro 1 Aboisso 1 Grand-Lahou 2

Grands-Ponts 1 Prikro 1 Adiaké 1 Adjamé-Plateau-Atecoubé 1

Abidjan 1 1 Abobo Est 1 Abobo Ouest 1 Anyama 1

Abidjan 2 1 Abengourou 2 Grand-Bassam 1 Cocody-Bingerville 1

Agnibilekrou 2 Tiapoum 1 Port Bouet-Vridi 1 Bettié 2 Jacqueville 1 Koumassi 1

Treichville-Marcory 1 Yopougon

Est 1 Yopougon Ouest Songon 1

Total 10 Total 10 Total 15 Total 12


TWG meeting agendas focused on analysis of district performance for: 1) IPTp coverage of pregnant women; 2) ITN distribution coverage for pregnant women and children under one during routine ANC and immunization services, and to children under the age of 5 on an outpatient basis; 3) Supply of antimalarial commodities and drugs, both in health facilities and at the community level, through iCCM; 4) Service providers’ compliance with national malaria guidelines; and 5) Analysis of clinical OTSS+ data in districts where this activity was implemented. All meetings were conducted by the IM-supported Regional Technical Advisors (RTAs). At the end of these meetings, recommendations were made, and follow-up was carried out, by regional and district teams with the support of the RTAs. Some recommendations focused on the operational level, including improving service provider performance through mentorship and OTSS+; and improving management and routine distribution of ITNs. Other recommendations focused on the central level, including addressing supply chain challenges impeding the regular supply of antimalarial commodities and drugs to the districts.

From the time that the MIP and iCCM TWG architecture was created in April 2019 until IM closed out on June 30, 2021, 94 decentralized TWG meetings were held. These included 23 in the regions and 71 in the districts. The health regions and districts would have held even more meetings if COVID-19 had not occurred in the country in March 2020.

Objective 3: In support of Objective 1, provide global technical leadership, support operational research, and advance program learning Key Accomplishment #1: Prepared and launched the TES IM Côte d’Ivoire worked with the NMCP to prepare and launch the TES of AL and ASAQ for the treatment of uncomplicated P. falciparum malaria in four sentinel sites in Côte d'Ivoire. IM supported the NMCP with protocol development, study site and health facility selection, and the development of study procedures and Terms of Reference for the study implementers. The IPCI won the competitive bid for the TES. The TES protocol was approved by the Côte d’Ivoire ethics committee on September 28, 2020. The protocol was approved by PMI/USAID. USAID approved the IPCI subcontract on December 10, 2020. The final contract between PSI and IPCI was signed on February 10, 2021. The official TES launch meeting was held on April 9, 2021, at the IPCI premises and attended by the TES steering committee. This included the NMCP Scientific Support Group, NMCP, IPCI, IM, USAID/PMI, and WHO. The study is currently being conducted at four sentinel sites, including two sites in PMI-supported areas, Aboisso District and Abengourou District, and two sites in Global Fund-supported areas, San-Pedro, and Bouaké Districts in the Northwest. The study fieldwork will end on November 30, 2021, and the final report is expected to be released by the end of February 2022. Key Accomplishment #2: Provided technical support to the NMCP and DSC IM Côte d’Ivoire provided technical support to the NMCP, including for the development of the NMSP 2021-2025. IM consistently involved NMCP staff in clinical and laboratory OTSS+ supervision activities that led to the smooth transfer of skills for the use of the OTSS+ supervision tool with KoBoCollect and


the expansion to other districts. IM facilitated problem-solving sessions with the NMCP, the Nouvelle Pharmacie de la Santé Publique (NPSP, New Public Health Pharmacy), the DSC, UNICEF, and Save the Children on the supply of iCCM commodities and drugs for CHWs. This included maintenance of the emergency allocation pending other sustainable alternatives. IM supported the 10 RTAs, who are part of the NMCP, to provide technical support to health authorities in the regions and districts with the coordination and monitoring of malaria response interventions, including the annual planning of activities in regions and districts, and the organization of TWG meetings. IM Côte d’Ivoire supported the DSC with various review sessions of the National Strategic Plan for Community Health 2017-2021 and the sessions for the development and validation of the Politique National de la Santé Communautaire (PNSC, National Community Health Policy). IM provided both technical and financial assistance and co-financed the document validation workshop with other partners, including UNICEF, Alliance Côte d’Ivoire, and Health Policy plus. IM has supported coordination and complementarity of action between technical partners. IM’s support to the DSC enabled smooth transfer of community activities from local NGOs to district health authorities, so that district health authorities were equipped to take ownership of iCCM activities.

Challenges and Solutions Challenges Solutions

The frequent stock-out of iCCM drugs and commodities

During a meeting between the MOH (DSC, NMCP, and NPSP) and iCCM partners (IM, UNICEF, and Save the Children), IM recommended that the NPSP make an emergency allocation for iCCM commodities and drugs, which are overstocked at the NPSP. The distribution of commodities for CHWs was made from December 2020 to January 2021, to compensate for the existing shortage and considering the number of CHWs per district. This action gave CHWs the needed commodities to conduct iCCM from January to March. Faced with the frequent stock-out of iCCM commodities in the field and pending effective and sustainable solutions, IM proposed to the NMCP and NPSP to maintain the emergency distribution over a period of at least six months, to reinforce the supply of commodities to CHWs.

Strengthened district leadership for the coordination and monitoring of community interventions:

− IM supported health districts to undertake CHW supervision. The supervising health workers were able to carry out, from January to April 2021, at least two supervision visits of 1,838 CHWs. The supervising health workers were also supervised at least once by the district CACs.

− IM equipped the CACs with laptops and internet credit, to facilitate the entry of community data collected by CHWs into DHIS2. The completeness and promptness of data in DHIS2



Ownership, coordination, and M&E of community activities (iCCM) by the districts

increased from 60% to 80% and from 40% to 76% respectively since January 2021.

IM supported the NMCP and DSC in the effective integration of community interventions into the health system IM supported the development of an orientation guide for the implementation and monitoring of community activities after the withdrawal of local NGOs. This was an operational document for coordination and M&E of community interventions. IM supported a joint mission, including the NMCP, DSC, PNSME, DIIS, and IM to monitor and supervise community stakeholders in six districts. This field visit made it possible to reinforce effective health district implementation of community activities, and to identify challenges as well as needed improvements. This was the first field visit at the central level after the transfer of iCCM activities to the districts. IM suggested to the NMCP and the DSC to encourage health regions and districts to include an update regarding community activities, specifically iCCM, in their quarterly coordination meeting agendas.

National appropriation of OTSS+

IM supported the transfer of skills for OTSS+ (KoBoCollect) digital tools, and the analysis of supervisory data (clinical and laboratory) at the NMCP. IM supported the health regions and districts to discuss OTSS+ supervision data during MIP and iCCM TWG meetings. IM proposed to the NMCP to record an update on clinical and laboratory OTSS+ supervision, to share the results, good practices and lessons learned from this approach in the agenda for the next meetings of the Malaria Task Force.

Improved coverage of pregnant women with IPTp3

Given the results of the pilot of outreach ANC activities in five districts, which showed an increase in ANC1 and IPTp3, IM recommended to the NMCP to gradually extend this strategy by targeting districts with low IPTp3 coverage among pregnant women.


Lessons Learned ● Transferring iCCM oversight from NGOs to district health authorities should improve

national ownership and sustainability of interventions. During the reporting period, IM Côte d'Ivoire, in collaboration with the DSC and NMCP, transferred community activities implemented by local NGOs to district health authorities. This approach aimed to strengthen CHW supervision by supervisory health workers as well as the supervision of the supervisory health workers by the CACs. This supervision had previously been delegated to NGOs. IM trained and equipped CACs to support data managers to enter community data into DHIS2, which improved the completeness and timeliness of community data in DHIS2. It is hoped that within a few years, district health authorities will be able to lead community interventions on their own, with continuous and regular assistance from the NMCP and DSC, including at the highest level of the MOH and as provided for in the national budget.

One of the major challenges, which is beyond the remit of district health authorities, was the frequent stock-out of commodities for iCCM activities. Discussions have been underway between the NMCP, NPSP, DSC and partners, to find more efficient and sustainable solutions.

● Decentralizing the MIP and iCCM Technical Working Groups allowed for lessons learned from supportive supervision to be discussed and solutions proposed at local level. The architecture for the MIP and iCCM TWG was created by the MOH in April 2019, with the support of IM Côte d'Ivoire. The decentralized TWGs in the health regions and districts held a total of 91 meetings, including 24 in IM regions and 67 in IM districts, from April 2019 to June 30, 2021, with the support of the RTAs. These were quarterly meetings to discuss performance indicators; supply of commodities; quality of services provided for malaria control activities, including compliance with national guidelines; and follow-up recommendations. Results of clinical OTSS+ were also discussed during these meetings, with districts that implemented them, followed by decision-making and formulation of recommendations. In the future, this TWG approach should be encouraged to continue in Côte d’Ivoire after IM closes out and shared as a good practice for TWGs in the health sector in the country and internationally.


IM Côte d’Ivoire Indicator Table The data provided in the indicator table below are reflective of the IM targets and results for the period October 1, 2020 – June 30, 2021. IM CDI ceased activities June 30, 2021. The data in the indicator table reflect activities in the IM-supported areas in Cote d’Ivoire which include twelve health regions: Abidjan 1 (five districts), Abidjan 2 (five districts), Grands Ponts (three districts), Sud-Comoe (four districts), N'zi (three districts), Moronou (three districts), Iffou (three districts), Agneby-Tiassa (three districts), La Me (four districts), Indenia -Djuablin (three districts), Gontougo (five districts) and Bounkani (four districts). Three OTSS+ rounds were completed, and a total 187 facilities visited during the OTSS+ rounds. Progress to Annual Target is calculated as actual result/target *100=progress to target. This provides an indication of how much progress has been made to meeting the annual target outlined in the country workplan

Objectives Indicators Target Result Progress to Annual Target

Comment



60% 70% 117%

Data from October 2020 to June 2021: 1,642,820 cases confirmed with a diagnostic test out of 2,330,647 cases reported


95% 93% 98% 2,330,647 suspected cases received a parasitological test out of 2,496,402 cases reported

Percentage of observed health workers demonstrating competency in correctly classifying cases as, uncomplicated malaria, and severe malaria

90% 90% 100%

Percentage of health workers demonstrating competency in mRDTs

90% 76% 85%

This result represented 76% (231/302) of health workers. Achievement of the indicator was 85% of the annual target. The rate of performance was improving. From October 1, 2019, to June 30, 2020, the annual target was 41%.



Comment


80% 70% 88%

21/30 (70%) health workers achieved the competency threshold, which represented 88% of the achievement of the annual target. The rate of performance was improving. From October 1, 2019, to June 30, 2020, the result was 21% of the annual target.


90% 57% 63%

The rate of achievement of the indicator was 63% of the annual target. This rate of performance has improved, based on the annual target of 33% for the October 2019 to June 2020 period. This low performance during this reporting period was the result of poor practices adopted by providers, which the OTSS+ approach has highlighted. This competency has improved and reached 63% for this period from October 2020 to June 2021, due to the coaching and mentorship provided.


100% - - No training was organized during this period.

Percentage of targeted health workers trained in malaria laboratory diagnostics




Objective 1.2 Improved access to targeted quality

Percentage of severe malaria cases that received first-line antimalaria treatment according to national guidelines

93% 65% 70% 28,570 severe malaria cases received first-line treatment out of 344,050 cases.



Comment

malaria treatment


93% 96% 104%

During the period of October 2020 to June 2021, 1,182,670 uncomplicated malaria cases received ACTs.

Percentage of supervised health facilities with health workers demonstrating competency in management of severe malaria

90% NA NA

OTSS+ in Côte d’Ivoire was implemented in primary healthcare facilities, where severe malaria is not generally treated.


90% 53% 59%

Out of 365 supervised health workers, 193 had skills in the management of uncomplicated malaria. This represented 53% of the achievement rate, i.e., 59% of the annual target. This was double the result from the period of October 1, 2019, to June 30, 2020, when it was 26%. Remaining challenges included the lack of mRDTs in most of the supervision sites; the presence of new providers in health centers, including Djangokro, Noffou, and CSU Dimbokro; and the lack of communication by some providers in providing treatment compliance advice to patients.


90% 43% 48%

Out of 365 supervised health workers, 158 adhered to treatment guidelines. This represented 43% of the achievement rate, or 48% of the annual target. This doubled compared to the period from October 1, 2019, to June 30, 2020, when it was 24%. Remaining challenges are the lack of communication by some providers in providing treatment compliance advice to patients and other non-compliance with malaria management guidelines by providers.



Comment


90% 93% 103%

Of 41 supervised providers who had negative mRDTs, 38 refrained from prescribing an antimalarial to their patients. This represented 93% of the achievement rate, which represented 103% achievement of the annual target.


90% 57% 63%

From October 1, 2019, to June 30, 2020, the percentage was 33%. Remaining challenges are the lack of communication by some providers in providing treatment compliance advice to patients and other non-compliance with malaria management guidelines by providers.


100% 100% 100% All health facilities regularly reported malaria case data using national tools (DHIS2).


90% 96% 107%

Out of 194 planned sites, 187 sites were visited during OTSS+, which represented a 96% achievement rate, or 107% of the annual target.

Percentage of health workers trained in management of severe malaria

100% - - No training organized during this period


100% - - No training organized during this period

Objective 1.3: Improved access to quality


90% 55% 61%

This result could be explained by ITN stock-outs which occurred during routine ANC in some health facilities.



Comment

prevention and management of malaria in pregnancy


80% 23% 29%

61,210 pregnant women received IPT4 or more, out of 259,999. This could have been due to late initiation of first ANC; subsequent ANC appointments missed; and low attendance at health facilities, possibly due to COVID-19.


80% 55% 68%

141,857 pregnant women received three doses of IPTp out of 259,999 ANC visits. This could have been due to late initiation of first ANC; subsequent ANC appointments missed; and low attendance at health facilities, possibly due to COVID-19. This is from data for October to December 2020. DHIS2 data for January to June 2021 have not been validated, and therefore, are not available.


80% 70% 87%

181,646 pregnant women received two doses of IPTp out of 259,999 ANC visits. This could have been due to late initiation of first ANC; subsequent ANC appointments missed; and low attendance at health facilities, possibly due to COVID-19.


95% 83% 88% 216,853 pregnant women received one dose of IPTp out of 259,999 ANC visits.


90% 62% 69%

This result represented 62% (42/68) of the achievement rate, which represented 69% of the achievement of the annual target. From October 1, 2019, to June 30, 2020, this was 46%.


90% 63% 70%

This indicator represented 63% (165/262) of the achievement rate, which represented 70% of the achievement of the annual target. For October 1, 2019, to June 30, 2020, this result was 46%.



Comment

Percentage of health workers trained in IPTp 100% - - No training organized during this

period

** Percentage of IM-supported countries with national guidelines for prevention and treatment of MIP that meet global standards **

90% 53% 59%

The directives were distributed during the training sessions. The directives were given to health workers and not directly to health facilities. Out of 380 facilities supervised, 202 (53%) had guidelines for prevention and treatment during pregnancy. The annual rate of achievement was 59%.

** Functional/ active RMNCH/ MIP/ ANC/ community health Working Group **

12 6 50%

At regional level, eight health regions organized at least one TWG meeting; three regions (Indénié Djuablin, Gontougo, Boukani) held two meetings; and five regions (Sud Comoé, Agneby Tiassa Mé, Grands-Ponts, Abidjan 1, Abidjan 2) held one TWG meeting during the year. At the district level, 33 health districts held at least one TWG meeting; 25 health districts held one meeting; and eight districts held two meetings during the year.


** Contribution to national, regional, or global policy/guideline documents related to malaria (including reproductive health) **

3 3 100%

IM contributed to: NMCP Monitoring and Evaluation Plan, National Community Health Policy Document, and Laboratory Quality Assurance Manual

Number of program activity results disseminated to the global health community **

3 Best practices success stories

4 133%

For the period from October 2020 to June 2021, IM documented four best practices: The appropriation of community activities by NGOs in the districts for sustainability. Coaching of providers after the OTSS+ supervision visit. The organization of the pilot phase of ANCs in advanced posts in five health districts.



Comment

** Participation in targeted national, regional, or global level Working group(s) and/or taskforce(s)

2 1 50% Regular TWG meetings organized by district and regional actors

225 IM DRC October 2020 – September 2021

Democratic Republic of the Congo Background In the Democratic Republic of the Congo (DRC), IM DRC provides support to the NMCP and works with the Institut National de Recherches Biomédicales (INRB, National Institute of Biomedical Research) and the MOH Laboratory Director to strengthen the capacity of the country’s microscopists in malaria diagnosis in nine PMI-supported provinces (Figure 1). These provinces are Haut-Katanga, Haut Lomami, Kasai Central, Kasai Oriental, Lomami, Lualaba, Sankuru, South Kivu, and Tanganyika.

To improve the quality of malaria microscopy, IM DRC continued to support the MOH in training lab technicians in malaria microscopy, conducting OTSS+, and implemented external quality assurance (EQA) at 154 referral-level facilities within the nine PMI-supported provinces. IM DRC also supported the NMCP to conduct joint clinical and laboratory OTSS+ at 80 health facilities (HFs), including 43 reference health facilities and 37 health centers. During this reporting period, IM expanded its support to the NMCP by revising the training curriculum content for nurses and doctors, to incorporate

the recently updated national malaria guidelines. With the NMCP, IM also assessed medical and nursing training institutions. Furthermore, IM DRC piloted a continuous quality improvement (CQI) program in the province of Haut-Katanga. This innovative approach complemented integrated clinical and laboratory OTSS+ visits with increased two-way communication between supervisors and providers. This communication allowed for close and productive exchanges to propose effective and sustainable solutions to identified gaps. IM DRC supported the NMCP to identify the root causes of providers' non-adherence to malaria test results, promoted the use of wallcharts in health facilities to encourage all providers to follow the key indicators, and organized focus group discussions with healthcare providers. IM DRC helped pilot this approach at both reference hospitals and health centers within the province. IM DRC also supported the NMCP, in coordination with the University of Kinshasa, to conduct TES studies in two sites: Kapolowe (Haut-Katanga) and Mikalayi (Kasai Central).

Figure 1: IM DRC Geographic Coverage


Key Accomplishments Objective 1: Improve the quality of and access to malaria case management and prevention of malaria during pregnancy Key Accomplishment #1: All targeted health workers in selected health facilities from nine provinces received training on malaria microscopy To reinforce lab technicians’ competencies in malaria microscopy, IM DRC supported the NMCP and the INRB to strengthen laboratory services at provincial levels for malaria microscopy through MDRT. IM DRC facilitated two sessions of basic MDRT (bMDRT) for 53 microscopists, with attendees from each of the nine provinces, including nine women and 44 men. Ten of the participants came from HFs supported by the OTSS+ program. The two five-day sessions took place in Lubumbashi and Mbuji-Mayi. Participant post-training test scores were classified into four performance levels based on a WHO grading scale, as shown in Table 1.1 Table 1: Scale for national level standards

National Level Standards Parasite detection Species identification Parasite counting Level A, expert >=90% >=90% >=50% Level B 80% - <90% 80% - < 90% 40% -< 50% Level C 70% - < 80% 70% - < 80% 30% - < 40% Level D < 70% < 70% <30%

Of the 53 participants, 43 (81%) reached levels ≥80% in Parasite Detection (PD) when assessed after their training (Figure 3). Among the 53 microscopists, 45 were from health facilities which have been recently integrated into IM DRC-supported activities and eight came from health facilities selected in the current reporting period to replace facilities that had closed. Participants showed improvement in their pre and post-test average scores in parasite detection (from 69% to 89%), parasite counting (from 18% to 48%), and species identification (from 39% f to 49%) as shown in Figure 4. Most participants (81%) met the recommended competency level of ≥80% in PD, and 64% met that same recommended competency level in parasite counting (PC). Only 6% of participants met the recommended competency level of ≥80% on species identification (ID). This is likely due to less practice of this skill at their health facilities and many participants receiving bMDRT for the first time. Most

1 WHO (2016). QA Manual on Malaria Microscopy Version 2.


participants (85%) work in HFs that IM DRC supported for the first time during this project reporting period (2020-2021).

All participants would benefit from additional practice on species identification. One factor that may be affecting these poor results, in ID is that 98.8% of malaria infections in the DRC are caused by Plasmodium falciparum, therefore, laboratory technicians are not accustomed to identifying other species.2 Some also require improvement of PD and PC skills, especially those from reference HFs where malaria microscopy is the primary diagnosis method. Although participants improved their average scores on ID, most participants from this training did not achieve the expected

performance according to the WHO classification (level A or B with a performance of ≥ 80% for an individual score).

IM DRC advised the NMCP to continuously update laboratory technicians’ microscopy skills through proficiency testing (PT), review of the laboratory quality assurance manuals, and use of job aids that have been provided to each HF. The IM DRC team also follows up during OTSS+ visits as part of ongoing EQA and provides on-the-job training as needed.

Figure 3: Percentage of participants who met the target at minimum score of malaria microscopy competency level A (=>90%) or level B (>=80%) during basic MDRT (N=53), Source: MDRT data

2 République Démocratique du Congo, Ministère de la Santé Publique, Programme National de Lutte contre le Paludisme. Plan Stratégique National (PSN) de Lutte contre le Paludisme 2020-2023.

Figure 2: bMDRT training in Mbuji-Mayi, 2021. Photo credit: IM DRC


Figure 4: Average scores of pre- and post-test results for the participants on bMDRT, Source: MDRT data

This training session made it possible to increase providers’ skills for malaria microscopy in health facilities and increase the critical mass of trained microscopists in the nine PMI-supported provinces. A critical mass of trained and competent microscopists contributes to the achievement of national objectives by improving the accuracy of malaria diagnosis for appropriate treatment. Key Accomplishment #2: Electronic data collection and analysis via the Health Network Quality Improvement System (HNQIS) supported for improving outreach training supportive supervision IM DRC supported the NMCP to use HNQIS for OTSS+ data collection and analysis. Surpassing their original target of training 23 supervisors, IM DRC supported the NMCP to train 26 supervisors. This joint training included 11 clinical and 15 laboratory supervisors from Haut-Katanga, Lualaba, Kasai Central, Kasai Oriental, Sankuru, Lomami, and Sud-Kivu provinces. The training covered a review of the supportive supervision strategy and objectives, and field use of the HNQIS application. The HNQIS tool enables feedback to be provided to healthcare providers immediately following supervision based on their observed performance. Participants learned how to use the tool to collect data through the app. During this training, pre and post-test assessments evaluated the knowledge acquired among supervisors on the use of the HNQIS. There was an improvement in the results, with participants’ scores increasing on average from 23% (10%-80%) during the pre-test to 66% (40%-100%) during the post-test. Key Accomplishment #3: Improved competencies in malaria microscopy through OTSS+ In 2021, IM DRC supported the NMCP and provincial health offices (PHOs) to conduct two rounds of OTSS+ using HNQIS. A total of 111 health facilities in eight PMI provinces were each visited twice from March to April 2021 during Round 4 and in July during Round 5, including 45 new HFs. These OTSS+ visits targeted the Hôpitaux généraux de référence (HGR, General referral hospitals) and Centres de santé de référence (CSR, Reference health centers) where microscopy is used for malaria diagnosis. IM DRC involved national- and provincial-level NMCP staff in all aspects of OTSS+ training and field visits. Furthermore, IM DRC used a wide range of mentoring approaches, such as phone calls, texting, and WhatsApp, as domestic travel restrictions imposed by the COVID-19 pandemic limited in-person mentoring.


Table 2: Health facilities visited during OTSS+ Rounds 4 and 5, 2021 Provinces Number of

health facilities visited during Rounds 4 and 5

Number of lab technicians observed

Number of lab technicians observed (during PT)

Round 4 Round 5 Round 4 Round 5

Haut-Lomami 7 27 21 18 14

Kasai Central 18 60 51 40 32

Kasai Oriental 32 99 85 78 62

Lomami 12 33 31 23 24

Lualaba 15 42 43 34 28

Sankuru 5 18 13 12 10

Sud-Kivu 15 54 39 35 27

Tanganyika 7 24 21 16 12

Total 111 357 304 256 209 Source: HNQIS Data

Figure 5: Percentage of health facilities with stock-outs of essential supplies for malaria diagnosis, observed during OTSS+ Round 4 and Round 5 (N=111 HFs), Source: HNQIS Data

During OTSS+ Rounds 4 and 5, 45 of the total 111 HFs (41%) were observed to have experienced stock-outs of essential supplies. This is because the 45 newly added HFs in outlying cities had not yet received essential supplies from other partners or benefitted from commodity support at the time of the OTSS+ visits. IM previously advocated with PMI to enforce the availability of microscopy commodities at the 109 health facilities initially supported by IM, which did not include the 45 newly supported HFs. This may also have led to the reported gap in the nine PMI provinces observed in Rounds 4 and 5.

Based on these results, IM DRC continues to inform and advise the provincial health office on how to redistribute commodities received to peripheral HFs to increase coverage of malaria microscopy reagents compared to HF utilization. IM DRC developed inventory forms to support HFs to keep track of their diagnostic supplies, which were analyzed at the end of each OTSS+ visit and the results were then shared with pertinent stakeholders. IM DRC also monitored the number of malaria blood slides examined at each HF, to forecast future reagent needs. As seen in Figure 5, HFs experienced decreases in stock-


outs of pH paper/pH meters, buffer solution tablets, and alcohol; however, there were some minor increases in stock-outs of Giemsa, slides, lancets, and immersion oil.

Of the 111 health facilities IM DRC visited: 68% were conducting internal quality assurance (IQA) during Round 4 compared to 89% during Round 5; 60% were recording their IQA findings in the registers during Round 4 and 72% during Round 5. Given these positive results, Supervisors encouraged laboratory technicians to continue maintaining the quality of microscopy skills through more IQA exercises at the HFs with routine slide cross-checks, parasite counting to improve their competencies, and recording of the findings in the register. If IQA is done correctly and documented in the register, more blood slides are likely to be read correctly, reducing errors and helping clinicians treat people based on microscopy evidence. Thus, the supervisors coached laboratory technicians in the use of the IQA system during OTSS+ visits. During OTSS+ visits, supervisors conducted PT as part of EQA and onsite training in malaria microscopy to improve and maintain the competency of laboratory technicians after MDRT training. Supervisors brought validated slides from the INRB national slide bank for laboratory technicians to read during the field visits. Supervisors compared the results provided by the lab technicians with the validated slide results and provided feedback to the lab technicians. Overall, the percentage of HFs meeting the target competency of 90% or greater in PD has increased from Rounds 1 to Round 5, with some variation between rounds and regions (Figure 6). In Sankuru and Kasai Oriental , performance during PT was particularly challenging. The proportion of health workers meeting competency scores of at least 90% in PD had decreased between Rounds 4 to Round 5 (Figure 6). One possible reason for decreased performance is the fact that the same health workers are not always assessed, even though the same HFs were visited for each OTSS+ round. IM DRC continued to support OTSS+ at these low-performing health facilities and will provide future analyses to assess performance following targeted site visits.

Figure 6: Percentage of health workers demonstrating competency at 90% or greater in PD during PT at 111 HFs, OTSS+ Rounds one (2019), two (2020), three (2020), four (2021), and five (2021), Source: HNQIS Data


During OTSS+, the percentage of health workers meeting the competency target of ≥90% in PD generally increased over each round among all provinces during microscopy observation (Figure 7). The scores from Figure 6 are lower than those reported in Figure 7 because the laboratory technicians were assessed using Proficiency Testing (PT) with slides from the national slide bank. This batch of slides contains all species of plasmodia. Reading these slides requires a higher level of microscopy expertise to correctly detect a wide range of parasite species and densities. In Sankuru, the performance in malaria microscopy was lower than in other provinces, due to having fewer laboratory technicians who attended the MDRT. IM DRC will continue to support the NMCP and INRB to conduct quarterly OTSS+ visits to health facilities with low performance in malaria microscopy and will invite those technicians who have low performance to attend MDRT. In Sankuru, the best performing lab technician of this province became a provincial supervisor and led OTSS+ visits to HFs with new laboratory technicians, IM DRC also supported the Sankuru regional health office to plan additional bMDRTs, OTSS+ visits, and participation of HFs in External Quality Assurance for improving the skills of malaria microscopy. IM DRC reinforced health worker’ competency through PT in selected HFs during OTSS+ visits. Additionally, IM DRC supported the NMCP and INRB to implement an EQA network as part of OTSS+ that is described below.

Figure 7: Percentage of health workers who met competency targets in malaria microscopy at 90% or more in PD during OTSS+ microscopy observation Rounds 1 (2019), 2 (2020), 3 (2020), 4 (2021), and 5 (2021), Source: HNQIS Data After two OTSS+ visits, IM DRC supported the NMCP to organize a Lessons Learned Workshop (LLW) for eight PMI-supported provinces: Haut Lomami, Kasai Central, Kasai Oriental, Lomami, Lualaba, Sankuru, Sud Kivu, and Tanganyika. Haut-Katanga Province was not included in this workshop because, with IM support, this province implemented a pilot project with the objective of improving malaria case management quality. To that end, two separate LLWs were scheduled to specifically review CQI pilot results in coordination with the provincial NMCP. The first CQI LLW was held between Rounds 1 and 2 and included data from the CQI Round 1 (baseline). The second LLW will take place in Q1 in the next project year (FY22) and will include data from CQI Rounds 1, 2 and 3.


The objectives of the LLW targeting the eight provinces involved discussing OTSS+ results from these provinces, proposing solutions to close the gaps in malaria microscopy quality, and identifying best practices and lessons learned. A total of 29 participants took part in both in-person and virtual sessions. Participants identified best practices from their respective HFs, including sharing OTSS+ achievements with facilities not enrolled in the OTSS+ program; holding monthly meetings of the laboratory networks; and sending overstocked resources to other laboratories that may be facing stock-outs. Key Accomplishment #4: Provincial laboratories implemented the EQA network for malaria microscopy IM DRC supported the NMCP and INRB to reinforce malaria microscopy skills of laboratory technicians to implement External Quality Assurance (EQA), using PT at provincial HFs. This activity maintains the skill level of microscopists and helps registered HFs be considered as part of the provincial network. IM DRC supported provincial laboratories to set up the laboratory network for EQA, using slides from the INRB bank for PT. The network consists of all IM-supported laboratories within the nine PMI provinces. Comparing EQA results in the nine provinces, there is notable improvement for all provinces, specifically for PD (Figure 8).

Figure 8: Provincial results for PD using PT, Source: Proficiency test report Key Accomplishment #5: 100% (2/2) of malaria case management TWG supported IM supported the NMCP to coordinate the malaria case management TWG. The TWG provides a platform for information sharing, review, and adoption of WHO guidelines and malaria service delivery best practices. IM DRC funded two of the four TWGs focused on discussing updates for DRC’s malaria case management guidelines, OTSS+ visits, the therapeutic efficacy study (TES), and abstracts for international conferences and national meetings. TWG participants included PMI, NMCP, WHO, and other partners. Key Accomplishment #6: Expert laboratory microscopists at central and provincial level trained in aMDRT To prepare participants for a malaria microscopy skills assessment, IM DRC supported the NMCP and INRB to conduct an advanced MDRT (aMDRT) for laboratory technicians who performed well in previous bMDRT sessions. The purpose of this training is to improve further on their competencies until their performance allows for their participation in microscopy competency assessments (nECAMM and ECAMM). This training identified microscopy trainers and supervisors. A total of 15 participants were selected from the provincial and central levels, coming from Haut-Katanga, Haut-Lomami, Kasai Central, Kasai Oriental, Lomami, Sankuru, and Kinshasa. The participants showed competency of malaria


microscopy with 100%, 47%, and 93% of participants obtaining the recommended competency levels of ≥80%, in PD, ≥80% in ID and ≥40% in PC, respectively (Figure 9).

Figure 9: Percentage of participants who met minimum competency level A or B during aMDRT, Source: MDRT data Key Accomplishment #7: Twelve expert microscopists at central and provincial level trained in nECAMM To strengthen the capacity of laboratory experts, IM DRC supported the NMCP and INRB to increase the number of expert microscopists in DRC by training 12 laboratory technicians through national ECAMM certification. After this training, the best performers will be able to conduct slide validation for reference slide banks and be eligible to be trainers of trainers and supervisors of microscopy and/or become laboratory supervisors.

Figure 10: aMDRT in Kinshasa, DRC, 2021, Photo credit: Jonathan Nsimba, IM


Figure 11: Average participant pre- and post-test scores during nECAMM, Source: Training data

The final PD assessment results were satisfactory, with PD scores ranging from 86% to 95% (mean 91%). Ten of the 12 participants achieved ≥90% in PD. Results for ID varied, with scores ranging from 58% to 94% (mean 83%). The results of PC were highly variable, with accuracy ranging from 29% to 71% (mean 52%). This session enabled participants to increase their skills in malaria microscopy, as well as to support future trainings and supportive supervision in DRC. During this session, four participants attained Level A and four participants Level B. Key Accomplishment #8: Piloted continuous CQI program in Haut-Katanga to improve case management for uncomplicated, severe, and malaria during pregnancy IM DRC supported the Haut Katanga division of NMCP to pilot a continuous quality improvement (CQI) approach, using an integrated laboratory and clinical OTSS+ package. The package included: malaria case management refresher trainings, joint clinical and laboratory outreach training, and joint clinical and laboratory OTSS+ visits. The OTSS+ visits identified gaps in malaria case management and developed action plans, while putting in place a continuous feedback platform in between visits that included virtual support through WhatsApp, in-person coaching, the use of data wall charts to monitor progress, and provider focus groups to address challenges and gaps. IM DRC supported this approach for 80 reference hospitals and health centers, which were selected in consultation with the NMCP and the integrated bilateral USAID Integrated Health Project (IHP) project. After training clinical and laboratory supervisors, IM DRC supported the Haut-Katanga provincial division of the NMCP to conduct three rounds of OTSS+ as part of the CQI approach, based on mentoring, continuous training, and feedback to address identified gaps. IM DRC followed up with HFs by telephone to share feedback from the OTSS+ visits, emailed feedback with their recommendations to each supervisor, and provided remote troubleshooting to address identified gaps, such as liaising with supply chain actors to address stock-outs. IM DRC also provided feedback during an LLW, as described below. Before OTSS+ visits, supervisors first contacted selected HFs. During OTSS+ visits, information was collected through the HNQIS digital checklist (lab and clinical checklists), interviews, observations, skill demonstration, and document reviews. Supervisors addressed the identified gaps through coaching and mentoring during observation of supervised clinicians or laboratory technicians. Supervisors provided


feedback to the providers and HF teams involved in malaria management and co-developed action plans to address identified malaria management issues. Common problems identified in most HFs were providers' lack of knowledge of the updated national guidelines, the lack of refresher training on updated national guidelines, and stock-outs of commodities. In coordination with the Haut-Katanga provincial division of the NMCP, IM DRC supported the creation of a WhatsApp group called "Clinician OTSS+" to facilitate and maintain continuous communication between supervisors and HFs and to remind providers of the issues that need to be addressed to improve the quality of care. This WhatsApp group allowed clinical supervisors to call HF clinical staff to check on activity progress and resolve any technical or administrative difficulties. Supervision visits increased the ability of the heads of HFs to follow up on OTSS+ results regarding case management guidelines. During this joint clinical and laboratory OTSS+, 13 clinicians and 10 laboratory supervisors supervised the HFs participating in this activity. All supervisors received a CQI refresher training in Quarter 2 (Q2). IM DRC supported the development of HF wallcharts that highlighted key indicators to be tracked by HFs and the Haut-Katanga provincial division of the NMCP (Figure 12). With guidance from the NMCP, IM distributed these wallcharts during the first round of OTSS+ to HFs to monitor management improvements daily. The contents of these wallcharts were reviewed with both clinical and laboratory staff in the second round of OTSS+ to better understand the challenges in each HF.


Figure 12: Examples of HF wall charts


IM DRC also supported the NMCP to disseminate the malaria management guidelines, which served as a reference document for clinicians to improve the quality of HF services. To learn about the root cause of substandard case management in health facilities, IM DRC supported the Haut Katanga provincial division of the NMCP to conduct focus group discussions and collect opinions on malaria case management from providers. These discussions taken together with OTSS+ data identified: poor knowledge about malaria, difficulties to classify malaria cases, administration of treatment despite a negative test, and systematic administration of quinine for severe malaria. Findings pointed to a root cause of work overload among providers in health centers. Other contributing causes to the observed deficiencies could be a lack of CM trainings or refresher trainings of HWs, failure to provide national case management guidelines to HFs, or a failure to make national case management SOPs visible and easily accessible to all health care workers. IM DRC made the following recommendations to the NMCP and relevant stakeholders, including the Haut-Katanga provincial division of the NMCP, based on these findings: 1) increase the frequency of meetings with stakeholders at health centers and reference hospitals at the provincial level; 2) intensify interpersonal and focus group communication to identify bottlenecks, 3) disseminate guidelines during the monthly monitoring meetings held at the health-zone level, 4) support the NMCP to empower heads of HF to operationalize updated guidelines The results for the management of uncomplicated malaria from OTSS+ Rounds 1, 2 and 3 showed a notable improvement among HWs requesting malaria diagnostic test and properly documenting mRDT results; however, there was a slight decrease in Round 3 in refraining from treating patients with a negative malaria test result. This was attributed to clinicians’ and non-clinicians’ strikes occurring at the same time as Round 2 and Round 3 visits, resulting in minimum service delivery. In particular, while the clinicians were on strike, non-clinicians (meaning nurses, lab technicians, pharmacists, and health aides) were providers of less skilled care. Some of these providers did not have the benefit of mentoring sessions regarding case management guidelines. During Round 3, there was a strike of lab technicians and non-clinician HWs. The small decrease in percentage of correct provider practices from Round 1 to Round 3 is attributed to clinicians reporting a negative test result after prescribing ACTs (Figure 13). Supervisors reported that clinicians during this time did not always wait for test results prior to prescribing treatment.

Figure 13: Observed health worker practices at outpatient (OTSS+), Source: HNQIS


There was a slight increase in the use of the recommended ACTs to treat positive cases between each round... To further improve the use of recommended ACTs, supervisors encouraged clinicians to respect the national guidelines, provided them with reference documents to enable them to properly manage malaria cases, and advocated to supply chain partners for ensuring an improved supply chain of ACTs. This likely contributed to a shift in ACT stock use. The continued improvement in use of recommended ACTs by round 3 would appear to be due to the increase in compliant prescriptions of ACTs written by providers in participating health facilities. During OTSS+ field visits, correct identification and management of malaria severity were also assessed. Figure 14 presents the percentage of patients with severe malaria symptoms in OTSS+ Rounds 1, 2, and 3, based on data collected by supervisors through clinical observation or review of the registers. The results demonstrate that two of five competencies improved from Round 1 to Round 3. Although these results are primarily attributed to the malaria caseloads at participating HFs, the shifts in results can also be attributed to clinicians diagnosing signs and symptoms more accurately. Previously, most clinicians were not able to accurately classify complications or other signs and symptoms of severe malaria. It is expected that the dissemination of case management guidelines will contribute to a better understanding of the correct identification and management of severe malaria.

Figure 14: Competency in management of severe malaria (OTSS+), Source: HNQIS During the OTSS+ visits, IM DRC supported sessions of malaria case management training within 13 HFs where discussions took place on how to improve provider behavior related to classification of malaria and recommended ACT use The comparison of data related to management of severe malaria during the OTSS+ showed that the use of injectable quinine increased in Round 2 due to the clinician's strike, in parallel to a decrease in the administration of specific treatment for severe malaria (Figure 15). Use if injectable quinine decreased again in Round 3 when clinicians returned to the HFs, likely because clinicians have a better understanding of the specific severe malaria treatment and injectable artesunate guidelines due to the recent distribution of guidelines and increased support by supervisors. There were slight decreases in appropriate treatment practices for severe malaria, for example in not respecting the infusion time for quinine treatment in Round 2 due to a clinicians’ strike. The clinicians’ strike was no longer in effect by Round 3, and clinicians who


had by then returned to their HFs respected the infusion time. Although there was a decrease in confirming malaria infection by an mRDT or by microscopy in Round 2, an increase is noted in Round 3 due to clinicians increasing the use of mRDTs in the absence of laboratory technicians who were on strike (Figure 16).

Figure 15: Observed health worker practices on inpatient ward (OTSS+), Source: HNQIS

Figure 16: Observed cases on inpatient ward (OTSS+), Source: HNQIS During OTSS+ visits, certain indicators were monitored to improve the quality of services. Figure 16 shows improvement from Rounds 1 to 3 of various practices among supervised providers managing malaria cases in pregnant women including general ANC visits, such as adequately welcoming patients, collection of their medical history, appropriate diagnosis, with an mRDT or microscopy and treatment of malaria in pregnancy upon a positive test result. IM DRC supported the NMCP to implement a Provider Behavior Change approach, developed by IM and Breakthrough Action at the global level with HW inputs to further improve their skills in properly treating malaria in pregnant women.


Fig 17. Health worker competency in prevention and treatment of MIP at ANC (OTSS+), Source: HNQIS The CQI OTSS+ round three results also showed that 58% of clinicians correctly classified cases as not malaria, uncomplicated, and severe malaria, 49% of facilities reached the expected score regarding the availability of reference materials, including case management guidelines and technical SOPs in the health facilities, 92% of facilities had reference documents for malaria case management, and 17% of facilities had trained formally in the case management guidelines during the last two years. After the CQI OTSS+ visits, IM DRC supported the NMCP to organize an LLW. The LLW aimed to discuss the gaps observed during OTSS+ Round 1 in the CQI Pilot in the Haut-Katanga Province with a wide range of relevant actors and jointly identify solutions. The LLW took place in Lubumbashi, Haut-Katanga, with 24 participants that included clinical and laboratory supervisors, HFs heads, health zone heads, provincial pharmacists, and a health zone malaria focal person. With the support of IM DRC, the Haut-Katanga provincial division of the NMCP and a consultant facilitated this workshop, which reviewed results of OTSS+ Round 1, malaria case management guidelines, and HF wallcharts. Action points identified include creating a clinician group to monitor malaria case management in health facilities; strengthening communication with providers by organizing inter-personal communication through focus groups; and taking advantage of monitoring meetings organized at the health zone level to disseminate the guidelines to providers. These activities were followed up and resulted in encouraging HWs to report data into facility wallcharts; disseminating case management guidelines through the monitoring meeting; organizing focus groups to identify the root causes of low HF performance; and organizing a future LLW for evaluating actions taken. The next step was to support the Haut-Katanga Province in organizing integrated lab and clinical OTSS+ to compare results, as well as organizing a LLW to share, discuss, and propose solutions for identified gaps. Additionally, suggestions arose during the workshop to conduct continuous training through on-site mentoring of providers.


Figure 18: LLW participants in Haut-Katanga, June 2021, Photo credit: Patrice Kabwe, IM

The second LLW to review the results from the three CQI OTSS+ rounds was postponed due to the national HW strike. It is scheduled for Q1 of the next project year (FY22). The OTSS+ CQI results dissemination meeting with relevant stakeholders was also postponed due to the strike and is also scheduled to occur in the next project year. Key Accomplishment #9: Strengthened pre-service training for malaria case management The pre-service training curricula of health workers (clinicians and nurses) in most of the higher-level training institutions often does not build sufficient skills in malaria case management, which leads to HWs having inadequate diagnostic skills when working in HFs. Recent graduates must therefore go through refresher training to achieve minimal competencies. To bridge the gap between pre-service education and in-service training courses, IM DRC supported the NMCP to evaluate the curricula of universities and higher-training institutions in Kinshasa, Kisangani, Bukavu, and Lubumbashi. As part of this activity, IM DRC supported the NMCP to hold working meetings with the MOH Director of Health Sciences, the University of Kinshasa, the Ministry of Higher and University Education, and some technical medical institutes and National Institutes of Health. IM DRC supported the NMCP to share the results of the evaluation with key stakeholders. Assessment results showed that malaria is taught in all nursing and doctor training institutions and malaria case management guidelines are integrated into the courses. However, the malaria guidelines are not up to date. In lower-level nursing training schools, course content is fixed by the national reference system, which was last updated in 2008. At universities and higher institutes of medical technology, course content is fixed by the national program at the Ministry of Higher and University Education. The IM assessment found that current national malaria guidelines are mostly integrated into the basic curriculum, but it also revealed that the material is being taught at different levels of university within different training modules. As such, there currently is no stand-alone malaria training module. In the next project reporting period, IM DRC will support the NMCP and other stakeholders to develop a malaria training repository which will serve trainers in the malaria course development for the different levels of providers.


Following the assessment, IM DRC supported the NMCP and the MOH Director of Health Sciences to update the curriculum for the institutions that train nurses, midwives, pharmacy assistants and lower-level laboratory technicians. After this update, IM DRC supported the organization of a day of awareness and orientation on the guidelines to the staff of the provincial division of health and managers of these institutions. As a next step, IM DRC will support the update of the curriculum of universities and higher-level technical institutions, which train physicians and higher-level laboratory technicians, nurses, and midwives. Objective 3: Provide global technical leadership, support operational research, and advance program learning Key Accomplishment #10: Support provided for the TES IM DRC supported the NMCP through the Unit of Clinical Pharmacology and Pharmacovigilance, University of Kinshasa, to conduct TES in two PMI sites, Mikalayi and Kapolowe. The study was completed at the Kapolowe site in Haut-Katanga, and the preliminary report was shared. In summary, the Kapolowe site enrolled 91 patients in the AL arm and 89 patients in the ASAQ arm between March-May, 2021. At the time of the report, the site was still completing patient follow-up to Day 28. Of the 91 patients in the AL arm, 2 were excluded and none were lost to follow-up. In the ASAQ arm, 5 patients were excluded and 6 were lost to follow-up. The report also noted the importance of providing the materials necessary for COVID-19 protective measures, along with the need to move microscopists from Lubumbashi to the study sites. The study is underway in the Mikalayi site, located in the Central Kasai Province. PCR-uncorrected and corrected adequate clinical and parasitological responses will be calculated for both arms and sites, and the study final report is expected in 2022. Table 3. Number of people enrolled for each study arm vs. target

KAPOLOWE MIKALAYI Total Enrolled Target AL ASAQ AL ASAQ

People enrolled

91 89 92 89 361 352

Target per site

88 88 88 88

Source: TES study Key Accomplishment # 11: Support ASTMH participation IM DRC submitted two abstracts to ASTMH 2021 which were both accepted as poster presentations. The annual meeting takes place in November of 2021. The titles of the two posters are:

● Reinforcing microscopy skills during Malaria Diagnosis Refresher Trainings to improve the quality of malaria diagnosis in the Democratic Republic of Congo, and;

● A Tablet-Based Health Network Quality Improvement System (HNQIS) for Data-driven Decision Making and Targeted Outreach Training Supportive Supervision (OTSS+) at Low Performing Sites in the Democratic Republic of Congo.



Weak implementation of IQA due to poor documentation in the health registers

● IM DRC raised awareness among laboratory technicians about the need to carry out internal quality control and documentation in registers.

● IM DRC supported the NMCP to harmonize an IQA job aid highlighting information to be collected in registers.

● IM DRC distributed this job aid to laboratory supervisors for IQA.

Weak availability of reagents and quality microscopes.

● IM DRC informed PMI, NMCP, provincial health offices and HF managers of reagent stockouts and shortage of microscopes.

● IM DRC recommended providing needed reagents and microscopes to rural HFs.

An insufficient number of trained providers in malaria case management in Haut-Katanga Province

● Informed the NMCP, PMI and IHP USAID of the need to increase number of providers trained in malaria case management

● IM DRC disseminated updated CM guidelines to health facility managers and the Haut-Katanga provincial division of the NMCP to organize scientific meetings of their health facilities to brief providers on these guidelines.

● Supported the Haut-Katanga provincial division of the NMCP to disseminate case management guidelines in health facilities.

Ensure the transition of the HNQIS tool to the NMCP for the continuity of the use of the tool at the national level.

IM DRC met with the NMCP and other implementing partners to advocate for a national HNQIS transition plan.

Only one person can analyze and interpret OTSS+ results at the national and provincial level.

● IM DRC supported the training of national and provincial NMCP staff on OTSS+ data collection through the HNQIS tool to strengthen nation-wide capacity of OTSS+.

● In the next fiscal year, IM DRC will support the training of national and provincial NMCP staff on OTSS+ data analysis and reporting.

COVID-19 pandemic-related domestic travel restrictions delayed preparation and implementation of OTSS+.

IM DRC worked closely with the NMCP and provincial coordinators to ● Provide remote technical support for the OTSS+ activities ● Support provincial OTSS+ supervisors previously trained to

conduct the OTSS+ visits in their respective provinces ● Send the OTSS+ checklists and tablets by cargo ● Organize a remote briefing for provincial supervisors prior to

the start of the OTSS+ round ● Implement remote mentoring of supervisors


Lessons Learned ● Effective partnership with the NMCP, INRB and other government agencies helped to fast-track

decision-making processes, such as the finalizing of the malaria case management guidelines. ● Effective collaboration with other implementing partners such as IHP expedited the adaptation of

the malaria case management guidelines, ● Remote technical support to provincial supervisors during OTSS+ visits, using WhatsApp and

phones, allowed supervisors to support sending the data to the server. ● Using HNQIS to improve the efficiency of OTSS+ instead of paper checklists allowed for timely

reporting of lab OTSS+ data for decision-making that led to the redistribution of reagents at provincial level, support for the low performing HFs through an external quality assurance approach, additional OTSS+ visits, and inclusion of malaria microscopy training to reinforcing microscopy skills.

● Innovative activities were successfully implemented to complement routine OTSS+ visits and monitor progress. These activities include reinforcing communication between OTSS+ visits between providers and supervisors; the use of wallcharts to track key indicators at the HF level; and organization of focus group discussions.


IM DRC COVID-19 Response Background

In DRC, the MOH declared the first case of COVID-19 in March 2020. IM DRC began its response in May 2020 and continued activities until March 2021 in the same nine PMI-supported provinces where IM DRC intervenes. Activities focused on strengthening the capacity of laboratory technicians and clinicians to collect, process, and transport respiratory samples. IM DRC also reinforced appropriate fever diagnosis, triage, referral, and case management, including enhanced biosafety and personal protection procedures. IM DRC also provided critical ongoing support to MOH COVID-19 response

mechanisms, including supporting national and provincial COVID-19 steering committees, providing cellular data bundles so that surveillance data could be sent, and sending respiratory samples for testing to the national laboratory. This administrative and logistical support reinforced coordination and decision-making.

IM DRC COVID-19 Key Accomplishments Key Accomplishment #1: Supported the DRC COVID-19 Response Coordinating Committee During the current reporting period, IM DRC continued to support the DRC COVID-19 Response Coordinating Committee and participated in lab commission, scientific committee, and coordination meetings with the USAID Mission in Kinshasa. IM DRC also supported and participated in key COVID-19 meetings at national and provincial levels as well as the transmission of COVID-19 data for maintaining the surveillance system. As more provinces reported COVID-19 cases, IM DRC provided advice on setting up response committees; however, IM DRC was unable to provide more direct support for Kasai Oriental, Kasai Central, and Tanganyika as these provinces had not set up provincial-level coordination meetings. As part of coordination efforts, IM DRC organized a project dissemination meeting on December 15, 2020, with government and other relevant stakeholders. The meeting involved 30 in-person and three remote participants who represented the national and some provincial governments, WHO, and other international partners, including Metabiota, PATH, CHAI, and UNDP.3

3 Tumpa, H. (2021). RDC : Le gouvernement appelé à la pérennisation des résultats de l’appui aux activités sur la Covid-19. C-ACTU. Retrieved September 20, 2021, from : https://c-actu.com/2020/12/16/1532/.

Figure 19: IM DRC COVID-19 Response Geographic Coverage

https://c-actu.com/2020/12/16/1532/


Key Accomplishment #2: Supported the procurement and distribution of hygiene supplies to 109 HFs Responding to a shortage of personal protection supplies critical for the prevention of COVID-19 transmission at the facility level, IM supported provincial health offices to procure enhanced personal protection materials and hygiene supplies for 109 HFs (Table). Due to ongoing need, a second round of hygiene supply distribution took place in October 2020, following the first distribution in July 2020. Many necessary supplies were not available at the local level and needed to be purchased centrally and transported to the provinces. Table 4: Distribution of hygienic supplies and personal protective equipment by province in October 2020.

Province # Facilities

Number of Units Procured and Distributed

Disposable face masks (Packages of 50)

Liquid soap Hand-sanitizer

Cleaning alcohol

Jerry cans

1 Haut-Katanga 32 7 151 151 22 10 2 Lualaba 10 7 149 149 17 10 3 South Kivu 10 7 147 147 18 10 Total 52 21 447 447 57 30

Key Accomplishment #3: Supported the collection, processing, and transport of respiratory samples for COVID-19 testing IM DRC worked closely with the WHO country office to support provincial health offices in COVID-19 affected provinces to collect and transport respiratory samples for COVID-19 testing from the field to the central laboratory in Kinshasa. This was done through a WHO-approved freight company, for safe movement of hazardous biological samples. A total of 92 tests were transported in 2020 with IM DRC support, with 55 of the 92 tests being transported during the current reporting period (Table 5). While all efforts were made to collect and deliver samples within 24 to 48 hours, this was not always possible as flight schedules for some remote areas were several days, or up to a week, apart. IM DRC also supported the INRB to assess the Lubumbashi provincial lab capacity for COVID-19 diagnosis to locally conduct COVID-19 testing; however, supplies were not consistently available in the Lubumbashi lab, thus sample transportation support to the central laboratory remained necessary. IM DRC did not transport respiratory samples in the Haut-Katanga, Lualaba, and Sud-Kivu provinces during this period because they have acquired capacity to perform COVID-19 testing. Table 5: Transportation of respiratory samples to the central laboratory for COVID-19 testing

Province Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Total

Haut-Katanga 0 0 0 0 0 0 0

Lualaba 0 0 0 0 0 0 0

Sud-Kivu 0 0 0 0 0 0 0

Kasai Central 0 0 10 14 16 14 54

Kasai Oriental 0 0 6 7 25 0 38

Total 0 0 16 21 41 14 92


Challenges and Solutions during the COVID-19 pandemic Challenges Solutions Lack of support for the functioning of the government’s COVID-19 response structure

IM DRC included support for management activities, such as meetings, data sharing, and sample transportation, which proved essential for IM’s support to the government.

The continuation of the COVID-19 pandemic IM DRC supported the second round of procurement for personal protective equipment for 52 HFs in three PMI provinces (Haut-Katanga, Lualaba, and South-Kivu).

Lessons Learned during the COVID-19 pandemic While not always common activities for external partners to support, some of the most appreciated contributions of IM to the government came in the form of logistical support to the government’s COVID-19 response mechanism. Providing resources to (a) support national and provincial COVID response committee meetings, (b) cover mobile credit to facilitate data transfer, and (c) facilitate the transportation of samples, are all operational activities, but would not have been possible without IM’s support, which would have hampered the government’s response.

IM DRC COVID-19 Response Training Indicator Table There has been no further update to the indicators outlined in the COVID-19 Response Training Indicator Table between the previous and current reporting periods. All information regarding trainings and materials were updated during the previous reporting period. During this reporting period, IM DRC primarily focused on distribution of supplies for infection prevention and control, supporting coordination meetings, and disseminating items that were not captured in the performance monitoring table.


IM DRC Indicator Table The data in the indicator table reflect activities in the IM-supported areas in DRC which include Haut-Katanga (19 zones), Haut Lomami (4 zones), Kasai Central (12 zones), Kasai Oriental (16 zones), Lomami (10 zones), Lualaba (six zones), Sankuru (four zones), South Kivu (eight zones), and Tanganyika (two zones). IM DRC piloted the CQI program in Haut-Katanga. IM DRC completed three rounds of clinical and lab OTSS+ visiting 80 facilities and training 26 health workers. Progress to Annual Target is calculated as actual result/target *100=progress to target. This provides an indication of how much progress has been made to meeting the annual target outlined in the country workplan.

Objective # Indicator Target Result

Progress to

Annual Target

Comments

1.1 Improved access to quality malaria diagnosis


90% 85% (N=58) 94%

IM DRC supported the NMCP to organize a bMDRT for 53 participants, during which43 participants demonstrated their PD skills. IM DRC also organized an aMDRT for 15 participants. A total of 58 participants of the bMDRT and aMDRT improved their competencies for PD out of 68 total participants (85% demonstrating competency in malaria microscopy).

Percentage of health workers demonstrating competency in malaria microscopy (PD)

90% 90% (N=595) 100%

During OTSS+ visits at 154 HFs, 89% (N=318/357) of health workers met the target standard (90%) for parasite detection in malaria microscopy during the observation in Round 4 versus 91% (N=277/304) in Round 5. A total of 595 HWs demonstrated competency out of 661 total HWs (90% demonstrating competency in parasite detection).


70% 56% (N=172) 81%

During the recent laboratory OTSS+, 154 HFs were visited. During this round, IM DRC added 45 new HFs. A total of 172 HFs were supervised, 55% (N=82) in Round 4 and 58% (N=90) in Round 5 of the 308 planned (56% facilities met the standard for quality diagnosis).) IM DRC will advocate with the Provincial Health Office to locally redistribute reagents allocated.

Percentage of health workers meeting minimum standard (80%) for PD during EQA for lab supervision

90% 90% (N=733) 100%

IM DRC focused on competency of health workers to meet the minimum 80% for PD during malaria microscopy observation. A total of 89% (N=383/430) of HWs met the minimum standard for PD in Round 4 compared to 91% (N=350/385) in Round 5.



Progress to

Annual Target

Comments

Percentage of health workers meeting minimum standard (90%) for PD during PT for lab supervision

90% 59% (N=354) 66%

IM DRC focused on HWs who met the minimum standard of 90% or higher for PD. 56% (N=184/328) of HWs met the standard for PD during PT in Round 4 compared to 63% (N=170/270) in Round 5. IM DRC will support the provincial laboratory to implement EQA through PT.


100% 106% (N=26) 106%

IM DRC supported the NMCP to support 11 trained clinicians and 15 laboratory technicians as supervisors.


100% 105% (N=68) 105%

IM DRC supported the NMCP to train 53 microscopists in bMDRT and 15 participants in aMDRT who performed the best during nECAMM.

Percentage of targeted provinces with national malaria diagnostic supervision tools that adhere to global standards

100% 100% 100% IM DRC supported the NMCP to integrate global standards with national malaria supervision tools.

Percentage of targeted facilities with national guidelines for malaria diagnosis that meet global standards

100% 100% 100%

IM DRC supported the NMCP to disseminate national guidelines for malaria diagnosis to HFs in alignment with global standards.

Objective 1.2: Improved access to targeted quality malaria treatment


100% 23% (N=54) 23%

During OTSS+ CQI, most clinicians did not demonstrate adherence regarding a negative test. IM DRC will distribute case management guidelines, facility wallcharts, and provide additional support of clinical visits. Only 15% of HWs (N=12) in Round 1, 33% (N=26) in Round 2 and 21% (N=16) in Round 3 demonstrated adherence.

Percentage of observed health workers demonstrating competency in correctly classifying cases as not malaria, uncomplicated malaria, and severe malaria

70% 50% (N=116) 71%

During OTSS+ CQI, only 51% of HWs demonstrated competency in correctly classifying cases. IM DRC will advocate with the IHP to organize clinical trainings regarding correctly classifying malaria cases. IM DRC will support additional clinical visits (N=40), 42% (N=33) in Round 2 and 58% (N=43) in Round 3.



Progress to

Annual Target

Comments


80% 13% (N=30) 16%

During OTSS+ CQI, only 10% (N=8) of HWs were found to have been trained according to national guidelines in malaria case management with ACTs in Round1 compared to 11% (N=9) in Round 2 and 17% (N=13) in Round 3. IM DRC will advocate with the IHP to organize trainings of national guidelines in malaria case management with ACTs (N=8).

Percentage of targeted health workers demonstrating competency in management of severe malaria

70% 60% (N=142) 86%

During OTSS+ CQI, only 65% (N=51) of HWs demonstrated competency in management of severe malaria in Round 1 compared to 52% (N=41) in Round 2. IM DRC will distribute case management guidelines and organize the mentoring of continuous training for improving the competencies of HWs in severe malaria. IM DRC will add visits (N=51). In Round 3, 64% of HWs (N=50) demonstrating competency in management of severe malaria.


70% 48% (N=160) 69%

During OTSS+ CQI, only 44%(N=35) of HFs met standards (including appropriate materials, documentation, and qualified staff) in Round 1 compared to 46% (N=58) in round 2. In Round 3, 53% (N=67) of supervised facilities meet standard for quality because IM DRC will distribute case management guidelines and advocate with the IHP to organize case management trainings.

Objective 1.3: Improved access to quality prevention and management of malaria in pregnancy (MIP)

Percentage of observed health workers demonstrating competency in treatment of MIP.

80% 82% (N=193) 103%

During OTSS+ CQI, only 74% (N=58) of HWs demonstrated competency in treatment of MIP in Round 1 compared to 86% (N=68) in round 2. In Round 3, 85% of HWs demonstrating competency in treatment of MIP (N=67). IM DRC will support the NMCP to organize focus groups with HWs demonstrating the lowest competency in treatment of MIP and add visits (N=42).


70% 69% (N=165) 99%

During OTSS+ CQI, only 71% (N=57) of HWs demonstrated competency in prevention of MIP in Round 1 and 67% (N=53) in Round 2. In Round 3, 69% of HWs demonstrating competency in prevention of MiP (N=55). IM DRC will support the NMCP to focus groups with HWs demonstrating the lowest competency in prevention of MIP and add another visit (N=57).



Progress to

Annual Target

Comments

Objective 3: Provide technical leadership contributes to PMI-led global policy development and Ops Research (OR)

Contribution to national, regional, or global guidance/policy documents related to malaria (including Reproductive Health).

3 4 133%

IM DRC supported the NMCP in updating malaria case management guidelines, training modules for curricula of nurses, SOPs regarding national malaria guidelines and reviewed national monitoring and evaluation guidelines.

Number of program activity outputs disseminated to the global health community.

2 3 1.5

IM DRC disseminated outputs of activities during World Malaria Day, participated in ASTMH, including submission of two abstracts s.

Participation in targeted national-, regional-, or global-level working group(s) and/or taskforce(s)

4 8 200%

IM DRC participated in eight global l working groups including three workshops on disseminating outcomes of some projects, two health cluster meetings, and three taskforces.

Non-PMP Indicators (Analyzed after CQI OTSS+ Round)

Percentage of observed health workers demonstrating competency in mRDTs

90% 75% (N=178) 83%

During OTSS+ CQI, only 56% (N=44) of HWs in Round 1 demonstrated competency in using mRDTs compared to 85% (N=67) in Round 2 and 85% (N=67) in Round 3. IM DRC will support the NMCP to improve continuous communication and demonstration of mRDT use with HF managers.


100% 80% (N=188) 80%

During OTSS+ CQI, only 76% (N=60) of observed HWs in Round 1 demonstrated competency in management of uncomplicated malaria compared to 79% (N=62) in Round 2. In Round 3, 84% (N=66) of HWs demonstrating competency in management of uncomplicated malaria. IM DRC will support the NMCP to distribute case management guidelines to the HFs.


100% 77% (N=182) 77%

During OTSS+ CQI, only 85% of observed HWs (N=67) in Round 1, 67% in Round 2 (N=53) and 79% in Round 3 (N= 62) demonstrated compliance to treatment according to WHO guidelines for cases with positive malaria results. IM DRC will support the NMCP by encouraging HWs to treat according to WHO guidelines and distribute case management guidelines to the HFs.



Progress to

Annual Target

Comments


100% 100% (N=240) 100%

During OTSS+ CQI, all HFs (N=80) received a supervisory visit for malaria case management, MIP, and/or diagnosis /lab. IM DRC will support HFs through further OTSS+ visits.

Percentage of supervised health facilities with essential commodities for the management of malaria

80% 83% (N=199) 104%

During OTSS+ CQI, only 82% of HFs had essential commodities in Round 1 (N=66), Round 2 (N=66) and 84% in Round 3 (N=67) for the management of malaria. Low levels of essential commodities were available in HFs during OTSS+ visits. IM DRC will advocate with commodities supply chain partners to reduce stock-out of commodities and add visits to confirm stock levels.

Percentage of supervised health facilities with essential drugs for the management of malaria

80% 64% (N=150) 80%

During OTSS+ CQI, only 59% (N=47) of HFs had essential drugs in Round 1, 63% (N=50) in Round 2 and 70% (N=53) in Round 3 for the management of malaria. IM DRC will advocate with commodities supply chain partners to reduce stock-out of commodities and add visits to confirm stock levels

253 IM Ghana October 2020 – September 2021

Ghana Background IM Ghana contributes to national efforts to improve malaria case management, the control of MIP, and other malaria drug-based service delivery interventions. In Ghana, IM Ghana is providing support to the NMCP, Clinical Laboratory Unit (CLU), Director General’s office, and other Ghana Health Service (GHS) stakeholders to implement the National Malaria Strategic Plan for Malaria Prevention and Control 2021-2025. During this project reporting period, activities and accomplishments focused on evidence-based and long-term sustainability of interventions beyond the lifespan of the project by building strong partnerships to prioritize support needed, and identify long-term solutions required for effective implementation. IM Ghana’s objective has been to learn from experiences and to apply best practices to scale up malaria service delivery through efficient and effective project implementation. Key indicators at all levels track and reinforce effective allocation and use of resources in building the capacities of healthcare professionals. IM Ghana is improving malaria service delivery through two key global project IM objectives.

• Objective 1: Improve the quality of and access to malaria case management and malaria prevention during pregnancy

• Objective 31: In support of Objective 1, provide national technical leadership, support

operational research, and advance program learning. Geographic Focus: IM Ghana focused on all levels of the continuum of care for malaria in all 16 regions and 260 districts to improve the quality of malaria clinical case management, management of MIP, and diagnostic capacity strengthening activities.

1In FY21 IM Ghana workplan, SMC was removed from our scope of work and the original objective 2 (improve the quality of and access to other malaria-based approaches and provide support to pilot/scale-up newer malaria drug-based approaches) was removed from the IM Ghana approved workplan. Thus, the inconsistent numbering of objectives list.

Figure 1: IM Ghana Geographic scope


Key Accomplishments

Objective 1: Improve the quality of and access to malaria case management and malaria prevention during pregnancy Key Accomplishment #1: Supported six regional hospitals with high antenatal care (ANC) attendance but low IPTp coverage to improve the quality of MIP services and IPTp coverage using facility-based MIP training and quality improvement (QI) methods IM Ghana supported the NMCP to address a systemic challenge of non-adherence to the recommended MIP guidelines and policies, including data management forms, in teaching hospitals providing primary health care services including ANC. Regional hospitals in Ghana provide primary health care services including ANC and have high rates of ANC use. Review of routine health management information systems

(HMIS) data from the targeted hospitals persistently show high IPTp 1 and 3 coverage, of 79% and 75% respectively. Coverage of insecticide-treated mosquito nets (ITNs) among pregnant women attending ANC is low at 77% from January 2019 to September 2020. During the reporting period, IM Ghana partnered with the NMCP to conduct facility-based MIP trainings integrated with QI and data management. The training was aimed at improving IPTp uptake, data quality, and data use for decision-making; identifying

and resolving facility-specific challenges to strengthen the provision of MIP services across these targeted hospitals; improving their IPTp coverage and overall national IPTp coverage. The facility-based MIP trainings revealed non-adherence to GHS guidelines on MIP and HMIS standard operating procedures (SOP). Therefore, the IM Ghana team identified an error in data reported for this period which led to high IPTp coverage reported in the six regional hospitals, based on IPTp tablets instead of doses given to pregnant women. IM Ghana supported several activities critical to the success of the facility-based MIP training, impact, and sustainability as listed below. Review and finalization of training slides: IM Ghana supported a systematic review of the national training documents/presentations using the reviewed national guidelines which aligns with WHO and PMI standards for MIP service delivery.

56%

36%

54% 53%44% 43%

86%75% 75% 78%

69% 72%

Bono Eastern EffiaNkwanta,Western

GreaterAccra

Upper East UpperWest

Pre-test Post-test

Figure 2: Pre-and post-assessment performance at six regional hospitals, Source: Training database, 2021


Digitization: IM Ghana supported the development of a digital platform for a pre- and post-assessment to identify the specific gaps and needs of participants, which the trainers used to tailor training sessions as needed during the training. Support for planning, preparation and training: To strengthen implementation and ownership of the training, IM Ghana organized an orientation meeting with the NMCP, regional malaria focal points, management teams from targeted regional hospitals, and facilitators on October 30, 2020. This meeting was organized to discuss the rationale, approach, needs of participating HWs, and selection of facility-based focal points to serve as the intervention lead at the hospital. IM Ghana supported a facility-based MIP training of 183 HWs (37 male, 146 female) from November 8, 2020, to January 14, 2021, in the six targeted regional hospitals. Table 1 shows the number trained by cadre. Table 1: Number trained for MIP guidelines, QI, and data management

Cadre Number Trained

Male Female

Midwives 0 76

Physicians 4 20

Nurses 0 20

Health information officers 11 2

Medical laboratory scientists (MLS) 11 0

Pharmacy 8 2

Public health nurse/community health nurse 0 11

Store managers 2 4

Other paramedics 1 11

Total 37 146

All participants took a pre- and post-training assessment showing an overall 50% increase in the assessment score across staff and hospitals. Males had an average pre-test score of 48% and post-test scores of 77%. Females had an average pre-test score of 47% and post-test scores of 78%. However, only Bono Regional Hospital met the target of >80% at post-assessment. Post-training follow-up (PTFU) visit: This has been an integral part of the intervention as it provides HWs with further support and skills development towards improved outcomes; assesses the status of


action plan implementation developed during the training; and enables facilitators to provide support for action plan implementation. During the reporting period, IM Ghana collaborated with the NMCP to design, plan, and execute two PTFU visits, with the aim of supporting regional hospitals to achieve their set objectives as illustrated in Figure 3 below.

Figure 3: PTFU flow chart IM reached a total of 78 out of 183 HWs trained during two rounds of PTFU visits in the period. Implementation progress includes:

● ANC services include counselling for pregnant women to prevent and manage MIP; however, health education materials are not available to support efforts. IM Ghana collaborated with the NMCP to provide national guidelines, job aids, and SOPs for the facilities.

● IPTp is being given to pregnant women on admission to the hospitals to address previous missed opportunities. Data is captured and used for decision-making.

● Midwives received orientation for the documentation and reporting of IPTp during ANC. ● Monthly supervision by the unit head on the use of the job-aids and the updated guidelines. ● Weekly, biweekly, and monthly data validation meetings to improve data quality.

Shared learning workshop: This workshop created a forum for all the targeted regional hospitals to share innovations, lessons learned, and best practices in implementing their ideas for change in their journey to improvement. This activity aimed to further build the competency of HWs who provide service in targeted regional hospitals to provide quality MIP services through peer learning. A total of 26 (10 male, 16 female) from the six regional hospitals participated in a three-day shared learning session from July 26 to 28, 2021. Some of the best practices shared included that:

● The adoption of IPTp defaulter tracing through home visits and phone calls address missed doses

Step 1- Before Visit - Develop PTFU tool - Review and finalize QI tools developed (process maps and

Step 2 - During Visit - Conduct entry meeting with RHMT and hospital management

Step 3 - Before Exit - Agree on action and follow-up plans - Conduct exit interview

Step 4 - Reporting - Submit a technical report progress and challenges - Share report with


● Reducing the congestion at ANC services through establishment of an appointment system reduces wait times and enhances quality counselling for IPTp demand and use.

● Effective weekly or monthly data validation of IPTp and ITN data reduces data inconsistencies and improves data quality and use of data for decision-making.

● Scheduled exit interviews address client satisfaction issues and enhance ANC attendance for IPTp administration.

● Linking registered pregnant women to community health officers (CHO) improves follow-up and continuity of services.

● Organizing systems for maternity wards to administer SP to inpatients who are due for it addresses missed opportunities.

● Motivating pregnant women for early registration is an important activity and awarding congratulatory stickers on ANC cards reinforces opportunities to make ANC appointments.

This partnership has resulted in improvements in key MIP indicators across the targeted facilities. Figure 5 below shows indicator performance in comparing ITN coverage, IPTp coverage, and the fourth ANC visit. It indicates that IPTp3 coverage and the fourth ANC visits exceeded 100% prior to the facility-based MIP intervention due to the data quality issues noted above. This includes facilities incorrectly counting tablets of SP dispensed instead of doses, maintaining poor documentation, and lack of understanding of the variables used in the register. After IM identified and addressed all the issues, there has been improvement in data quality at the six regional hospitals. In addition, the IPTp3 coverage is similar to fourth ANC visits, indicating that facilities are no longer missing opportunities to administer IPTp. Overall, the implementation of this innovation in all facilities is gradually showing improvement in the IPTp3 coverage, as seen in the routine HMIS data.

Figure 4: Shared learning session in Eastern Premier Hotel, Koforidua, Photo Credit: Felicia Babanawo, IM

Figure 5: IPTp coverage and ANC fourth visit for the six regional hospitals, Source: DHIMS2, 2021


Key Accomplishment #2: Improved access to quality MIP interventions in 16 targeted high burden districts through CHO task shifting training ANC forms part of the essential service package to be delivered at the community level through the Community-Based Health Planning and Services (CHPS) strategy. However, CHOs who work in these communities lack adequate skills to provide this crucial service and the delivery of MIP services including the administration of IPTp. Midwives are the cadre of health workers who are mandated to provide these services at the sub-district level and organize outreach to the community level. Routine District Health Information Management System (HIMS) data shows low IPTp3 coverage of 28%, from January 2019 to December 2020 in the 16-targeted districts. Providing CHOs with required skills to support midwives to provide ANC and MIP services and foster teamwork within the sub-district teams, especially in regions where use of ANC and IPTp services are poor is necessary to improve IPTp coverage. During the reporting period, IM Ghana supported the NMCP and the GHS Family Health Division (FHD) to build CHO capacity to task shift the provision of ANC and IPTp services from midwives to CHOs in four regions (Oti, North East, Savannah, and Western North regions) from April 17 to June 23, 2021, to improve the uptake of ANC and IPTp. Some of the tasks shifted included provision of ANC and IPTp from the second dose, and mobilization of pregnant women for the first dose IPTp. IM supported activities critical for the implementation of MIP CHO task shifting during the reporting period as listed below.

Training Curriculum: IM Ghana supported the NMCP and FHD to develop a training curriculum, which includes the ANC service package, prevention, and case management of MIP, diagnosing MIP using mRDTs, effectively mobilizing pregnant women to use ANC services, and data and logistics management. The training included both didactic and skills building approach through role-play, group work, and practice sessions. Prioritization of CHPS zones: In collaboration with the NMCP and FHD, four regions including North East, Oti,

Savannah, and Western North regions were prioritized based on their low IPTp coverage for the intervention. Using routine HMIS and qualitative data, four districts were prioritized in each region and ten CHPS zones in each district. Selection criteria for targeted CHPS zones included low (<40%) IPTp and ITN coverage, lack of a resident midwife in CHPS zone, and the distance of CHPS zone to a health center. Training: With the developed training curriculum, IM Ghana supported the NMCP, FHD, Regional Health Management Teams (RHMT), and DHMTs to conduct regional and district level trainings. Below is the breakdown of HWs trained:

Figure 6: Group discussions in Western North, June 2021. Photo Credit: Raphael Akpah, IM


Table 2: Number of health workers trained for CHO task shifting

Level

Regional Level (N = 16 targeted districts;

District mentors)

District Level (N = 160 CHPS zones; CHOs and

Midwives) Total

Grand Total Male Female Male Female Male Female

Number trained

21 45 139 239 160 284 444

In a pre-and post-assessment during the training, males had an average pre-test score of 64% and post-test scores of 87%, and females had an average pre-test score of 70% and post-test scores of 89%. The average pre-assessment score was 71% and post-test score was 86%, for an overall 15% increase in assessment scores.

Figure 7: Improved knowledge performance training assessment, Source: Training database Some of the challenges identified during the trainings and actions taken were:

Challenges Action Taken

Recurrent stock-outs of SP due to inadequate logistics management

Trained and made available bin cards to health workers for easy tracking of SP use and management. Informed PSM to pay more attention to this during their visits.


Challenges Action Taken

Inadequate HW knowledge for updated MIP guidelines

Trained health workers and provided job aids and SOPs for facilities to be used as reference material.

Unavailability of appropriate dose of folic acid (0.4mg) for co-administration with SP

Worked with NMCP to ensure GHS provides the appropriate dose.

Client refusal of SP due to concerns of side effects, and inadequate education by HWs

Community engagement and mobilization was introduced to CHO to educate mothers during outreach and home visits.

This activity, which advanced NMCP and FHD focus in the four targeted regions, has been useful in improving the capacity of health providers in the CHPS zone level to expand and deliver better quality MIP services to reach national IPTp coverage targets (80%+).

Key Accomplishment #3: Improved capacity of facility-based microscopists with resultant increase in proportion of reported malaria case confirmed with a diagnostic test Laboratory OTSS+ and the Proficiency Testing Scheme (PTS) for malaria diagnosis is a USAID government-to-government arrangement to improve the skills and competencies of selected microscopists from beneficiary facilities. To sustain these capacity building gains, IM Ghana continued to provide technical support for the laboratory OTSS+ and PTS, including training of new supervisors to improve supervision skills and provide quality coaching and technical support using the HNQIS application.

Figure 8: IPTp coverage from CHO task shifting, Source: DHIMS2, 2021


During this reporting period, IM Ghana supported the following activities: Supervisor training: IM Ghana worked with the CLU and NMCP to provide training for 75 newly appointed medical laboratory scientists (MLS) as laboratory OTSS+/PTS supervisors (68 males and seven females) from all 16 regions from October 26 to 30, 2020 and April 7 to 9, 2021. In addition, IM Ghana built the capacity of the 75 MLS in creating a dashboard using key indicators from laboratory OTSS+/PTS on the data hub and the usage of the data-to-action framework for decision-making and facility prioritization for future laboratory OTSS+. The overall pre-and post-assessment shows improvement with an average score of 66% at pre-test and 93% at post-test. This shows a 27% increase. The frequent knowledge gaps addressed through the training include parasitemia levels associated with severe malaria, common complications of severe malaria, management of treatment failure, use of QI tools for supervision, and the principles of supportive supervision.

Figure 9: Laboratory OTSS+ and PTS implementation plan


Lab OTSS+ Implementation: IM Ghana worked closely with the CLU, NMCP, and RHMT to plan and conduct one round of OTSS+ in 260 out of 755 health facilities providing laboratory services in all 16 regions of Ghana from November 2 to 20, 2020. This was following the lesson learned workshop (LLW) held on June 24 to 26, 2020 to document and share best practices across regions and develop innovative ideas for change in response to challenges faced during the field activities. IM Ghana supported the configuration of the laboratory OTSS+ and PTS checklist, assignment of facilities per region on the HNQIS application for supervision, and provision of technical support during supervisory visits to facilities. During the supervisory visits, 742 HWs (474 lab staff and 268 non-lab staff) were trained and mentored. Findings from laboratory OTSS+ Round 19 showed that HWs performed very well in mRDT preparation (91%), patient preparation (97%), blood collection and dispensing (98%), mRDT procedures and reading of results (93%), recording results (95%), disposal of infectious material (98%), and result delivery (100%) compared to Round 18. Commonly missed steps were storage of mRDTs at <30 0C, checking expiry dates, hand washing, explaining the procedure to patients, wearing gloves, wiping the first drop of blood, and writing the reading time of the cassette. The overall performance in microscopy showed that 77% of the 260 facilities visited for lab OTSS+ met the target in slide preparation, 69% of the facilities met the target in staining and reading, while 30% of the 70 facilities visited for PTS met the target (90%) in parasite detection and 18% met the target in species identification (Table 3). In addition, 10% of the facilities met the target (50%) for parasite density. The performance was low since the majority of the microscopists supervised had not been trained in MDRT and had not had any formal malaria microscopy training. However, the OTSS served as on the job training.

Figure 10: Knowledge pre- and post-assessment by gender, Source: Training Database


Table 3: Overall performance scores for lab OTSS+ Round 19

Competency Area Overall average score

Total # Target threshold

% HF scoring at/above target

# HF at/above target

Slide preparation 84% 260 90% 77% 200 Staining and reading 81% 260 90% 69% 179 mRDT performance observation 96% 260 90% 91% 237 Adherence to negative test mRDT 91% 260 90% 90% 234 Microscopy 92% 260 90% 90% 234 Parasite detection 71% 70 90% 30% 21 Species identification 52% 70 90% 18% 13 Parasite density 30% 70 50% 10% 7

Performance of 98 health facilities in Lab OTSS+ Round 18 and Round 19 A total of 98 health facilities that participated in the laboratory OTSS+ Round 18 were targeted for Round 19. Figure 11 shows overall improved competency in mRDT observation across all regions, except for the Eastern, Bono, Oti, and Volta regions that showed a decrease. North East facilities scored 0% in Round 18 and improved to 91% in Round 19. Fifteen out of the 16 regions met the target (90%+). There was an overall 13% increase in performance from Rounds 18 to 19.

Figure 11: Competency in mRDT observation (n=98 HFs), Source: Datahub, 2021 There was a decline in malaria microscopy competency in Ahafo, Oti, Savannah, and Western North regions. The major reason for the decline is the issue of staff attrition. Regional supervisors developed


ideas for change to curb gaps identified at facilities and scheduled post-OTSS+ follow-up to help enhance their performance. Notwithstanding, all other regions improved their performance from Rounds 18 to 19.

Figure 12: Competency in malaria microscopy observation (n=98 HFs), Source: Datahub, 2021 Test performance for suspected malaria cases in health facilities by mRDT and microscopy (District Health Information Management System – 2, DHIMS2) Figure 13 shows improvements in testing of suspected malaria cases from 2017 (79%) to June 2021 (98%). In addition, the majority of tests are done using mRDTs as compared to microscopy.

Figure 13: Improved performance in testing rates by mRDT and microscopy, Source: DHIMS2


Key Accomplishment #4: Improved functionality of the national malaria slides bank (MSB) by updating the national operational manual A pre-requisite for effective and quality malaria microscopy diagnostic training is the availability of quality malaria slides, including all species. The national MSB has provided slides for these trainings over previous years. Prolonged usage since 2012 has resulted in loss of slides, reduced quality of the slides, and consequently the lack of the full required complement of malaria species slides in the MSB for malaria microscopy diagnostic training including the PTS and MDRT. An essential step in replenishing and upgrading the MSB is to review and update the national operational manual for establishing and managing the MSB. During the project reporting period, IM Ghana supported a TWG of eight members (seven male, one female) from the NMCP, CLU, and Kintampo Health Research Centre (KHRC) to have two meetings on April 23, 2021, and May 20-21, 2021. The goals of these meetings were to review and finalize the operational manual for the establishment and management of the MSB and to develop the protocol and timelines for the process according to national and WHO standards. The operational manual is to be finalized and signed off by the MOH. This will be disseminated to the KHRC to be used as the manual to manage the MSB. In addition, IM Ghana supported the NMCP, CLU, and KHRC to start the process to replenish and upgrade the MSB, by listing and procuring the necessary materials for the MSB. Key Accomplishment #5: Strengthened competency of national and regional level supervisors using the national competency assessment for malaria microscopy (nCAMM) In order to address the challenge of inadequate national and regional supervisors for malaria microscopy, IM Ghana supported the NMCP and CLU to conduct an nCAMM for the eight new regions (i.e., Ahafo, Bono, Bono East, North East, Northern, Oti, Savannah, and Western North regions) from March 22 to 26, 2021. Participants included five MLS per region. This will provide the regions with a sufficient number of supervisors who can cover all facilities which have laboratories in the communities. Out of the 29 MLS who participated in the nCAMM certification process, 20 achieved level D and five achieved level C. Participants at levels C and D should only be performing malaria microscopic clinical

Figure 14: MSB meeting in Koforidua, Eastern Region, May 2021, Photo Credit: James Sarkodie, IM

Figure 15: nCAMM in Sunyani, Bono region, Photo Credit: Mohammed Adams, IM


testing under close supervision and their microscopy results should be checked regularly. However, four participants who achieved level B will go on to conduct quality malaria microscopy training, including forming part of the national core group of microscopists to spearhead relevant malaria microscopy quality assurance (QA) programs in the facilities. A re-assessment is planned in the next year, and this will be preceded by MDRT training for the participants who scored at levels D and C. Table 4: Results of participant nCAMM performance (N=29) Level Number Target

A 0 Parasite detection- 90%+; Species identification- 90%+;

Parasite density- 50%+

B 4 Parasite detection- 80 to 89%; Species identification- 80 to 89%

Parasite density- 40 to 49%

C 5 Parasite detection- 70 to 79%; Species identification- 70 to 79%

Parasite density- 30 to 39%

D 20 Parasite detection- <70%; Species identification- <70%;

Parasite density- <30%

Key Accomplishment #6: Reinforced capacity for quality malaria case management and MIP in 867 health facilities by supporting the NMCP to conduct clinical OTSS+, coaching, and mentoring Clinical OTSS+ has been an effective and efficient approach to build and sustain the capacity of HWs to provide quality and accessible malaria services and has measurably contributed to adherence to guidelines, resulting in maintaining an adequate level of HF competency to deliver quality malaria services. The NMCP, with support from IM Ghana and other stakeholders, uses defined training, supportive supervision, coaching, and mentoring approaches. During this project reporting period, IM Ghana supported the NMCP to build capacity of clinical OTSS+ supervisors and conduct supervisory visits in seven of the 16 regions (i.e., Ahafo, Ashanti, Eastern, Bono, Bono East, Upper East, and Upper West) from September 1 to December 18, 2020. To prevent duplication of efforts, IM Ghana targeted seven regions because the NMCP focuses their OTSS+ implementation in the other nine regions. IM Ghana supported several critical activities for the overall implementation of OTSS+ as listed below. Prioritization of health facilities: To reinforce efficient use of resources, IM Ghana supported the NMCP and RHMTs to use data from the national HMIS to prioritize low-performing health facilities for the clinical OTSS+ in the seven regions. The data focused on the following indicators: IPTp3 coverage; malaria case fatality rate (children under the age of 5 years); confirmed uncomplicated cases treated with


ACTs; suspected uncomplicated malaria tested negative but treated including not tested but presumptive treatment; and malaria testing rates. A total of 687 health facilities were prioritized from 101 out of 131 districts in the seven-targeted regions. Training of Supervisors: To support effective implementation of clinical OTSS+ and enhanced training during fieldwork, IM provided technical support to the NMCP and RHMT to train regional- and district-level supervisors on all nine modules (clinical observation, MIP, adherence, data management, general OTSS, microscopy, mRDT, pharmacy and ITN), QI approaches and processes, and updated malaria case management guidelines from the seven regions. A total of 529 supervisors (371 male, 158 female) participated in the training. The overall average pre-test score was 60% and the average post-test score was 84%. This shows a 24% increase between pre- and post-test scores across all the seven regions. Lessons Learned Workshop: IM Ghana also supported the NMCP to organize LLWs in November 2020 and February 2021 to review the performance of HWs and HFs and to document best practices and challenges during clinical OTSS+. IM Ghana supported RHMTs and DHMTs to develop ideas for change and improvement using the quality improvement model to address challenges identified at the facility level. A total of 202 participants (125 male, 77 female) from the 38 districts and 12 participants from three regions (i.e., Bono, Upper East, and Upper West regions) participated in the LLW. Findings showed that:

● There were issues of frequent stock-outs of SP. This was attributed to the non-availability of bin cards and an inability of HWs to calculate the maximum and minimum stock levels for their facilities. HWs were trained and coached on the job on how to calculate minimum, maximum, re-order, and monthly stock levels to prevent stock-out of IPTp, ITNs, mRDTs, and ACTs. HWs were also tasked to liaise with DHMTs to get copies of bin cards for managing malaria commodities.

● All targeted facilities in the region had HWs observed delivering services during the visit. In some facilities, supervisors conducted a role-play if clients were not available at the time of visit (i.e., 2% of the targeted facilities). Forty-one percent of health facilities met the minimum competency target of >90% compliance with clinical management steps. From district presentations, however, clinicians conducted incomplete assessments of clients, as they were not assessing for other conditions and their related severity. Furthermore, some clinicians did not conduct a physical examination, due to fears of COVID-19, or did not check for signs of severe malaria from the patient’s clinical history before they established a final diagnosis.

● All facilities were using mRDTs to diagnose malaria when a client presents signs and symptoms of malaria. Eighty-one percent of the HFs met the minimum competency target of 75% compliance

Figure 16: Group session in Bono East Region, October 2020, Photo Credit: Charles Agblany


with mRDT steps. It was revealed that HWs have basic knowledge and skills for the use of mRDT kits for testing. However, some detailed steps, such as adding inaccurate number of buffer drops, not documenting the time when the buffer was added, not tracking time to read results, and certain techniques in collecting the blood sample were performed incorrectly during observation. The majority of facilities were using a single buffer drop instead of two. Health workers were coached by the supervisors who demonstrated the correct procedures and advised them to read the manufacturer’s instructions for reference before starting the procedure.

Clinical OTSS+ Implementation and Findings: During the field visit, a total of 3,312 HWs (869 male, 2,443 female) from 867 HFs were coached and mentored on-the-job to improve their competency in adherence to and compliance with national malaria case management guidelines to reduce the incidence of malaria burden. Overall, the average results show that HFs were adhering to the Test, Treat, Track initiative. For example, 91% of HFs met the minimum competency target of 90%+ adherence to testing prior to treatment, 83% of HFs met the minimum competency target of 90%+ adherence to negative test results, and 95% of HFs met the minimum competency target of 90%+ adherence to positive test results respectively during the review process. Also, 91% of health facilities met the minimum competency target of 90%+ compliance with mRDT steps and 76% of health facilities met the minimum target of 90%+ for microscopy steps during observation. Results from MIP observations showed an increase in knowledge about the newly updated guidelines on IPTp administration from 72% in 2019 to 79% in 2020. Also, there was an increase in availability of SP tablets from 83% of the facilities visited in 2019 to 92% of the targeted facilities visited in 2020. Performance for SP and ITN inventory management at the facility level improved from 40% to 70% comparing OTSS+ results from 2019 to 2020. However, 27% out of the 634 health facilities in 2020 experienced stock-out of SP for more than seven days in the past three months as compared to 20% out of 284 in 2019. IM Ghana is working with NMCP and GHSC-PSM to address these stock-out challenges.


Key Accomplishment #7: Supported revision of the national malaria case management training slides and nationwide malaria case management training to improve adherence to case management guidelines The NMCP Malaria Program Review (MPR) 2019 and analysis of routine DHIMS2 data indicated 1) Inadequate HW capacity to adhere to the guidelines and procedures for the management of severe malaria, across all levels of the health system including tertiary facilities; 2) Inadequate competency and tools for the management of test-negative fevers (differential diagnosis) at health centers and CHPS; and 3) Inefficient referral practices resulting in late and inappropriate referral and poor data quality. As part of the measures to address these challenges, IM Ghana supported the NMCP to review the national training guides for malaria case management in line with the recently reviewed national guidelines and WHO policies. This initiative supported the development of technical guides for epidemiology, diagnosis, management of uncomplicated and severe malaria, prevention and management of MIP, data management, procurement, and supply chain management. With the newly developed training guide and preparation of national supervisors, IM Ghana supported the NMCP to organize and co-facilitate training sessions nationwide from February 22 to June 11, 2021. A total of 30 national level facilitators (17 male, 13 female) and 231 regional-level facilitators from all 16 regions (150 male, 81 female) at the zonal level were oriented on the developed training guide and slides including the new updates. All regional-level facilitators took pre- and post-assessments during the training, showing an overall 31 percentage point increase in the assessment score. Males had an average pre-test score of 50% and post-test scores of 75%, whereas females had an average pre-test score of 44% and post-test scores of 77%.

Figure 17: Improved performance in prevention of MIP in the seven regions, Source: Electronic Data System (EDS)- DHIS2, 2021


IM Ghana supported the NMCP and RHMT to conduct district-level facilitators’ trainings in seven out of the 16 regions (i.e., Ashanti, Central, Northern, Volta, Greater Accra, Bono, and Bono East regions). A total of 643 district facilitators (365 male, 278 female) were trained and demonstrated an overall 17 percentage point increase in assessment scores. The average pre-assessment score was 59% and post-test score was 76%. Moreover, IM Ghana supported the training of 229 (91 male, 138 female) HWs at four out of five teaching hospitals in Ghana (i.e., Cape Coast, Ho, Tamale, and Komfo Anokye teaching hospitals). The overall average pre-course assessment score was 58% and post-course assessment score was 76%, with an overall18% increase in the assessment score. Furthermore, IM Ghana supported the NMCP and RHMT to expand training of 560 HWs (208 male, 352 female) from regional, quasi-government, and municipal hospitals in 14 out of the 16 regions. Overall, in pre-and post- course assessment, males had an average pre-test score of 57% and post-test scores of 79%, whereas females had an average pre-test score of 52% and post-test scores of 85%. There was overall a 33% increase in the assessment score. Some of the gaps identified and actions to be taken by HFs are noted below. Table 5: Action points developed during training Description of gap(s) identified Action(s) to be taken by the facility

Non-compliance with the test and treat guidelines for suspected uncomplicated malaria

● Orient clinicians on standard treatment guidelines for malaria

● Obtain and display job-aids for standard treatment protocols for malaria in consulting rooms

● Conduct a monthly review of folders to monitor clinician adherence to malaria treatment guidelines and provide feedback led by facility unit heads and management

Delays in initiating parenteral artesunate treatment for patients with severe

● Liaise with the pharmacy unit to stock anti-malarial medicines for emergency start-doses in wards

Figure 18: Case management training sessions at Elmina, Central region, Photo credit: Amos Asiedu, IM


Description of gap(s) identified Action(s) to be taken by the facility

malaria as result of non-availability of medicine and high workload of nurses

● Orient nurses on triaging and the urgency in treating severe malaria

● Advise ward managers to provide supervision and feedback for severe malaria cases

Poor documentation of data in source registers

● Constitute functional data validation teams

● Provide orientation for all outpatient department (OPD) staff on documentation in the source registers

● Conduct weekly supervision of staff and review of register by facility unit heads

mRDTs not deployed as a point of care device with testing restricted to lab in some facilities

● Train ANC, OPD, and maternity staff on how to perform mRDT tests

● Weekly supervision of mRDTs being performed by staff led by laboratory unit head

Incomplete and inaccurate reporting of malaria data in DHIMS2

● Form data verification teams

● Review data entered in DHIMS2 by health information units and other departments.

● Provide job coaching on the SOPs for data management including DHIMS2

Performance in MIP testing rates and case fatality rates for children under and over the age of 5 years are shown below. Results for Ghana from January 2020 to June 2021 show an improvement in intermediate indicators, including testing rates for suspected uncomplicated MIP increasing from 80% in December 2020 to 97% in June 2020, while the percentage of suspected MIP cases treated without testing has reduced from 17% to 7% for the same time period.


Similarly, malaria case fatality rates for children under and over the age of 5 years for the targeted facilities reduced from 0.11% in December 2020 to 0.0% in June 2021.

Figure 20: Malaria case fatality rate in targeted health facilities in Ghana 2020 – 2021 (n=16 HFs), Quarterly, Source: DHIMS2, 2021 Key Accomplishment #8: Strengthened the capacity for effective management of malaria and febrile illness at peripheral facilities through CHO internship training CHPS compounds managed by CHOs represent the first point of contact within the health care system and play a major role in the management of malaria. CHOs had previously received orientation on the management of patients for febrile illnesses, including malaria, before deployment to CHPS compounds.

Figure 19: Trend in testing rate pf suspected MIP and malaria cases not tested but treated in targeted facilities in Ghana, 2020 – 2021 (n=16 HFs), Quarterly, Source: DHIMS2, 2021


As such, they were challenged in the management of malaria, including appropriate referral and compliance to the Test, Treat, Track guidelines for the management of malaria. During this project reporting period, IM Ghana collaborated with the NMCP, RHMTs, and DHMTs to build the capacity of CHOs to appropriately manage uncomplicated malaria cases and offer pre-referral treatment and referrals to district hospitals. This capacity building was provided through a mentorship and internship training at district hospitals. It aimed to establish continuous mentorship between district hospital clinicians and CHOs. With limited funding and a focus on achieving efficiency, the team systematically reviewed and used data to prioritize low performing clinics and CHPS compounds in each district. Focus indicators included testing rates; uncomplicated malaria not tested but treated as malaria; adherence to positive test results; adherence to negative test results; and malaria caseload. IM Ghana supported the scale-up of the CHO Internship to 520 CHPS zones from 52 districts in 10 out of the 16 prioritized regions. A total of 188 out of 200 targeted districts level mentors (115 male, 73 female) have been trained from 47 districts in nine regions (i.e., Bono, Bono East, Greater Accra, North East, Oti, Savannah, Upper West, Volta, and Western North regions). The training included peripheral level national standards for case management, a guide to clinical assessment of febrile patients, facilitation, and mentoring skills. District mentors included medical doctors, physician assistants, senior nurses, midwives, health information officers at selected hospital units, and the district malaria focal point. Overall, the average pre-course assessment score was 65% and the average post-test score was 83%, with an overall 18% increase.

Figure 21: Interns at the ward with a mentor at the Ada East Hospital, Greater Accra, August 2021, Photo credit: Suleman Ziblim, IM


Table 6: Pre-and post-assessment for district mentors training Region(s) Pre-Test [Range] Post-Test [Range]

Bono East 64% [34% - 83%] 80% [59% - 94%]

Oti 71% [ 6% - 90%] 84% [ 67% - 95%]

Volta 66% [ 30% - 85%] 82% [ 71% - 97%]

Bono 56% [ 45% - 91%] 88% [ 80% - 98%]

Greater Accra 70% [51% - 89%] 86% [72% - 100%]

Savannah 50% [40% -75%] 90% [75% - 93%]

Upper West 69% [ 60% - 80%] 85% [ 75% - 87%]

North East 60% [ 35% - 80%] 82% [ 70% - 93%]

Western North 44% [ 30% - 70%] 85% [ 77% - 94%]

Total 61% [ 6% - 91%] 85% [59% - 100%]

270 CHO (87 male, 183 female) clinical competency assessments conducted during the internship in five out of 10 targeted regions, show improvements as compared to pre-internship scores for the practical assessments. It is anticipated that the performance, as demonstrated, will translate into better management and reporting of malaria cases in their respective facilities. Table 7: Clinical competency assessment scores

Region(s) Pre-Assessment Post-Assessment

Greater Accra 27% [0% - 56%] 57% [28% - 81%]

Oti 40% [5% - 79%] 68% [47% - 91%]

North East 6% [0% - 11%] 39% [35% - 41%]

Savannah 44% [12% - 92%] 85% [71% - 94%]

Volta 28% [2% - 62%] 60% [48% - 80%]


Key Accomplishment #9: Supported health facilities to improve malaria data quality and data use for local planning through data management coaching visits Malaria data analysis and visualization through regional holistic assessment, Surveillance, Monitoring, and Evaluation (SME) TWG meetings and OTSS+ revealed several challenges: poor data capture; poor documentation of service provision (which affects data quality); lack of data use by managers and HWs to inform prioritization, decision-making, planning, and service delivery; and lack of data visualization tools for HWs thereby limiting their ability to measure their own performance at the facility level. During the project reporting period, IM Ghana supported the NMCP and RHMTs to conduct malaria data management coaching visits in five out of the 16 regions (i.e., North East, Northern, Savannah, Greater Accra, and Oti regions) reaching 211 HFs in 35 out of the 45 targeted districts. A total of 833 HWs were coached and mentored on malaria standard registers and monthly reporting forms, malaria data recording, data extraction, GHS SOPs for HIMS, visualization and use of data for planning and decision-making through facility-based wallcharts. IM Ghana supported the NMCP and RHMTs to conduct data coaching follow-up visits in three out of the five regions (i.e., North East, Northern, and Savannah) reaching 90 out of the 211 health facilities in 15 districts. A total of 418 HWs were coached and mentored. Observations from the data coaching follow-up visits showed that: ● In total, 285 action points were reviewed in 90 health facilities, with 60% of the action points

completely implemented, 23% of the action points in progress and 17% not started. ● The quality of malaria data improved in all targeted facilities. This was demonstrated by remarkable

consistency between data reported into DHIMS2 and data in reporting forms as indicated below. Some data inconsistencies between DHIMS2 and registers persist in some facilities. This could be attributed to staff not tallying service data either daily or weekly and not conducting data validation prior to report submission, in line with the SOP on health information management. Action plans have been developed to address these issues in the health facilities which need additional support.

Findings from Figures 23 and 24 show improvement in all areas of assessment after three months of implementing action points. The reliability of data being reported by facilities also improved, from 29% to 65% and the precision of data from 48% to 78% after three months of implementation.

Figure 22: Reviewing consulting room register at Nasoyiri CHPS, Savannah region, July 2021 Photo credit: Amos Asiedu, IM


Figure 23: Comparing data quality at baseline and three months after implementing action items (N=90), Source: Field assessment

Figure 24: Comparing data quality at baseline and three months after on malaria data quality (N=90 HFs), Source: Field assessment Data from DHIMS2 for the five regions (i.e., North East, Northern, Savannah, Greater Accra, and Oti) shows improvement in completeness of data reporting on DHIMS2 and gradual reduction on error rate of data being reported on DHIMS2.


Figure 25: Data completeness and error rate in the five regions, Source: DHIMS 2 Observation of facility-based wallcharts shows that staff acknowledged the usefulness of the tool and demonstrated adequate knowledge in the use of various malaria indicator wallcharts. Some facilities were able to demonstrate the use of the wallcharts for planning and decision-making. In addition, some facilities have updated and displayed their wallcharts. Figure 26 shows that a majority (84%) of HWs have been oriented on the use of the facility-based wallcharts, 75% were displayed with 68% of the displayed wallcharts accurately updated. Furthermore, 60% are using the wallchart to make decisions at the facility level. For example, the wallchart was used by some heads of facility for managing the stock of malaria commodities and reviewing their performance against targets during clinical meetings to improve coverage.


Figure 26: Performance in facility-based wallcharts (n=90 HFs), Source: Field assessment Key Accomplishment #10: Trained district and hospital-level managers on data visualization and use of data for decision-making to improve the quality of malaria service delivery Health centers and CHPS do not have access to the DHIMS2 platform to visualize and track their performance for key malaria indicators at the facility level. IM Ghana, in collaboration with the NMCP, supported RHMTs, DHMTs, and hospitals to develop malaria dashboards in DHIMS2 and build capacity to customize the dashboards for specific districts to facilitate data-led malaria discussions at district- and facility-level. The facility-based wallcharts also support HWs to understand the importance of the data and to plan their activities based on current performance and trends. Four facility-based malaria indicator wallcharts (i.e., for key IPTp, ACT adherence, inpatient, and outpatient indicators) and corresponding job aids for specific malaria indicators were developed. To reinforce appropriate use of the designed wallcharts and to strengthen data visualization for DHMTs and RHMTs, IM collaborated with the NMCP and the GHS Policy, Planning, Monitoring and Evaluation Division (PPMED) to train regional, district and hospital health information officers (HIOs), district directors of health services, hospital managers, and malaria focal points on the wallcharts and customization of dashboards for key malaria indicators in DHIMS2. Thus, a total of 314 participants (234 male, 80 female) from 86 targeted districts in seven regions were trained. The overall average pre-course assessment was 63% and post-course assessment was 87%, for a 24% increase post-training. The


assessment was done on the knowledge of GHS SOPs on Health Management Information Systems (HMIS). Participants were trained on how to create malaria indicator dashboards in DHIMS2. All participants logged into their DHIMS2 accounts and were guided by facilitators to create malaria indicator dashboards including tables, charts, graphs, and maps to visualize malaria data. In addition, participants were taken through the rationale for using data to prioritize malaria interventions and tools for analyzing malaria data to aid prioritization, such as Excel dashboards, Pareto charts, and maps. In addition, a data quality audit, from January to March 2021, was done with the developed dashboard to highlight key district gaps in data reported into DHIMS2 and to task districts with data quality issues to address them immediately after the training. To promote use of the dashboard, facilities and DHMTs designed action plans to roll out the customized dashboard and wall charts. Based on indicator trends observed on the chart, action plans were developed to be implemented to maintain or improve coverage where needed for underperforming indicators. Key Accomplishment #11: Digitization of national integrated supportive supervision (ISS) tools to improve efficiency and promote timely analysis for decision making The current GHS data collection tool for ISS is paper-based, with inherent challenges in its administration, action planning, analysis, and feedback. During the last project reporting period, IM Ghana supported the process of conversion of the paper-based tool into an electronic HNQIS application. HNQIS is an enhanced EDS for national ISS that supports effective and efficient planning of visits, facilitates assessment, improvement approaches, and monitoring of supervisees. IM Ghana collaborated with the ISS coordinating team, ISS TWG, and other key stakeholders, to review the national supervisory checklist based on national and WHO standards in the following five technical areas: clinical, public health, management, reproductive and child health, and monitoring and evaluation. After this, the checklists were pulled into an electronic HNQIS platform. The updated digitized checklist on HNQIS provides for effective and quality supportive supervision through effective planning for visits, efficient and quality assessment of facilities and HWs, timely availability of supervision data to facilitate prompt feedback, and targeted mentoring as well as monitoring of health teams.

Figure 27: Completing wallchart by districts team, Volta region, July 2021, Photo credit: Amos Asiedu, IM


To support supervisors to be competent in the use of HNQIS for supervisory visits, IM Ghana supported the ISS coordinating team and PPMED to train national level facilitators from February 1 to 6, 2021. This reinforced national supervisor competency to use HNQIS for ISS for the next level of training. Eight participants from PPMED were trained as master trainers from February 1 to 2, 2021, and 33 participants (23 male,10 female) from the ISS TWG and other GHS departments were trained as trainers from February 3 to 6, 2021. During the training:

● GHS demonstrated ownership of the process, HNQIS application and DHIS2 platform for visualizing data and use for decision-making.

● The HNQIS app was accepted by both national staff and the TWG as an application that will help them to provide effective coaching and mentoring during ISS. They were particularly excited by the ability of HNQIS to enable them to identify weak areas for coaching and monitoring of HF performance in real-time.

● The TWG found it easy to understand how to navigate through the application and use it for supervision. At the end of the first day, most of them could work on the application with minimal support.

In addition, IM Ghana supported the ISS coordinating team and PPMED to finalize, validate, and approve the checklist content on the HNQIS application for the next level of training.

Figure 28: HNQIS training session in Koforidua, Eastern Region, February 2021, Photo credit: Amos Asiedu, IM



Delays in activity implementation due to competing activities after the easing of COVID-19 restrictions

IM Ghana collaborated and negotiated with the NMCP and RHMTs to make implementation of activities possible.

Occasional stock-outs of some malaria commodities (SP, mRDT, ACTs) in some facilities and regions.

● IM Ghana shared the concerns with the NMCP and USAID’s Global Health Supply Chain-Procurement and Supply Management (GHSC-PSM) project

● IM Ghana discussed the issues at the MIP TWG meeting

The national HIMS was down and had not been operating since December 2020 and January 2021 due to issues with space in the cloud to host more data.

IM Ghana collaborated with the USAID Evaluate for Health project to support PPMED to resolve the issue.

The National Health Insurance Agency (NHIA) reimburses health facilities only up to four ANC visits.2

IM Ghana collaborated with the NMCP and FHD to discuss with the Director General’s office to advocate for NHIA to pay up to eight ANC visits, in line with the WHO recommendation for the minimum number of ANC contacts.

Access to training and assessment data not funded by IM Ghana is difficult to access, especially in the area of diagnostics (e.g., MDRT, nCAMM).

IM Ghana negotiated with the NMCP for data sharing guided by adherence to the GHS and USAID open data policies.

Lessons Learned ● Developing malaria case management training assessment questions and evaluation forms on

Google forms allows real-time participant responses. This allows facilitators to focus additional attention to content areas where participants frequently missed questions and to clarify outstanding issues before the end of the training. This has become the accepted norm for assessments by all stakeholders.

● Working with the NMCP to implement a nationwide malaria case management training was essential for smooth training implementation across all levels.

● Training on customizing dashboards for DHIMS2 was essential for DHMTs to see the performance of key malaria indicators to enable them to develop ideas for change to address poor performing indicators and to follow steps to address missing DHIMS2 data.

2 Ghana’s national health insurance starts off as covering all services as fee for service. Under this payment method, after the provider had seen the insured client, the provider’s facility would send a bill listing everything that had been done for the client and how much was being charged for it and request payment.


IM Ghana Indicator Table The data provided in the indicator table below are IM targets and activity results from October 1, 2020 – September 30, 2021 across the IM-supported areas which includes the 260 districts and 16 regions in Ghana. IM Ghana team supported one laboratory round and one clinical OTSS round; a total of 260 and 867 facilities visited during Lab and Clinical OTSS respectively. A total of 2,448 individuals were trained (183 trained on MIP, 444 trained on CHO task shifting, 75 supervisors trained on lab, 529 supervisors trained on Clinical OTSS, 314 trained on data for decision making, 833 trained on malaria registers and tools, 29 trained on nCAMM and 41 trained on ISS digital tools). Progress to Annual Target is calculated as actual result/target *100=progress to target. This provides an indication of how much progress has been made to meeting the annual target outlined in the country workplan.


Progress to Annual

Target (actual/ target *100)

Comments


Percentage of confirmed malaria cases (test positivity rate)

45% 49.60% 90.70%

Target not met due to COVID-19 restrictions and lockdown. This reflected data from all the health facilities from the 260 districts and 16 regions in the country


97% 97% 100%

Met the target for this year. This reflected data from all the health facilities from the 260 districts and 16 regions in the country

Percentage of HWs demonstrating competency in malaria microscopy

80% 83.40% 104%

The results exceeded the target. This is from the 260 targeted health facilities for laboratory OTSS+. Also, the 302 targeted for clinical OTSS+ showed 76% competency in microscopy. This reflected data from 101 districts and 16 regions in the country

Percentage of HWs demonstrating competency in mRDTs

80% 89% 111%

The results exceeded the target for the year. This is from 867targeted facilities for clinical OTSS+. However, results from the 260 targeted health facilities for laboratory OTSS+ show 91% competency in mRDT. This reflected data from 101 districts and 16 regions in the country

Percentage of HWs demonstrating competency in correctly classifying

94% 89% 95%

The indicator is progressing well toward the target. This is from 867 targeted facilities for clinical OTSS+. This reflected data from



Progress to Annual


Comments

cases as not malaria, uncomplicated malaria, and severe malaria

125 districts from IM targeted 7 regions in the country

Percentage of targeted supervisors trained in supervision of malaria diagnostics

100% 100% 102%

Conducted a training for 72 out of the targeted 70 lab OTSS+ supervisors. Train supervisors across all the 16 regions

Percentage of targeted districts adhering to national malaria diagnostic supervision protocol

100% 100% 100%

All laboratory supervision visits are led by the CLU; therefore, all targeted districts used the national malaria diagnostic supervision protocol.

Percentage of targeted HWs trained in malaria laboratory diagnostics

100% 100% 100%

Trained a total of 1,049 HWs out of 1,049 targeted as part of the nationwide case management guidelines. This reflects from data from all 260 districts and 16 regions in Ghana

Percentage of targeted facilities with at least one provider trained in malaria parasitological diagnosis

80% 100% 125%

All 260 facilities visited have one provider trained. This reflects data from 101 districts and 16 regions in the country

Percentage of targeted facilities with national guidelines for malaria diagnosis

50% 52% 104%

Fifty-two percent of the 260 facilities visited have SOPs. This reflects data from 101 districts and 16 regions in the country



90% 98% 108%

Exceeded the target for this year. This reflects data from all the health facilities from the 260 districts and 16 regions in the country

Percentage of severe malaria cases that were treated according to national guidelines

90% 91% 104%




Progress to Annual


Comments

Percentage of targeted HWs demonstrating compliance to treatment with WHO-recommended ACTs for cases with positive malaria test results

100% 95% 95%

The indicator is progressing well toward the target. This is from 867 targeted facilities for clinical OTSS+. This reflects data from 125 districts from IM targeted 7 regions in the country

Percentage of HWs demonstrating adherence to negative test results according to global standards

90% 83% 92%

The indicator is progressing well toward the target. This is from 867 targeted facilities for clinical OTSS+. This reflects data from 125 districts from IM targeted 7 regions in the country

Percentage of targeted HWs demonstrating competency in management of severe malaria according to WHO guidelines

80% 83% 104%

The result has exceeded the target. This is from 867 targeted facilities for clinical OTSS+. This reflects data from 125 districts from IM targeted 7 regions in the country

Percentage of targeted HWs demonstrating competency in management of uncomplicated malaria

80% 83% 104%

The result has exceeded the target. This is from 867 targeted facilities for clinical OTSS+. This reflects data from 125 districts from IM targeted 7 regions in the country

Percentage of targeted HWs trained in management of severe malaria according to national guidelines in malaria case management

100% 100% 100%

Target achieved. Trained 560 (208 male, 352 female) out of 560 targeted HWs from regional hospitals. This shows data from 14 regional and municipal hospitals from 12 out of 16 regions.

Percentage of targeted HWs trained according to national guidelines in malaria case management with ACTs

100% 100% 100%

Target achieved. Trained 560 (208 male, 352 female) out of 560 targeted HWs from regional hospitals. This shows data from 14 regional and municipal hospitals from 12 out of 16 regions.



Progress to Annual


Comments

Percentage of targeted health facilities that receive a quarterly/semi-annual supervisory visit

100% 135% 135%

Clinical OTSS+ reached 867 facilities out of 643 targeted facilities in seven regions. This reflects data from 125 districts from IM targeted 7 regions in the country

Percentage of targeted health facilities regularly reporting routine malaria case data

90% 97% 108%


Percentage of targeted districts with national guidelines for malaria treatment that meet national standards

100% 100% 100% All 260 district administrators and facility staff trained and disseminated national guidelines.

Objective 1.3: Improved access to quality prevention and management of MIP

Percentage of pregnant women who received an ITN during routine ANC visit/interaction

93% 93% 100%

Achieved the target for this year. This reflects data from all the health facilities from the 260 districts and 16 regions in the country


68% 62% 91%

Target not achieved owing stock-out in some facilities etc. This reflects data from all the health facilities from the 260 districts and 16 regions in the country


78% 71% 91%

Target not achieved owing stock-out in some facilities etc. This reflects data from all the health facilities from the 260 districts and 16 regions in the country

Percentage of targeted HWs demonstrating competency in prevention of MIP

85% 89% 105%

The indicator has exceeded the target. This is from 634 targeted facilities for clinical OTSS+. This reflects data from 125 districts from IM targeted 7 regions in the country

Percentage of targeted HWs demonstrating competency in treatment of MIP

91% 91% 100%

The indicator achieved the target. This is from 634 targeted facilities for clinical OTSS+. This reflects data from 125 districts from IM targeted 7 regions in the country



Progress to Annual


Comments

Percentage of targeted HWs trained in IPTp per national guidelines

100% 100% 100%

Trained a total of 1,004 HWs out 1,004 (i.e., 560 case management and 444 CHO task shifting training) targeted as part of the nationwide case management. This reflects data from 30 districts and 14 regions.

Percentage of targeted districts with national guidelines for prevention and treatment of MIP that meet national standards

100% 100% 100% All 260 district administrators and facility staff trained and disseminated national guidelines.

Number of national MIP/RH/ANC working group participated in by IM Ghana staff

16 14 88%

MIP TWG- 1; regional annual performance review- 13 (Ahafo, Ashanti, Bono, Bono East, Eastern, Greater Accra, North East, Northern, Oti, Savannah, Upper East, Upper West, and Wester North regions) regions;



1 1 100%

One abstract submitted for American Society of Tropical Medicine and Hygiene (ASTMH) on facility-based MIP training.

Number of targeted national, regional or global level working group(s) and/or taskforce(s) in which IM participated

21 23 91%

MIP TWG- 1, case management TWG- 1, ISS TWG- 1; SME- 2; LLW- 3; regional annual performance review- 13 (Ahafo, Ashanti, Bono East, Eastern, Greater Accra, North East, Northern, Oti, Savannah, Upper East, Upper West, and Western North regions)

Number of regional or global guidance/policy documents contributed to malaria related issues

2 2 100% National operational manual for the MSB and national diagnostics guidelines


IM Ghana COVID-19 Response Background In the previous reporting period, the Ghana MOH and GHS requested IM support to develop and roll out COVID-19 case management and laboratory guidelines; assess facility preparedness; and determine the impact of COVID-19 on the delivery of essential services. IM Ghana continued this support into the current project reporting period, ending in March 2021. Reporting as of December 1, 2020 indicated a total of 51,667 confirmed COVID-19 cases, representing a case/population ratio of 1.7/1,000; 50,547 recoveries/discharges; 797 active cases in treatment centers or receiving home-based care; and 323 deaths representing a case fatality rate of 0.6%. The most affected regions were the Greater Accra and Ashanti regions, which are reporting about 54.4% and 21.5%, respectively, of the total cases. In response to the COVID-19 pandemic, USAID provided additional funding through IM to provide technical and financial support to the MOH to strengthen and build the capacity of health facilities and health workers to manage COVID-19 cases. IM supported the government’s COVID-19 response through the following activities:

● Support the GHS to conduct supervision to assess and strengthen COVID-19 preparedness of health facilities and health care workers.

● Develop and implement a rapid health facility assessment of the COVID-19 impact to deliver essential services.

● Support the GHS to update clinical and laboratory guidelines and tools for the COVID-19 context. ● Support the implementation of updated guidelines on diagnosis, triage, referral, and case

management of fevers. ● Support quality control for sample taking, testing, and diagnostic capabilities of testing and

reference laboratories and biosafety procedures.

Figure 29: Map, IM Ghana's COVID-19 response


IM Ghana COVID-19 Key Accomplishments Key Accomplishment #1: Training clinicians and non-clinicians for COVID-19 case management and infection, prevention, and control (IPC) To support HWs to have updated knowledge and competency to implement the newly updated case management and laboratory COVID-19 guidelines in Ghana, IM supported the GHS and the Regional Health Administration to train clinical and non-clinical staff on COVID-19 case management and IPC from October 12 to December 22, 2020, in Bono and Savannah regions, using the updated guidelines. This training was based on the findings from the health facility and HW’s preparedness assessment for COVID-19. It aimed to improve the quality of COVID-19 case management and HW and patient safety at the facility-level. A total of 911 clinicians (443 male, 468 female) were trained on case management and IPC. Clinicians average pre-course assessment was 53% and average post-course assessment was 85%, indicating a 32% increase. Key Accomplishment #2: Supported TOTs on the newly developed COVID-19 laboratory guidelines and tools To support laboratory staff at the facility-level to have the latest guidelines and for the sustainability of trainers in Ghana, IM collaborated with the Africa Society of Laboratory Medicine (ASLM) and Resolve to Save Lives (RTSL) to support the Institutional Care Division (ICD)-GHS to conduct national TOTs on the newly developed COVID-19 national laboratory guidelines from October 21 to 23, 2020, in Accra. Participants included two MLSs from each of the 16 regions of Ghana, and 10 participants from GHS national level. The training introduced participants to the updated guidelines, SOPs, tools, and biosafety procedures to enable them to serve as

Figure 30: Demonstrating hand washing during training in Bono region, October 2020, Photo credit: Charles Agblanya, IM

Figure 31: Assessment of health worker’s knowledge on COVID-19 case management and IPC


national facilitators for nationwide training. In addition, IM distributed 500 flash drives embedded with the updated guidelines and SOPs, to all 16 regional health directorates. A total of 42 (33 male, nine female) master MLS trainers were trained. The average knowledge pre-assessment score was 55% and average post-assessment course was 81%.

Figure 32: Knowledge assessment of MLS for COVID-19 laboratory guidelines


The GHS prefers a traditional in-person approach to training instead of remote or virtual training. IM Ghana’s plan did not budget for supporting in-person training as part of the original COVID-19 implementation approach.

IM continued to negotiate with the GHS to find a solution to meet training needs. A blended training model was agreed upon that included some remote learning and other in-person didactic sessions.

Lessons Learned – COVID-19 Response ● PMI/USAID’s initiative to inform all partners and the government of the division of responsibility

between partners early in the pandemic was a useful contribution to ensuring smooth coordination and avoiding duplication of effort.

● To support a safe in-person learning environment, it was necessary to provide adequate personal protective equipment (PPE) for all facilitators and participants and establish standard COVID-19 prevention guidance in advance of the trainings.


IM Ghana COVID-19 Response Training Indicator Table # Indicator Data

Source Verification Fre-

quency Total Disaggregation of Results, as applicable

Men Women National Sub-nat.

1 Number of people trained on COVID-19 clinical guidance

Training report

List of participants

Monthly 911 443 468

911

2 Number of people trained on COVID-19 laboratory guidance

Training report


Monthly 42 33 9 42

3 Number of people trained on COVID-19 clinical biosecurity measures

Training report


Monthly 740 296 444 740

4 Number of people trained on COVID-19 laboratory biosecurity measures

Training report


Monthly 42 33 9 42

5 Number of providers trained on enhanced fever case management and triage

Training report


Monthly 732 332 400 732

6 Number of health facilities that have available COVID-19-related technical guidance documents and tools

OTSS+ data/ reports

OTSS+ review

Monthly 0 N/A N/A N/A 0

7 Number of COVID-19-related guidelines and tools developed or adapted and disseminated

Project documents

Documents produced

Monthly 0 N/A N/A N/A N/A

8

Number of health facilities who received an ISS/OTSS+ visit using COVID-19-adapted tools

OTSS+ data reports

OTSS+ review

Monthly 0 N/A N/A N/A 0

291 IM Kenya October 2020 – September 2021

Kenya Background IM Kenya works in close collaboration with the Division of National Malaria Program (DNMP) to operationalize the Kenya Malaria Strategy (KMS) 2019-2023 and its goal to reduce malaria incidence and deaths by 2023 and by at least 75% of the 2016 levels. The country has four malaria epidemiologic zones: endemic (lake and coastal), highland epidemic-prone, low-risk, and seasonal transmission. Malaria is highly prevalent in the lake-endemic zone that encompasses eight counties: Bungoma, Busia, Homa Bay, Kakamega, Kisumu, Migori, Siaya, and Vihiga (Figure 1). Despite the disruptions in the provision of essential services due to COVID-19, the lake-endemic zone registered an incidence of 292 per 1,000 people in 2020 compared to 308 in 2018.1

IM Kenya provides implementation and technical support for malaria service delivery in the eight lake-endemic counties through two objectives: ● Objective 1: Improve quality of and access to malaria case management and malaria prevention during pregnancy ● Objective 3 (Kenya Objective 2): In support of Objective 1, provide global technical leadership, support operational research, and

advance program learning

At the national level, IM Kenya supported the review of guidelines, tools, and training curricula for the diagnosis, treatment, and prevention of malaria. Support includes routine monitoring of antimalarials by conducting TESs in select sites to inform malaria treatment policy. Across all 63 sub-counties in the eight lake-endemic counties, IM Kenya provided technical support to develop sub-county and county workplans to align with the KMS 2019-2023 and evidence-based prioritization of interventions. These include training sub-county level mentors who facilitate capacity building interventions for HWs; disseminating revised guidelines and tools; and sharing malaria intervention messages, tools, and approaches in platforms such as World Malaria Day, TWG meetings and learning forums. In collaboration with the County and Sub-County Health Management Teams (C-SCHMTs), IM Kenya defined a focused package of interventions, including capacity building through training, supportive supervision, and mentorship to HWs in health facility and community settings. The package is provided to high-impact sub-counties whose selection is informed by malaria burden based on incidence, reported confirmed malaria cases per 1,000 persons. IM Kenya provides focused implementation support to 50 sub-counties covering 974 of 1,211 (80%) public

1 Division of National Malaria Program (2020). Malaria Surveillance Bulletin Issue 35, October to December 2020.

Figure 1: Malaria Endemicity and IM Kenya Focus Areas


health facilities, both government-owned and those managed by faith-based organizations in the eight counties. At the community level, IM Kenya builds on support provided by the Global Fund through Amref by providing MIP interventions in 771 (63%) community health units (CHUs) in the 50 sub-counties.

Key Accomplishments Objective 1: Improve quality of and access to malaria case management and malaria prevention during pregnancy Key Accomplishment #1: Finalized, launched, and disseminated malaria policy documents During the reporting period, IM Kenya supported the DNMP to finalize revised technical reference documents (Table 1) that provide national guidance on malaria diagnosis, treatment, and prevention. With support from IM Kenya and in collaboration with other stakeholders, the DNMP revised the documents to align with the KMS and global guidance. Future reviews of the policy documents will be based on new recommendations as strategies are reviewed or global initiatives adopted. The review process involved convening consultative stakeholders’ workshops and providing technical inputs, including review of the draft documents by IM headquarters (HQ). IM Kenya supported the printing of 200 initial copies of each of the revised documents. In the next reporting period, IM will support the printing of an additional 100 copies of the guidelines and 1,000 copies of job aids2 for distribution to targeted service delivery points. The guidelines were officially launched during the World Malaria Day celebrations on April 25, 2021. IM Kenya has supported continuous dissemination of the revised reference documents during training, supportive supervision, and mentorship sessions. With guidance from the DNMP and support from IM Kenya, other stakeholders have integrated dissemination of revised guidelines in similar activities, such as during the recent training by Amref with support from GlaxoSmithKline. In-service training curricula on parasitological diagnosis of malaria and job aids including dosing schedules for AL and injectable artesunate, have been updated in line with the revised guidelines. The revised curricula were used during recent trainings of medical laboratory technologists and quality assurance laboratory staff. In addition, the revised IPTp provision schedule has been included in the Mother-and-Child Health Handbook. IM Kenya supported the DNMP to review diploma and undergraduate pre-service curricula targeting five core diploma-level cadres of health workers, including clinical officers, nursing officers, pharmaceutical technologists, laboratory technologists, as well as health records and information officers who are key to the delivery of malaria services following the revision of the guidelines. IM Kenya facilitated the development of a report on gaps in knowledge and competencies related to malaria case management and prevention of malaria during pregnancy in the existing curricula. IM Kenya supports the DNMP through the committee of experts, with participation of regulatory bodies and institutional academic leadership, to update respective course content, sequencing, and mode of delivery.

2 The tools include the case management and prevention of malaria in pregnancy job aids; case management algorithm; AL dosing chart; IPTp provision chart; and job aids on preparation of a chlorine solution for disinfection, and artesunate reconstitution.


Table 1: List of reviewed policy documents, launched and in the process of dissemination (Online versions can be found here: https://www.nmcp.or.ke/index.php/resource-centre/download-centre/case-managment#)

Technical reference document

Rationale for document development/revision and IM

interventions Deliverable

Guidelines for the Diagnosis, Treatment, and Prevention of Malaria in Kenya

● Revised the start of IPTp to 13 weeks, from the prior recommendation of 16 weeks of gestation and updated the IPTp schedule in line with WHO guidance

● Updated dosing charts for AL, dihydroartemisinin-piperaquine (DHA-PPQ), and injectable artesunate to include both weight- and age-range particulars. This update will enhance adherence to treatment guidelines among health workers

Kenya Quality Assurance Guidelines for Parasitological Diagnosis of Malaria

● Document was in draft form for nearly ten years

● Revisions were motivated by the lack of a functional QA/quality control (QC) system for malaria diagnosis. Sections were added to guide implementation of internal QC and external QA programs

● Provided guidance on surveys to determine the extent of gene deletion and its effect on routine mRDT-based malaria diagnosis


Technical reference document

Rationale for document development/revision and IM

interventions Deliverable

Implementation Framework for Malaria Rapid Diagnostic Tests

● IM facilitated the roll-out of malaria diagnostics QA/QC in line with the KMS 2019-2023

● The M&E framework was expanded to include the performance matrix.

● IM developed a costed implementation matrix to provide guidance on costing of activities in line with the KMS 2019-2023.

Biosafety Guidelines for Malaria Rapid Diagnostic Testing at Community Level

● Developed new guidelines to address emerging QA and biosafety concerns at community level

● In fulfilment of the requirements by the Kenya Medical Laboratory, Technicians, and Technologists Board to allow for a new waiver for community health volunteers (CHVs) to conduct testing using mRDTs.

Key Accomplishment #2: Achieved 100% treatment for patients testing positive for malaria through capacity building of health workers in Kenya’s lake-endemic region The IM training and mentorship model focuses on building capacity of mentors at national, county, and subcounty health facilities. Mentors then conduct targeted training, post- training follow-up, mentorship, and support supervision for HWs to acquire up-to-date knowledge and capacity for provision of quality malaria treatment services. This model has received positive reviews across the eight lake-endemic counties where IM Kenya collaborates with C-SCHMTs. In a recent meeting, the Busia County Malaria Control Coordinator (CMCC) indicated that the region will be fully adopting the model beyond IM Kenya’s project period. Since May 2021, four counties (Bungoma, Busia, Migori, and Siaya) have adopted the model for new case management partners. Through this approach, more health workers have been reached and the project supported counties to achieve improved performance for the percent of confirmed positive patients receiving the first-line recommended treatment (Figure 2). In particular, IM


Kenya collaborated with C-SCHMTs in the eight lake-endemic counties to train 1,502 health workers, 902 (60%) female and 600 (40%) male from 573 health facilities for malaria case management and MIP. The number trained represents 93% of the target 1,400 health workers. On the request from and recommendation of the C-SCHMTs, IM Kenya expanded the scope of coverage from 38 sub-counties (60% of the total 63) in October to 55 (87%) in December 2020 by conducting entry meetings and identifying and training an additional 140 mentors from the 17 new sub-counties. Cumulatively, IM Kenya has supported the training of 423 mentors (194 female, 229 male) from the 55 sub-counties (Figure 4). A total of 1,330 health workers from 353 health facilities have received up to three structured mentorship visits by a multidisciplinary team of mentors, including clinical officers, nursing officers, laboratory technologists, pharmacists, and health records and information officers. Mentors provide integrated follow-up, on-the-job training, health worker observation, and data reviews in the facility setting, and along the continuum of patient care. Data reviews using facility wall charts provided by IM Kenya has allowed all departments to jointly conduct an in-depth review of their monthly data by quickly pointing out the gaps and addressing them in one meeting. This approach of training and structured mentorship allows malaria coordinators to build health worker capacity in an objective manner, while taking stock of the gains for cross-learning, and at the same time, keeping track of the gaps with action items that are followed up on during subsequent visits. Health facilities now have competent workers who adhere to the Kenya malaria guidelines. This translates to the performance depicted in Figures 2 and 3, where the percent of reported confirmed positive malaria cases treated with AL dropped from 178% in the October-December 2019 reporting period to 97% following the July-September 2021 reporting period. The overtreatment of patients of up to 178%, was due to HCW inadequate capacity, gaps in data reporting especially on consumption and stocks for malaria testing, treatment, and microscopy commodities. The project has been working with the counties and other malaria partners to address these gaps, and IM continues to see improvements as depicted in Figure 2. In addition, the C-SCHMTs have expressed appreciation for the TrainSmart database, which tracks and avoids repeat training for previously trained health workers. The database is used to inform training gaps, thus allowing for a new pool of health workers to be reached by other partners providing similar interventions.


Figure 2: Malaria case management cascade January 2019 to September 2021, Source: Kenya Health Information System (KHIS)

Figure 3: Treatment of confirmed positive malaria cases with AL, Source: KHIS


Figure 4: Cumulative number of mentors and sub-counties trained, Source: IM training data Key Accomplishment #3: Improved inpatient malaria reporting and patient outcomes in the lake-endemic region of Kenya Supporting the DNMP and counties to offer quality malaria services is more fulfilling when health workers are able to positively impact the lives of target communities. Feedback, given by patients and their care givers, can motivate the HWs and encourage them to identify areas of improvement. Through improved capacity, HWs can save lives, as illustrated by the experience of a Clinical Officer at the Muchimeru Health Center below of making the right diagnosis.

A six-year-old girl was admitted in the ward and was being managed for septicemia without improvement. Since I had been trained on severe malaria management, I requested malaria microscopy testing that indicated the child was positive for malaria. This was twenty-four hours after a test using an mRDT had given negative results on admission and so the patient was still on antibiotics. The blood slide positive results warranted a change in the patient’s management to use of injectable artesunate. The health of the girl, who came in lying down, got better after administration of two doses of artesunate. - Clinical Officer at the Muchimeru Health Center in Bungoma County

To build capacity for severe malaria management in admitting facilities, IM Kenya collaborates with the C-SCHMTs to conduct training and mentorship for malaria case management and MIP. IM Kenya supported the eight malaria-endemic C-SCHMTs to conduct a five-day residential bed-side severe malaria training, using the approach shown in Figure 5 – the IM Severe Malaria Capacity Building Schema. IM Kenya supported the C-SCHMTs in training 64 clinicians from 62 health facilities in March 2021 (Cohort 4) and July 2021 (Cohort 5). The 64 HWs from 62 health facilities were prioritized from Level 4 and Level 5 admitting sites in the 16 new sub-counties which IM Kenya had planned to focus during the current reporting period.


Figure 5: IM Kenya Severe Malaria Capacity Building Schema Since 2019, five cohorts (three in FY20, two in FY21) of 149 clinicians from 126 of a total of 238 (53%) admitting facilities in the 63 Sub counties have been trained on severe malaria. The 126 sites were prioritized due to the burden of malaria prevalence in the first 32 sub-counties where IM began

• TOT mentos supported to conduct follow up visits to the 64 mentees facilities. A total of 450 HCWs targeted for mentorship at the facilities offering inpatient services.

• Severe malaria mentorship checklist targeted at all HCW at the inpatient department (rather than index mentee only) utilized to assess competency levels in clerkship, complications management, data capture, treatment administration and follow vests

• Gaps identified addressed • Facility indicators reporting and monitored on KHIS

• Total number of health facilities in supported region mapped and categorized from Level 1-5.

• Level 4 and 5 facilities with admitting capacity identified • National and regional sever malaria physicians/experts

identified, trained (TOTs), and promoted for capacity

• IM identified two regional teaching hospital hubs with capacity to train.

• 1. Level 6 Jaramogi Oginga Odinaga Referral Hospital in Kisumu to serve Nyanza Region (Siaya, Homa Bay, Kisumu, and Migori Counties)

• 2. Kakamega Teaching and Referral Hospital to serve Western Region (Kakamega, Busia, Bungoma, and Vihiga

• Targeted to train at least one HCW in admitting sites at the new 16 sub counties- 64 HCWs

• Training conducted by TOTs • Action plan drawn by both TOTs and mentees for the next

three structured follow up visits. • Mentees required to sensitize all the HCWs at their

inpatient department service delivery points

Planning

Identify Regional Training Hub

Total Mentors: 12

Conduct Training 10 HCWs trained 149

Facilities reached 126 (63%)

Three follow Up Visits HCWs Mentored 791 Facilities reached 126


implementation. IM plans to build capacity of at least one HW from the remaining 112 admitting health facilities in the 31 sub-counties through training and mentorship.

Using IM trained regional master trainers and consultant specialists from the county hospitals, IM Kenya has facilitated 122 visits to the 62 index admitting facilities, during which a further 791 health workers were reached with severe malaria mentorship. Conducting mentorship and post-training follow–up, up to three times at the same sites, while using a severe malaria checklist, has enabled the facilities to address capacity gaps for the management of severe malaria complications, especially among children. The visits have resulted in facilities procuring appropriate patient files, complete with tools such as fluid and vital monitoring charts. An analysis of data from the 62 health facilities trained as of September 2020 indicated that the proportion of facilities with at least one health worker trained on management of severe malaria increased from 50% at baseline (April 2019) to 72%. The proportion of facilities documenting inpatient malaria data also improv ed, from 31% at baseline to 67% in December 2020. Health worker competency levels in severe malaria management improved from 64% to 77%,

while data discrepancies between primary source documents and KHIS decreased from 67% to 35%. In addition, facility wall charts have promoted quality data capture and enhanced decision-making and improved clinical practice. The wall charts are a good starting point when C-SCHMTs, with support from IM Kenya, visit the facilities for mentorship and supportive supervision. In Figure 6, the Ntimaru Sub-County Hospital in Migori County has an up-to-date wall chart at the inpatient department that shows reduced admissions due to malaria as a result of improved severe malaria case management. Key Accomplishment #4: Improved competency of health workers on malaria microscopy and malaria QA/QC IM Kenya supported the DNMP to strengthen laboratory services at national and county levels for malaria microscopy by facilitating four sessions of bMDRT for 72 microscopists, with attendees from each of the eight counties, including 30 females and 42 males. The four five-day sessions took place in Kisumu city. The criteria for selecting participants for the training was based on those having not participated in any previous malaria diagnostics refresher trainings (MDRT). Participants were taken through theoretical and practical training content, based on the WHO QA Manual on Malaria Microscopy Version 2, 2016.

Figure 6: Facility wall chart at Ntimaru Sub-County Hospital in Migori County, Photo credit: Maureen Mabiria, IM


Table 2: Criteria for national competency levels Competency

level Parasite detection (%) Species identification

(%) Parasite count within

±25% of true count (%)

A 90–100 90-100 50–100

B 80–89 80-89 40–49

C 70–79 70-79 30–39

D 0–69 0-69 0–29

Scores were classified into levels A to D based on a WHO grading scale as shown in Table 2. Average performance for participants during pre- and post-test assessments improved for parasite detection, species identification, and parasite quantification from 69% to 88%, 42% to 54%, and 13% to 25% respectively (Figure 7). All participants will be provided an additional opportunity to practice all skill areas of malaria microscopy. The final results show that one participant scored at level B, ten at level C, and 61 at level D. Of the 72 participants, 23 (32%) scored above 80% on parasite detection at pre-test compared to 63 (88%) at post-test. On species identification, none scored above 80% at pre-test and five (7%) scored above 80% at post-test. On parasite quantification, ten (14%) of the participants scored above 40% at pre-test and post-test. The targets of 80% for parasite detection and species identification and 40% for parasite counting targets have been set by the project (Figure 8). IM continues to support monthly technical support supervision visits and targeted mentorship to address these gaps.

Figure 7: Performance on key malaria microscopy skills during bMDRT, Source: Training Data


Figure 8: Percent of participants who scored above 80% in parasite detection and species identification and above 40% in parasite counting, Source: Training Data Furthermore, IM Kenya’s mentorship and training model for laboratory staff, which incorporates training and onsite mentorship, has received positive feedback from all laboratory staff across the eight lake-endemic counties where IM Kenya collaborates with C-SCHMTs. County and sub-county QA officers cascade this approach to lower-level health facilities. Figure 9 shows 1) a laboratory staff member preparing thick and thin blood slides after receiving mentorship from a supervisor and 2) the resultant blood slides prior to and post-mentorship.

During the reporting period, IM Kenya supported the DNMP to track indicators on slide preparation, parasite detection, and species identification. Figure 10 shows an improvement in performance of the indicators between the laboratory assessments conducted in September 2020 and technical supportive supervision activities during the period of October 2020 to September 2021.

Figure 9: Health worker preparing blood slides. Blood slides prior to and post-mentorship by supervisor, Photo credit: Janet Adisa, IM


Figure 10: Health worker competency in slide preparation, parasite detection, and species identification, Source: project data

Key Accomplishment #5: Strengthened capacity of CHVs to identify pregnant women in early pregnancy, counsel them on MIP, and refer them to health facilities for services IM Kenya supports C-SCHMTs in the eight lake-endemic counties to implement prevention of MIP interventions through strengthening CHV capacity to identify pregnant women at household level; effectively conduct messaging on MIP to create demand for services; and refer pregnant women to health facilities for IPTp and insecticide-treated mosquito net (ITN) issuance among other ANC services. IM Kenya has advocated to the counties to prioritize supervision of CHVs and support them to continuously provide quality services. Between October 2020 and September 2021, IM Kenya supported C-SCHMTs to orient 1,858 CHVs (1,383 female, 475 male) drawn from 153 linked health facilities in 16 sub-counties for MIP interventions. This represents an achievement of 74% against the annual project target of 2,500 CHVs. Cumulatively, IM Kenya has supported sensitization of 6,754 CHVs from 530 CHUs in 33 sub-counties (Table 3) on MIP prevention interventions. During this period, 269,832 pregnant women attended ANC clinics. Of those, 145,474 (54%) completed at least four scheduled ANC visits, with 117,201 (43%) receiving at least three IPTp doses as per WHO recommendations. Of all the pregnant women who received ANC services, 224,252 (83%) received counselling on ANC services through CHVs, with 135,501 (50%) referred for CHV services. Table 3: CHU coverage with MIP interventions

County Sub-county Total number of CHUs

Number of CHUs sensitized on MIP

MIP sensitization coverage

Kisumu Seme 28 11 28% Muhoroni 34 10

Nyando 42 12


County Sub-county Total number of CHUs

Number of CHUs sensitized on MIP

MIP sensitization coverage

Kisumu West 33 6 Siaya Bondo 26 26

53% Gem 38 15 Alego Usonga 42 22 Ugunja 23 6

Homa Bay Suba South 29 29

47% Rangwe 28 20 Rachuonyo North 62 12 Mbita 36 12

Migori Nyatike 38 24

51% Kuria East 31 25 Kuria West 32 10 Uriri 26 6

Busia Teso North 43 17

71% Butula 21 12 Bunyala 17 17 Teso South 38 38

Bungoma Kabuchai 34 9

41% Sirisia 28 15 Webuye West 31 17 Bumula 42 9 Kanduyi 9 9

Kakamega Ikolomani 26 12

42% Khwisero 26 26 Butere 47 9 Mumias East 29 7

Vihiga Emuhaya 29 29

76% Vihiga 22 9 Hamisi 31 16 Sabatia 33 33

Objective 2: In support of Objective 1, provide global technical leadership, support operational research, and advance program learning Key Accomplishment #1: Conducted a gender and barrier study IM Kenya, in collaboration with the DNMP, Bungoma and Siaya County Health Management Teams (CHMT), conducted a qualitative study to understand the gender and socio-cultural barriers associated with early ANC attendance and IPTp uptake by pregnant women in Bungoma and Siaya counties of Kenya. The study was conducted using qualitative data collection in the form of Focus Group Discussions (FGD) and Key Informant Interviews. FGDs used illustrative vignettes to elicit responses about typical behaviors


related to malaria in pregnancy. KIIs focused on typical services offered by community and facility providers, as well as provider opinions regarding client behavior. While evidence links gender and socio-cultural barriers to reduced uptake of reproductive and maternal health services in general, information is limited about their link to early entry into ANC and retention in care throughout pregnancy, as well as their link to the uptake of malaria services. The study sought to answer the question: What are the key gender, social-cultural, and other barriers that influence the provision and uptake of MIP services, with a focus on IPTp, in Kenya’s malaria-endemic counties of Siaya and Bungoma? The findings and recommendations from the study (Table 4) are being used to adapt programming to address major barriers to uptake of IPTp. Findings are categorized under early ANC initiation, ANC continuation, IPTp uptake, and ITN use in intervention areas. The findings from the study will be featured in a poster presentation at ASTMH in November 2021.

Table 4: Summary of findings and recommendations from the gender and barrier analysis

Intervention Area

Study Finding Recommendations

Early ANC initiation

● Women and their partners have complete and correct information about when and why to attend ANC. Lack of awareness is not the reason why women do not attend ANC.

● Male partners and mothers-in-laws influence (and in some cases control) whether and when a woman attends ANC or seeks traditional care or no care at all.

● Male partners are responsible for “facilitating” ANC attendance by granting women permission to attend and providing transport.

● Discord within the couple may keep men from supporting their partners or women from telling their partners that they are pregnant.

● Women fear judgment or mistreatment by providers, while male partners may forbid ANC attendance due to worries of provider abuse.

● Focus on the role of key influencers and those with decision-making power over women’s action

● Help providers build their own skills in interpersonal communications

● Explicitly address abusive behaviors in all provider training curricula

● Prioritize the integration of couples’ communication interventions

● Build the capacity of health care providers in couples’ counseling

ANC continuation

● Women are motivated to continue to attend ANC because they understand the health benefits for mother and baby.

● After beginning ANC, the provider takes the place of the male partner as the person with the most influence over a woman’s likelihood to continue to attend ANC services.

● The main determinant of a woman’s likelihood to continue ANC services is the treatment she

● Support providers to create a strong client-provider relationship

● Do not prioritize partner accompaniment of women for care, as (1) male accompaniment has not shown to be a main driver for ANC uptake, and (2)


Intervention Area


receives from the provider during her initial visit. If the provider treats her kindly, then she is more likely to return.

● Reminders can help women consistently attend ANC.

this practice can have unintended negative consequences by discouraging ANC for women who do not have partners or whose partners cannot accompany them.

● Integrate additional opportunities for reminders, such as through CHVs or Short Message Service (SMS)

IPTp uptake ● Women and their partners are aware of the benefits of IPTp.

● The main barriers to IPTp uptake for women are the immediate negative physical effects, i.e., it makes some women feel nauseous or dizzy, and has a bad smell or taste.

● Providers view DOT as a benefit to protect women, but women see this practice as coercive. It discourages some women from returning for care, because they feel they will be forced to take IPTp against their will.

● If a woman is treated with respect and kindness during the administration of the first dose, the woman will continue to return for ANC services and take future doses of IPTp.

● Providers do not have the power to make IPTp less unpleasant for pregnant clients, but they can support clients by giving them the opportunity to voice their concerns, listen with empathy and respect, and address any questions they may have.

● When building providers’ interpersonal communication skills, malaria programs should focus on providers’ and clients’ conflicting views about DOT: providers can explain to clients the reason behind the use of DOT, but also must acknowledge clients’ discomfort at feeling like they do not have control of their own health choices.

ITN use ● Women and their partners understand the benefits of sleeping under ITNs to prevent

● Providers should be trained to listen to women’s concerns with


Intervention Area


malaria but may lack information about how to properly clean and hang their ITN.

● The main barrier to sleeping under an ITN was physical discomfort: it is hot, smells bad, irritates the skin, and may be perceived to attract bedbugs.

● Male partners can influence ITN use, either positively (by encouraging his partner to use it) or negatively (by refusing to sleep under it himself).

● It is more likely that a pregnant woman will sleep under an ITN if she perceives that she has a high risk of contracting malaria.

empathy, answer their questions regarding ITN hanging and care, and work with them to develop strategies to make sleeping under an ITN more comfortable.

● Provider and CHV messaging should be adapted to include community testimonials, stories, and statistics to describe the real malaria risk in their communities, which can help women understand their risk of contracting malaria.

In addition, IM Kenya supported the DNMP, to write a protocol, seek ethical approval from institutional review boards, and initiate the treatment efficacy study (TES) in Bungoma and Siaya counties from March 2021. The study drugs used are WHO approved first and second line antimalarials including artemether lumefantrine and dihydroartemisinin-piperaquine. The sites (Makhonge and Kaluo health centers) had enrolled 298 (74%) of 400 participants by the end of September 2021. IM Kenya provided support for the two-day training and mentorship of health facility staff in the two study sites, procurement of study equipment, tools, and consumables, data entry and conduct of two quality assurance visits by the investigators. A learning activity focused on review of the management of severe malaria practices also began following receipt of ethical review committee approval in June 2021. The study involves review of inpatient case notes from the Kakamega County Referral Hospital and Jaramogi Oginga Odinga Teaching and Referral Hospitals to gather data on the management practices for severe malaria in IM-supported facilities to document best practices, gap areas, and lessons that will guide program improvements to achieve high quality severe malaria management practices in admitting facilities throughout the project areas. Data collection is ongoing, and preliminary findings will be reported during the next project reporting period.


Challenges and Solutions Challenges Solutions High turnover of trained staff at the health facilities, leading to capacity drain shortly after trainings

Engagement with C-SCHMTs and Directors of Health on the importance of retaining trained staff especially those trained on severe malaria or transferring them to facilities that provide the service. Most counties have appreciated the importance of staff retention and will take this into consideration during the subsequent processes of human resource redistribution.

Disruptions related to COVID-19, including health facility closures and transmission among HWs; as well as health worker strikes for a large part of Quarter One contributed to activity delays, including two delayed facility interventions for mentorship and supportive supervision

IM Kenya supported the counties to hold more facility contact sessions once COVID-19 measures were put in place and health worker strikes were over. Data reconstruction was done for the months during which facilities were closed, to allow for better commodity management and reporting.

The documentation and tracking of community level malaria services remains a bottleneck in community-level management of malaria. None of the counties has budgeted for community level data tools. Counties continue to rely on partners for this data tracking. Tools for community-level data collection are also unavailable for capturing and reporting household data on referral of pregnant women for MIP services.

IM Kenya has articulated this gap at county level and advocated for county prioritization through the County Directors of Health. At the national level, IM Kenya has raised this issue with the DNMP and other stakeholders in the committee of experts’ meetings. However, to date there has been no commitment to address this gap, due to the cost implications. IM Kenya will continue to advocate for this support at both county and national government levels.

Cost of production of hard copies of the reviewed guidelines and updated job aids and Social and Behavior Change (SBC) materials

IM produced initial paper copies for county and sub-county malaria coordinators and focal points for quick reference. IM also enabled photocopying of the job aids and SOPs for use by HWs at service delivery points and SBC materials for CHVs at the community level. Soft copies were shared with health workers.

Poor quality diagnostic services due to a limited number of laboratory staff trained in parasitological diagnosis of malaria; lack of equipment maintenance for tally counters and microscopes; and lack of supplies, like chemicals for preparation of Giemsa stains

The few trained laboratory staff are unlikely to make an impact in diagnostic services, therefore, a change of schedule for conducting the technical support supervision (TSS) from quarterly to monthly was implemented to allow for more opportunities to provide onsite trainings and mentorship to more laboratory staff. Support was provided to county and subcounty malaria laboratory QA officers to conduct the monthly


Challenges Solutions TSS mentorships in targeted facilities to improve the competency of laboratory staff in parasitological diagnosis of malaria and establishment of internal quality control systems in the laboratories to improve results.

Lessons Learned ● QI initiatives targeted at county health leadership can improve malaria service outcomes. In Vihiga

County, the County Director of Health was involved in setting up the County QI team. Through this involvement, the critical gaps from occasional stock-outs of SP in health facilities were highlighted, resulting in a directive to health facility managers to purchase the commodity to alleviate stock-outs in cases of delayed supply by the national supply chain mechanism, the Kenya Medical Supplies Agency (KEMSA).

● Institutional collaboration between faith-based organizations and public health facilities has contributed to improved SP commodity stocks in Teso south sub-county, Busia County. During periods of acute shortage due to delays from KEMSA, health facilities managed by faith-based organizations collaborated with public health facilities to purchase the commodity in bulk from the Missions for Essential Medicines and Supplies and redistribute to public health facilities at a moderate fee to mitigate stock-outs.

● C-SCHMT capacity and commitment is critical to planning, ownership, financing, and execution of malaria case management and MIP interventions. This enables counties to provide leadership and increase coverage of interventions at facility- and community-levels through their capacity to conduct training, mentorship, supportive supervision, and use of data for decision-making, a critical ingredient for sustainability.


IM Kenya Indicator Table

The data provided in the indicator table below are IM Kenya targets and results from the period October 1, 2020 – September 30, 2021. The data in the indicator table reflect activities in the IM supported areas in Kenya which include counties in the Lake-Endemic Zone (Bungoma, Busia, Homa Bay, Kakamega, Kisumu, Migori, Siaya, and Vihiga). Progress to Annual Target is calculated as actual result/target *100=progress to target. This provides an indication of how much progress has been made to meeting the annual target outlined in the country workplan.

Objective # Indicator Target Result Progress to Annual Target (%)

Comments

Objective 1: Improve the quality of and access to malaria case management and prevention of malaria in pregnancy

Percentage of suspected malaria cases confirmed positive

KHIS data does not capture the number of presumed malaria cases, which is part of the denominator in the revised IM PMP indicator #1.


100% 81% 81% Target was not met due to RDT stockout experienced in the early quarters of the FY.

Percentage of HWs demonstrating competency in correctly classifying cases as not malaria, uncomplicated malaria, and severe malaria

100% 91% 91% Mentorship in 204 health facilities for 898 HWs


100% 65% 65% Average score for the 81 HWs observed was 90%; 53 scored 90% or greater. Monthly TSS is being implemented to improve competency.

Percentage of HWs demonstrating competency in malaria microscopy - slide preparation

90% 41% 46% The average score is 72% for the 396 HWs observed during the reporting period, with 161 HWs scoring 80% or greater. Monthly TSS is



Comments

being implemented to improve competency.

Percentage of HWs demonstrating competency in malaria microscopy - parasite detection

90% 82% 91% Parasite detection agreement for 323 of the 396 observed HWs

Percentage of HWs demonstrating competency in malaria microscopy - species identification

80% 69% 86% Species identification agreement for 274 of the 396 observed HWs. Monthly TSS is being implemented to improve competency.

Percentage of supervised facilities that meet standards3 (including appropriate materials, documentation, and qualified staff) for quality diagnosis of malaria

90% 4% 4% Only 24 of the 116 facilities that received malaria laboratory technical supportive supervision in July to September 2021 scored 80% or greater. Frequency of TSS and mentorship is being increased to monthly to improve the competency of lab staff, which was the major gap area.

Percentage of supervised facilities with at least one provider trained in malaria diagnosis (mRDT and microscopy)

90% 90% 100% 61 of the 68 facilities that received mRDT supervisory visits in April to June 2021

Percentage of targeted HWs trained in malaria diagnostics (mRDT and microscopy)

100% 100% 100% 72 of the targeted 72 HWs trained on malaria microscopy.

3 Percent of supervised health facilities that meet 90% or greater on facility checklists for diagnosis during supervisory visit



Comments


100% 100% 100% All targeted 24 laboratory staff were trained in QA/QC.

Percentage of targeted counties with malaria diagnostic supervision tools that adhere to recommended standards

100% 100% 100%

Percentage of supervised facilities with recommended guidelines/SOPs for malaria diagnosis

90% 32% 36% 25 of the supervised 79 facilities have hard copies of revised guidelines on parasitological diagnosis. IM printed only a few seed copies of the guidelines due to production costs. However, soft copies are made available to the staff in all IM-supported facilities.

Percentage of uncomplicated malaria cases that received first-line antimalarial treatment according to recommended guidelines

100% 107% 107% Annual cumulative value still above the 100% target due to non-adherence by HWs in Q1 & Q2. But Q3 and Q4 values are below 100%.

Percentage of supervised facilities with HWs demonstrating competency in management of severe malaria according to guidelines

100% 63% 63% The low achievement was due to the addition of a new cohort of health workers (cohorts 4 & 5), newly added for mentorship in Q3. Competency will improve with further mentorship.

Percentage of observed HWs demonstrating competency in management of uncomplicated malaria

90% 88% 97% Mentorship data for 898 HWs from 204 facilities.

Percentage of expected malaria reports from IM

100% 100% 100%



Comments

Kenya -supported facilities received


100% 91% 91% 437 of 480 targeted facilities were supervised (120 in Q1, 120 in Q2, 90 in Q3 and 107 in Q4).

Percentage of targeted HWs trained in management of severe malaria

90% 100% 111% 64 of the target 64 clinicians trained on management of severe malaria

Percentage of HWs trained according to national guidelines in malaria case management with ACTs

100% 107% 107% 1502 of the target 1,400 health workers trained in malaria case management/MIP/mRDT

Percentage of IM Kenya -supported counties with recommended guidelines for malaria treatment that meet global standards

100% 100% 100% All eight counties received the revised guidelines.

Percentage of pregnant women who received an insecticide-treated net during routine ANC

100% 93% 93%


70% 45% 63% Late initiation of ANC contributed to low IPTp uptake. Mobilization for early initiation is being implemented by CHVs.


78% 62% 79% Late initiation of ANC contributed to low IPTp uptake. Mobilization for early initiation is being implemented by CHVs.



Comments


78% 78% 100%

Percentage of observed HWs demonstrating competency in treatment of MIP

95% 96% 101% Mentorship data for 898 HWs from 204 facilities.

Percentage of observed HWs demonstrating competency in prevention of MIP

95% 91% 96% Mentorship data for 898 HWs from 204 facilities

Percentage of HWs trained in IPTp/MIP

90% 107% 118% 1502 of the target 1,400 health workers trained in malaria case management, MIP, and mRDT

Percentage of IM Kenya -supported counties with recommended guidelines for prevention and treatment of MIP that meet global standards

100% 100% 100% All eight counties received the revised guidelines.

Percent of malaria case management/MIP Committee of Experts (COE) meetings convened at national level

100% 100% 100%

Objective 2: In support of objective 1, provide global technical leadership, support OR, and advance program learning

Contribution to national, regional, or global guidance/policy documents related to malaria (including Reproductive Health)

2 100% 100% Finalized and disseminated the two guidelines for diagnosis, treatment, and prevention of malaria


8 63% 63% One success story and four abstracts submitted to ASTMH were accepted for poster presentation



Comments

Participation in targeted national, regional, or global level working group(s) and/or taskforce(s)

4 100% 100% Participation in the quarterly malaria sector working group meeting

315 IM Laos October 2020 – September 2021

Lao People’s Democratic Republic (PDR) Background Between 2000 and 2010, the number of probable and confirmed cases of malaria in Lao PDR fell by 92%, from 279,903 to 23,047, and the number of malaria related deaths decreased from 250 to 24. After mRDTs were introduced in 2012, the number of cases detected increased. However, since then, case numbers have continued to decline. Between 2000 and 2020, the number of probable and confirmed cases of malaria in Lao PDR fell by 99%, from 279,903 to 3,537. Malaria-related deaths decreased from 250 in 2000 to 0 in 2019. The National Strategic Plan (NSP) for Malaria Control and Elimination 2016-20201 created by the MOH Department of Communicable Disease Control (DCDC) and the Centre for Malariology, Parasitology and Entomology (CMPE), has called for malaria elimination by 2030, with planned phases and strategies to be rolled out leading up to that date. The first phase of the NSP, from 2016 to 2020, aimed for the elimination of P. falciparum in all northern and central provinces as well as the reduction of the annual parasite incidence (API) to less than 5 cases per 1,000 population in the southern provinces. In 2019, the API fell below five cases per 1,000. The 2021-2025 NSP has presented the second part of a three-phase approach to eliminate all forms of malaria in Lao PDR and has included strengthened interventions targeted to the southern part of the country to reduce malaria burden, while also expanding and enhancing efforts to eliminate malaria in low-burden focal areas across the country. The most recent malaria stratification exercise, conducted in 2019, included a two-step process: 1) a district level API-based stratification using data from January 2017 to September 2019 to determine whether districts should focus on burden reduction activities (API>1) or elimination activities (API<1); and 2) a Health Facility Catchment Area (HFCA) level caseload-based stratification to identify HFCAs within each district which need intensified intervention packages. A risk map using a predictive model based on demographic, environmental, and other ecological data was also used to complement and validate the case data. The HFCAs were classified into four strata based on caseload during the previous two years and nine months: Stratum 1, malaria free; Stratum 2, low risk (<5 cases); Stratum 3, moderate risk (5-20 cases); and Stratum 4, high risk (>20 cases). The 2019 stratification exercise indicated that 125 of Lao

1 MOH (2016). National Strategic Plan for Malaria Control and Elimination 2016-2020. Retrieved October 23, 2021, from https://apmen.org/sites/default/files/all_resources/National%20Strategic%20Plan_Malaria%20Control%20%26%20Elimination_Laos%20%282016-2020%29.pdf

Figure 1: IM Laos Focus Areas in 69 districts within 11 provinces

https://apmen.org/sites/default/files/all_resources/National%20Strategic%20Plan_Malaria%20Control%20%26%20Elimination_Laos%20%282016-2020%29.pdf

https://apmen.org/sites/default/files/all_resources/National%20Strategic%20Plan_Malaria%20Control%20%26%20Elimination_Laos%20%282016-2020%29.pdf


PDR’s 148 districts should focus on elimination while the remaining 23 districts in five southern provinces should focus on burden reduction.2 The NSP for 2021-2025, developed by the DCDC and CMPE, has called for malaria elimination by 2030. The NSP targets have focused on eliminating P. falciparum from the entire country; eliminating all forms of malaria from the 13 northern provinces; and reducing the annual incidence of P. vivax in the five southern provinces to less than one case per 1,000 population. Specific targets have included:

● Eliminate the transmission of P. falciparum in the 13 northern provinces by 2021 ● Eliminate the transmission of P. falciparum in the entire country by 2025 ● Eliminate the transmission of P. vivax in the 13 northern provinces by 2025 ● Reduce the incidence of indigenous cases of P. vivax to <1 per 1,000 population in the southern

provinces by 2025 ● Prevent re-establishment of malaria in areas where it has been eliminated3

By 2030, the process for certifying Lao PDR as malaria free is expected to be initiated. The country is well along the path to achieving this goal. To achieve malaria elimination by 2030, Lao PDR must strengthen its case reporting, investigation, and response systems to provide data and information on sources of transmission and the behavior of high-risk groups.4 Although confirmed malaria cases decreased between 2017 and the third quarter of 2019, malaria has remained a threat for about half of the population, with 3.6 million of Lao PDR’s 7.3 million population at risk according to the WHO World Malaria Report 2018.5 The NSP identified an effective nationwide and integrated surveillance system as a strategic priority that will enable successful elimination. To support this priority, IM Laos has worked with the CMPE and other stakeholders to strengthen case reporting, investigation, and response capacity while providing technical support for improved targeting and efficiency of service delivery in elimination areas. PSI Laos, with funding from other sources, has worked to strengthen surveillance in the private sector, with PSI supporting 432 public private mix (PPM) outlets to report all cases into the malaria database within the HMIS. In 2019, the PSI-supported PPM network reported 9% of all cases detected in Lao PDR. From 2020-2021, IM Laos, with funding from PMI, supported the strengthening of malaria surveillance by providing training on the 1-3-7 approach to Provincial Centers of Disease Control (PCDC) health facilities, thereby building their capacity to implement case reporting, investigation, and response in line with national guidelines. The 1-3-7 approach targets reporting of confirmed cases within one day, investigation of specific cases within three days, and targeted control measures to prevent further transmission within seven days.6 This strengthening process first involved review and revision of training materials for all HWs

2 MOH (2020). Lao PDR Malaria Elimination Surveillance and Response guidelines.

3 MOH (2020). National Strategic Plan for Malaria Control and Elimination 2021-2025.

4 UNV Ravindra (2021). Road Map for Certification of Malaria Free Status in Lao PDR.

5 WHO (2018). World Malaria Report 2018. Retrieved October 23, 2021, from https://www.who.int/ publications/i/item/9789241565653

6 Kheang, S., Sovannaroth, S., Barat, L., et al. (2020) Malaria elimination using the 1-3-7 approach: lessons from Sampov Loun, Cambodia. BMC Public Health. April 22, 2020. Retrieved October 23, 2021, from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-08634-4

https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-08634-4

https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-08634-4


based on updated guidelines, followed by dissemination and roll-out of the revised materials. As of September 2021, IM trained 634 of the 688 targeted health workers on the 1-3-7 approach. IM Laos then supported CMPE trainers to implement a cascade training approach. First, key staff from 11 provinces and 69 district levels participated in a five-day TOT workshop, focused on the implementation of the 1-3-7 malaria elimination approach. Specifically, the TOT workshop focused on strengthening case notification, classification, and investigation; foci investigation and response; and capacity for reporting and analysis. TOT participants, in turn, provided training for key staff from 446 health centers through a three-day training course that likewise covered case notification, classification, investigation, response, and reporting. This cascade approach aimed to strengthen the long-term sustainability of knowledge and skills transfer. Additionally, IM Laos strengthened CMPE elimination efforts by evaluating 1-3-7 activities implemented at the provincial, district, health center, and community levels. The assessment also reviewed the human and financial resources required to effectively implement the 1-3-7 approach and the readiness of health officials at the provincial, district, health facility, and community levels to implement the approach after the training. After evaluating post-training knowledge and implementation, as well as the ability to adapt based on the gaps identified in the training, the IM Laos team and CMPE identified a need for health officials at all levels to effectively analyze and use case investigation data for decision-making to enhance the elimination approach. Geographic Scope: As noted above, a total of 125 districts in 17 provinces in Lao PDR were identified in 2019 as the focus for malaria elimination activities. IM Laos, with funding from PMI, supported the CMPE to roll out activities for improved targeting and efficiency of service delivery. Due to the disruptions of COVID-19 and an updated approach to training, IM Laos and CMPE adapted the original approved plan and training approach to focus these activities in elimination areas concentrated in 69 districts.

Key Accomplishments Objective 1: Improve access to high quality malaria diagnosis and treatment Key Accomplishment #1: Finalized and disseminated national guidelines on malaria case reporting, investigation, and response for all 17 provinces with malaria elimination districts IM Laos worked with its counterparts from the CMPE, WHO, Clinton Health Access Initiative (CHAI), and the Artemisinin-resistance Initiative 3 (RAI3E) to improve uptake of the updated malaria elimination guidelines at PHOs, District Health Offices (DHO), and health centers, by supporting the printing of tools for dissemination in the elimination areas. This guideline, pictured in Figure 2, was produced, and distributed to all HWs in 125 target elimination districts during the training session.


Key Accomplishment #2: Conducted training on updated national guidelines for case reporting, investigation, and response for PCDC, Provincial Anti-Malaria Stations (PAMS), District Anti-Malarial Nuclei, and health centers Early in the reporting year, IM Laos, CMPE, WHO, PAMS, and District Anti-Malarial Nuclei developed a plan to train provincial, district, and community HWs on the updated national malaria elimination guidelines for case reporting, investigation, and response. The national training plan and budget was updated, based on revisions made to the training component of the national malaria elimination guidelines, such as increasing the number of training days from three to five and expanding the targeted training recipients to include PHOs, DHOs, and health facility staff. Under the revised plan, a total of 634 HWs were trained, of which 342 were male and 292 were female. IM Laos worked with the CMPE and national stakeholders to estimate the full cost of surveillance for elimination training in all elimination provinces to identify financial gaps and avoid duplication of efforts between partners.

IM Laos supported the CMPE to roll out training activities for 69 districts. The reduction from the original plan of 125 districts was to accommodate the cost and logistics of the longer training, which had increased from three to five days. The training approach was modified in part in response to the COVID-19 pandemic. IM Laos and CMPE developed a new training methodology, by adopting a TOT cascade approach. The CMPE formed three teams with 24 national trainers (15 female, 9 male) and 56 trainers from the provincial and district levels (28 female, 28 male), representing 80 trainers in total. The trainers conducted training sessions simultaneously to complete the training within two months. Training started in the provinces and districts with the fewest COVID-19 related restrictions. CMPE trainers conducted nine workshops for key staff at provincial and district levels in these 69 districts. Provincial and district training participants then provided training for key staff at the health center level in 446 health centers over the course of three days for 19 workshops. This training approach complied with COVID-19 social distancing measures by limiting the number of participants in each workshop, while also completing training within the project timeframe and supporting long-term sustainability of knowledge and skills transfer. IM Laos staff, in cooperation with the CMPE, WHO, CHAI, and the Population Education and Development Association, completed malaria elimination training for all 11 target provinces during July 2021. The training reached a total of 200 trainees (97 female, 103 male) in nine workshops, each lasting five days. Trainees included PHOs, DHOs, and staff from army, police, provincial, and district hospitals. Fifty-six of the 200 trainees (the same 56 provincial and district level trainers noted in the previous paragraph) went on to train health center personnel in accordance with the cascade training approach. Figure 3 shows the results of pre- and post-training technical knowledge tests administered to provincial

Figure 2: Laos Elimination Surveillance Response Guideline, first revision, November 2020


and district HWs participating in the TOT. The test consisted of 20 questions covering technical knowledge on surveillance, DHIS2 use, and the 1-3-7 approach. It also included practice sessions during the classroom training on foci response, case classification, mapping, paper-based 1-3-7 reporting, DHIS2 reporting, malaria testing including mRDT and G6PD, and complete treatment. The average pre-test scores ranged between 47% and 71%, and the average post-test scores between 63% and 89%, indicating an overall improvement in trainee knowledge, as shown in Figure 3. Trainees were not familiar with, and did not retain, learning on the processes of investigation and foci response and Integrated Drug Efficacy Surveillance. Therefore, the trainers from CMPE and IM Laos prioritized follow-up support for these areas in trainings at the health center level.

Figure 4. Average pre- and post-test training scores at the health center level, by province Figure 4 shows the results of pre- and post-training technical knowledge tests for health center level training, administered by trainers from provincial and district health centers, with support from IM Laos

Figure 3. Average pre- and post-test results for TOTs at provincial and district levels, by province


staff and the CMPE. Training participants included 434 health center workers (195 female, 239 male) in nine of the 11 targeted provinces, through 19 workshops lasting three days each. The pre- and post-training test included 15 questions about technical knowledge on surveillance, reporting, and 1-3-7 implementation. It also included practice sessions during the classroom training. Average pre-test scores were between 42% and 69%, and the post-test average scores were between 66% and 97%, indicating that, on average, trainees increased their knowledge. Some trainees did not retain information on the process of investigation, general knowledge about surveillance, and appropriate treatment. Therefore, these areas will need close supportive supervision during implementation. Most IM-supported trainings occurred prior to lockdowns related to COVID-19. For the trainings that took place after those lockdowns went into effect, IM Laos and the CMPE were able to successfully adapt plans to conduct further training that enabled full program completion. Key Accomplishment #3: Developed the supportive supervision checklist for HW coaching and conducted supportive supervision visits in two elimination districts The purpose of supportive supervision visits has been to monitor the implementation of the 1-3-7 approach by PAMS and District Anti-Malarial Nuclei officers over time. In coordination with the CMPE, CHAI, and WHO, IM Laos developed a paper-based supportive supervision checklist to support IM Laos staff to coach HWs on reporting quality, completeness, and timeliness, as well as data use, analysis, and response according to the 1-3-7 approach. The supportive supervision visit checklist was developed and adapted from CMPE and CHAI supervision checklists and was piloted and improved as part of the first supportive supervision visit to address project objectives. One round of supportive supervision visits was conducted, following completion of the 1-3-7 malaria elimination strategy training in July 2021, following delay in obtaining the signed Memorandum of Understanding (MOU) from the government. IM Laos staff worked with provincial officers, to conduct supportive supervision visits using the new checklist in two of the new elimination districts in the south, Vilabouly and Xaibouly. These two districts had received training on the national elimination guidelines in December 2020. The areas targeted for this first round of supportive supervision visits were districts that had delays in case notification, incomplete case investigation, and late foci response. During the supervision visits, 18 PAMS and District Anti-Malarial Nuclei officers received visits. The main findings from supportive supervision visits indicated that while provincial and district officers possessed the national 1-3-7 malaria strategy manual and had malaria DHIS2 accounts, some had problems accessing DHIS2 because they were not sufficiently familiar with using it. The provincial and district officers were able to access DHIS2 for the purpose of monitoring and analyzing malaria surveillance dashboard data. However, not all PHOs and DHOs were able to provide a complete explanation or demonstrate understanding of how to use the dashboard data for foci investigation and response, nor how to describe actions that should be taken based on the dashboard data. The data that both provincial and district officers referred to and monitored were the cases in their respective districts; the village location of each case; as well as whether the case was notified within 24 hours, investigated, classified, and with the foci


response carried out. They also monitored ITN distribution and malaria cases in their province, other provinces, and throughout the country. In addition to looking at data use among the officers, IM Laos also reviewed the data with the officers by looking at the testing data and reviewing the malaria knowledge of the officers. Knowledge areas reviewed included malaria symptoms, testing process, treatment, and case reporting to support officers to adhere to the national malaria testing and treatment guidelines. Furthermore, IM Laos discussed malaria commodity data with PAMS and the District Anti-Malarial Nuclei. This revealed that provincial and district officers had not reported stock-outs in local health facilities in areas under their control. The officers were able to describe the process of the national 1-3-7 malaria elimination strategy, including case notification, case investigation, foci investigation and response. However, some officers could not describe the process completely, especially the activities that should occur within seven days of case confirmation. During the final supportive supervision, IM Laos provided recommendations to the PAMS and District Anti-Malarial Nuclei officers. These included advising PAMS and District Anti-Malarial Nuclei officers to note the login account and password for access to DHIS2; regularly monitor the data in DHIS2, including consumption of malaria medicines and malaria testing kits; identify stock-outs; and provide regular refreshers on the 1-3-7 malaria elimination strategy. After IM Laos Officers completed the supportive supervision visit with the District Anti-Malarial Nuclei, they provided a summary of the supportive supervision visit assessment to PAMS and the District Anti-Malarial Nuclei, as well as real-time feedback and coaching based on the assessment results. IM Laos Officers worked with PAMS and the District Anti-Malarial Nuclei to highlight strengths, review areas for improvement, and develop a joint action plan. Key Accomplishment #4: Adapted routine supportive supervision to the COVID-19 pandemic Lockdowns and restrictions related to COVID-19 prevented IM Laos staff travel, and supportive supervision was therefore adapted and redesigned for the virtual context. IM Laos staff piloted this virtual approach in August and September 2021, with provincial- and district-level personnel who have online access. Supervision was conducted by using the paper-based supportive supervision visit checklist mentioned under Key Accomplishment #3, to pose structured questions and ask health officers to demonstrate their practices through online video sharing. The lessons learned from this online approach will be used to improve the supportive supervision model in the next project reporting period to mitigate disruptions caused by any future travel restrictions or local lockdowns. Key Accomplishment #5: Developed the 1-3-7 strategy assessment tool In collaboration with the CMPE, WHO, and RAI3E teams, IM Laos developed a full 1-3-7 malaria elimination strategy assessment protocol. IM Laos also obtained feedback from the PMI team based at the USAID Regional Development Mission for Asia. Subsequently, a meeting was held to finalize the timeline, questionnaire, and assessment concept note with the CMPE, WHO, and RAI3E teams.


Key Accomplishment #6: Conducted the 1-3-7 assessment in the field using the strategy assessment tool Delays related to COVID-19 affected training implementation, so IM Laos revised the geographic focus of the 1-3-7 assessment to target elimination districts in the south, instead of also in the north as originally planned. This was done so that the assessment could be conducted in districts where training for elimination surveillance had already occurred. Elimination surveillance training in the southern districts was completed during a pilot in 2020. The assessment results and corresponding recommendations were provided to the CMPE so they could make targeted improvements to the strategy. Training participants included in the assessment were eight PAMS officers (three female, five male), 19 District Anti-Malarial Nuclei officers (seven female, 12 male), 23 health center officers (12 female, 11 male) and 18 village malaria workers (five female, 13 male) from four provinces including Savannakhet, Champasack, Saravan, and Sekong. Results of the assessment will be shared with the CMPE and WHO once they are finalized.

Additional Achievements IM Laos coordinated with relevant departments within the MOH and Ministry of Foreign Affairs (MOFA) to expedite the approval of the MOU with PSI. With CMPE support, IM Laos secured approval more quickly from the central level, thereby allowing activity implementation to begin throughout the country. This accelerated the process from the standard 19 months to only three months. PSI received final MOU approval from the MOH and MOFA in June and July respectively. On July 28, 2021, the MOU signing ceremony for the ‘Strengthening Surveillance to Accelerate Malaria Elimination’ project took place at MOH meeting facilities. The MOU was signed jointly by the Director General representing the MOH DCDC, and the PSI Laos Country Director. The MOH Vice Minister, USAID Country Office Representative to Lao PDR, a representative from the MOFA, and relevant MOH departments also attended the ceremony to commemorate the start of the project.

Figure 5: MOU signing ceremony for the Strengthening Surveillance to Accelerate Malaria Elimination project. Photo credit: Kaspa Bounphasinh, PSI Laos


Challenges and Solutions Challenges Solutions The revision of the national malaria elimination guidelines training had an impact on original training budget requirements. The number of training days increased from three to five and required an expanded range of participants from provincial, district, and health facility levels.

IM Laos worked with the CMPE, WHO, and RAI3E to finalize the training plan and budget. IM Laos discussed the additional financial needs with PMI. PMI identified additional resources to allow IM Laos to expand support for training from 33 to 69 districts. However, this was less than the originally planned 125 districts. CMPE sought other donors to cover the remaining districts; and subsequently received funding from RAI3E and WHO to cover the remaining districts. Due to COVID-19 restrictions, training was paused and will resume when possible.

IM Laos experienced delays obtaining signatures for the MOU, limiting the project’s ability to fully implement activities.

IM Laos, working with the PSI Laos country office, arranged a meeting with the CMPE, DCDC, the MOH cabinet office, and the MOFA to seek solutions. It was agreed that an MOU would be signed at the national level with PSI and the CMPE. This overcame the need to have signatories from all provinces and accelerated the process from 19 months to approximately six weeks.

Some provincial and district health officers expressed concern about the quality of training provided through a cascaded approach, given that participants would not receive direct training from the CMPE and IM Laos staff.

To reinforce the quality of training for health centers, a pre- and post-test was administered during each training session. Test results informed planning to support health center training, by targeting districts and provinces with the largest gaps. Results also informed the planning for continued coaching at the health center level by CMPE and IM Laos staff.

The delay in obtaining MOU approval reduced the time available to conduct supportive supervision. This reduced the duration of the training period, which was then further disrupted by COVID-19 restrictions on IM Laos staff travel.

IM Laos staff adapted routine supportive supervision to apply it virtually. They conducted one round of supportive supervision, based on instances when case notification data was reported later than 24 hours (per DHIS2 data) and wherein a complete case and foci investigation and response was not completed within the required time.

Several unpredictable challenges required ongoing revision to the plan throughout the 1-3-7 assessment, such as heavy rains causing road collapses and villages that could not be accessed. Also, time spent finding village health volunteer workers in target villages disrupted planning, as did HWs missing appointments.

IM Laos field interviewers either walked to villages or coordinated with local DHOs to change the venue. In some cases, they had to return later, which took time, or plans had to be revised to travel to different districts. Interviewers learned to build flexibility into the schedule for HWs, to accommodate unpredictable challenges.


Lessons Learned ● The cascade training approach was designed in response to the new wave of COVID-19 occurring

in April 2021. Consequently, IM Laos and CMPE had to quickly revise the budget and training plan. Despite limited human resources within CMPE, and time constraints, the cascade training approach effectively allowed IM Laos to address the challenges created by COVID-19.

● More generally, the cascade training approach can strengthen skills transfer, resolve the issue of limited human resources, and save time. The approach can be used to build the capacity of HWs from the provincial and district levels, with the support of the CMPE, whereby trained provincial and district workers go on to train health facility level workers.

● For the next period of performance, IM Laos will collaborate closely with the CMPE, PAMS, and the District Anti-Malarial Nuclei to improve efficiencies around the payment of government staff for per diems and travel for supportive supervision activities. This will include quarterly refresher orientations on financial policies and coaching of key health care workers to initiate feedback loops regarding both the payment process and implementation of supportive supervision.


IM Laos Indicator Table The data provided in the indicator table below are IM Laos targets and results from the period from October 1, 2020, to September 30, 2021. The data in the indicator table reflect activities in the IM supported areas in Laos which include 69 districts. A total of 634 health workers were trained. Progress to Annual Target is calculated as actual result/target *100=progress to target. This provides an indication of how much progress has been made to meeting the annual target outlined in the country workplan.

Objective #

Indicator

Bi-annual target

Jan-Jun 2021

Bi-annual target

July-Dec 2021

Results Jan-June

Results July-Sept

Progress to Annual Target

Comments

Objective 1: improve access to high quality malaria diagnosis and treatment

Percentage of case reports received within 24 hours of detection

100% 100% 83.8% 108/130

95.35% 41/43

89.6%

These figures were updated as of Sep 30, 2021. Since the training was delayed and was conducted in July 2021, some cases were still not reported in time due to district HWs being unfamiliar with reporting on DHIS2 before the training. Also, some HWs report on paper but later submit in DHIS2.

Proportion of cases investigated and classified, according to revised national guidelines

76% 19/25

77% 23/30

64% 70/109

82% 41/50

73%

Government results will be tracked bi-annually, January to June, and July to December. The bi-annual results from July to December have not been produced yet. Only results from July to September 30, 2021, were available – at 82%. The average for the two periods, from January to June and from July to September was 73%. This was less than the target, as most of the cases occurred in one district of the Khammouane province, where there are few HWs. HWs were also unable to conduct investigations on time. Furthermore, communications


Objective #

Indicator

Bi-annual target

Jan-Jun 2021

Bi-annual target

July-Dec 2021

Results Jan-June

Results July-Sept


Comments

were late, sometimes due to poor telephone signals and because of a lack of familiarity with DHIS2. A completed investigation may be reported late in DHIS2.

Proportion of foci investigated and classified, according to revised national guidelines

75% 6/8

78% 7/9

45% 13/29

29.41% 10/34

37%

Government results will be tracked bi-annually, January to June, and July to December. The bi-annual result, from January to June was 45%. The result from July to December has not been produced yet. The result from July to September 30, 2021, was available and was 29.41%. The average for two periods from January to June and from July to September was 37%. These figures were updated as of Sep 24, 2021. The figure was low because HWs were not familiar with implementing 1-3-7. They could not complete the foci protocol for any step, so it was missing, and the foci could not be counted as investigated in the report. From July to September, most of the malaria cases occurred in the Khammouane province where there were very few HWs present. This area is also remote, so the lack of timely financial support for the team, poor internet connection, and telephone signal were also disruptive.


Objective #

Indicator

Bi-annual target

Jan-Jun 2021

Bi-annual target

July-Dec 2021

Results Jan-June

Results July-Sept


Comments

Percentage of staff trained on case investigation and case classification (based on revised national guidelines)

N/A as activity was planned for second half of the year.

100% 688/ 688

0% 92.15% 634/688

92.15% 634/688

The target was set by the national record system, to include provincial and district health facilities and all health centers in the targeted 11 provinces. However, in practice there were no health centers in the capital city of Vientiane. This caused the actual number of participants to be less than that targeted.

Percentage of staff in malaria elimination districts who received the revised national malaria elimination guidelines


100% 0% 100% 1,362/ 1,362

100%

The national malaria elimination guidelines were distributed at the provincial, district, and health center levels in all elimination areas.

Percentage of targeted districts where the 1-3-7 assessment was completed


100% 100% 4/4

100%

Implementation of the assessment was completed in all targeted areas, including four provinces and 11 districts.

328 IM Madagascar October 2020 – September 2021

Madagascar Background Since 2019, Madagascar has committed to supporting the NMCP’s goal of progressive elimination of malaria as outlined in the National Malaria Strategic Plan 2018-2022. For elimination to be successful and sustainable, it is essential for Madagascar to have a strong foundation of malaria prevention, case management with appropriate and high-quality diagnostics, surveillance, and response from community to national levels. During this reporting period, IM Madagascar continued its support to the NMCP in accelerating progress towards its elimination goal. This included: ● Mobilization of elimination TWGs at national and sub-national levels ● Preparation for a quantitative assessment of malaria risk factors in pilot elimination districts ● Support for community-based elimination efforts ● Provision of regular, cyclical training and supervision in malaria diagnosis and case management through

MDRTs and OTSS+ visits IM Madagascar is committed to supporting the NMCP in the progressive elimination of malaria in line with two IM objectives:

• Objective 1: Improve the quality of and access to malaria case management and malaria prevention during pregnancy

• Objective 3: In support of Objective 1, provide global technical leadership, support operational research, and advance program learning

During the reporting period, IM Madagascar maintained its support to the NMCP in the strengthening of laboratory capacity and diagnostic services in all 23 regions of the country.1 The 81 basic MDRT participants represented all 23 regions in Madagascar, and laboratories in all regions received new laboratory registers through IM support. IM also expanded its support to the NMCP for supportive supervision through the laboratory OTSS+ approach for laboratory workers from 10 regions to 13 regions: Analamanga, Atsimo Andrefana, Atsimo Atsinanana, Atsinanana, Boeny, Diana, Ihorombe, Sofia, Vakinankaratra, Vatovavy Fito Vinany, Menabe, Alaotra Mangoro, and Haute Matsiatra (Figure 1). A total of 184 health facilities in 75 districts received laboratory OTSS+ visits with the support of IM this year.

1 Note: Until recently, Madagascar had 22 regions, but one has been divided into two, resulting in a total of 23 regions.

Figure 1: Thirteen regions receiving IM Madagascar support for laboratory OTSS+


To reach the elimination goal, the government of Madagascar has established district elimination stratification based on malaria incidence (Figure 2). Of the 114 districts in Madagascar, 13 are stratified as elimination districts (Table 1). Table 1: Lists of the thirteen elimination districts with annual malaria incidence, 2017-2021

N° REGIONS DISTRICTS Malaria incidence %

2017 2018 2019 2020 Mid-2021 (Jan-Jun)

1 VAKINANKARATRA Ambatolampy 1.19 0.94 0.59 0.62 0.24

2 ANALAMANGA Ambohidratrimo 1.02 2.19 0.86 1.84 2.93

3 ANALAMANGA Antananarivo Atsimondrano 0.39 0.72 0.36 0.30 0.36

4 ANALAMANGA Antananarivo Avaradrano 0.52 0.59 0.45 0.23 0.18

5 ANALAMANGA Antananarivo Renivohitra 0.14 0.14 0.14 0.28 0.11

6 VAKINANKARATRA Antsirabe I 0.76 0.81 0.53 0.87 0.38

7 VAKINANKARATRA Antsirabe II 0.39 0.53 0.30 0.52 0.83

8 DIANA Antsiranana I 1.23 0.40 0.37 0.53 0.19

9 ITASY Arivonimamo 0.95 1.07 0.51 0.78 0.73

10 VAKINANKARATRA Faratsiho 1.61 1.91 0.86 0.71 0.52

11 ANALAMANGA Manjakandriana 0.57 0.81 0.45 0.46 0.23

12 ITASY Miarinarivo 4.14 4.68 0.976 4.47 9.26

13 ITASY Soavinandriana 6.54 9.70 0.88 1.03 0.53

Figure 2: Map, District malaria stratification in Madagascar, 2018-2020


To support the achievement of Objective I during this reporting period, IM focused on accelerating efforts to achieve elimination in three target elimination districts: Antsirabe II, Antsiranana I, and Faratsiho. IM began supporting the NMCP to strengthen case management, surveillance, and response in Antsirabe II and Antsiranana I in 2020. Antsiranana I is in the Diana region in the north of Madagascar and Antsirabe II is in the Vakinankaratra region in the central highlands of Madagascar (Figure 3). During the reporting period, IM scaled up and expanded activities based on best practices and lessons learned. Geographically, IM expanded its support to a second district in the Vakinankaratra region, Faratsiho, which borders Antsirabe II. In addition to direct support to elimination districts, IM Madagascar supported the NMCP to conduct clinical OTSS+ visits in malaria control districts bordering Faratsiho and Antsirabe II in the Vakinankaratra region: Mandoto, Betafo, and Antanifotsy (Figure 4).

Figure 4: IM Madagascar support to malaria control districts bordering the elimination districts in the Vakinankaratra region

Figure 3: Elimination districts supported by IM Madagascar since


Key Accomplishments

Objective 1: Improve the quality of and access to malaria case management and malaria prevention during pregnancy Key Accomplishment #1: Conducted quarterly laboratory OTSS+ visits in 13 regions In 2019, IM supported the NMCP to conduct laboratory OTSS+ in five regions. In the previous reporting period, laboratory OTSS+ was expanded to an additional five regions. During this reporting period, IM supported the NMCP to expand laboratory OTSS+ to an additional three districts, expanding the total number of regions to thirteen receiving OTSS+ for malaria diagnostic and laboratory services. Details of the laboratory OTSS+ visits supported during this reporting period can be found in Table 2. In total, IM supported 262 laboratory OTSS+ visits across 184 health facilities in 75 districts. During Round 4 in Analamanga region, only 18 of the 26 targeted health facilities were supervised due to a local COVID-19 outbreak that required the supervision team to suspend the supervision mid-round. Overall, 95% of targeted health facilities were reached during laboratory OTSS+ visits.

Table 2: Health facilities visited by region and round (R) for laboratory OTSS+ during this reporting period

Region Round Quarter Districts visited

HFs supervised

HFs targeted HFs supervised

Targeted HFs supervised

Alaotra Mangoro R1 Q4 5 10 10 100%

Analamanga R3 Q1 5 17 17 100%



Atsimo Andrefana R1 Q1 4 9 9 100%

Atsimo Andrefana R2 Q4 9 19 19 100%

Atsimo Atsinanana R1 Q1 4 4 4 100%

Atsimo Atsinanana R2 Q4 4 6 6 100%

Atsinanana R1 Q1 2 4 4 100%

Atsinanana R2 Q4 5 15 12 80%

Boeny R4 Q1 2 15 15 100%

Boeny R5 Q4 3 16 16 100%

Diana R4 Q1 3 8 8 100%

Diana R5 Q4 4 15 14 93%

Ihorombe R1 Q1 1 4 4 100%

Ihorombe R2 Q4 1 4 4 100%

Matsiatra Ambony R1 Q4 5 12 12 100%

Menabe R1 Q4 4 8 8 100%

Sofia R3 Q1 5 7 7 100%

Sofia R4 Q4 7 13 13 100%

Vakinankaratra R3 Q1 5 15 15 100%

Vakinankaratra R4 Q4 3 13 13 100%

Vatovavy Fitovinany R1 Q1 1 2 2 100%


Region Round Quarter Districts visited

HFs supervised

HFs targeted HFs supervised

Targeted HFs supervised

Vatovavy Fitovinany R2 Q4 6 8 8 100%

TOTAL 276 262 95% With the support of IM Madagascar, the NMCP decentralized laboratory OTSS+ activities, with 10 of the 13 regions supervised by 23 regional-level supervisors. Only the three new regions added this year: Alaotra Mangoro, Haute Matsiatra, and Menabe, were supervised directly by the NMCP with support from IM Madagascar. Looking at the laboratory OTSS+ indicators across all 13 regions (Figure 6), performance has steadily improved. Health facility readiness scores have increased from 54% to 72%, panel test scores from 65% to 71%, microscopy observation scores from 76% to 87%, External Quality Assurance (EQA) scores from 83% to 92%, and mRDT scores from 81% to 94%. These results show that improvement is needed most in 1) health facility readiness, which was affected in large part by frequent unavailability of commodities such as reagents and slides and 2) microscopy slide proficiency panel testing, which was due in part to the lack of opportunities for laboratory technicians to practice with different Plasmodium species. IM will continue to support the NMCP in the delivery of laboratory commodities during OTSS+ supervision visits and by increasing opportunities for panel testing.

Figure 6: Average scores by indicator and round of laboratory OTSS+ (13 regions)

Figure 5: Laboratory OTSS+, Centre Hospitalier Universitaire (CHU, University Hospital Center) Mitsinjo Betanimena Toliara. Photo credit: Judith Lennox, IM


Figure 7 shows the overall laboratory OTSS+ scores across the three new regions and the five regions having completed two rounds of laboratory OTSS+. Among these regions, a relatively strong baseline score was noted in those with one round of laboratory OTSS+. Generally, regions with more than one round of laboratory OTSS+ showed stable trends from their first to second rounds with some notable improvements. Among the regions with one laboratory OTSS+ round, Matsiatra Ambony showed a low overall score (57%) due to frequent stock-outs of malaria microscopy commodities and low demand for thick and thin smears. On the other hand, the region of Menabe scored higher (77%) in its first round of laboratory OTSS+ as compared to some regions that had already completed two or more rounds. For example, in both their third and fourth rounds, the regions of Sofia and Vakinankaratra scored lower than Menabe did in its first round of laboratory OTSS+. It should also be noted that private health facilities in the three new regions have not yet received MDRTs. Among regions that have completed two or more laboratory OTSS+ rounds, laboratory performance increased by around 10 percentage points in Atsimo Atsinanana and Ihorombe, while it decreased slightly in Atsimo Andrefana, Atsinanana, and Vatovavy Fitovinany. These three regions added new health facilities in their second round, some of which had microscopes in poor condition or laboratory technicians who had not yet received MDRTs. IM Madagascar supported the distribution of new microscopes to the health facilities needing them or connected those facilities to the NMCP’s maintenance services.

Figure 7: Overall laboratory OTSS+ scores by region and round (three new regions and five regions having completed two rounds)


Figure 8 shows the overall laboratory OTSS+ performance in the five regions that have received at least three rounds of supervision visits. Scores in these regions were generally stable, with gradual increases recorded in Analamanga. However, performance decreased in the Diana region from Round 4 (79%) to Round 5 (70%), which may be explained by the addition of six new health facilities in Round 5 which had laboratory technicians who did not yet undertake MDRT.

Figure 8: Overall laboratory supervision scores by region and round (five regions having completed three rounds or more) Key Accomplishment #2: Supported bMDRT for 81 microscopists at regional and district levels Since 2019, IM Madagascar has supported the NMCP to ensure that each HF has at least one laboratory technician who had received bMDRT. The bMDRT includes training on parasite detection (PD), species identification (ID), and parasite counting (PC), as well as slide preparation, slide staining, use of mRDTs, biosafety, microscope maintenance, and improvement of QA measures according to national guidelines. Pre- and post-test performance was assessed for the theory and practical components of slide reading. Improvement scores were classified into one of four performance levels based on a WHO grading scale (Table 3). Participants should meet at least level B for PD and ID (≥ 80%) and PC (≥ 40%). Table 3. Classification of National MDRT Standards: National Standards PD ID PC

Level A (expert) ≥ 90% ≥ 90% ≥ 50% Level B 80% - < 90% 80% - < 90% 40% - < 50% Level C 70% - < 80% 70% - < 80% 30% - < 40% Level D < 70% < 70% <30%

During this reporting year, IM Madagascar supported the NMCP to conduct four bMDRT sessions for 81 new participants. Of the 81 participants, 31 (38%) were women and 65% were from public health facilities. The participants represented 44 districts in 17 regions. In PD, 81% of bMDRT participants achieved the goal of at least level B (Figure 10). For ID, 14% achieved at least level B. Thirty percent of participants


achieved at least level B in PC. Those who did not reach the minimum acceptable levels will be re-invited to the next bMDRT training. Overall, bMDRT participants improved their competency in malaria microscopy. Average pre- and post-test scores show increases from 66% to 89% for PD, 42% to 56% for ID, and 10% to 26% for PC (Figure 11). For participants with low scores in ID and PC, IM supported the NMCP to develop and execute different action plans: ● Procurement and distribution of slide panels from

slide banks to laboratories to practice and strengthen their microscopy skills

● Continued training through laboratory OTSS+ cycles ● Remote coaching of laboratory technicians by telephone as a follow-up to the recommendations from

past laboratory OTSS+ visits

Figure 9: bMDRT in Toamasina, Photo credit: Oméga Raobela, IM

Figure 10: Competency levels achieved by bMDRT participants from 17 regions (N= 81)


Key Accomplishment #3: Procured 411 validated malaria slide banks for IQA With the support of IM Madagascar, the NMCP acquired 411 validated slides from slide banks during this reporting period. These were in addition to the 364 slides IM helped procure in the previous period. The 411 slides contain plasmodium ovale and malariae species, as well as mixed slides containing plasmodium falciparum/ovale and plasmodium falciparum/malariae species. The slides were used for capacity building of laboratory technicians during MDRT trainings and are being supplied in slide panels to health facilities with low scores in species identification and parasite counting. Key Accomplishment #4: Printed and distributed 180 laboratory registers to improve data quality and availability During laboratory OTSS+ visits, stock-outs of laboratory registers were reported in most laboratories. As a result, the NMCP determined the need to print and distribute laboratory registers to improve the quality and reliability of data. IM Madagascar supported the NMCP to print and distribute registers to all 180 laboratories nationwide performing malaria diagnostics. Key Accomplishment #5: Supported clinical OTSS+ supervisors training for four district staff in the new IM-supported elimination district of Faratsiho IM Madagascar supported the training of four Faratsiho district health management teams in clinical OTSS+. During the three-day training, the new supervisors were trained on how to use the clinical checklists to conduct OTSS+ to improve the capacity of HWs. The importance of the key indicators monitored through the clinical OTSS+ checklists was also reviewed during the supervisors training. Additional training in malaria data quality monitoring was conducted to reinforce the timely recording and submission of data, especially by private sector facilities, to

Figure 11: Average pre- and post-test scores of bMDRT participants from 17 regions (N= 81)

Figure 12: Training of district supervisors in Faratsiho for clinical OTSS+, Photo credit: Patrick Raoiliarison, IM


the national DHIS2. Electronic tablets were given to each supervisor for data entry and analysis using HNQIS.

Training results for Faratsiho clinical OTSS+ supervisors showed an average improvement of 10 percentage points between the pre-test (68%) and post-test (78%). Figure 14 shows the points that need further attention, including adoption of supportive supervision techniques, the importance of using the supervision checklist, and the necessary documents to bring during supportive supervision.

Figure 14: Pre- and post-test scores for indicators requiring further strengthening, clinical OTSS+ supervisors training, Faratsiho

Figure 13: Laboratory register, 200 sheets, size A3


Key Accomplishment #6: Supported three rounds of clinical OTSS+ in three elimination districts During the reporting period, IM supported the NMCP to conduct three rounds of clinical OTSS+ instead of the four rounds that had originally been planned. The round that was scheduled to take place from January to March 2021 was canceled due to COVID-19 movement restrictions in Madagascar. Table 4 provides a summary of the health facilities visited in Antsiranana I, Antsirabe II, and Faratsiho. In Antsiranana, most health facilities (76%) were private whereas in Antsirabe II and Faratsiho the majority were public (78% and 88%, respectively).

Table 4: Distribution of health facilities visited during clinical OTSS+ by type and level

Antsiranana I

(N=21) Antsirabe II

(N=50) Faratsiho (N=25)

HHF type Public 5 39 22 Private 16 11 3

HF level

CHU 3 0 0 CHD (Centre Hospitalier de District,

District Hospital Center) 1 2 1

CSB1 (Centre de Santé de Base Niveau I, Basic Health Center Level I)

2 13 12

CSB2 (Centre de Santé de Base Niveau 2, Basic Health Center Level 2)

15 35 12

IM supported the NMCP to conduct a total of 261 clinical OTSS+ visits during this reporting period (Table 5). In Antsiranana I and Antsirabe II, IM built on its support for clinical OTSS+ visits from the previous year. Despite the rainy season that made access difficult to almost all health facilities in Faratsiho and Antsirabe II, IM Madagascar supported the NMCP to complete three rounds of supervision in each of these districts. In Antsiranana I, 20 health facilities and 20 HWs were supervised during the first two rounds of supervision. One new HF was found and added during the third round, (Round 4). In Antsirabe II, 50 health facilities and HWs were supervised during the three rounds of supervision. A total of 25 health facilities and 25 HWs were supervised during the first two rounds of supervision conducted in the new support district of Faratsiho. Table 5. Clinical OTSS+ rounds conducted this reporting year, by number of targeted and supervised HFs and HWs

Region *R *Q

Health facilities supervised HWs supervised

HFs targeted

HFs supervised

HFs supervised HWs

targeted HWs

supervised

HWs supervised

/Target /Target

Antsiranana I R2 Q1 20 20 100% 20 20 100% Antsiranana I R3 Q2 20 20 100% 20 20 100% Antsiranana I R4 Q3 21 21 100% 21 21 100% Antsirabe II R2 Q1 50 50 100% 50 50 100%

Figure 15: Clinical OTSS+ in Faratsiho. Photo credit: Dr Eliane Bakoly Raharinirina, IM


Region *R *Q

Health facilities supervised HWs supervised

HFs targeted

HFs supervised

HFs supervised HWs

targeted HWs

supervised

HWs supervised

/Target /Target

Antsirabe II R3 Q2 50 50 100% 50 50 100% Antsirabe II R4 Q3 50 50 100% 50 50 100% Faratsiho R1 Q2 25 25 100% 25 25 100% Faratsiho R2 Q3 25 25 100% 25 25 100%

Total 261 261 100% 261 261 100% *Note: R = Round; Q = Quarter

To build on the lessons learned from previous clinical OTSS+ rounds, IM supported the NMCP to conduct briefing and debriefing meetings with each supervisor from each district before, during, and at the end of Round 2 in Faratsiho and of Round 4 in Antsirabe II and Antsiranana I. Supervisors from the district, the NMCP, and the IM Madagascar team met through video-conference and discussed successes, challenges, and ways to improve standardization of the approach and the sharing of best practices. The meetings also provided an opportunity for a refresher training on clinical OTSS+ implementation for the supervisors. The use of videoconference for the briefing and debriefing meetings was an innovation used because of the travel and meeting restrictions related to COVID-19.

Figure 16 presents the overall results of the clinical OTSS+ visits by round in the three districts. HW performance gradually increased in all districts, with only one exception in Antsiranana I for Round 4. The decrease in performance in Antsiranana I may be in large part explained by slight changes in the methodology used to implement the clinical OTSS+ outpatient department checklists. In previous rounds, supervisors used a combination of observation and simulation that captured both HW behavior and knowledge. Prior to the fourth round, IM supported a refresher training of supervisors to provide training on how to strictly implement an observational approach. Implementing the strictly observational approach revealed additional gaps in provider service delivery, such as the provider’s failure to provide counseling to patients. These issues have been addressed through in-situ training. Moving forward, IM Madagascar will continue to support the NMCP to implement this observational approach and will use the simulation method to provide mentoring to health providers.

Figure 16: Clinical OTSS+ overall supervision scores by round and district


The improved standardization of the OTSS+ observations allowed IM to uncover certain weaknesses in provider management of uncomplicated malaria and malaria in pregnancy, as well (Figure 17). An improvement in the remaining indicators was observed in each round of clinical OTSS+ in the three pilot districts. The improvement, in addition to being a result of continuous case management strengthening through clinical OTSS+ rounds, may also be partially attributed to IM’s support to the NMCP for the implementation of remote, systematic mentorship and follow-up on action plans as agreed with each health center between clinical OTSS+ rounds. Each health center was briefed and de-briefed by phone or conference call before and after each OTSS+ round.

Figure 17: Overall clinical OTSS+ supervision scores by OTSS+ module and round for the three pilot districts: Antsirabe II, Antsiranana I, and Faratsiho


Figure 18 shows each district’s average clinical OTSS+ scores during their last supervision visit (Round 4 in Antsiranana I and Antsirabe II and Round 2 in Faratsiho). Antsiranana I continued to have the lowest performance in clinical OTSS+ despite having received four rounds of supervision. As noted previously, 76% of facilities in the district are privately operated and have demonstrated difficulty in complying with national guidelines and standards. With the support of IM Madagascar, clinical OTSS+ supervisors will collaborate with another malaria project in Antsiranana I (the Global Fund's New Funding Model) for the joint supervision of private health facilities to improve standardization of the supervision and training language and approach. In Madagascar, severe malaria cases are usually transferred to hospitals. As such, the clinical OTSS+ severe malaria indicators are only assessed in hospitals (four in Antsiranana I, two in Antsirabe II, and one in Faratisho). Antsiranana I, Antsirabe II, and Faratsiho districts have had very few severe malaria cases in the past several years. The three districts cumulatively recorded an average of 31 severe malaria cases per year since 2018. Overall, the three districts have demonstrated continuous improvements in the management of severe malaria (Figure 19). In Round 1 in Antsiranana I and Antsirabe II, infrequent exposure to and experience with severe malaria cases and stock-outs of severe malaria treatment can explain the poor performance of HWs in severe malaria case management. However, through IM support to clinical OTSS+, HW trainings, and the improved ordering and use of injectable artesunate for the management of severe malaria cases, facilities in all three districts demonstrated dramatic improvements in the management of severe malaria in their subsequent clinical OTSS+ rounds.

Figure 18: Average score per indicator for Antsiranana I and Antsirabe II (Round 4) and Faratsiho (Round 2) on clinical OTSS+


Figure 19: Average severe malaria case management OTSS+ scores in hospitals (CHUs and CDUs), in the three pilot elimination districts Key Accomplishment #7: Supported production and dissemination of job aids and other critical documents Four previous clinical OTSS+ rounds revealed gaps in the availability of various management and technical tools and reference documents for malaria service delivery at the HF level. Only 35% of supervised health facilities had all required reference documents. During this reporting period, IM Madagascar supported the NMCP in assembling, printing, and distributing these documents to reinforce availability of tools and reference documents to support provider alignment with standards for malaria case management and reporting (Table 6). Sets of twelve key documents were printed and disseminated to the 70 health facilities that had gaps in the availability of documents. Any improvement in HW performance through these documents will be evaluated by the "health facility readiness" clinical OTSS+ indicator. Table 6: Framework Documents

Framework Documents Edition year Manuel de procédures de gestion de la Dotation CSB (CSB Supplies Management Procedures Manual) March 2020 MANUEL DE PROCEDURES EN GESTION LOGISTIQUE DES INTRANTS DE SANTE (Logistical Management of Health Supplies Manual) July 2017 Manuel de référence Prise en Charge du Paludisme (Malaria Case Management Reference Manual) June 2017 Prévention et contrôle du Paludisme Pendant la Grossesse (Prevention and

Control of Malaria During Pregnancy) May 2018 POLITIQUE NATIONALE DE SANTE COMMUNAUTAIRE A MADAGASCAR (Madagascar National Community Health Policy) July 2017 Guide CPN (soins prénatals) (Antenatal Care Guide) 2020 Ordinogramme PEC du paludisme en zone d'élimination (Malaria Case Management in Elimination Areas Flowchart) 2021 Ordinogramme RDT (RDT Flowchart) 2020 Job aid protocole de traitement du paludisme (Job Aid for Malaria Treatment Protocols) 2020 Fiche d'alerte (Alert Form) 2018


Framework Documents Edition year Formulaire de notification des cas de paludisme au niveau communautaire (Community Malaria Case Notification Form) 2018 Job aid Artésunate injectable (Job Aid for Injectable Artesunate) 2021

Key Accomplishment #8: Developed and validated training materials on malaria case management in children over 5 years of age at the community level IM Madagascar was invited to a five-day MOH workshop to provide technical input to the development and validation of training materials on malaria case management in children over 5 years of age at the community level. Once this curriculum is validated by MOH, it will be adopted for future trainings and activities of CHVs supported by IM Madagascar Key Accomplishment #9: Strengthened community-based malaria elimination efforts through CHV training and supervision and community advocacy IM Madagascar supported the NMCP in the implementation of malaria elimination strategies by CHVs in the two pilot elimination districts of Antsirabe II and Faratsiho. Community activities in Antsiranana I are supported by the USAID ACCESS project., IM Madagascar collaborated with the ACCESS project team to standardize community-based elimination activities. CHVs are considered malaria elimination first-line actors for the detection and prevention malaria transmission. Findings from the Malaria elimination readiness assessment (MERA) 2019-2020 included a recommendation to ensure a robust and capable CHV network. With this objective, IM supported the training of 646 CHVs from the three pilot elimination districts (408 CHVs from Antsirabe II, 188 from Faratsiho, and 50 from Antsiranana I) in malaria elimination strategies.

The NMCP facilitated a TOT for forty-seven district health management teams and HWs, the Vakinankaratra regional health management team, and the IM Madagascar team. The district health management teams and HWs then trained 646 CHVs in malaria elimination strategies, including malaria prevention, diagnosis, case management, surveillance and monitoring including foci investigation, and the importance of timely and complete data reporting.

Figure 20: TOT of CSB chiefs and HWs, Antsirabe II, Photo credit: Raoiliarison Patrick, IM Nov 2020

Figure 21: CHW Training participants. Photo credit: RAOLIARISON Patrick, IM


Among the 188 CHVs who were trained in the reporting period, skill level in malaria service delivery improved after the training, with an average gain of 18 percentage points from 40% in pre-test to 58% in post-test. Training and tools for CHV supervisors IM, in collaboration with key partners, supported the NMCP to create a CHV malaria elimination supervision checklist, train HWs on CHV supervision, and implement and monitor the CHV supervision activities. First, the national elimination TWG collaborated with the NMCP and IM Madagascar, in close partnership with USAID-ACCESS and PMI Measure Malaria, to revise the malaria section of the national integrated CHV checklist and create the CHV malaria elimination supervision checklist. IM Madagascar supported the digitization of the supervision checklist for the national DHIS2.

IM also supported the NMCP to train 48 HWs for CHV supervision using the checklist, in Antsirabe II and 23 HWs in Faratsiho, from both the private and public sectors. To comply with COVID-19 preventive measures, the training was divided into two groups.

Participants were tested on a range of malaria case management, prevention, and elimination topics. The pre-test and post-test included the following topics: - Diagnosis of fever by CHVs - The realization of the mRDT - Malaria cases management at community level - Reporting of community activities - Carrying out investigations around a malaria case - Means of malaria prevention - The role of CHVs on the elimination of malaria

The average pre-test score for training participants from the two districts was 54%, with an average post-test gain of 13 percentage points (Figure 23). Participants were also tested on their knowledge of the operationalization of the CHV supervisions. Figure 24 shows specific areas for further improvement among the participants in Antsirabe II and Faratsiho, including knowledge of the purpose for using the supervision checklist, for documents provision during formative supervision, and knowledge of the indicators to be supervised during supportive supervision of CHWs.

Figure 22: Training of Antsirabe II HWs in CHVs supervision, Photo credit: Patrick Raoiliarison CMS, IM

Figure 23: Average pre- and post-test scores of HWs during training on CHW supervision, Antsirabe II and Faratsiho


IM Madagascar supported the NMCP to complete the first round of supervision of 596 CHVs by trained HWs in Antsirabe II and Faratsiho. HWs were supposed to collect CHV supervision data using the tablet computers provided by IM Madagascar in 2020, but a nationwide DHIS2 outage resulted in the need to collect data using the paper-based checklist. CHVs were supervised on malaria diagnosis, case management, and case reporting. CHVs were also supervised on the provision of malaria commodities including mRDTs and ACTs as well as provision of community monthly reports. Finally, CHVs were tasked with raising awareness on malaria care and prevention. Supervision of CHVs in Antsiranana I was supported by the USAID ACCESS Project using the same DHIS2-based digital supervision checklist.

Results of the CHV supervision will be available in the next reporting period. Weaker performing CHVs will undergo a validation of their skills in mRDT and malaria treatment at their corresponding HF before the next round of supervision.

According to the elimination TWG recommendations, community advocacy should be carried out before the implementation of community malaria elimination activities to engage the community and senior leaders in the activities and their completion. The objective of community advocacy is to promote malaria prevention and case management among the population.

Figure 24. Low pre- and post-test training scores in the CHW supervisor training, Antsirabe II and Faratsiho

Figure 25: Community advocacy, Faratsiho. Photo credit: Patrick RAOLIARISON, IM


During this reporting period, IM supported the NMCP to carry out community advocacy in Antsiranana I among community and senior leaders including 25 village chiefs and representatives of the mayor and the prefecture. In Antsirabe II and Faratsiho, community advocacy was combined with clinical OTSS+ visits. In total, IM supported community outreach in 20 Anstirabe II communes and nine Faratsiho communes. In addition to communal and local authorities, 204 village chiefs in Antsirabe II and 98 in Faratsiho participated in the outreach meetings. A commitment was signed at the end of the meetings by the community and senior leaders to support malaria prevention and surveillance activities such as social and behavior change. Commitment monitoring was carried out during the supervision of community sites by the HWs and during the OTSS+ visits carried out by the district supervisors. Key Accomplishment #10: Trained and supervised HWs in villages bordering elimination districts in malaria case management, surveillance, and elimination strategies The residual malaria foci in the pilot elimination districts of the Vakinankaratra region are located at the borders of the malaria control districts of the region. IM supported the NMCP to accelerate towards its goal of malaria elimination in Madagascar by training HWs in bordering districts in malaria case management to reduce the incidence of imported malaria cases from control districts to pilot elimination sites. IM supported the NMCP in providing a TOT to district health management teams from three malaria control districts bordering Antsirabe II: Betafo, Antanifotsy, and Mandoto, in the national malaria elimination strategy. This was immediately followed by a cascade training for 26 HWs from these three districts. Training HWs on malaria case management and surveillance Twenty-six HWs from the three control districts were trained in malaria case management through IM support to the NMCP.

Baseline skills of HWs in malaria case management were very low as the last case management training took place over five years ago. An average improvement of 36 percentage points was observed between the pre-test and post-test. (Figure 30). During this reporting period, IM supported the NMCP to carry out semi-annual clinical OTSS+ visits in the three border districts of Betafo, Antanifotsy, and Mandoto. The same clinical OTSS+ checklists used in the elimination district were used in the control districts to supervise 28 HWs. IM supported two Vakinankaratra regional malaria managers to conduct the supervision visits. Figure 31 shows the results of the first clinical OTSS+ visit done in the three border control districts.

Figure 26: Official opening of the training of districts bordering pilot elimination districts (Betafo, Antanifotsy and Mandoto), Photo credit: Martin Rafaliarisoa, IM

Figure 27: Clinical OTSS+, Betafo. Photo credit: Sandy Ralisata, IM


Among the clinical OTSS+ indicators, only mRDT performance reached the target score of over 90% in Antanifotsy and Betafo (Figure 29). All indicators need to be strengthened and will be closely monitored during the next clinical OTSS+ round.

Figure 28: Overall supervision score by district on clinical OTSS+ in the three districts bordering elimination areas

Figure 29: Overall supervision scores by indicator and district for clinical OTSS+ in the three border districts

Key Accomplishment #11: Supported elimination TWG meetings Three national and two district TWG meetings were supported by IM Madagascar during the reporting period. Apart from monitoring malaria elimination activities, the main outcomes of these meetings were the development of elimination job aids for HWs and CHVs, strategy development for strengthening control efforts in districts bordering elimination areas, and the validation of the CHV supervision checklist. The IM Madagascar team actively participated in each of these three activities.


Objective 3: In support of Objective 1, provide global technical leadership, support operational research, and advance program learning Key Accomplishment #1: Finalized tools and preparations for the High-Risk Populations quantitative assessment According to results of the district Malaria Elimination Readiness Assessment supported by IM Madagascar in 2019, risk factors for malaria transmission should be identified at a local level to efficiently tailor and target interventions. Due to COVID-19 surges and associated travel restrictions from February to May 2021, implementation of the malaria high-risk populations quantitative assessment was postponed until October 2021, in alignment with the next malaria transmission season. IM Madagascar supported the NMCP in the digitization of the high-risk population assessment questionnaire under the national DHIS2 platform. The questionnaires were tested and validated for data collection and were pilot tested during this reporting period by the NMCP and the district team, with IM Madagascar support. HW training and launch of data collection is planned for early in the next reporting period.

Challenges and Solutions Challenges Solutions Ensuring protection of participants and trainers against COVID-19

IM specifically requested spacious rooms and cars for all activities supported by IM Madagascar to maintain at least 1 meter of distance between participants during training and catering. IM supported the provision of personal protective equipment (PPE) to all participants in activities supported by IM Madagascar

Need for improvement in the quality of clinical OTSS+ implementation for better performance of HWs in malaria case management

An online refresher training was conducted prior to the most recent clinical OTSS+ round to standardize the quality of the supervision.

Difficulties in conducting clinical OTSS+ during the rainy period due to additional time and budget needed to access health centers

Virtual follow-up and coaching were supported by IM Madagascar. The next clinical OTSS+ round is planned to take place during the dry season.

Delay in CHV supervision reporting due to the failure of the national DHIS2. CHV supervision data were entered on the paper version of the checklist instead of directly in DHIS2 on tablets. As a result, there have been difficulties in compiling and entering paper-based data for data analysis and reporting.

IM Madagascar ensured the installation and updating of digital supervision tool in each supervisor's tablet at least one week before the planned supervision visit. CHV supervision data that was collected on paper forms will be entered into the DHIS2 system.

Lack of microscopic malaria diagnostic kits IM Madagascar will support the NMCP to follow-up and distribute microscopic diagnostic kits that are in the process of being procured by the New funding model (NFM)


Challenges Solutions Microscopes in poor condition due to lack of maintenance

IM Madagascar supported the transportation of microscopes to the NMCP maintenance department for repair. IM has also supported the identification of priority health facilities in need of new microscopes. Regional health authorities have also been engaged to provide microscopes on loan until quality microscopes are in place.

Laboratory technicians in new supervised health facilities not yet trained in malaria diagnosis

The newly identified laboratory technicians will be added to the participant list of upcoming bMDRT.

Health facilities prefer to do mRDT rather than microscopy, as a result, the demand for malaria microscopy analysis is very low

IM has planned a lessons-learned workshop (LLW) between NMCP, district, and regional health directors, as well as health facility managers to harmonize and improve malaria diagnostics

bMDRT training must be done face-to-face, which is difficult with COVID-19 travel restrictions.

bMDRT activities were postponed until after the opening of international borders.

Lessons Learned

● Decentralization of OTSS+ supervision is an important way of strengthening the capacity of the Madagascar government to carry out the OTSS+ approach beyond the life of the IM project. The decentralization of lab OTSS+ supervision to supervisors at the regional level has proved to be very successful and is planned for regions where the approach was introduced more recently.

● Laboratory OTSS+ continues to be effective in strengthening laboratory capacity. There has been a steady improvement in overall lab OTSS+ scores across the last five rounds, and average scores in EQA and mRDT now exceed 90%.

● Microscopists need continuous practice in malaria slide reading to improve their poor performance in Parasite Identification (ID) and Parasite Counting (PC) recorded during bMDRT sessions (overall score on ID=56%, PC=26%). IM Madagascar will support to the NMCP to procure 411 slides and finalize an additional 2,500 slides to provide the country's microscopists with validated slides for practice.

● Overall clinical OTSS+ scores have steadily improved in Antsirabe II and Antsiranana I, which have completed four rounds each, and in Faratsiho, which completed its first two rounds during the reporting period. Strengthening the implementation of clinical OTSS+ by ensuring it is strictly observational resulted in declines in some indicators but was imperative for the approach to yield its intended results of quality improvement at the health worker and health facility levels.

● Notable improvements in the severe malaria clinical OTSS+ results demonstrate the importance of this checklist in areas of the country that may not record many malaria cases. For example, the checklist revealed persistent shortages of life-saving malaria commodities. As a result, IM has supported the Madagascar NMCP in ensuring hospitals are regularly stocked with artesunate Injectable and other severe malaria commodities and proper treatment can be provided to those who need it.

● Through the support of IM Madagascar, the NMCP has been able to systematize the use and availability of low-dose primaquine in the elimination districts by updating job aids and the malaria


case management flowchart by inserting low-dose primaquine and by updating the HF monthly reporting template and stock cards by adding a section for the use of low-dose primaquine. IM Madagascar's approach to regular monitoring of primaquine availability and use could be adopted and standardized by the NMCP and the elimination districts through: 1) Monitoring the national primaquine stock during weekly RBM meetings, 2) Ensuring the availability and use of low-dose primaquine at the regional and district levels through the regular Gestion et Approvisionnement du Stock / Stock Management and Procurement meetings to validate orders of primaquine and other malaria commodities at the peripheral level, and 3) through capturing the availability and use of low-dose primaquine at the HF level through the quarterly OTSS+ supervisions..

● A TOT, followed directly by cascading training, is a way of ensuring high-quality training and reinforces the district level’s journey to self-reliance. Furthermore, organizing supervision visits directly following supervisors' training is a way of improving training uptake and supervisor performance.

● Refresher training and exchange of good practices between clinical OTSS+ supervisors have been instrumental in improving OTSS+ implementation and further strengthening the capacity of HWs visited to achieve malaria elimination.

● Malaria control efforts inherently advance elimination efforts through the strengthening of malaria case management and, as a result, reduction in malaria transmission. The reduction in malaria transmission may also contribute to reduced incidence of imported cases in bordering elimination districts and help Madagascar reach its goal of sub-national malaria elimination. With the support of IM Madagascar, the 10 non-pilot malaria elimination districts were able to participate in the online meetings for the peripheral elimination TWG. NMCP leadership for the implementation of elimination strategies in these non-pilot districts is the best approach to achieve the progressive elimination of malaria in Madagascar.


IM Madagascar Indicator Table The data provided in the indicator table below are IM targets and activity results from October 1, 2020 – September 30, 2021. The data in the indicator table reflect activities in the IM supported areas in Madagascar which include 13 regions (75 districts) for laboratory OTSS+, and two regions: Vakinankaratra (two districts: Antsirabe II and Faratsiho) and Diana (1 district: Antsiranana I) for clinical OTSS+ and elimination activities.

During the reporting period, IM Madagascar supported the implementation of three rounds of clinical and laboratory OTSS+, resulting in 261 clinical OTSS+ visits in three districts (Antsirabe II, Antsiranana I, and Faratsiho), and 262 laboratory OTSS+ visits across 184 health facilities in 75 districts. IM Madagascar also supported the training of 370 health workers (81 bMDRT, 4 clinical OTSS+ supervisors, 188 CHVs, 71 CHV supervisors, 26 HWs on case management and surveillance).

Progress to Annual Target is calculated as actual result/target *100=progress to target. This provides an indication of how much progress has been made to meeting the annual target outlined in the country workplan.

Objective Indicator Target Result

Progress to

Annual Target

Comments

Objective 1: Improved access to malaria diagnosis

Percentage of confirmed malaria cases

<1% 5%

759 confirmed cases among 15 233 cases tested were recorded in three pilot districts. An abnormal increase in malaria cases was recorded in Antsirabe II (479 confirmed cases). Three communes have been identified and actions have been undertaken: foci investigation, malaria microstratification, riposte/ response by ITN distribution, involvement of CHVs in case management, and sensitization of the population.


90% 98% 108%

Constant improvement of malaria systematic diagnosis for each fever case. 15 233 cases tested among 15 616 suspected cases of malaria.

Percentage of HWs demonstrating competency in malaria microscopy

90% 81% 91%

Through OTSS+ and MDRT, a clear improvement in microscopic diagnosis skills was recorded this reporting period. 66 HWs out of 81 trained HWs obtained a score 80% or greater during MDRT post-test.



Progress to

Annual Target

Comments


95%

Q1: 77% (54/70)

81%

Gradual improvement of HW use of mRDTs, as a result of OTSS+ and job aids. The recent decrease in this indicator can be attributed to lower health worker scores in Antsiranana I during this reporting period. The reasons for this decrease in mRDT and microscopy performance are: 1) the frequent turnover at private HFs, especially considering that 85% of HFs in Antsiranana I are private; and 2) non-compliance with quality standards for mRDT use, such as: - verification of the expiry date - failure to record the patient's identification information on the mRDT cassette (name or patient identification number and time of mRDT).

Q2: 83% (80/95)

87%

Q3: 82% (79/96)

86%

Percentage of targeted facilities that meet standards (including appropriate materials, documentation, and qualified staff) for quality diagnosis of malaria

10%

Q1: 0% (0/85)

0%

Despite IM Madagascar's support in providing quality assurance (QA) manuals for malaria microscopy to all HFs in the country, the gap in malaria microscopy commodities and materials remains a major problem for improving laboratory performance.

Q3: 0% (0/28)

0%

Q4: 0% (0/149)

0%


60%

Q1: 89% (62/70)

148%

The training, OTSS+ rounds, and job aids disseminated with IM Madagascar support has strengthened HWs’ competency for malaria classification.

Q2: 91% (86/95)

152%

Q3: 91% (87/96)

152%



Progress to

Annual Target

Comments


100% N/A N/A

While IM Madagascar planned to train 80 laboratory technicians during the reporting period, there was no supervisor training planned.

Percentage of targeted districts adhering to national malaria diagnostic supervision protocol

100% 91% 91%

Due to the inaccessibility of some landlocked sites, the number of supervised districts is lower than the target (75). Among the districts not supervised are: Manja, Antanambao Manampotsy, Vohibato, Ikalamavony, Mandoto, and Mitsinjo.

Percentage of targeted HWs trained in malaria laboratory diagnostics

100% 101% 101%

The NMCP objective was to train all laboratory technicians in all the districts on the four MDRT sessions during the current reporting period. 81 laboratory OTSS+ supervisors, out of 80 planned, were trained in the 13 supported regions. This explains why the number of participants trained in MDRT is higher than the target.

Percentage of targeted facilities with at least one provider trained in malaria parasitological diagnosis

100%

Q1: 78% (66/85)

78%

Through the laboratory OTSS+ rounds, new health facilities have been identified. More MDRT sessions will be scheduled in FY22 to complete the objective.

Q3: 79% (22/28)

79%

Q4: 77% (115/ 149)

77%

Percentage of targeted facilities with national

100%

Q1: 89% (76/85)

89%

Newly identified laboratories have not received national guidelines for malaria diagnosis. IM Madagascar will support the duplication of



Progress to

Annual Target

Comments

guidelines for malaria diagnosis

Q3: 66% (25/38)

66%

documents for the next reporting period.

Q4: 82% (122/ 149)

82%

Objective 2: Improved access to targeted malaria treatment

Percentage of malaria cases (presumed and confirmed) that received the recommended antimalarial treatment according to national guidelines

100% 98% 98%

IM Madagascar supports the NMCP in the continued availability of antimalarial treatment at the central and peripheral levels, but also in the creation and dispatch of job aids and OTSS+ clinic rounds to maintain performance in malaria case management. During the reporting period, 754 among 759 malaria cases received first-line antimalarial treatment.

Percentage of severe malaria cases that were treated according to national guidelines

100% N/A N/A

In general, the rare severe malaria cases are treated at the hospital level. Unfortunately, these hospitals do not adhere to the MOH monthly activity report template.

Percentage of targeted HWs demonstrating compliance to treatment with WHO-recommended ACTs for cases with positive malaria test results

80%

Q1: 64% (36/56)

80%

The rotation and assignment of trained HWs to other districts is the main factor hindering the achievement of the expected performance for the three pilot districts.

Q2: 71% (49/69)

89%

Q3: 67% (46/69)

83%



Progress to

Annual Target

Comments

Percentage of HWs demonstrating adherence to negative test results according to global standards

100%

Q1: 100% (10/10)

100%

IM will maintain efforts through clinical OTSS+ to meet the target.

Q2: 95% (20/21)

95%

Q3: 87% (20/23)

87%

Percentage of targeted HWs demonstrating competency in management of severe malaria according to WHO guidelines

65%

Q1: 34% (24/70)

53%

The adoption of treatment for severe malaria with injectable Artesunate, even at hospital level, is still being acquired for HWs trained in malaria management. Data are collected at hospital level, using the Clinical OTSS+ checklist, through record review.

Q2: 44% (42/95)

68%

Q3: 29% (2/7)

44%

Percentage of targeted HWs demonstrating competency in management of uncomplicated malaria

85%

Q1: 49% (34/70)

57%

ACT use is already established for most HWs following from previous rounds of Clinical OTSS+. But there is still work to be done in the clinical examination of patients, according to the standards required



Progress to

Annual Target

Comments

by the MOH and the checklist such as: - complete clinical examination: palpation, auscultation - Taking of parameters: blood pressure and weight of the patient - Re-explaining the treatment dosage by the patients.

Q2: 55% (52/95)

64%

Q3: 55% (53/96)

65%

Percentage of targeted facilities that meet global standards (including appropriate materials, documentation, and qualified staff) for quality malaria case management

65%

Q1: 1% (1/70)

2%

The main deficiency is: - Lack of qualified staff due to rotation and assignment of previously trained health workers with Impact Malaria support - Gap of appropriate equipment For documentation, IM Madagascar continues to support HWs in the availability of main documents

Q2: 2% (2/95)

3%

Q3: 21% (20/96)

32%

Percentage of targeted HWs trained in management of severe malaria according to national guidelines in malaria case management

100% 100% 100%

The objective is to train one HW per HF. A total of 39 HWs trained from Antsiranana I and 25 HWs from Faratsiho were trained.



Progress to

Annual Target

Comments

Percentage of targeted HWs trained according to national guidelines in malaria case management with ACTs

100% 100% 100% Same comment as above

Percentage of targeted health facilities that receive a quarterly or semi-annual supervisory visit

100% 100% 100%

The objective is to train one HW per HF (39 HWs trained for Antsiranana I and 25HWs trained for Faratsiho).

Percentage of targeted districts with national guidelines for malaria treatment that meet national standards

100% 100% 100% IM Madagascar ensured the availability of malaria management documents.



1 2 200%

• IM Madagascar success story published

• For World Malaria Day, IM Madagascar supported content development for radio and video spots related to malaria prevention and awareness, for use during activities in pilot districts.

Participation in targeted national, regional, or global level working group(s) and/or taskforce(s) – number of groups

3 5 167%

• National and regional elimination TWG

• USAID implementing partners’ HMIS TWG

• NMCP communication TWG • NMCP M&E TWG



Progress to

Annual Target

Comments

Number of regional or global guidance/policy documents contributed to malaria related issues

1 3 300%

• Extend CHV malaria case management children under the age of 5

• Job aids for mRDT and preparation of thick and thin blood films

• Job aid for CHVs on malaria elimination in finalization process with the NMCP and other technical and financial partners

• Mid-term review of the NMCP National Strategic Plan 2018-2022

359 IM Malawi October 2020 – September 2021

Malawi Background IM Malawi’s overarching goal has been to support the NMCP and the National Public Health Reference Laboratory (NPRL) to strengthen malaria service delivery through enhancing capacity for malaria diagnosis, MIP, and case management.

IM Malawi supports the NMCP to improve malaria service delivery through the following two project objectives:

• Objective 1: Improve the quality of and access to malaria case management and prevention of malaria during pregnancy.

• Objective 3: In support of Objective 1, provide global technical leadership, support operational research, and advance program learning.

With funding from PMI, IM Malawi provides technical and implementation support to the NMCP to facilitate improved malaria service delivery at the national, district, and community levels, focusing on improving malaria case management and MIP service provision. Specifically, IM Malawi is helping to strengthen rational testing of fever cases as well as prompt and appropriate treatment for confirmed malaria cases, thus ensuring that all malaria cases are identified and managed appropriately at the facility and community levels. Additionally, IM Malawi is helping to strengthen MIP services to prevent and appropriately treat malaria infections in pregnant women.

IM Malawi’s support to the NMCP is based on the following key principles: ● Bolstering and supporting the NMCP as a top priority ● Building on lessons learned from the Improving Malaria Diagnostics Project, MalariaCare, and the

Organized Network of Services for Everyone (ONSE) ● Coordinating with in country and global partners ● Avoiding parallel systems by implementing activities using existing structures within the NMCP

and district health systems ● Achieving scale and sustainability

Geographic Focus: In addition to its national-level technical support, IM Malawi implements malaria case management and MIP activities in the three districts of Kasungu, Mchinji, and Nkhata Bay (Figure 1).

Figure 1: IM Malawi focus districts for enhanced case management


IM Malawi is building on more than a decade of PMI and USAID investments at country level to strengthen malaria diagnosis, case management, prevention, and treatment of malaria during pregnancy, and the health system that supports these activities. IM Malawi began activity implementation in January 2021.

Major activities completed during this reporting period included the 1) Development of a country-level M&E package, including a Performance Management Plan, baseline data, and other supporting documents; 2) Development of a project monitoring system or Data Hub; 3) Review and update of the NMCP integrated supervision checklist; 4) Validation, and customization of OTSS+ checklists; 5) Development of critical documents relevant to malaria case management and MIP; 6) Support for the MIP, case management and M&E TWG meetings; 7) Planning and coordination for data-driven meetings with heads of districts; 8) Execution of basic and advanced MDRT (b MDRT, a MDRT) and nECAMM; 9) Launch of IM district-level introductory meetings in IM-supported districts; 10) Review of OTSS+ data to align with the supportive supervision process; 11) Convening of a National Malaria Advisory Board; and 12) Assistance to the NMCP to launch the Zero Malaria Starts With Me (ZMSWM) campaign.

Key Accomplishments


Key Accomplishment #1: In coordination with the NMCP, conducted district level introduction meetings in IM-supported districts IM Malawi, in collaboration with NMCP, held introductory project meetings in all three IM-supported districts of Nkhata Bay, Kasungu, and Mchinji. The aim of the visits was to introduce the IM project to District Commissioners and to District Health Management Teams (DHMTs). The visits provided an opportunity for NMCP and IM Malawi to interact with these groups and understand their challenges and opportunities. The meetings also helped the team create buy-in for project activities. IM Malawi and NMCP were also able to identify partners with synergistic activities, like ONSE, and discuss how IM Malawi would collaborate with these partners to improve facility-level malaria service delivery. Some of the specific issues raised during the meetings have been outlined below in Table 1.

Table 1: Discussion points with DHMTs Issue Discussion IM Malawi inclusion of iCCM as part of the case management activities

IM Malawi clarified that all activities presented are facility-based, however, plans are underway to include iCCM activities in the next project workplan.

IM Malawi support for District Drug Therapeutics Committees, as was the case with ONSE

IM Malawi clarified that this will not be part of the support, as it falls under supply chain activities which are not part of the IM workplan.

IM Malawi inclusion of activities in district implementation plans (DIP)

IM Malawi participated in the DIP meetings in IM-supported districts and will present on the approved workplan building on those meetings.

IM Malawi ability to meet quarterly activities as presented within the specified time frame

IM Malawi team noted that the activities would be achieved within the specified period unless communicated otherwise.


Key Accomplishment #2: Supported the review and development of critical documents relevant to malaria case management and MIP IM Malawi supported the NMCP to review and update all relevant policies, guidelines, and standard operating procedures (SOPs) in malaria diagnosis, case management, and prevention of malaria during pregnancy. This review was important, as a similar update has not taken place since 2013. In addition, with the COVID-19 pandemic, it was necessary to realign critical documents relevant to malaria diagnosis, case management, and MIP in relation to pandemic prevention measures to protect health workers providing malaria services. Stakeholders were drawn from academia, the Public Health Institute of Malawi (PHIM), referral hospitals, the NPRL, NMCP, Reproductive Health Department (RHD), Department of Quality Management (DQM), and IM Malawi. For case management, the team reviewed the Guidelines for the Treatment of Malaria in Malawi where several items were updated according to WHO guidelines and global best practice. In addition, a policy on malaria treatment in Malawi was aligned with updated WHO recommendations. IM Malawi also worked with the NMCP to review and revise the MIP guidelines for health workers. Furthermore, the team reviewed and updated documents on malaria diagnosis, including the Bench Aids for Laboratory Diagnosis of Malaria, Malaria Microscopy Slide Validation Protocol for Malawi, and Protocol for Malaria Microscopy Proficiency Testing in Malawi. IM Malawi will support the printing and distribution of these documents to all supported health facilities during the next reporting period. Key Accomplishment #3: Supported the review and updating of relevant job aids and wall charts IM Malawi supported the NMCP to review job aids and wall charts for malaria case management and prevention MIP so that they align with global best practices. The following job aids and wall charts were reviewed jointly with MOH, NMCP technical leads, and stakeholders:

● Algorithm for the Assessment of Children and Adults with Fever in the Context of COVID-19 ● Number of required vials of parenteral artesunate by body weight ● Dosing Chart for Second line antimalarial treatment: ASAQ fixed-dose combination ● Dosing schedule for dispersible AL ● Dosing schedule for double-strength AL ● Initial (pre-referral) Dosage of artesunate Suppositories for Children Aged <6 Years ● Diagnosis and Treatment of Severe Malaria ● IPTp algorithm for determining eligibility of SP ● IPTp Job aid for Administration of SP ● SOPs for malaria parasite counting, preparation of blood films, preparation of Giemsa stain, and

diagnosis of malaria using mRDTs Key Accomplishment #4: Supported the NMCP to review and update existing supportive supervision checklists IM Malawi supported the NMCP to review and update two separate sets of supportive supervision checklists. Stakeholders included in the review exercise for both sets of checklists consisted of representatives of NMCP, PHRL, Medical Council of Malawi, academia, and the IM Malawi team.


The first set of checklists to be reviewed and updated was an existing integrated mentorship checklist that was derived from a previous version of the OTSS checklist and is in use in all districts throughout the country. Although IM Malawi will not implement these checklists, they were asked to review for technical quality. The second set of checklists reviewed were the OTSS+ checklists, which will be used in the three districts supported by IM Malawi. As part of the review, the OTSS+ checklists were aligned to fit the country context, global best practices, and reflect updates precipitated by the COVID-19 pandemic. OTSS+ checklists addressed during this process included:

● Assessing clinical management of patients suspected of malaria ● Assessing clinical management of patients suspected of severe malaria ● Assessing competencies for prevention and treatment of MIP ● Assessing health facility readiness ● Assessing mRDTs use the laboratory checklist ● Malaria register scoring checklist ● NMCP integrated mentorship checklist

During the discussions, the team recommended the need to pre-test the OTSS+ checklists once uploaded on the HNQIS platform and to observe suitability to the country health system prior to rolling them out. In the next reporting period, IM Malawi will support the NMCP with trainings across IM districts for OTSS+ and the use of HNQIS for supervisors to have adequate skills in managing the platform. Key Accomplishment #5: Supported national MIP TWG meeting The National MIP TWG is a key platform to establish and maintain coordination of MIP interventions between the NMCP and RHD, as well as to engage other key stakeholders within and outside the government to coordinate and implement MIP programming. The MIP TWG also provides a forum to discuss potential policy changes, review indicator trends and achievements, address challenges in MIP program implementation, and discuss MIP-related research opportunities and results. During Q3 of the current reporting period, IM Malawi supported the NMCP to convene one MIP TWG meeting in Lilongwe, Malawi, and members who were unable to attend the meeting physically participated virtually (Figure 2). The team included members from the NMCP, RHD, Department of Quality Management (DQM), PMI, academic and research institutions, representatives from District Hospitals (DH), Medical Council of Malawi, and IM Malawi staff. The meeting focused on a

Figure 2: MIP TWG meeting, Photo credit: Ethel Chilima, IM


review of progress on MIP indicators, an update on the results of a study to determine the effectiveness of using Health Surveillance Assistants (HSA) to administer SP to pregnant women in communities (community IPTp), and a review of the uptake for reporting MIP M&E indicators. Following lengthy deliberation and discussions, members recommended the following action items to the NMCP and RHD to consider for the improvement of MIP programming:

● Intensify SBC activities at all levels to promote early ANC attendance to increase IPTp uptake and other MIP interventions.

● Build capacity of all ANC providers and HMIS personnel to improve documentation in ANC and ITN registers.

● Sustain and strengthen existing collaboration between NMCP, DRH, and other key stakeholders to promote the delivery of MIP interventions.

● The NMCP, RHD, PMI, WHO Malaria Program officer, WHO Safe-motherhood team, and CMED should have periodic meetings to review and gain consensus on national ANC and IPTp uptake measurement indicators.

Key Accomplishment #6: Supported the NMCP to review existing OTSS+ and other data to determine gaps in malaria service delivery in IM-supported districts IM Malawi supported the NMCP to review OTSS+ and other existing routine data, including HMIS/DHIS2 data, to determine gaps in malaria service delivery in IM Malawi-supported districts. The activity helped IM Malawi generate baseline data against which future OTSS+ rounds will be measured. Furthermore, the data were used to identify underperforming facilities so that they could be prioritized for support. A total of 116 participants (91 male, 25 female) participated in the meeting and these included DHMT representatives, malaria coordinators, heads of laboratories, health information management officers, nursing officers, pharmacy officers and heads of health centers. IM Malawi notes a gender imbalance, skewing towards men, across much of the health workforce. While this challenge is systemic, IM Malawi prioritizes the participation of women in all its activities and trainings through direct invitations. For Mchinji and Nkhata Bay districts, IM Malawi worked with the NMCP to review data from the six rounds of OTSS+ supported by USAID through ONSE from 2017 to 2020. In Kasungu district, the focus was on two rounds of OTSS+ data supported by the Global Fund between 2019 and 2020. In addition to OTSS+ data, the HMIS data review included critical malaria indicators such as the distribution of ACTs and malaria community data from village health clinics (VHCs). Of the selected facilities whose data was reviewed, most did not meet the 75% performance target. This poor performance was attributed to inadequate history taking and physical examination by health workers. Similar trends were observed when HMIS data were compared to OTSS+ data over the same period. HMIS data showed low positivity rates for cases tested for malaria in some facilities, which may suggest that mRDTs are being used more as a screening tool than as a testing tool to confirm suspected cases of malaria, or that malaria prevalence is low or the mRDTs are not being performed or read correctly.


Figure 3: Adherence trends in Nkhata Bay, Data source: IM previous OTSS+ rounds data review, 2021, EDS, 2021

In addition, some facilities had a high number of cases without any parasitological test. This practice is not aligned with the test and treat approach recommended in the treatment guidelines. HMIS data revealed that there were more ACTs dispensed than there were documented cases. While a small percentage of this discrepancy may be acceptable, the discrepancies were large in some facilities with no plausible explanation. Further analysis of previous OTSS+ data (Figure 3), shows that some facilities were not adhering to treatment guidelines, which advise that ACTs are prescribed for cases confirmed with positive test results. OTSS data from 2017 to 2020 suggest that in-patient facilities are still struggling with the management of severe malaria cases (Figure 4), including diagnosis, treatment, and monitoring of patients with severe malaria. Specific patient treatment and monitoring challenges include the checking of vital signs and blood glucose levels, as well as management of severe malaria complications, like hypoglycemia and convulsions. The MOH has strived to ensure that all HFs with in-patient services also have a laboratory capable of malaria microscopy. In IM Malawi-supported districts, two of the ten HFs with in-patient services do not have a laboratory.


Figure 4: Severe Patient Monitoring in Nkhata Bay, Data source: IM previous OTSS+ rounds data review, 2021, EDS, 2021.

Key Accomplishments #7: Supported the NMCP to review and update relevant in-service training curricula To improve the quality of malaria diagnosis and case management, IM Malawi supported the NMCP and NPRL to review and update in-service training documents. The in-service training documents are important for improving the quality of malaria case management in Malawi as they contribute to training health providers on the latest approaches and strategies. For case management, the Training Manual for Health Workers on Case Management in Malawi and the Facilitators’ Guide for Health Workers on Malaria Case Management in Malawi were reviewed, and the content was realigned with WHO recommendations and global best practices. In addition, malaria diagnosis training materials i.e., the Malaria Microscopy OTSS+ Laboratory Training Manual, Malaria Training Learners’ Manual, and Malaria Microscopy Facilitators’ Manual were reviewed and updated. IM Malawi will support the printing of training materials as part of the implementation process during the next reporting period. Key Accomplishments #8: Conducted one bMDRT and one aMDRT IM Malawi supported the NMCP and NPRL to train laboratory staff in bMDRT and aMDRT in IM-supported districts. The aim of the trainings was to provide microscopists with the essential knowledge and skills in malaria diagnosis to improve their competency in malaria microscopy. A total of 60 laboratory staff (45 male, 15 female) were trained in bMDRT, and 21 of the best performing participants (19 male, 2 female) were selected to participate in the aMDRT.

10%

52%55%

47%44%

52%

R1 R2 R3 R4 R5 R6

Seve

re P

atie

nt M

onit

orin

g sc

ores

(%

)

OTSS rounds (2017-2020)


During the bMDRT, microscopists undertook a practical session where they were provided with 20 well-characterized blood film slides and their pre- and post-training test scores were recorded for parasite detection, species identification, and parasite counting. In addition, microscopists also underwent a practical assessment on mRDT use and slide preparation. According to the WHO, microscopists are deemed to have attained a satisfactory performance on parasite detection, species identification, parasite counting, mRDT use, and slide preparation if they scored ≥80%, ≥80%, ≥40%, ≥90% and ≥80%, respectively.

Figure 6. Percent performance by district during bMDRT; Data Source: Malawi MDRT 2021 Overall, microscopists who participated in the bMDRT performed well on post-test in parasite detection, reading of mRDTs, and slide preparation. However, performance was poor on species identification and parasite counting. In the next project reporting period, IM Malawi will continue supporting the NMCP-NPRL in strengthening the quality of malaria diagnosis through OTSS+ supervision, targeted mentorship, district-level supervision and developing a proficiency testing scheme for malaria microscopy at the NPRL.

Figure 5: Participants to bMDRT, Photo credit: Lawrence Kachule, IM


IM Malawi supported the training of 21 microscopists selected from the bMDRT for aMDRT. Like the bMDRT, microscopists were assessed on parasite detection, species identification and parasite counting

using 20 well-characterized malaria blood slides for the aMDRT. Participants were given pre- and post-tests assessing the same competencies as were examined during the bMDRT. Microscopists were deemed to have satisfactory performance if they scored ≥80% on parasite detection, ≥80% on species identification, and ≥40% on parasite counting.

Figure 8: Performance by district in advanced MDRT, Data Source: Malawi MDRT 2021

Key Accomplishment #9: Supported participation of qualified microscopists to attend nECAMM certification The 13 participants to attend nECAMM were selected from a pool of 21 participants who attended the aMDRT, based on their performance. There were three participants from Kasungu, four from Mchinji, four from Nkhata Bay, one from the Community Health Services Unit (CHSU) and one from IM Malawi. Table 2 shows microscopist performance in the attainment of WHO levels (1-4) by gender and district.

Figure 7: Participants to bMDRT, Photo credit: Lawrence Kachule, IM


Table 2: Percent performance by gender and district on WHO accreditation levels of microscopists during nECAMM; Data Source: Malawi MDRT 2021   Level 1 Level 2 Level 3 Level 4 Districts Kasungu 1 0 1 1 Mchinji 1 1 0 2 Nkhata Bay 1 3 0 0 Lilongwe (CHSU) 1 0 0 1 Gender Male 2 3 1 4 Female 2 1 0 0

Four microscopists attained level 1, and four attained level 2. The six have been chosen to attend regional External Competency Assessment for Malaria Microscopists (ECAMM) in November 2021 at the AMREF International University in Nairobi, Kenya. Objective 3: In support of Objective 1, Provide global technical leadership, support operational research, and advance program learning Key Accomplishment #1: Supported the NMCP to launch the ZMSWM campaign Through the NMCP, the Malawi government launched the ZMSWM Campaign on June 22, 2021, at an event presided by the President of Malawi. The ZMSWM campaign is a continent-wide public-facing campaign for a malaria-free Africa based on three pillars:

● Political engagement: Engaging political leaders to reinforce that malaria elimination efforts remain a funding and policy priority.

● Private sector engagement: Diversifying funding sources and establishing innovative public-private partnerships to increase financial resources to accelerate malaria elimination.

● Community engagement: Creating a community-based movement to increase awareness and ownership of protecting the most vulnerable families and communities from malaria.

The initiative is co-led by the African Union Commission and the RBM Partnership to End Malaria. The campaign has encouraged grassroot movements – led by individuals, families, communities, religious leaders, private sector, political leaders, and other members of society – to take personal responsibility for winning the fight against malaria. IM Malawi, in consultation with PMI, provided logistical support that enabled NMCP and other MOH staff to attend the launch.


Challenges and Solutions Challenges Solutions COVID-19 cases are rising, with an estimated third wave since June 2021. There has been a heightened sense of fear and uncertainty, which affects activity planning with the NMCP and stakeholders.

IM Malawi will continue to implement activities in compliance with COVID-19 preventive measures instituted by the Government of Malawi, including physical distancing, washing, and sanitizing hands, and wearing PPE, including face masks, for each step of malaria service delivery. IM Malawi will convert in-person events to virtual events, when possible, like TWGs. For example, the MIP TWG was conducted in a hybrid fashion, with options for both physical and virtual attendance.

There are often competing priorities within the NMCP and NPRL. For example, the NMCP is planning for a 2021 mass ITN distribution, which is a large and complex undertaking requiring meticulous planning and involvement of NMCP staff. During the reporting period, the NMCP and NPRL were also involved in the Malaria Indicator Survey (MIS).

IM holds planning meetings with the NMCP and NPRL on a regular basis. This helps to avert disturbances in activity planning. For example, IM Malawi rescheduled OTSS+ rounds to a later date to accommodate the NMCP’s schedules.

The NMCP is shifting supervision toward an integrated approach, using an integrated supervision checklist.

Coordination discussions are taking place between the NMCP, PMI and IM on its role in using the OTSS+ checklist

Heads of HFs have not been transmitting meeting resolutions to community levels (for possible actions and change

IM will extend invitations to community focal points in addition to heads of HFs depending on the nature of the meetings

Lessons Learned ● IM Malawi placed MIP and Diagnostics technical support personnel at the NMCP and NPRL. This

has enhanced collaboration and has improved the working relationship between the NMCP and IM Malawi.

● It is important to engage the NMCP on a regular basis to identify gaps, coordinate availability, support training, supervision, coordination, data management and analyses for IM Malawi-supported activities. To further strengthen this engagement, IM Malawi will work with the NMCP to identify a focal point for IM activities in Malawi.


● To promote gender balance in IM activities, efforts should be undertaken to promote women participation in activity implementation. IM Malawi engages NMCP to address gender imbalances through deliberate efforts to give priority to women.

IM Malawi Indicator Table

The data provided in the indicator table below are reflective of the IM targets set during Q2, and the results are from the period of January 1, 2021, to June 30, 2021. HMIS data presented below is for period January 1, 2021 to September 30, 2021. IM Malawi works in two regions – the northern which has one district, Nkhata Bay and the central region which has two districts of Kasungu and Mchinji districts. Nkhata Bay has 24 facility, Kasungu 38 and Mchinji 19 facilities. One round of OTSS+ was completed. During this round, a total of 14 health care workers (supervisors) were trained, and 74 facilities were visited, 17 in Mchinji, 33 in Kasungu, and 24 in Nkhata Bay.


Objective # Indicator Target Result Progress to Annual Target

Comments

Objective 1.1 Improved access to quality malaria diagnosis


100% 99.7% 99.7% Performance from 81 IM supported health facilities in Kasungu, Mchinji, and Nkhata Bay.


80% N/A N/A To be updated after the first full IM-supported OTSS+ round in March 2022.

Percentage of observed health workers demonstrating competency in correctly classifying cases as not malaria, uncomplicated malaria, and severe malaria

75% N/A N/A To be updated after the first full IM-supported OTSS+ round in March 2022.

Percentage of health workers demonstrating

100% 73% 73% The mRDT module was administered during the MDRTs in June. Forty-four



Comments

competency in malaria mRDTs

of the 60 participants demonstrated competency (90% or above) during the bMDRT post-test.

Percentage of health workers demonstrating competency in malaria microscopy - MDRT

100% 58% bMDRT

100% aMDRT

69% Thirty-five of the 60 participants scored 80% and above in MM (slide preparation and parasite detection) during the bMDRT; and all 21 participants from the aMDRT scored 80% and above in MM

Percentage of health workers demonstrating competency in malaria microscopy - Lab OTSS+

80% To be updated after the first full IM-supported OTSS+ round in March 2022.


100% 88% 88% During the bMDRT, 51 participants passed the post-test in either mRDT/MM; and 21 passed the post-test aMDRT. 13 passed nECAMM. Trainings in malaria diagnostics targeted 97 total participants during the project reporting period.


100% To be updated after the OTSS+ supervisor trainings.

Percentage of targeted districts with national malaria diagnostic supervision tools adhere to national standards




Comments



Percentage of targeted facilities with national guidelines for malaria diagnosis


Objective 1.2 Improved access to targeted quality malaria treatment


100% 99% 99% Performance from 81 IM-supported health facilities

Percentage of severe malaria cases that received first-line antimalarial treatment according to national guidelines

Target will be set following baseline

To be updated after the first full IM-supported OTSS+ round in March 2022.

Percentage of observed health workers demonstrating compliance to treatment with WHO-recommended ACTs for cases with positive malaria test results


Percentage of observed health workers demonstrating adherence to negative test results according to national guidelines


Percentage of observed health workers demonstrating competency in management of severe




Comments

malaria according to national guidelines

Percentage of observed health workers demonstrating competency in management of uncomplicated malaria according to national guidelines


Percentage of supervised facilities that meet national standards (including appropriate materials, documentation, and qualified staff) for quality malaria clinical management



100% No case management trainings supported during this project year.


100% 94% 94% Performance from 81 IM-supported health facilities from the three districts. These results are based on the timely monthly reporting of malaria data with Nkhata Bay being lowest at 87%.

Percentage of targeted health facilities that receive a supervisory visit


Percentage of IM-supported health facilities with national guidelines for malaria treatment that meet global standards


Objective 1.3 Improved access to quality


N/A N/A N/A This indicator is part of the IM global PMP and is currently not captured in the national HMIS.



Comments

prevention and management of malaria during pregnancy

according to national guidelines Percentage of pregnant women who received three doses of IPTp according to national guidelines

50% 55% 111% Despite COVID-19, it appears there were no stock-outs of SP in all facilities in IM districts. The targets were set based on national targets and appear to be on the lower side, therefore IM will adjust targets upward in the next workplan.


67% 77% 115% Despite COVID-19, it appears there were no stock-outs of SP in all facilities in IM districts. The targets were set based on national targets and appear to be on the lower side, therefore IM will adjust targets upward in the next workplan.


85% 96% 113% Despite COVID-19, it appears there were no stock-outs of SP in all facilities in IM districts. The targets were set based on national targets and appear to be on the lower side, therefore IM will adjust targets upwards in the next workplan.









Comments


100% No IPTp trainings supported during this project year.

Percentage of IM-supported facilities with national guidelines for prevention and treatment of MIP that meet global standards


Number of functional/active national MIP/MNCH/ANC Working Groups

1 1 1 IM supported one MIP TWG during this project year.

Objective 2 Project technical leadership contributes to PMI-led global policy development and OR

Number of country-level program activity outputs disseminated to the global health community

5 0 Malawi started implementation in January 2021 and is yet to disseminate outputs.

Number of targeted regional or global level Working group(s) and/or taskforce(s) participated in

3 3 100% IM participated in three TWG meetings: (1) Aspects of case management; (2) MIP; and (3) M&E

Number of regional or national guidance/policy documents contributed to malaria related issues

20 IM Malawi supported the NMCP to update the relevant documents (13) and checklists (7).

376 IM Mali October 2020 – September 2021

Mali Background IM Mali worked closely with the NMCP, the Directorate General of Health and Public Hygiene (DGHPH) through the Sub-Directorate of Reproductive Health (SDRH), and the Sub-Directorate of Health Institutions and Regulations (SDHIR) within the Ministry of Health and Social Affairs on priorities to improve the delivery of malaria services, in alignment with the National Malaria Strategic Plan, which was recently revised with an extension to 2024. IM Mali supported three IM project objectives.

• Objective 1: Improve the quality of and access to malaria case management and the prevention of malaria during pregnancy

• Objective 2: Improve the quality of and access to other malaria drug-based approaches and

provide support to pilot and scale up newer malaria drug-based approaches

• Objective 3: In support of Objectives 1 and 2, provide global technical leadership, support operational research, and advance program learning

From 2018 through 2020, IM Mali worked in the regions of Mopti and Ségou. In October 2020, IM Mali was redeployed to the regions of Kayes and Koulikoro and the District of Bamako. IM Mali maintained support to three districts in the Sikasso region for the SMC campaign, which included an extension of SMC to children up to the age of 10 years. IM Mali also supported operational research on strategies to increase the use of IPTp, by improving ANC, a TES on antimalarial treatments, and an SP resistance study. Figure 2 below shows malaria incidence in regions supported by IM Mali from October 2020 through September 2021.

Figure 1: IM Mali Geographic Focus Areas


Key Accomplishments Objective 1: Improve the quality of and access to malaria case management and malaria prevention during pregnancy Key Accomplishment #1: Conducted rapid situation assessment in the new geographic focus areas IM Mali started the reporting period by carrying out a rapid situation assessment in the new geographic focus areas to establish baseline results for project indicators. In collaboration with the NMCP and the SDRH, IM Mali assessed the quality of malaria services in 45 public HFs in the new IM Mali regions of Kayes, Bamako, and Koulikoro from November 4 to December 6, 2020. HFs were randomly chosen in consultation with district management teams, considering the sample size needed; HF attendance, security, and accessibility; and the functionality of the community health association. The methodology included a baseline round of OTSS+ combined with a structured interview guide. OTSS+ was configured in HNQIS and the interview guide on KoBoCollect. Data analysis was performed with the IM Mali Data Hub, operating DHIS2, and Excel. Different OTSS+ checklists were used in different parts of health facilities. The checklist for uncomplicated malaria was used in the general OPD, where doctors and nurses were observed. The MIP checklist was used in the maternity department, where midwives, obstetric nurses, and matrons were observed. The checklist for severe malaria was used to assess inpatient services of doctors and nurses. The laboratory checklist was used in the laboratory, where laboratory technicians were observed. Rapid situation assessment baseline results:

o Among health facilities assessed, 14% (N=45) had at least 50% of staff trained on national guidelines for malaria case management within the last two years

Figure 2: Malaria incidence in the Kayes, Koulikoro, and Bamako regions


o Among providers observed, 47% (N=71) demonstrated competency (scoring 90% or above) in conducting rapid malaria diagnosis tests

o Among providers observed, 32% (N=36) demonstrated competency (scoring 90% and more) in malaria microscopy

o Among HFs assessed, 29% (N=283) the appropriate documents and qualified staff for appropriate management of malaria cases

o Among providers observed, 22% (N=494) the 90% competency threshold in treating MIP o The percentage of women seen during ANC who received at least three doses of SP was 48%1

IM Mali worked with the NMCP to share the rapid situation assessment baseline results with the MOH and the SDRH. This allowed them to see the needs on the ground and the relevance of planned IM Mali activities. IM Mali’s recommendations to the NMCP were to strengthen:

● Capacity of HF service providers to improve the quality of care ● Training of service providers in biological and clinical diagnosis, including interpersonal

communication, and implementation of regular supervision ● Capacity of microscopists and monitoring during supervision ● Directly observed administration of SP by staff providing maternity care ● Dissemination of reference documents, including the latest national treatment guidelines, for the

prevention and management of malaria Key Accomplishment #2: Strengthened health worker capacity for providing respectful gender-sensitive ANC, including preventing MIP in the regions of Kayes, Koulikoro, and Bamako During a one-day workshop, the managers of the Kayes and Koulikoro Regional Health Directorate and the Bamako District were briefed on the training documents. Discussions focused on:

● Training methodology for facility-based health providers ● The profile of district trainers who also serve as key malaria focal points and district midwives ● Planning for the printing of training documents, including trainer’s guides, MIP case management manuals, and participants’ notebooks ● Organization of clinical internships during the MIP training After the workshop, IM Mali in collaboration with the NMCP and SDRH, strengthened the capacity of 698 providers in prevention and treatment of MIP and provision of ANC services, through 28 three-

day trainings. Providers included 256 midwives (37%), 248 obstetric nurses (36%), 171 birth attendants (24%), and 23 other profiles (3%) from 676 HFs. These included 580 Centres de Santé Communautaire

1 Mali HMIS, January – October 2020

Figure 3: Photo of the communication focal point for malaria prevention for the MIP prevention module


(CSCom, Community Health Centers), 26 Centre de Santé de Référence (CSRef, Referral Health Centers), 42 private clinics, and 28 other facilities. Classroom training focus Module 1: ANC

● WHO’s four components and eight contacts Module II: Malaria transmission

● How malaria is transmitted ● The effects of malaria on pregnant women,

fetuses, and the community ● HIV and malaria co-infection ● Malaria epidemiology

Module III: Malaria prevention ● IPTp-SP ● ITN use ● Indoor Residual Spraying

Module IV: Diagnosis and treatment of malaria in pregnant women

● Signs of uncomplicated and severe malaria ● Parasitological diagnosis using mRDTs, thick and thin blood smear ● Treatment

Module V: Gender aspects ● Definition of gender concepts ● Gender-related malaria control activities.

Figure 5: The evolution of providers’ knowledge, per MIP module, Source: MIP Training reports On average, providers’ knowledge improved from 76% to 96% on all the modules taught from the pre-test at the beginning of the training to the post-test.

Figure 4: Midwife supervised administration of IPTp1 for a pregnant woman


Table 1: Breakdown of providers trained on MIP, by region and facility type

Region Hospitals CSRef CSCom Faith-led Hospital

CMI/PMI/ Mutual

Private Hospitals Garrisons

Rural Maternity Wards Total

Bamako 0 6 64 4 4 24 4 0 106

Koulikoro 0 10 251 1 0 17 1 6 286

Kayes 2 10 265 4 0 1 2 0 284

Total 2 26 580 9 4 42 7 6 676 Key Accomplishment #4: Strengthened the capacity of laboratory technicians for the diagnosis of malaria To strengthen the performance of microscopists in HFs, IM Mali supported the NMCP and l’Institut National de Santé Publique (INSP, National Institute of Public Health) to implement a bMDRT training of 96 laboratory technicians from 26 CSRefs in PMI-supported regions (Kayes: 10, Koulikoro: 10, Bamako: 6); one laboratory technician from Kayes Regional Hospital; 66 from Bamako, Kayes, and Koulikoro CSComs; two INSP managers; and one NMCP manager. The eight training sessions took place in Bamako from February to June 2021.

Figure 6: Evaluation of technicians trained in bMDRT in Kayes, Koulikoro, and Bamako, Source: Reports from the training of laboratory technicians During the training sessions, the skills of laboratory technicians were strengthened for the parasite detection, species identification, and parasite counting. The average improvement from pre- to post-test was 24% in detection, 11% in identification, and 14% in counting (Figure 6). During the next reporting period, laboratory technicians will continue to receive follow-up through OTSS+ visits to improve these skills. During the final assessment no participant achieved WHO Level A and one participant out of 12 achieved Level B, three participants, Level C and eight participants, Level D. Key Accomplishment #5 Conducted Advanced Malaria Diagnostic Refresher Training (aMDRT) In total, twelve laboratory technicians were trained in advanced biological diagnosis, eleven men and one woman, from Bamako (4), Kayes (3), and Koulikoro (5). Participants who achieved the highest scores during the bMDRT were selected to attend the aMDRT course.


Figure 7: Performance evaluation of laboratory technicians in aMDRT, Source: Reports from the training of laboratory technicians During this advanced training, the skills of laboratory technicians were strengthened in species identification and parasite counting, with an average improvement of 22% and 17% respectively. As these participants were the ones who had the highest scores during the bMDRT, this improvement was important in further improving already high scores. One participant achieved level B during the post-test and is eligible to take the nECAMM or ECAMM course.

Key Accomplishment #6: Strengthened clinical and laboratory OTSS+ Clinical OTSS+ At the request of the NMCP, IM Mali organized a training of trainers on HNQIS to strengthen the competency of OTSS+ supervisors, from January 25-27, 2021. To do this, 16 NMCP and IM Mali trainers at the central level were trained, and they in turn trained 85 district supervisors, 39 women and 46 men, at the regional and CSRef level. The training familiarized the supervisors with the OTSS+ checklist and use of the tablet for OTSS+ data collection. It also demonstrated navigation of the digital checklists in HNQIS. After training the service providers, IM Mali conducted two rounds of OTSS+ during the reporting period. In the first round, 283 health facilities were supervised (Table 2). During the second round of OTSS+, 261 health facilities were supervised (Table 3).

Figure 8: Advanced malaria microscopy training, August 16, 2021


Table 2: Breakdown of the number of clinical OTSS+ observations carried out by checklist and by region for Round 1

Organization Unit Health Facility

Readiness Uncomplicated

Malaria MIP

Severe Malaria

Bamako 72 104 151 1 Kayes 102 166 194 1 Koulikoro 109 150 149 3

Total 283 420 494 5 Table 3: Breakdown of the number of clinical OTSS+ observations carried out by checklist and by region for Round 2

Organization unit Health Facility

Readiness Uncomplicated

Malaria MIP

Severe Malaria

Bamako 66 122 111 1 Kayes 99 219 151 6 Koulikoro 96 196 161 13 Total 261 537 423 20

Figure 9: Percentage of health workers demonstrating skills in the management of uncomplicated malaria by region, Source: IM Data Hub, OTSS+ In IM Mali-supported zones, 35% of service providers demonstrated competency in the management of uncomplicated malaria in Round 1 versus 41% in Round 2 (Figure 9). In the district of Bamako, 57% of service providers observed were competent in managing uncomplicated malaria, compared to 9% for the Koulikoro region. In the IM zone, these low percentages may be explained by the lack of provider training for malaria case management during the last two years. IM Mali supported the NMCP to update the providers' training manual and malaria management guidelines. During the next reporting period, the NMCP, in collaboration with IM, will strengthen the capacity of providers for malaria case management through the organization of training sessions, and dissemination of guidelines and job aids.


Figure 10: Percentage of HWs demonstrating skills in the management of severe malaria by region, Source: IM Data Hub, OTSS+ In the first round of OTSS+, 16% of service providers demonstrated good competency in the management of severe malaria within the new IM Mali zones, although the number of direct observations was low, five in total (Figure 10). The methodology has since been revised to include record review, because it was unlikely that a supervision round would be in progress at the exact moment when a severely ill patient needed an artesunate injection. During the second round, only 14% of observed providers demonstrated competency in the management of severe malaria cases, which was like the previous round. The lack of training for providers in the management of severe malaria may also explain this low percentage. To improve competency, IM Mali in collaboration with the NMCP organized a six-day training for 21 providers in the CSRef and hospitals for the management of severe malaria from August 25 to 30, 2021. This training was done in two phases theory and practice. After the theory course, the participants were divided between four health facilities for the practical phase.

Figure 11: Average score of providers in the management of severe malaria by region Round 2, Source: IM Data Hub, OTSS+


During this second round of OTSS+, competency in managing severe malaria was assessed through record review. The data from record review showed that the average score in the IM-supported zones was 82% for the treatment of severe malaria, meaning that in most cases providers were prescribing the appropriate treatment. The average score for severe malaria diagnosis was 66%. Bamako scored lower than the other regions, but there was only one record of a severe malaria case available for review. Encouragingly, the average score of all six records of severe malaria cases reviewed in Kayes was 91%, which was above the competency threshold for the specific treatment of severe malaria, and the 13 records of severe malaria cases reviewed in Koulikoro demonstrated that most of the providers reached the 90% competency threshold with an average score of 85%.

Figure 12: Percentage of observed health workers demonstrating adherence to negative test results according to standards by region, Source: IM Data Hub, OTSS+

Figure 13: Percentage of observed health workers demonstrating competency in classifying malaria cases as uncomplicated or severe, by region, Source: IM Data Hub, OTSS+


In the IM-supported regions, 82% of the providers observed adhered to the results of the negative tests in Round 1 compared to 74% in Round 2. Bamako-based providers had the lowest adherence to test results, 72% in Round 1 versus 55% in Round 2. Some of the providers observed in Round 1 were different from those observed in Round 2, which could explain this decrease in competency. In the IM-supported regions, 91% of observed providers correctly classified cases of malaria as uncomplicated or severe in Round 1, versus 95% Round 2. OTSS+ in ANC

Figure 14: Percentage of observed health workers demonstrating competency in preventing MIP by region, Source: IM Data Hub, OTSS+ In the health facilities visited, 38% of service providers demonstrated competency in the prevention of MIP in Round 1 compared to 55% in Round 2.

Figure 15: Percentage of observed health workers demonstrating competency in the treatment of MIP by region, Source: IM Data Hub, OTSS+


At the time of the first round of OTSS+, 27% of providers were competent in the treatment of MIP versus 43% in Round 2. Weaknesses observed included a failure to carry out the physical examination; screen for symptoms of severe malaria; and ask pregnant women if they took antimalarial medication at home. The second round of OTSS+ supervision exceeded the annual target of having 35% of providers in IM Mali zones who are competent in treating malaria during pregnancy. To maintain this achievement during the next reporting period, IM Mali will support quarterly OTSS+ monitoring of providers in health centers. Laboratory In the IM-supported regions, in Round 1, 57% of laboratory technicians were competent in using mRDTs versus 71% in Round 2. OTSS+ and the coaching of laboratory technicians likely contributed to the improvement in competency.

Figure 16: Performance of laboratory technicians in mRDT, Source: IM Data Hub, OTSS+

Figure 17: Performance of laboratory technicians in microscopy, Source: IM Data Hub, OTSS+


During the first round of OTSS+, 36% of laboratory technicians were competent in microscopy versus 47% in Round 2. The training and follow-up of laboratory technicians may be the main reason for improvement in microscopy competency. Supervision During OTSS+ visits in these three regions, management teams observed and provided on-the-job training to 106 laboratory technicians in the laboratories at the CSRef and CSCom levels in Kayes, Koulikoro, and Bamako in malaria microscopy (preparation and staining of slides, parasite detection, species identification and parasite counting), and establishment of an internal quality assurance program. In the laboratory, mentoring focused on: o Training laboratory staff present on the day of the visit on blood sampling; preparation and staining of

thin and thick smear slides; as well as parasite detection, identification, and counting o Introducing SOPs for QC internal and external, for reading slides; QC of Giemsa dye batches; and

results reporting o Improving solid and liquid waste management

Monitoring laboratory technicians during two OTSS+ rounds The competencies of species identification and parasite counting improved between the two rounds of OTSS+, by 2% and 8%, respectively; as did the specificity, or ability to detect negative slides, which

Figure 18: Clinical OTSS+ visit, observation by a clinician

Figure 19: Average score of laboratory technicians during OTSS+, Source: Data Hub, OTSS+


improved by 13%. However, the parasite detection rate was unchanged. The poor performance of the laboratory technicians in parasite counting may be explained by insufficient follow-up of trained technicians, the absence of a counter in most of the laboratories visited, and the high workload in the laboratory. When comparing the reading of PT slides, the rate of agreement between the results of laboratory staff and those of supervisors varied between 83% (in Kayes) and 94% (in Koulikoro), with Bamako at 84%.

Key Accomplishment # 7: Coordinated and facilitated LLW for OTSS+ IM Mali supported the NMCP to hold LLWs after the two rounds of OTSS+ on malaria prevention and case management in health facilities in the Kayes region and the Bamako district. The Koulikoro region LLW was scheduled for mid-October.

The NMCP demonstrated commitment to the transition of the HNQIS tool in the next project year during the LLW and made recommendations to improve service delivery quality. These included to:

o Organize a training session on the HNQIS tool for NMCP supervisors (scheduled for January 2022)

o Support the continuation of OTSS+ o Confirm that either the mRDT or microscopy checklists are used in each supervision visit o Include demonstration of mRDT use by all participants during the training sessions on malaria

management o Involve all malaria focal points in the correct management of free malaria treatment o Revise the HNQIS tool to add N/A (Not Applicable) to all questions that require this modality o Create a IM Data Hub user account for all supervisors o Organize a feedback workshop by district after each round of OTSS+ supervision.

Figure 20: Average performance of regions by sub-section of the microscopy checklist, Source: IM Data Hub, OTSS+


Lessons learned included: o The transfer of local skills was essential for the continuous training of health providers. o The application of the free malaria treatment policy was not in place in most health facilities. o Irregular supervision of providers has a negative impact on their skills. o Encouraging ownership among head of district medical teams was essential for improving service

quality. o The HNQIS tool needed to be revised to add the N/A modality. o Supervision teams at the national, regional, and CSRef levels did not have access to HNQIS data.

Key Accomplishment # 8: Organized refresher training for CSRefs and regional hospital providers on case management of severe malaria in Kayes, Koulikoro, and Bamako In collaboration with the NMCP, IM Mali continued to strengthen providers’ capacity in providing quality malaria services, particularly for the management of severe malaria. From August 26 to 30, 2021, a total of 21 providers at CSRefs (12), hospitals (7), and the NMCP (2) were trained in the management of severe malaria. Given the interest in this training, the Director of the NMCP and the USAID mission Resident Advisor participated. The PMI representative led the training session on the incidence of severe malaria. Provider scores improved from an average of 15.5/25 on the pre-test to an average of 22.5/25 on the post-test. Where only three providers achieved a score of 20 or higher on the pre-test, all providers scored 20 or higher on the post-test.

Figure 21: Presentation of the severe malaria context in Mali, by the PMI Resident Advisor

Figure 22: Opening ceremony for the training session on severe malaria by the Director of the NMCP, the General Health Directorate, and IM Mali


Table 4: Malaria training modules with focus on severe malaria Module 1: Malaria transmission and symptoms

● Mode of transmission of malaria ● Minor and serious symptoms ● Epidemiology of malaria in Mali

Module III: Biosafety ● Infection prevention and control ● Management of biomedical waste

Module II: Diagnosis and treatment of malaria ● Symptoms of uncomplicated and severe malaria, ● Parasitological diagnosis by mRDT, thick smear,

thin smear ● The laboratory ● National malaria case management policy:

uncomplicated and severe cases, pre-transfer treatment, reference system for serious cases, emergency treatment for complications

Module IV: Gender: ● Definition of gender concepts ● Gender considerations for malaria control

activities

Key Accomplishment # 9: Strengthened essential care services in the community IM Mali supported the DGHPH, through the SDHIR, in the implementation of the Soins essentiels dans la communauté (SEC, Essential Care in the Community) strategy, which included iCCM. In this reporting period, the activities supported were: (1) CHW Mapping in the IM-supported regions; (2) Semi-annual SEC review in the Kayes region; and (3) Supervision of CHWs in Koulikoro and Kayes regions. IM Mali participated in the annual national review workshop of SEC 2019-2020 activities, which took place March 29-31, 2021, in the Kangaba and Koulikoro regions. During this workshop, it was recommended to:

o Revise the presentation outline of the review by inserting the management of uncomplicated malaria cases in pregnant women and adults

o Provide a guide for completing the outline o Strengthen the capacity of all involved in data management o Organize advocacy with decision-makers to support CHWs at all levels o Strengthen collaboration between partners and technical colleagues at district and regional levels o Reinforce the mobilization of domestic resources to support incentives for CHWs, including from

Community Health Associations, Mining companies, Industrialists, and Communities o Respect the principle of “one CHW, one site” o Strengthen the harmonization of DHIS2 data and reports from CSRefs


Key Accomplishment # 10: Held semi-annual regional iCCM coordination meetings On June 9-10, 2021, the NMCP, in collaboration with the SDRH and IM, held the regional review of essential care activities in the community, in the Kayes region. Challenges discussed:

● End of payment of incentives for CHWs, because the USAID/Services de Santé à Grand Impact (SSGI, High-Impact Health Services) project ended in November 2020

● Frequent absences of CHWs from their sites in the region ● Lack of supervision at the level of the CHW sites in the region ● Lack of CHW training

Recommendations made for future support:

▪ Improve coordination between stakeholders to restart incentives for the CHWs at the commune/CHW site level

▪ Draw up a contract for commitments for CHW incentives ▪ Implement a permanent payment system for CHWs by the MOH ▪ Support the regular supply of commodities to CHW sites ▪ Reinforce regular monitoring of CHWs ▪ Train CHWs on new skills

Key Accomplishment # 11: Supported the MOH with iCCM supervision IM Mali supported the supervision of CHWs in the Koulikoro and Kayes regions. During the reporting period, IM Mali supported the Directorate General of Health through its SDHIR to organize a joint supervision visit of 11 CHW sites in the regions of Kayes and 12 in Koulikoro. During this supervision, the supervisory teams met with 23 presidents of Community Health Associations, Directeurs Techniques de Centre (DTC, Heads of Health Center) and village chiefs in Kayes (11) and Koulikoro (12). At the end of each supervision visit, the supervisory team provided feedback to community authorities, including the DTC, and shared an action plan to resolve the problems identified at CHW sites. Some beneficiaries were also interviewed to learn their opinions on the quality of CHW service provision. For electronic data collection, a tablet was configured with a checklist developed by the IM Mali team and the NMCP. The graphs below show results from on-the-job observation of CHWs, key informant interviews, and the assessment of work environment. Figure 23: CHW in the village of Bantona,

Baoufoulala health region


Figure 24: Availability of mRDT, ACT, and rectal artesunate at supervised CHW sites, Source: KoboCollect, iCCM supervision At the sites visited, the availability of the mRDTs was 95%, and 87% for ACTs. Only 9% of CHW sites had rectal artesunate for the pre-transfer treatment of patients with severe malaria. This low rate was explained by the stock-out of rectal artesunate in health districts.

Figure 25: Performance of supervised CHWs in checking for symptoms, Source: KoBoCollect, iCCM supervision At the sites visited in Kayes, 20% of CHWs supervised reached the 80% competency in checking for malaria symptoms in sick children, including asking about fever at home in the previous twenty-four hours, and vomiting. This could be explained either by weaknesses in pre-service training or lack of regular outreach training and supportive supervision of CHWs. In Koulikoro, 60% of observed CHWs reached the 80% competency score for checking for malaria symptoms.


Figure 26: Performance of supervised CHWs in checking for severe malaria danger signs, Source: KoBoCollect, iCCM supervision At the sites visited in Kayes and Koulikoro, only 29% of observed CHWs reached the 80% competency in correctly looking for danger signs of severe malaria, for example to ask caregivers about a history of convulsion at home, frequency of vomiting, or conjunctival pallor. This could be explained by weaknesses in pre- or in-service training of CHWs or weak linkages to HFs for referral of suspected severe malaria cases.

Table 5: Summary of the findings at the CHW sites Strengths Weaknesses

● Availability of certain CHWs at their sites ● Clean premises and consultation room

separate from CHW’s dwelling ● Good collaboration between the CHW

and the community ● Existence of certain supporting

documents, including the site consultation register, individual management sheets, CHW supervision notebook, and monthly activity report

● Availability of functional equipment, including scales, thermometer, timer, and Shakir strip in most of the sites visited

● Availability of mRDTs ● Availability of hand washing facilities and

gloves in some sites ● Availability of other personal protective

equipment against COVID-19, including masks and hydroalcoholic gel

● Availability of safety boxes for mRDT sharps

● Stock-out of rectal artesunate for pre-referral treatment of severe malaria cases

● Absence of a timer at certain sites to reinforce accuracy of mRDT use and respiratory rate counting

● Insufficiency in the assessment of respiratory rate in children who cough

● Inadequate identification and compliance with the reading time of mRDTs

● Weaknesses in adapting the dosage of cough medicines to the weight of the child and compliance with the duration of treatment

● Stock-out of gloves at certain sites ● Insufficient compliance with

protective measures, for example wearing a mask


Actions taken Following the stock-out of rectal artesunate in the field, IM Mali reported the information to the NMCP, and measures were taken to resupply the health districts. Some boxes of rectal artesunate expired because of low usage rates. Usage rates were low in some cases because the need for pre-transfer treatment arose rarely. Expired rectal artesunate boxes were also recovered from some CHWs in the Koulikoro region. Mentoring CHWs CHWs collected data daily through individual patient sheets and compiled these in a monthly activity report, which was sent to the DTCs for entry into the national HMIS in DHIS2 and for analysis. The figure below shows the evolution of malaria cases treated by CHWs from October 2020 through September 2021 in Kayes and Koulikoro. Of the 83,536 patients under the age of five seen for fever, 58,230 tested positive with mRDTs and 58,106 treated with ACTs. ACT stock-outs led to approximately 1% of patients who sought treatment not being treated at the community level.

Figure 27: Malaria in children under the age of 5 seen by CHWs, October 2020 to September 2021, Source: National DHIS2 Objective 2: Improve the quality of and access to other malaria drug-based approaches and provide support to pilot and scale up newer malaria drug-based approaches Key Accomplishment # 1: Held regular meetings of the SMC TWG During the reporting period, IM Mali supported the NMCP to coordinate meetings with the SMC TWG. During the preparation phase of the campaign, from May to June, three meetings were held between the NMCP and its partners, which include IM, the Global Fund, and UNICEF. These meetings focused on the:

● Organization of regional micro-planning sites ● Procurement and supply situation for Mali’s SMC medicines ● Revision of data collection tools ● Validation of regional micro plans ● SMC campaign schedule.


Key Accomplishment #2: Exceeded 2021 SMC coverage targets During the reporting period, IM Mali supported implementation of the fourth cycle of the 2020 SMC campaign in October 2020 and the first three cycles of the 2021 campaign. During the 2021 SMC campaign, the number of health districts in the Sikasso region conducting SMC with an extension to children aged 5 to 10 increased from two to three. SMC has been a priority community activity for the NMCP. IM Mali supported the NMCP to implement SMC campaigns in 11 health districts, including five health districts in the Kayes region: Kita, Bafoulabe, Yelimané, Diema, and Nioro; three in the Koulikoro region: Kolokani, Fana, and Dioila; and three in the Sikasso region: Koutiala, Kadiolo, and Selingué. The target population in these 11 districts was 790,437 children aged 3 to 59 months and 235,902 children aged 5 to 10 years, which was a total of 1,026,339 children aged 3 to 120 months. As part of SMC implementation, IM Mali supported regional microplanning workshops to estimate needs, budget activities, and train the DTCs and their deputies to be trainers for community distributors. This year, these workshops were held face-to-face given the low incidence of COVID-19, with strict compliance to COVID-19 preventive measures. In accordance with SMC micro plans, IM Mali trained 600 DTC and their deputies in the eleven health districts. The door-to-door strategy was retained by the NMCP in 2021 and entailed training 6,122 community distributors to administer SP-AQ to eligible children and specialized health workers to test febrile children with mRDTs and treat those who have confirmed malaria with AL during the SMC campaign. Specialized

Figure 28: A team of community distributors from the Kersignané Kaniaga health area, Yelimané district, Kayes region


health workers were nurses or auxiliary nurses who normally work in health facilities. Among the distributors, 54% were men and 46% were women (Figure 30). The first cycle of the 2021 SMC campaign started in July 2021 and IM Mali initiated daily submission of SMC data from districts by KoBoCollect through District Officers (DO). IM Mali trained one SMC data entry officer for DHIS2 per district. IM Mali also supported the organization of workshops for the validation of results in the districts after the fourth cycle of the 2020 SMC campaign and the first cycle of the 2021 campaign. These workshops gathered DTCs, prefects and town authorities, and CHA representatives to share findings with stakeholders, correct data anomalies, and find solutions to any potential gaps in the data.

Figure 30: Number of SMC community distributors by sex, Source: NMCP, SMC

Figure 29: IM Mali District Supervisor supported a CSRef with SMC commodities


Figure 31: Rate of coverage per SMC cycle and per age group, Source: NMCP, SMC

The NMCP objective is to reach at least 90% of children during each SMC cycle. Coverage rates per age group in the fourth cycle in 2020 for all 11 districts reached 98.08% for children aged 3 to 59 months and 95.97% for children aged 5 to 10 years. In the first cycle in 2021, coverage rates per age group for all 11 districts reached 105.84% for children aged 3 to 59 months and 93.96% for children aged 5 to 10 years. In the second cycle in 2021, the coverage rates per age group for all 11 districts reached 101.97% for children aged 3 to 59 months and 96.05% for children aged 5 to 10 years. In the third cycle in 2021, the coverage rates per age group for all 11 districts reached 96.27% for children aged 3 to 59 months and 92.53% for children aged 5 to 10 years.

Figure 32: Number of febrile children among those targeted for SMC, and number that test positive for malaria, Source: NMCP, SMC

Children who present with fever at the time of the SMC campaign are excluded from receiving that cycle of SP-AQ. In Mali, the community distributor who comes across a febrile child among those targeted for SMC calls in a health worker, who tests for malaria with an mRDT on the spot, and if positive provides a


course of AL to the caregivers to treat the child’s malaria. If negative, and if the child can swallow, SP-AQ is administered, and the child is referred to the health center for follow up. Key Accomplishment #3: Conducted independent monitoring of the SMC campaign after the first and fourth cycles Given challenges with the operational denominator used for setting targets in SMC campaigns, because of outdated census data, the NMCP, in collaboration with IM, organized an independent rapid monitoring survey one week after the fourth cycle of the 2020 campaign and one week after the first cycle of the 2021 campaign to measure actual household coverage. After updating the survey tools and checklist, these were uploaded to tablets. Then data were collected in two health areas in two districts per region, for a total of six districts and 12 health areas, 48 randomly selected villages, and 30 randomly selected households in each village for a total of 1,440 households in the Kayes and Koulikoro regions. Caregivers were interviewed on the administration of the drugs and asked their opinion on the quality of campaign communication. The survey enumerators also verified the evidence of the child’s treatment by checking SMC cards and/or empty blister packs of the AQ left by the community distributors for the caregivers to administer on days two and three.

Figure 33: Percentage of children aged 3 to 59 months having received SP-AQ, by cycle in 2020, IM Mali Zones, Source: Independent monitoring surveys According to the analysis in October 2020, survey results showed that 93% of children under the age of 5 in IM Mali zones were reached four times according to caregiver declaration. This rate was 63% when correctly completed SMC cards or empty blister packs can be shown as proof of treatment. This was comparable to the national average provided by the NMCP, showing that caregivers for 55% of children in Mali could prove that their child(ren) had received treatment with SP-AQ during the four cycles of the SMC campaign.


Figure 34: Percentage of children aged 5 to 10 years having received SP-AQ according to the SMC cycles in 2020, IM Mali Zones, Source: Independent monitoring surveys

Figure 35: Percentage of children aged 3 to 59 months having received SP-AQ, by region during the SMC campaign in cycle one, 2021, IM Mali Zones, Source: Independent monitoring surveys Analysis of the 2021 cycle one survey results showed that 97% of children under the age of 5 years in IM Mali zones were treated according to their caregivers, compared to 81% upon verification of evidence, such as correctly completed SMC cards or empty blister packs.


Figure 36: Percentage of children aged 5 to 10 years having received SP-AQ in the first SMC cycle of 2021, IM Mali Zones, Source: Independent monitoring surveys

According to caregiver declarations, the coverage rate in children aged 5 to10 years was 100%, compared with 65% based on verification of the proof of treatment.

Figure 37: Proportion of caregivers of children aged 3 to 59 months who reported administering the second and third doses of AQ in the first SMC cycle of 2021, IM Mali Zones Source: Independent monitoring surveys The longer the time interval between the SMC cycle and the independent monitoring survey the less evidence is available. Objective 3: In support of Objectives 1 and 2, to provide global technical leadership, support operational research, and advance program learning Key Accomplishment #1: Supported operational research IM Mali supported four operational research studies. Two of these were conducted by the Malaria Research and Training Center (MRTC) to find innovative strategies to increase the uptake of IPTp through improvement of ANC. Two were conducted by the Applied Molecular Biology Laboratory (LBMA,


Laboratoire de Biologie Moléculaire Appliquée) evaluating the therapeutic efficacy of antimalarials and resistance to SP for pregnant women targeted for IPTp and children targeted for SMC. The first study, “To increase the use of intermittent preventive treatment by improving the provision of services in the antenatal clinic to improve maternal and child health” launched in the San district of the Segou region in April 2020. To date, IM Mali has: • Trained 189 community health workers • Completed the baseline survey, • Initiated implementation from April 2020 to May 2021 • Conducted monthly supervision by MRTC and the CSRef • Supported national joint supervision by the NMCP, SDRH, MRTC and IM, including the most recent

joint supervision conducted August 1-8, 2021 The study is expected to complete all activities and reporting by October 31, 2022. The second study was entitled, “INCREASE IN COVERAGE OF INTERMITTENT PREVENTIVE TREATMENT THROUGH STRENGTHENING OF PRENATAL CONSULTATION SERVICES TO IMPROVE MATERNAL AND CHILD HEALTH AND EVALUATION OF

PRENATAL CONSULTATION DATA FOR ROUTINE SURVEILLANCE IN THE HEALTH DISTRICTS OF KITA AND NIORO (KAYES, MALI).” and launched in August 2021. To date, IM Mali has:

• Received approval of the protocol by the Mali ethics committee in March 2021, followed by that of PMI and CDC after scientific review

• Shared the protocol with local representatives of IM Mali and USAID-PMI • Signed the sub-contract • Conducted an introductory trip to meet with health managers of the Kayes region and Yelimané

and Kita districts April 18-22, 2021.Photos are included below. • Trained 50 interviewers on study data collection tools July 13-16, 2021, in Bamako, and August

16 - 24, 2021, in Kita • Launched the baseline survey in the Kita and Nioro district on August 25, with data collection

through September 24, 2021 • Supervised the baseline survey by the NMCP, SDRH, Société Malienne de Gynécologie Obstétrique

(SOMAGO, Malian Obstetric Gynecology Society), MRTC, and IM Mali • Started implementation of the study planned for the end of September 2021

The study is expected to complete all activities and reporting by December 31, 2022. For the third study, IM Mali supported a TES, to assess the therapeutic efficacy and safety of AL and DHA-PPQ for the treatment of uncomplicated P. falciparum malaria in Mali. The TES has been implemented by the LBMA at the Université des Techniques et des Technologies de Bamako (USTTB, University of Sciences, Techniques, and Technologies of Bamako). The study was launched in May 2020 and conducted across three sites: Selingué, Missira in the Sikasso region, and Dioro in the Ségou region. After a pause in enrollment from February to June due to the low malaria transmission season, the study resumed recruitment in June 2021 after the extension of the sub-contract and ethics committee approval for the resumption of the study.


The research team and IM Mali regularly monitored progress of the TES through a WhatsApp platform for information sharing and updates. After resumption of the TES on June 17, 2021, a total of 354 patients out of a target of 480 were enrolled, including 133 patients in Dioro, 160 in Missira, and 90 in Selingué. The Missira study site achieved its target sample size of 160 patients. The study is expected to complete all activities and reporting by September 2022. The fourth study, for the molecular monitoring of SP, is also implemented by USTTB. The study, launched in November 2020, targets children with parasites and ANC participants who received SP for malaria treatment to estimate the frequency of mutant alleles of Pfdhfr and Pfdhps (two genes associated with malaria resistance to pyrimethamine and sulphadoxine) in Sélingué, Missira and Dioro. The study launched in November 2020 and has enrolled 165 out of a target of 480 patients as of September 9, 2021. The study is expected to complete all activities and reporting by June 2022.


SMC Many caregivers did not remember to correctly complete the SMC card after administering the second and third doses of amodiaquine to their children.

Raised parental awareness through community distributors, community leaders, TV, and radio broadcasts

SMC daily data submission was slow or incomplete, from the health district to the national level.

Initiated SMC data entry directly into DHIS2 rather than in parallel Excel sheets that got emailed up the chain

It was challenging for the IM Mali team to get timely and complete daily SMC coverage data from the field, as they were not included in the data transmission chain from district to the national level.

Configured a checklist in KoBoCollect and initiated the submission of SMC data by the IM Mali district officers

On-time payment of SMC per diem costs posed a challenge, due to the number of community stakeholders involved and the fact that not all town criers and imams had a mobile money account.

Mobilized PSI payment agents in the districts to help

MIP Interpersonal communication for IPTp at ANC clinics posed a challenge, as ANC staff did not systematically offer IPTp nor counsel pregnant women to return to continue IPTp.

Emphasized counseling related to IPTp in feedback sessions with ANC staff during outreach training and supportive supervision

Insufficient involvement of rural ANC staff in NMCP activities posed a challenge, principally training and supportive supervision, often due to de-prioritization and relatively lower patient volumes.

Included rural ANC staff in MIP training sessions

Private facilities offered ANC, but did not always offer IPTp-SP.

Included ANC staff from private facilities in MIP training sessions


Challenges Solutions Severe malaria

The unavailability of commodities for treating severe malaria and use of injectables for some non-severe malaria cases

Followed up with relevant authorities to support availability of commodities, especially rectal artesunate Focused on severe malaria during classroom training and OTSS+ and reinforced that injectables are reserved for severe malaria cases

Non-compliance with national treatment guidelines for classifying severe malaria

Focused on severe malaria during classroom training and OTSS+ to review and reinforce the key warning signs, clarifying for example that vomiting alone may not equal severe malaria

CHWs needed training to recognize danger signs of severe malaria and to effectively administer pre-referral treatment.

Trained CHWs in recognizing the danger signs of malaria and pre-referral treatment. Reinforced that even if the patient feels better, it may only be temporary.

Lessons Learned

● Initiation of the daily SMC data reporting by IM Mali District Supervisors through KoBoCollect improved data tracking.

● Practical internships during MIP training improved the skills of ANC managers. ● Adapting the language of communication to participants in training sessions, and using local

languages, increased participants’ engagement in the training. ● Training maternity service managers on MIP improved their mastery of and adherence to

antimalarial drug dosing. ● The managers of birth attendants undertaking ANC training can manage cases of uncomplicated

and severe malaria in pregnant women. ● The DOT approach for SP was acceptable to and applied by service providers after the training. ● Water sachets are needed instead of a community jar and cups for the water, at some CSComs

and CSRefs, for DOT with SP due to COVID-19. ● Training service providers on the management of biomedical waste helped to prevent infection

and protected safety in the provision of health services. The table below details how waste management training was integrated into different project activities.


Table 6: Management of biomedical waste Topic Mitigation measures for

biomedical waste management

Status of mitigation measures

Comments

Training of microscopy providers for malaria diagnosis

How waste, including slides, Giemsa dyes, empty sachets, empty boxes of slides, vaccine lancets, cotton swabs, and other materials should be managed

Trained 124 laboratory technicians in the biological diagnosis of malaria, during nine sessions, with orientation on biomedical waste management for slides, Giemsa dyes, empty sachets, empty boxes of slides, vaccine lancets, cotton swabs, and others

All service providers were trained and monitored in OTSS+ for biological diagnostics. Providers received training manuals and technical slide decks on the biomedical waste management plan, including sorting, transport of different types of trash cans, and incineration.

OTSS+ supervision

The supervisory team should check the equipment: sharps disposal containers, trash cans, pipeline and wastewater management, biomedical waste management at CSCom sites and should proceed with sorting and incineration.

All facilities visited had biomedical waste management and safety equipment, trash cans, and an incinerator.

Quarterly supervision.

Supervisors checked the availability of sharps disposal containers, trash cans, and gloves.

Training and Supervision of CHWs

The supervisory team should check the equipment: sharps disposal containers, and trash cans for biomedical waste management at CHW sites.

IM, in collaboration with the NMCP and the SDHIR, organized a site supervision visit to the Koulikoro and Kayes regions.

During these visits, the team verified waste management at CHW sites and provided guidance on the best approaches for waste management. During the project reporting period, IM Mali supervised 23 sites with sharps disposal containers, and trash cans for waste recovery, sorted according to type.

Quarterly supervision.

The availability of sharps disposal containers, trash cans, and gloves was checked by supervisors. Also, at each supervision, a reminder was given regarding the importance of wearing gloves and the management of biomedical waste.


IM Mali Indicator Table The data provided in the indicator table below are IM Mali targets and results reflect activities from the period October 1, 2020, to September 30, 2021. The data in the indicator table reflect activities in the IM supported areas in Mali which include Kayes Region, Koulikoro Region and district of Bamako. For SMC activities, IM Mali supports SMC in children 3-59 months in Kayes (five districts), Koulikoro (three districts), Sikasso (three districts) and supports SMC among children 5 to 10 years in Sikasso (three districts). During this period, two rounds of OTSS were completed, 292 facilities were visited during OTSS rounds and trained a total of 7,008 - 845 individuals trained in MIP, lab and OTSS supervision and 6,158 trained for the SMC campaign. Progress to Annual Target is calculated as actual result/target *100=progress to target. This provides an indication of how much progress has been made to meeting the annual target outlined in the country workplan.


Progress to Annual

Target Comments



75% 51% 68% The low rate was due to providers treating presumed cases without a diagnostic test.


97% 94% 97%

Stock-outs of mRDTs in some health centers could explain the rate, which was slightly below the target.

Percentage of observed health workers demonstrating competency in correctly classifying cases as uncomplicated malaria, and severe malaria

87%

R1=91% (N=385); R2=95% (N=503)

109%

Almost all providers demonstrated competency in the classification of cases as not malaria, uncomplicated malaria, and severe malaria.

Percentage of health workers demonstrating skill in using mRDTs

50%

R1=57% (N=186); R2=71% (N=473)

142%

Competency improved between Rounds one and two. The number of cases increased because round two occurred during a period of high malaria transmission.


35%

R1= 36% (N=190); R2=47% (N=159)

134%

Improvement might have been due to the impact of basic malaria microscopy training to build provider competency.

Percentage of supervised facilities that meet standards, including

39% R1= 10% (N=146);

133% Training and involvement of some CSCom teams in strengthening working



Progress to Annual

Target Comments

appropriate materials, documentation, and qualified staff for quality diagnosis of malaria

R2=52% (N=132)

conditions might have explained this strong result.


30%

R1= 49% (N=146); R2=57% (N=132)

190% IM Mali supported eight training sessions.


95% 133% 140% 96 laboratory technicians were trained.


90% 111% 123%

One supervisor was trained per district and region in the IM Mali intervention area, 29 in total out of 26 targeted.

Percentage of targeted health facilities with national guidelines for malaria diagnosis that meet global standards

70%

R1=61% (N=146); R2=72% (N=132)

101%

IM Mali supported the distribution of manuals for biological diagnosis, through OTSS+ and basic training.



100% 100% 100%

The training of providers, quarterly monitoring of providers through OTSS+, and NMCP and IM Mali supervision of data quality could explain this rate.


99% 102% 103%

The training of providers, quarterly monitoring of providers through OTSS+, NMCP and IM Mali supervision of data quality could explain this rate.

Percentage of supervised health facilities with health workers demonstrating competency in the management of severe malaria

15%

R1=16% (N=4);

R2=14% (N=20)

93%

The NMCP, in collaboration with IM, trained maternity care providers on the management of malaria during pregnancy and has organized two rounds of OTSS+. These activities may explain this improvement in providers' skills.



Progress to Annual

Target Comments

Percentage of observed health workers demonstrating competency in the management of uncomplicated malaria

20%

R1=35% (N=160); R2=41% (N=206)

205%



55%

R1=78% (N=110); R2=70% (N=226)

127%



97%

R1=82% (N=274); R2=74% (N=171)

76%

Some untrained providers in some health centers doubted the results of mRDTs and continued to combine antimalarials with antibiotics in the face of negative mRDTs. This may have explained this result, which was lower than expected. During the next reporting period, IM Mali intends to train untrained providers or those who were trained more than two years ago on malaria management in its intervention zones to improve the results.

Percentage of supervised facilities that meet global standards (including appropriate materials, documentation, and qualified staff) for quality malaria clinical management

40%

R1=39% (N=284); R2=69% (N=261)

172%

The NMCP, in collaboration with IM Mali, has trained providers on the management of malaria during pregnancy and has provided health centers with reference documents, including a training manual and trainer's guide which could explain this improvement.

Percentage of expected malaria reports from IM-

97% 97% 100% IM Mali achieved this target.



Progress to Annual

Target Comments

supported facilities received

Percentage of targeted health facilities that received a supervisory visit for malaria case management and/or MIP and/or diagnosis/lab

95%

R1=100% (N=284); R2=92% (N=284)

97%

Health centers targeted for OTSS+ supervision was visited at least once this year. Some health centers could not be visited in the second round because poor road conditions limited accessibility.

Percentage of health workers trained in the management of severe malaria

95% 37% 39%

IM Mali supported training of 22 providers from CSRef and Bamako hospitals. As a next step, those from the Kayes and Koulikoro regions remain to be trained. This activity was linked to the finalization of the reference documents for the provider training on the management of severe malaria. During the next reporting period, IM Mali plans to train the remaining providers on the management of severe malaria in the next project year.

Percentage of health workers trained according to national guidelines in malaria case management with ATCs

95% 0% 0% Finalization of the training manual was in progress.

Percentage of IM-supported Health Facilities or districts with national guidelines for malaria treatment that meet global standards

70%

R1=61% (N=284); R2= 84% (N=261)

120%

IM Mali provided health centers with provider training manuals for the management of severe malaria, which may explain this improvement.

Objective 1.3: Improved access to quality prevention


85% 86% 101%

Stock-outs of ITNs have been documented in some health centers this year, which may explain why women did not receive an ITN.



Progress to Annual

Target Comments

and management of malaria in pregnancy (MIP)


50% 52% 104%

The training of maternity managers and implementation of OTSS+ may have enabled IM Mali to achieve this objective.


58% 61% 105%



75% 75% 100%


Percentage of observed health workers demonstrating competency in the treatment of MIP

35%

R1=27% (N=494); R2= 43% (N=423)

77%

In some health centers, trained providers did not share the training with their colleagues, which explains this shortcoming. During the next reporting period, IM Mali intends to improve these results through quarterly OTSS+ visits.

Percentage of observed health workers demonstrating competency in the prevention of MIP

35%

R1=38% (N=494); R2= 55% (N=423)

109%

The training of maternity managers and OTSS+ supervision visits may have allowed IM Mali to surpass this annual objective.


95% 131% 138%

At the request of some referral health centers, IM Mali trained more maternity providers than expected on the prevention and management of malaria during pregnancy, which explains why the annual objective was exceeded.

Functional/active/RMNCH/MIP/ANC/ community health WG

3 3 100% IM Mali, through collaboration with the NMCP, achieved its annual target.

Objective 2: Improved access to quality transmission-


90% N/A N/A This result will be available after the fourth cycle of SMC.



Progress to Annual

Target Comments

appropriate drug-based prevention and treatment approaches 

Percentage of targeted children who received a course of SMC in the first cycle

90%

98.61% Previous reporting

period 103%

Current reporting

period

114%

IM Mali has leveraged lessons learned in the past years to improve SMC results. This could explain the good rate of coverage in the first cycle of SMC.

Percentage of targeted children who received a course of SMC in the second cycle

90%


period

101% Current reporting

period

112%

IM Mali has leveraged lessons learned in past years to improve the SMC results. This could explain the good rate of coverage in the second cycle of SMC.

Percentage of targeted children who received a course of SMC in the third cycle

90%


period

95% Current reporting

period

106%

Percentage of health workers trained to deliver SMC according to national guidelines

100% 100% 100%

Good collaboration between the NMCP and IM Mali made it possible to achieve this objective.


6158 6158 100%

Percentage of IM-supported regions with

N/A N/A N/A



Progress to Annual

Target Comments

annual SMC implementation plans

Objective 3: Project technical leadership contributes to PMI-led global policy development and Ops Research (OR)

Contribution to national, regional, or global guidance/policy documents related to malaria (including reproductive health)

2 0 0

IM Mali did not contribute to national documents during this reporting period, as many already existed, including training manuals on malaria prevention in pregnancy, diagnosis, and essential care in the community.


2 1 50%

The MIP manual was distributed to healthcare providers during the MIP training session.

Participation in targeted national, regional, or global level WGs and/or task force(s)

3 0 0

During this reporting period, IM Mali did not support any sub-regional or international workshops, due to COVID-19.

412 IM Niger October 2020 – September 2021

Niger Background IM Niger is supporting the Government of Niger (GON) and NMCP to achieve its goal of reducing malaria morbidity and mortality by 40% from 2015 levels by 2023. IM is working in close collaboration with the NMCP and other relevant MOH departments, including the Direction Régionale de la Santé Publique (DRSP, Regional Directorate of Public Health) for Dosso and Tahoua; Direction de la Santé de la Mère et de l’Enfant (DSME); Direction Générale de la Santé de la Reproduction (DGSR, General Directorate of Reproductive Health); Direction de l’Organisation des Soins (DOS, Directorate of the Organization of Health); Teaching hospitals of Niamey; Centre de Recherche Médicale et Sanitaire (CERMES, Center for Medical and Health Research), and University Abdou-Moumouni of Niamey to operationalize the Niger National Malaria Strategy Plan (NMSP) 2017 -2023 and the new community health policy adopted in 2019 for iCCM implementation.

IM currently focuses technical support in two of the Niger’s eight regions: Dosso and Tahoua (Figure 1). These two regions are composed of 21 health districts (HDs) with an estimated population of 7,176,537 in 2020 (National Institute of Statistics) In addition, IM Niger has been working in the region of Agadez to support a TES for antimalarials. IM Niger seeks to improve the delivery of malaria services in Dosso and Tahoua by providing operational and technical support for three key objectives:

• Objective 1: Improve the quality of and access to malaria case management and prevention of malaria during pregnancy

• Objective 2: Improve the quality of and access to other malaria drug-based approaches and

provide support to pilot and scale up newer malaria drug-based approaches

• Objective 3: In support of Objectives 1 and 2, provide global technical leadership, support operational research, and advance program learning

During the reporting period, based on the experience acquired by the project since 2018 and considering the national policies and NMSP, IM Niger has worked with the NMCP, DRSP, and other relevant MOH departments to continually support a core package of interventions in the targeted regions. These included reinforcing coordination at national, regional, and district levels, continuous capacity building of health providers at facility level through training and OTSS+; supporting and expanding iCCM; and implementation of the SMC campaign. IM has also provided technical support to the NMCP to conduct a TES for antimalarials in three sentinel areas.

Figure 1: IM Niger Geographic Coverage


Table 1: IM Niger Package of core interventions Objective Activity Description Level of Intervention

1 MIP/TWG IM Niger supports the NMCP and the DGSR for quarterly meetings of the national MIP TWG

Central

Hands-on training program for severe malaria

IM Niger has supported HW capacity building to manage severe malaria by implementing a hands-on training program in regional and district teaching hospitals in Dosso and Tahoua.

Regional and District

iCCM IM Niger supported five HDs in Dosso and Tahoua to expand iCCM through community mobilization as well as through training and supervision of CHWs in these districts.

District

Supportive supervision

IM Niger supports 12 DHMT in Dosso and Tahoua to conduct targeted quarterly OTSS+ to identify and resolve barriers to quality malaria service delivery and to develop action plans to address key issues arising related to malaria case management and prevention of MIP at Centres de Santé Intégrés (CSI, Integrated Health Center levels.

District

Coordination IM Niger has supported quarterly coordination meetings in 17 HDs and bi-annual coordination meetings in two targeted regions to assess malaria indicators, share findings from OTSS+ visits, and discuss challenges.

IM Niger has also supported CSI quarterly coordination meetings in the five HDs that are implementing iCCM.


2 SMC IM Niger supported the NMCP to implement the SMC campaign in 17 HDs of Dosso and Tahoua regions.


3 TES IM Niger supported a TES for AL in three sentinel sites in Niger.

Central and District

Key Achievements

Objective 1: To improve the quality of and access to malaria case management and the prevention of malaria during pregnancy

Key Achievement #1: Supported the National MIP TWG During the reporting period, the National MIP TWG, launched in 2020 with support of IM Niger, held l two (2) in-person meetings with the large group and seven (7) meetings of the small technical group (including IM’s case management and MIP technical advisor, NMCP chief of the Case Management Unit and DSME chief of maternal health Unit) to develop and validate an action plan and discuss major policies that need to be updated. As a result, under the leadership of the DGSR, the MIP TWG members, including the NMCP and the Direction de la Santé Mère et de l’Enfant (DSME, Mother and Child Health Directorate) agreed on the need to revise the national malaria case management guidelines and ANC training materials to align them with 2013 WHO recommendations regarding the administration of SP during ANC visits.


In response to these recommendations, the NMCP and DSME coordinators undertook advocacy with potential donors, such as WHO and UNICEF, to identify funding for revision of these national documents. Key Achievement #2: Reinforced capacity on the management of severe malaria in 12 regional and district hospitals by training 30 HWs at teaching hospitals.Inpatient malaria mortality in children under the age of 5 years in Niger country is estimated at 2%.1 To build the capacity of health providers in hospitals, where most of the severe malaria cases are being treated, IM Niger provided technical support to the NMCP to implement a hands-on training on severe malaria for clinicians from regional and district hospitals in Dosso and Tahoua, at teaching hospitals in Niamey Built on lessons learned from IM implementation in Cameroon, the NMCP and IM Niger have designed the program in three steps: The first step was the provision of the hands-on training in Niamey. From March 24 to June 12, 2021, 30 HWs (14 men and 16 women) from 12 regional and district hospitals in Dosso and Tahoua participated in hands-on training for severe malaria in three teaching hospitals of Niamey: National Hospital of Niamey, National Hospital Amirou Boubacar Diallo and Maternity Issaka Gazobi. Six trainers, pediatricians, gynecologists, and internists, were identified by the NMCP to revise the training materials and train participants. The training was organized into two phases, a theoretical phase of three days which consisted of teaching courses on malaria-related complications and a practical internship phase lasting 15 days in the university hospitals. On a practical level, each participant was integrated into a specialized hospital service throughout the duration of the training. During the internship period, hospital, NMCP, and IM staff evaluated participants' skills for the management of severe malaria. Out of the 30 HWs, 28 scored 15 or above out of 20, which is acceptable within GON norms.

1 République de Niger, Ministère de la Santé Publique, Programme National de Lutte contre le Paludisme (2020). Plan Stratégique National (PSN) de Lutte contre le Paludisme 2017-2021 avec extension jusqu'en 2023.

Figure 2: Management of severe malaria in the National Hospital of Niamey, the pediatric service, Photo Credit: Dr. Naroua, IM


Figure 3: Pre and post training results of severe malaria training A WhatsApp group has supported peers to stay in touch, share real-life experiences, and get feedback from each other during and after the training. This is a platform for NMCP coordination, trainers, and participants to discuss severe malaria cases managed in hospitals and to share scientific and other publications. Since June 2021, under the leadership of the NMCP, a severe malaria WhatsApp’s group has been set up. This forum has facilitated follow-up discussions among the trainees after the onsite training courses on severe malaria and after their return to their workplace. To reinforce skills acquired by 30 HWs trained on severe malaria, IM Niger provided technical and logistical support to the NMCP for the implementation of a post-training supervision visit in 13 regional and district hospitals in Dosso and Tahoua. As part of the preparation for the activity, the NMCP team and trainers revised the national severe malaria checklist adapted from the IM standard OTSS+ checklist and validated methods that will be used to assess trainee performance. IM Niger also supported the integration of this checklist into an electronic data system (KoBoCollect). Then, IM Niger supported the training of 10 supervisors (four men and six women) to carry out these post-training visits. The post-training supervision undertaken in August 2021, assessed follow-up actions taken by the participants in the severe malaria training to perform cascade training in their respective hospitals. This supervision also assessed competency for the management of severe malaria through chart reviews. As a result, 18 HWs benefitted from the post-training supervision. Of the 18 HWs, 16 conducted onsite refresher trainings in 16 hospitals on severe malaria for 170 of their colleagues and 113 patient charts were reviewed, 54 before and 59 after the hands-on training on severe malaria. In terms of case management of severe malaria in the hospitals visited, the supervisory team observed that after reviewing patients’ charts, there was an improvement in the treatment of patients who were seen after a severe malaria training: cerebral malaria (67% vs 100%), anemia (84% vs 95%), and shock (33% vs 80%). However, due to the shortage of G30 solution in all hospitals visited and lack of glucometers to monitor patient's blood glucose level, the management of hypoglycemia remained a challenge. These findings were shared with hospital managers


during the end-of-post-training supervision meetings, and advocacy was initiated to encourage them to provide the G30 solution and glucometers to the targeted departments.

Figure 4: Percentage of patients with severe malaria complications managed according to national guidelines

Key Achievement #3: Increased health provider competency in malaria service delivery through intensified OTSS+ visits in 96 priority CSIs2

During the reporting period, IM supported the NMCP and 12 HDs of Dosso and Tahoua to undertake three supportive supervision visits in 96 CSI (50 in Tahoua and 46 in Dosso); increasing the number of supervision rounds to four since the previous reporting year. In each district, a three-member pool of supervisors, including a midwife, physician, and a member from the DHMT are the backbone of this approach. Malaria supervision checklists, digitized in HNQIS, were used to assess the competencies of HWs and get scoring in real-time, enabling them to take corrective actions, and develop a plan for addressing areas of weakness for follow up on the next visit. Since 2020, DHMTs have led the planning, implementation, and data review for OTSS+ in 12 targeted HDs. Below are results of the trend in HW performance through the four rounds of OTSS+ conducted in the 96 CSI.

2 Health facilities located in urban or rural areas provide essential basic health care.

Figure 5: A midwife and a pregnant woman after antenatal care consultation Credit: Digital Mind Communication


Health facility readiness for malaria case management Performance has improved gradually from the first to the fourth round. This progress is due to several combined efforts, including the NMCP’s provision of national policy documents, a management flow chart, and small equipment, including scales, sphygmomanometer, and other items.

Figure 6: Percentage of supervised CSI with a score >=90% (availability of materials, documentation, and trained HWs)

Health worker competency in managing uncomplicated malaria The proportion of HWs demonstrating competency in using mRDTs almost doubled between Rounds 1 and 4, from 47% to 80%. However, improvement declined slightly between Rounds 3 and 4. Although the same CSIs were visited for OTSS+, the HWs assessed are not always the same from one round to another, which may partly explain lack of progress in competency during the reporting period.

Figure 7: Percentage of observed health workers demonstrating competency in malaria mRDTs

Of HWs regularly supervised, 100% adhered to negative mRDT results. This might be due to the impact of the efforts to train and to continuously supervise them.


Figure 8: Percentage of observed health workers demonstrating adherence to negative test results according to standards From Rounds 1 to 2, there was an increase in the proportion of HWs who correctly classified malaria cases. This proportion has remained high (around 90%) through Rounds 3 and 4.

Figure 9: Percentage of observed health workers demonstrating competency in classifying malaria cases The proportion of HWs with skills (performance ≥ 90%) in the correct management of uncomplicated malaria increased from 11% in Round 1 to 44% in Round 4. However, more than 50% of HWs continued to fail in taking patient medical histories, performing a complete review of symptoms, and conducting a physical examination.


Figure 10: Percentage of health workers demonstrating skills in the management of uncomplicated malaria Health worker competency in managing malaria during pregnancy The performance of HWs in the prevention of uncomplicated malaria during pregnancy has steadily increased from 27% in Round 1 to 73% in Round 3 and 78% in Round 4. The same trend is observed for treatment of uncomplicated malaria during pregnancy. This is a powerful testimony that OTSS+ has been successful in addressing issues related to HW competencies noted at the launch of this approach.

Figure 11: Percentage of observed health workers demonstrating competency in preventing MIP


Figure 12: Percentage of observed health workers demonstrating competency in the treatment of MIP

In conclusion, 12 HDs with the support of NMCP and IM Niger have undertaken three OTSS+ visits in 96 priority CSIs of Dosso and Tahoua regions. This activity has improved the capacity of HWs to provide quality malaria diagnosis. Overall, for the use of malaria mRDTs, 80% of HWs achieved more than the targeted 90%. 100% of the HWs met the target of >90% for adherence to negative test results. However, for the management of uncomplicated malaria and the prevention and treatment of malaria during pregnancy, many HWs did not meet the target of >90%. For the next reporting period, IM, the NMCP and the DRSPs plan to organize a meeting on OTSS+ and conduct a secondary analysis of the data

to jointly propose corrective measures. Among other measures, the DRSPs plan to increase the frequency of supervision (two per quarter instead of one per quarter, as recommended by the policy) in CSIs where performance has remained low despite supervision.

Key Achievement #4: Supported the reinforcement and expansion of iCCM in five HDs, including the two new HDs of Malbaza and Gaya. To improve access to healthcare for remote populations, IM Niger has continued to reinforce the expansion of access to and quality of the management of malaria, diarrhea, and pneumonia at the community level, through the iCCM approach into the two targeted regions.

Figure 13: Village assembly in Tounga Maisabé, Tchouroutt CSI, Photo Credit: Bachir Moussa, IM


Table 2: Distribution of CHWs by HD

Health Districts

# of active Community Health Workers Total Male Female

Dioundiou 116 27 143 Boboye 37 25 62 Konni 11 34 145 Malbaza 76 34 110 Gaya 125 38 163 Total 465 158 623

Supported a cascade training for 273 new CHWs Over the reporting period, IM Niger in coordination with the NMCP, DSME, and the HD of Gaya (Dosso), and Malbaza (Tahoua), recruited 296 new CHWs in areas with identified gaps in access to health services. In addition, IM provided support to conduct an eight-day training of 33 CHW supervisors, who are CSI and Health Hut Heads to create a supervisor pool for CHW training. These CHW supervisors trained 273 CHWs, out of 296 recruited, including 202 men and 71 women. Underrepresentation of women among CHWs remained a challenge due to social barriers and education levels that discourage engagement in community activities. To overcome this issue, IM and the DHMT sensitized community leaders on the need to promote female candidates and invited women or women's groups to actively participate in village assemblies during which CHWs are recruited.

Niger’s iCCM training curriculum was used for this training. IM Niger provided technical support for the roll-out of this cascade training, in coordination with the NMCP and DSME to ensure quality. With these 273 CHWs trained, the total number of operational CHWs delivering iCCM in five HDs of Dosso and Tahoua has reached 623. Above is the map of the iCCM HDs and below is the figure showing the distribution of CHWs by district.

Supporting monthly supervision for 211 CHWs

IM Niger also provided technical and logistical support to CHW supervisors in conducting regular supervision of iCCM activities and organizing quarterly coordination meetings with CHWs at CSIs. Over

Figure 14: Map of iCCM HDs supported by IM Niger in Dosso and Tahoua health regions


the reporting period, 211 CHWs, including 178 men and 33 women representing 60% of active CHWs in Dioundiou, Boboye, and Konni were supervised using the national community health supervision checklist, digitized on the KoboCollect app. Furthermore, 350 or 100% of previously trained CHWs attended quarterly coordination meetings and provided their reports.

With this support, over the reporting period, CHWs managed a total of 24,702 children under five years old. Among those, 94% (11,965 out of 12,788 children under five) with fever received a parasitological test with an mRDT, and 39% (4,690 out of 11,965 children under five) of those were positive for malaria. Of the 4,690 confirmed cases, 99% (4,688 out of 4,690 children under five) received the first-line antimalarial treatment. 813 children who came to iCCM sites with fever were automatically referred to the nearest CSI and Health Huts during the period because mRDT or ACTs were not available. These stock-outs were observed particularly in Konni. Since April 2021, the NMCP has begun to supply Pyramax directly to the CHWs and the USAID Global Health Supply Chain-Procurement and Supply Management (GHSC-PSM) team has integrated CHW needs into Niger’s last mile supply chain strategy. The number of children referred are not included in the cascade of febrile children treated by the CHWs figure below (Figure 16). An additional, 11,914 children were seen by CHWs and were either treated for diarrhea (19%), pneumonia (27%), or referred for other conditions (15%).

Figure 16: Cascade of febrile children treated by the CHWs from Boboye, Dioundiou, and Konni

Figure 15: Sick child treated by Relai Communautaire. Credit: Digital Mind Communication


An assessment of community satisfaction was carried out in May 2021 using the national iCCM checklist. As a result, 100% of parents interviewed expressed that they were satisfied or very satisfied with CHW services.

Figure 17: Parent satisfaction with iCCM sites Key Achievement #5: Supported a malaria coordination meeting in each region and 17 targeted HDs At the regional level, IM Niger successfully supported the organization of bi-annual coordination meetings in Tahoua and Dosso regions in April 2021. These meetings provided an opportunity to assess malaria indicators; share results from OTSS+ visits; and discuss operational challenges. About 76 participants were present (71 men and five women) including 42 from DHMT, NMCP, DSME, PMI Measure Malaria, and USAID GHSC-PSM. At the district level, IM Niger facilitated the organization of quarterly coordination meetings to discuss achievements, malaria epidemiological trends, challenges, and solutions. These meetings brought together more than 500 stakeholders. IM Niger also worked closely with other PMI implementing partners, such as Breakthrough ACTION (BA), MEASURE Evaluation, the PMI VectorLink Project, and PSM. IM Niger staff participated in workshops organized by BA for the revision and development of radio spots and posters promoting early and frequent ANC attendance, adherence to IPTp, use of ITNs, and prompt care-seeking for febrile children under the age of 5. IM Niger coordinated with VectorLink to support the biannual OTSS+ visits in 96 priority CSIs. These OTSS+ visits, co-funded by IM and VectorLink, were opportunities for district supervisors to holistically assess the quality of care. In addition to the quality of malaria management assessed using HNQIS, supervisors also collect data on the availability and distribution of ITNs during routine ANC and immunization services.


Objective 2: Improve the quality of, and access to, other malaria drug-based approaches and provide support to pilot and scale up newer malaria drug-based approaches Key Achievement #1: Supported effective implementation of three cycles of SMC in 17 HDs in Dosso and Tahoua SMC is a key intervention described in the NMSP 2017-2023, given its high documented impact on preventing malaria mortality and morbidity in children under the age of 5 during peak transmission season. From August to September 2021, IM Niger provided technical and operational support to the NMCP to implement three of the four SMC cycles in 17 HDs (eight in Dosso and nine in Tahoua) out of a total of 21 HDs conducting an SMC campaign in the 2 regions. During the reporting period, the overall target was to treat 1.3 million children aged 3 to 59 months with preventive malaria treatment Sulfadoxine Pyrimethamine-Amodiaquine (SP-AQ) once a month for three months during the four-month campaign. IM will support implementation of the fourth SMC cycle in October 2021, during the next reporting period. The preparatory phase for the 2021 SMC campaign started in May with a two-day workshop aimed to update SMC operational guidelines, microplans, recording tools, and communication materials. From May to June, IM Niger provided technical and logistical support to Dosso and Tahoua region health teams and the 17 eligible HDs to organize microplanning workshops. These meetings were held under the leadership of local health officials and allowed estimation of the overall needs (human resources, materials, and commodities) of each HD for the effective implementation of the four cycles of the 2021 campaign. Based on HD validated microplans, IM Niger procured and delivered SMC materials such as masks, recording tools, and communication materials to approximately 350 health facilities. One week before the start of the first cycle, IM Niger supported the 17 HDs in the organization of a series of activities, including training of campaign personnel (Table 3), advocacy with community leaders, and communication via mobilizers and 54 local radio stations. Table 3: Key actors trained to support the SMC campaign in Dosso and Tahoua

Figure 18: Door-to-door distribution of SP-AQ during the 2nd SMC campaign in 2021, Photo Credit: Digital Mind Communication


The NMCP target for SMC is to treat at least 85% of children 3-59 months of age in eligible HDs by cycle. The target is that all eligible children will receive treatment for all four cycles from July through October. In this report, IM Niger will provide results for children who have completed three cycles, as cycle four will be completed in October (during the next project year).

The overall administrative coverage rate per cycle for all 17 HDs was 97% for the first cycle in July (1,282,667 children treated),103% for the second cycle in August (1,359,345 children treated), and 104% for the third cycle in September (1,370,516 children treated).

Figure 20 shows that IM Niger supported the DRSP of Dosso and Tahoua to exceed national coverage targets of 85% of eligible children treated over all cycles. The percentages above 100% of targeted children treated are explained by the fact that the number of eligible children was determined through projections of data from the 2012 census. However, SMC distributors found more children under the age of 5 years.

Figure 20: Proportion of children treated with AQSP in the Dosso and Tahoua regions

During each cycle, DRSP authorities from Dosso and Tahoua conducted independent monitoring of SMC activities. This monitoring enables the DRSP to gain an understanding of implementation and to estimate household level coverage. About 1,080 households were visited per cycle. For each region, IM selected 117 villages based on the HDs with the highest and lowest administrative coverage during the previous cycle. At the end of the monitoring cycle, IM Niger compiled and analyzed the results, as shown in Figure 21 below. Based on caregivers’ declaration (self-report), independent monitoring visits found that 99.8%

Figure 19: A mother and her two children who received AQSP in the 2nd cycle of the 2021 SMC campaign, Credit: Digital Mind Communication


of children had received their first dose and 94.2% of children had received up to their third dose. Adherence rates for the 1st, 2nd and 3rd dose based on proof (verification of SMC card and /or blister) are almost similar to adherence rates when the monitoring team relies on caregivers 'declaration (see Figure 22 below). The explanations given by parents whose children had not completed the treatment were that they forgot or that they were too busy. Nevertheless, distributors, monitors, supervisors, and local radio stations continue to raise awareness about the importance of adhering to the treatment and timely administration before and during each SMC cycle. Implementing the monitoring has enabled health officials to become aware of any shortcomings and to take corrective measures as actions are rolled out.

Figure 21: Results of the independent monitoring of children who completed three doses of SP-AQ according to the caregivers’ declaration

Figure 22: Results of the independent monitoring of children who completed three doses of SP-AQ based on proofs The fourth cycle of the campaign was implemented from October 2–11, 2021, which is outside of this reporting period.


Objective 3: In support of Objectives 1 and 2, provide global technical leadership, support operational research, and advance program learning Key Achievement #1: Supported the implementation of the TES for the first-line antimalarial Since the previous reporting period, IM Niger has been working closely with the NMCP, CERMES, and the University Abdou-Moumouni in Niamey to support a TES from September 1, 2020, to June 31, 2021, for AL in three sentinel sites in Niger. These are 1) Agadez region and HD, Dagamanet CSI, 2) Dosso region, Gaya HD, Gaya CSI 3) Maradi region, Tessaoua HD, Guindaoua CSI. These sites were identified by the NMCP because of their high healthcare attendance rate, and location in three different malaria epidemiological strata. The study population is composed of children 6 months to 15 years of age and meeting the study inclusion criteria. The WHO 2009 standardized protocol was used. AL was administered during the peak transmission season from September to October 2020, by investigation teams composed of the NMCP, CERMES, and the University Abdou-Moumouni. Individuals with uncomplicated malaria, who meet the study inclusion criteria, were recruited and treated in the three selected CSI. They were monitored for 28 days. Follow-up consisted of a series of fixed-date monitoring visits and corresponding clinical examinations and laboratory tests. Based on the results of these assessments, patients were classified as having treatment failure (early or late) or adequate clinical and parasitological response. During this phase, 318 children were examined and 246 completed follow-up to Day 28. All patients had monoinfection with P. Falciparum. The average combined clinical and parasitological response rate without correction for the three sites is 87.65%, noting a disparity in Tessaoua where this response rate is only 71.07%. The proportion of patients with treatment failure during follow-up were sent to the CERMES laboratory for further analysis. From December 2020 to June 2021, CERMES performed Polymerase Chain Reaction (PCR) correction on these samples. The first step consisted of the analysis of msp1, msp2 and glurp genes. The second focused on molecular resistance testing by sequencing of the dhfr, dhps, mdr, crt and k13-propeller genes. Preliminary PCR results from CERMES are being discussed with the NMCP, University Abdou-Moumouni, IM, and CDC. In the first quarter of the next reporting period, IM Niger and the NMCP will finalize the TES report and organize a meeting with key MOH departments and partners, including the WHO, Global Fund, PMI Niger, University Abdou-Moumouni, CRS, and GHSC-PSM to review and discuss key findings and recommendations from the study. Abstracts and manuscripts based on these findings for publication will be prepared with the NMCP and University Abdou-Moumouni. Key Achievement# 2: Development of one abstract for presentation in international conference In collaboration with the NMCP, IM Niger supported the submission of an abstract to the ASTMH conference. The abstract, “Assessing Seasonal Malaria Chemoprevention (SMC) adherence in Niger through an independent monitoring survey using a randomized cluster design,” was accepted for poster presentation. The abstract described the method of independent monitoring applied in Dosso and Tahoua regions to assess children’s adherence to medication during the 2020 SMC campaign. The abstract also explored caregiver attitudes and practices during the campaign and provided recommendations to improve implementation.


Challenges and Solutions Challenges Solutions The presence of many newly assigned health providers in priority CSIs who have not received training on the management of malaria in accordance with national guidelines.

Supervisors continue to provide on-the-job training for malaria case management, based on gaps identified during OTSS+ visits.

For the first round of the training for severe malaria, Dosso and Tahoua regional health authorities did not comply with criteria for participant selection for the training.

For the second round of the training, prior to the start of the training, the NMCP supported regional health authorities to establish the list of hospitals and services targeted.

Under-representation of women among CHWs in the five iCCM Health districts

Sensitized community leaders on the need to promote female candidates and invite women or women's groups to actively participate in village assemblies

Stock-outs of malaria commodities at iCCM sites, due to insufficient quantities of medicines received by CSIs

IM Niger organized several meetings with the GHSC-PSM team and the NMCP to pledge to maintain availability of malaria commodities at iCCM sites.

Due to the level of insecurity in six health zones in Tahoua department, the governor of Tahoua region has issued a directive prohibiting motorcycle travel in these areas.

To facilitate access to insecure areas, the DHMT of Tahoua has prioritized the rental of locally owned motorized tricycles, rather than renting vehicles.

Lessons Learned ● The written commitments signed by trainees during the hands-on training for severe malaria as

well as the implementation of an ongoing post-training follow-up process, via WhatsApp and post-training supervision, have encouraged the trained HWs to organize a short training course for their colleagues.

● Internal micro-plan consolidation workshops, which brought together IM project management teams and PSI operations, helped anticipate the operational challenges of the 2021 SMC campaign.

● In order to ensure the continuity of community activities such as iCCM and SMC, CHW supervisors systematically replace community actors who are no longer available due to relocation, death, resignation.

● The success of the formative supervision is strongly linked to the commitment and ownership of the approach by the health district teams.

● Involvement of DHMT at all stages of OTSS+ implementation, particularly during the planning phase and the data review meeting, is key to the success of this approach at the sub-national level.


IM Niger Indicator Table

The data provided in the indicator table below are IM targets and activity results from October 1, 2020 – September 30, 2021. The data in the indicator table reflect activities in the IM supported areas in Niger which include Dosso Region (eight districts) and Tahoua Region (13 districts) etc. For SMC activities, IM supports eight districts in Dosso and nine districts in Tahoua.


Objective

Indicator

Source

Target

Result

Progress to

Annual Target

Comments


Percentage of observed HWs demonstrating competency in correctly classifying cases as not malaria, uncomplicated malaria, and severe malaria

OTSS+ 90%

R2 =91% N=101

R3=92%, N =60

R4= 91% N=115

101%

In round 4 of OTSS+, 105 out of 115 observed HWs demonstrated competency in correctly classifying cases as not malaria, uncomplicated malaria, and severe malaria. There is improvement from 51% (Round 1) to 91% (Round 4)

Percentage of HWs demonstrating competency in malaria RDTs

90%

R2=81%, N2=82

R3=88%, N3=98 R4=80% N4=85

89%

In round 4 of OTSS+, 68 out of 85 HWs demonstrated competency in malaria RDTs. The use of mRDTs increased from 81% (73/92) in Round 2 to 88% (86/98) in Round 3. A decrease was observed in Round 4 (80%), likely because of the turnover of the HWs.


Percentage of uncomplicated malaria cases receiving first-line antimalarial treatment according to recommended guidelines

DHIS2 100% 88% 88%

88% (1,154,527 out of 1,311,582) uncomplicated malaria cases have received first-line antimalarial treatment according to national guidelines during the reporting period.


Objective

Indicator

Source

Target

Result

Progress to

Annual Target

Comments

Percentage of observed HWs demonstrating competency in management of uncomplicated malaria

OTSS+ 90%

R2=16%, N2=105 R3=49, N3=85 R4=44% N4=106

49%

In round 4 of OTSS+, 47 out of 106 HWs demonstrated competency in management of uncomplicated malaria. HWs continue to fail to comply with proper patient medical examination procedures for malaria.

Percentage of observed HWs demonstrating compliance to treatment according to guidelines for cases with positive malaria test results

OTSS+ 100%

R2=77%, N2=105 R3=86% N3=59 R4=86% N4=59

86%

In round 4 of OTSS+, 51 out of 59 observed HWs demonstrated compliance with treatment according to guidelines for cases with positive malaria test results

Percentage of observed HWs demonstrating adherence to negative test results according to recommended guidelines

OTSS+ 100%

R2=100%, N2=18

R3=100% N3=20

R4=100% N4=8%

100%

8 out of 8 HWs demonstrated adherence to negative test results according to guidelines. The proportion of HWs adhering to the results remained stable at 100% for all three rounds of OTSS+.

Percentage of supervised facilities that meet global standards (including appropriate materials, documentation, and qualified staff) for quality malaria clinical management

OTSS+ 100%

R2=25 % N=93

R3=58% N=93

R4 =69% N4=89

69%

62 HFs reached a performance threshold of 90% out of 89 facilities visited, i.e., 69% in Round 4 compared to 58% in Round 3

Percentage of expected malaria reports from IM-supported facilities received

DHIS2 100% 94.50% 94.50%

297 CSI out of 388 functional CSI promptly submitted reports at least twice in the quarter


Objective

Indicator

Source

Target

Result

Progress to

Annual Target

Comments

Percentage of targeted HFs that received a quarterly supervisory visit for malaria case management and/or MIP and/or diagnosis/lab

OTSS+ 100%

R2=99% N=96

R3=100% N=96

R4=100% N=96

100%

96 out of 96 targeted HFs received a quarterly supervisory visit for malaria case management and/or MIP and/or diagnosis/lab

Percentage of HWs trained in management of severe malaria

IM training

data 100% 100% 100%

30 HWs, of 30 expected, were trained for the management of severe malaria

Percentage of HWs trained according to national guidelines in malaria case management with ACTs

OTSS+ 100% 110% 110%

At least 106 HWs were trained during three rounds of OTSS+ in 96 priority CSIs

Objective 1.3: Improved access to quality prevention and management of malaria in pregnancy

Percentage of pregnant women who received an insecticide-treated net during routine ANC

DHIS2 100% 66% 66%

174,738 pregnant women received ITNs during ANC1 out of 265,432 women registered forANC1 in DHIS2 from October 1, 2020, to September 30, 2021. Report completeness is 97%.


DHIS2 78% 61% 78%

160,975 pregnant women received IPTp3+ out of the 265,432 registered forANC1 in DHIS2 from October 1, 2020, to September 30, 2021. Report completeness is 97%.


DHIS2 85% 81% 95%

216,088 pregnant women received IPTp 2 out of 265,432 registered forANC1 in DHIS2 from October 1, 2020, to September 30, 2021.


Objective

Indicator

Source

Target

Result

Progress to

Annual Target

Comments

Report completeness is 97%.


DHIS2 100% 86% 86%

228,944 received IPTp1 out of 265,432 women registered in ANC1. (DHIS2 October 1, 2020, to September 30, 2021). Report completeness is 97%.

Percentage of supervised HWs demonstrating competency in treatment of MIP

OTSS+ 90%

R2=65% N=62

R3 =64% N=81

R4=69% N=81

77%

In Round 4 of OTSS+ 56 out of 81 observed HWs demonstrated competency in treatment of uncomplicated malaria during pregnancy, In Round 2, 65% demonstrated competency, with 64% in Round 3, and 69 % in Round 4.

Percentage of supervised HWs demonstrating competency in prevention of MIP

OTSS+ 90%

R2 =49% N=89

R3 =73% N= 81

R4=78% N=77

87%

In Round 4 of OTSS+, 60 out of 77 observed HWs demonstrated competency in prevention of MIP. HWs competency in MIP prevention has improved from Round 2 (49%), to Round 3 (73%), to Round 4 (78 %). This improvement may be explained by the feedback and on-the-job training sessions organized following each supervision.

Percentage of HWs trained in IPTp/MIP

OTSS+ 100% 84% 84%

At least 81 HWs were trained during three rounds of OTSS+, in 96 priority CSIs.

Objective 2: Improved access to quality transmission-

Percentage of targeted children who receive all 3 doses of SMC during a campaign

SMC campaign

data 85% 94,2% 111%


Objective

Indicator

Source

Target

Result

Progress to

Annual Target

Comments

appropriate drug-based prevention and treatment approaches to SMC

in an intervention area Percentage of targeted children who receive course of SMC in the first cycle 2021

Routine campaign monitoring data

85% 97% 115% 1,282,667 treated out of 1,315,623 targeted children

Percentage of targeted children who receive course of SMC in the second cycle 2021



Percentage of targeted children who receive course of SMC in the third cycle 2021



Percentage of HWs trained to deliver SMC according to national guidelines

Training report

100% 100% 100%

350 HWs were trained to deliver SMC, according to the SMC operational guidelines.


Training report

6.27 6.27 100

A total of 6,270 distribution agents were trained: 2,646 in Dosso and 3,624 in Tahoua region.

Percentage of IM-supported regions with annual SMC implementation plans

Micro plans completed 100% 100% 100%

Objective 3: project technical leadership contributes to PMI-led global policy development and OR

Contribution to national, regional, or global guidance/policy documents related to malaria (including RH)

2 2 100%

IM Niger contribution in the development of the: ● 2021 World Malaria

Report ● NMCP Niger annual

report

Number of program activity outputs

2 1 50% One abstract has been accepted to present at ASTMH.


Objective

Indicator

Source

Target

Result

Progress to

Annual Target

Comments

disseminated to the global health community Participation in targeted national, regional, or global level working group(s) and/or taskforce(s)

4 4 100% Participated in: ● 2 MIP TWG meetings ● 2 M&E TWG meetings

435 IM Rwanda October 2020 – September 2021

Rwanda

Background IM Rwanda, in support of the Malaria and Other Parasitic Diseases Division (MOPDD) of the Rwanda Biomedical Center (RBC), seeks to improve the delivery of malaria control services through two project objectives.

● Objective 1: Improve the quality of and access to malaria case management and malaria prevention during pregnancy

● Objective 3: In support of Objective 1, provide global technical leadership, support

operational research, and advance program learning Geographic Focus: IM Rwanda works to support malaria service delivery at national and district levels and implements iCCM activities in Nyamaseheke and Rusizi, two districts located in the Western Province of Rwanda (as shown in Figure 1). During the current reporting period, IM Rwanda prioritized case management, MIP, and capacity building for MOPDD and RBC staff as outlined in the current workplan.

Key Accomplishments

Objective 1: Improve the quality of and access to malaria case management and malaria prevention during pregnancy Key Accomplishment #1: Conducted MIP supportive supervision IM Rwanda worked with the MOPDD to organize and conduct the second round of MIP supportive supervision, as part of an integrated supervision activity in targeted health facilities. IM Rwanda held a preparation meeting and included an evaluation of the previous integrated supportive supervision recommendations. Recommendations from the supervision included organizing a training of health care providers on updated National Malaria Treatment Guidelines; sharing malaria program updates, data, and current instructions to reinforce joint malaria intervention implementation; avoiding program disparities; advocating to strengthen malaria drugs and commodities supply chain to avoid stock-outs; and digitizing malaria integrated supportive supervision tools. Among the five proposed recommendations, all were completed except digitizing the malaria integrated supportive supervision tool, which is planned to be completed by the bilateral USAID Ingobyi project. This activity was conducted from April 18 to June 4, 2021, and health facilities were selected based on their performance. In total, 52 out of 204 health facilities from the 10 targeted districts were selected and

Figure 1: IM Rwanda Geographic Focus


supervised. Figure 2 and Table 1 below show the results from two rounds of supportive supervision and areas to improve on in malaria prevention and control.

Figure 2: Results of two rounds of MIP supportive supervisions conducted during the previous and current reporting periods Table 1: Findings from MIP supportive supervision visits Strengths Areas to improve ● 91% of visited health centers had qualified

staff in malaria diagnosis and case management

● ITNs for ANC and EPI were available in 96% of all visited health centers

● 100% of visited health centers had at least two outpatient department (OPD) consultation rooms

● 100% of health centers had designated staff for ANC services and MIP management

● 100% of visited health centers had a functional laboratory with malaria microscopy

● The health centers were not conducting malaria supportive supervision to health posts

● Monthly malaria data validation meetings were not conducted regularly in all visited HFs

● Only 44% of visited HFs had Social Behavior Change (SBC) materials to support behavior change interventions related to malaria

● Counseling on malaria prevention for pregnant women attending ANC was not systematic in all visited health facilities


Key Accomplishment #2: Conducted malaria death audits From February 15 to March 5, 2021, IM Rwanda, in collaboration with the MOPDD, conducted malaria death audits in district hospitals in iCCM-supported districts: Gihundwe, Mibilizi, Kibogora, Bushenge, Karongi, Rutsiro, Gisenyi, and Ruhengeri. The activity focused on building capacity of health care providers for severe malaria management, as well as reviewing and confirming deaths attributed to malaria reported through the Health Management Information System (HMIS) from July to December 2020. IM Rwanda and the MOPDD reviewed 20 death cases. First, they verified if the cases were due to malaria as reported in the HMIS and then assessed if the cases were treated according to guidelines. By using the established malaria death audit template, all key information and challenges were documented, then the team discussed what was needed to have avoided the death. All 20 cases were confirmed as deaths due to malaria and most were due to the delay in seeking care by patients. Some deaths were attributed to mismanagement of severe malaria at the health center and at district hospital level. To address this issue, IM in collaboration with the MOPDD has started training health care providers on the updated National Malaria Treatment Guidelines and will continue to conduct supportive supervision at health facility level. Key Accomplishment #3: Implemented 2021 TES Monitoring the efficacy of antimalarial medicines is a key component of malaria control. WHO recommends to national malaria control programs continued use of current first-line antimalarial treatments if it maintains an Adequate Clinical and Parasitological Response of 95% or greater and that treatments should be monitored at least once every 24 months at established sentinel sites. Protecting ACT efficacy as the current first-line treatment for P. falciparum malaria is among top national and global public health priorities. During the previous year, IM Rwanda, in collaboration with the MOPDD/RBC, developed the TES protocol based on the standard WHO recommended protocol. This study is evaluating the efficacy of AL and Dihydroartemisinin-piperaquine (DHA-PPQ) for the treatment of uncomplicated malaria in three study sites across Rwanda. During the reporting period, IM supported the MOPDD to obtain approvals for the implementation of the 2021 TES protocol from Institutional Review Boards (IRB), including Johns Hopkins University (JHU) IRB, the Rwanda National Health Research Committee, the Rwanda National Ethics Committee, and the Rwanda Food and Drugs Authority (FDA).

Figure 3. IM and RBC staff discuss severe malaria management with Murunda DH, Rutsiro District, Photo Credit: Jacqueline Nyziyirambaho, IM


Enrollment of study participants started in June 2021 (Table 2), after setting up the three study sites, procuring study supplies and commodities, and hiring and training study teams. The study teams experienced challenges in enrolling patients due to the decrease of malaria cases seen at health facilities. This decrease is mainly due to the effectiveness of Indoor Residual Spraying (IRS) recently conducted in the catchment area of Rukara and Bugarama health centers and home-based management of malaria at the community level. IM Rwanda consulted with MOPDD districts and health facilities to address this challenge, launching malaria screening at the community level in August 2021 to increase the number of enrolled patients. Further consultative meetings are planned to reach consensus among study stakeholders for additional actions that can be implemented to increase patient enrollment in the study. Table 2. Number of enrolled TES participants at the three sites since June to September 2021

TES Study Site Screened Enrolled Sample Size

Rukara 288 0 176 Masaka 63 3 176 Bugarama 179 11 176 Total 530 14 528

Key Accomplishment #4: Disseminated Rwanda’s Malaria Treatment Guidelines In the previous project reporting period, IM Rwanda supported the MOPDD to review the fourth version of the Rwanda Malaria Treatment Guidelines and the 2020 Edition of the Rwanda Integrated Malaria Control Guidelines. During this project reporting period, IM Rwanda printed 1,600 copies of these documents and provided them to the MOPDD for dissemination to all public and some private health

facilities. Two copies were provided per health center and five per hospital, for a total of 1,289 copies for public health facilities, 250 copies for private health facilities, and 61 copies for central level and malaria stakeholders. Key Accomplishment #5: Developed the malaria case management training materials workshop and TOT From May 17 to 28, 2021, IM Rwanda supported a capacity building workshop for the National Malaria Trainers and the development of malaria case management training materials, using the fourth edition of Rwanda’s Malaria Treatment Guidelines and other evidence-based and global technical documents for the diagnosis and treatment of malaria. This workshop was attended by 25 participants from the University of Rwanda, Medical Doctor Specialists from referral and district hospitals, IM, the USAID Ingobyi project, and the MOPDD/RBC.

Figure 4: Rwanda Integrated Malaria Control Guidelines and Rwanda Malaria Treatment Guidelines


From June14 to 18, 2021, IM Rwanda supported the MOPDD to conduct a five-day training of trainers on malaria case management. The objective was to equip clinicians at hospitals with up-to-date and evidence-based guidance on the management of malaria to improve the quality of healthcare provided to patients through the following topics:

● Overview and basic facts about malaria at national and regional levels ● Description of the clinical signs of uncomplicated and severe malaria ● Explanation of the physiopathology of uncomplicated malaria, severe malaria, and malaria in

pregnant women ● Malaria microscopy diagnosis and how and when to use mRDTs ● Explanation of the management of both uncomplicated and severe malaria ● Explanation of the referral system for severe malaria in Rwanda ● Discussion of the importance of malaria prevention ● Surveillance of malaria and other parasitic diseases in Rwanda

The training was attended by 36 participants from 12 hospitals across the country and involved all categories of health providers, including 12 medical doctors, 12 nurses, and 12 community health supervisors. National malaria trainers facilitated the training. All 36 participants did pre- and post-tests of their knowledge before and after the training workshop. The average pre-test score and post-test scores were 63% and 81.5%, respectively (Figure 5). All participants were requested to return to their health facilities and organize a cascade training for their health care provider colleagues, including CHWs, using the new National Malaria Treatment Guidelines.

Key Accomplishment #6: Strengthened the quality of malaria microscopy capacity in laboratories During the reporting period, IM Rwanda organized a training for 86 lab technicians from Musanze, Burera, Ngororero, Nyabihu, Gisagara, Gakenke, and Rutsiro districts on performing malaria microscopy diagnosis

Figure 5: Pre and post-test result progress of trained healthcare providers in malaria case management (n=36)


in collaboration with the MOPDD and the National Reference Laboratory/Rwanda Biomedical Center. The training took place in Musanze district from May 16 to June 18, 2021.

Figure 6: Pre- and post-test results of laboratory technicians trained in malaria microscopy Among the 86 trainees, 36 were female and 50 were male. The objective was to provide skills to lab technicians for malaria microscopy diagnosis, focusing on the differentiation of malaria species and the quantification of parasites. The practice session demonstrating the correct method for preparing a thick and thin blood film on the same slide, distinguishing malaria parasites in thin and thick films, and differentiating the four human species of malaria parasites, P. falciparum, P. vivax, P. malariae, and P. ovale, are examples of skills acquired during training The overall average performance during the pre-test was 59.5%, and 85.5% for the post-test (Figure 6). At the end of the training, all trainees were encouraged to share gained skills and mentor their fellow lab technicians at their respective health facilities. Key Accomplishment #7: Supported iCCM implementation During the reporting period, IM Rwanda began the implementation of iCCM field activities in catchment areas of the 39 health centers of Nyamasheke and Rusizi districts in the Western Province. The following activities were conducted: an iCCM needs assessment, refresher training of CHW supervisors, training of newly identified CHWs, and supportive supervision. iCCM needs-assessment in Nyamasheke and Rusizi districts The assessment was conducted in iCCM-supported districts in October 2020 and consisted of assessing the daily work of CHWs at the field level. The results showed that in the two districts, there were 4,610 CHWs with 2,360 male-female pairs who are in charge of testing and treating malaria among children and adults. Among the CHW pairs, 97% provided services during the assessment period, but 18% were not trained in iCCM or Home-Based Management of malaria (HBMm). Among the 82% of CHWs who were trained in iCCM and HBMm, 37.5%


underwent training in the last two years, while 62.5% of CHWs received monthly supportive supervision and mentorship from a health center. Sixty-nine percent of CHWs conducted health education and community mobilization; however, all of them had outdated education materials for behavior change regarding malaria prevention and treatment. As part of results from the need assessment, Figure 7 below indicates the percentage of CHWs that had tools, materials and other supply during the period of the assessment.

Findings from the needs assessment showed that several CHW supervisors and nurses in charge of Integrated Management of Childhood Illness (IMC I) were not trained on iCCM and HBMm. For this reason, IM Rwanda, in collaboration with the RBC through the MOPDD and the Maternal, Child, and Community Health (MCCH) Division, conducted a five-day TOT on iCCM and HBMm. The main objective of the training was to improve skills, knowledge, and attitudes of CHW supervisors and nurses for the iCCM package and HBMm, to improve the provision of quality malaria case management services in the community.

Refresher training of districts and health center trainers on iCCM In total, 80 participants attended the training, including 40 IMCI nurses and CHW supervisors from health centers in the Nyamasheke district, 36 IMCI nurses and CHW supervisors from health centers in Rusizi district, and four community health supervisors from Bushenge, Kibogora, Mibilizi, and Gihundwe hospitals. In total, 36 females and 44 males attended this training. The pre-test given to the trainees to assess their knowledge on iCCM and HBMm showed that the basic level of knowledge among participants in both districts was scored at 31% (Table 3). After the training, there was an increase in knowledge, and the average post-test score increased to 90%. This showed that participants achieved an advanced level of knowledge for iCCM and HBMm. Table 3: Pre- and post-test marks among attendees of iCCM and HBMm TOT refresher trainings (N=80 participants)

Test Type District Sex

Overall Average Nyamasheke Rusizi Female Male

Pre-Test 27% 35% 31% 31% 31% Post-Test 91% 90% 90% 90% 90%

Training of new CHWs in two targeted districts One of the objectives of the iCCM needs assessment was to identify new CHWs. The findings showed that 426 new CHWs were not trained in both districts (116 from Rusizi and 310 from Nyamasheke). The

Figure 7: Percentage of CHWs with tools and materials


new CHWs elected at village level are to replace those who left due to different reasons including lack of financial support, irregularity in performing duties, and disciplinary actions. The CHW needs assessment in both districts indicated that there was no standard training offered to them since 2017. Thus, IM Rwanda conducted a training of all new CHWs identified, and the training was conducted over two consecutive weeks from December 1 to 11, 2020, covering both districts. The training took place at CHWs respective health centers and was facilitated by Community Environment Health Officers and IMCI Nurses at each site. Training supervision was conducted by IM Rwanda in collaboration with CHW supervisors from district hospitals. In general, CHW levels of knowledge in iCCM and HBMm was very low as shown by the pre-test scores where the average was 23%. Following the effort of trainees and trainers, a remarkable increase to an average of 73% was observed post-test (Table 4). Through quarterly supportive supervisions, IM Rwanda continued to build capacity of CHWs for iCCM. Table 4: Participant demographics and pre- and post test marks among CHW attendees during new CHW training sessions (N=426)

District Number of Participants

Number of Female

Participants

Number of Male

Participants

Average Pre-Test Score

Average Post-Test

Score Rusizi 116 61 55 20% 72% Nyamasheke 310 161 149 25% 73% Total/Average 426 222 204 23% 73%

iCCM Supportive supervision In this project period, 39 CHW supervisors at health centers visited 2,164 out of 2,359 CHWs in their villages in Nyamasheke and Rusizi districts. CHWs from one or several villages met the CHW supervisor at a convenient location with their tools. The supervisor randomly picked the iCCM register from one CHW and found a case received in the current quarter. The supervisor read a description of how the case was managed and then gave opportunities to all CHWs attending the session to comment. Afterwards, the CHWs agreed on the approach the client should have received referring to the National Community Case Management guidelines.

Figure 8: Training of CHWs in Nyamasheke Health Center, Photo Credit: Eliab Mwiseneza, IM


Regarding storage of malaria commodities, some CHWs had been keeping drugs and registers inappropriately, such as storing drugs in open spaces where children can easily access them or in spaces exposed to water or extreme heat. IM Rwanda provided guidance on how to safely keep drugs and registers. To address insufficient storage space and security, IM Rwanda has started to advocate at the national level and with other partners to provide CHW storage boxes. IM Rwanda supported district hospitals to provide technical expertise to CHWs who received higher volumes of malaria cases to improve their reporting system and quality of care. The key findings from these interventions are grouped into three points below. Improved access to and quality of malaria case management by CHWs Following the IM training conducted in December 2020, there was an increase in the number of CHWs trained in some villages, which has helped village members who used to seek health care far away in other villages or HFs. In addition, new CHWs trained by IM Rwanda are more competent in completing the tools. Among 375 CHWs, 345 (92%) of visited CHWs had demonstrated good performance in malaria community case management and had updated reporting tools, while 44% of the visited CHW supervisors had conducted supervision in the previous quarter. Improved methodology of supervising CHWs by CHW Supervisors. Before IM Rwanda, 60% of all CHW supervisors were not trained in the iCCM package, so they did not conduct supervision of CHWs on the iCCM package. During the most recent supervision, IM Rwanda noticed that CHW Supervisors improved their performance in mentoring CHWs, which helped them to reach all CHWs in their area of responsibility. Improved usage of M&E tools Since the beginning of the implementation of iCCM supported activities by IM in Nyamasheke and Rusizi districts in October 2020, reporting has improved by both CHWs and their supervisors. The reports include, but are not limited to, number of cases tested, number of cases treated, cases referred to a higher-level facility, stock-outs and risk of stock-outs of malaria commodities, and the number of fever cases received.

Figure 9: CHWs from three villages, CHW supervisor, and IM staff discussing malaria case management, Photo Credit: Diana Kaliza


Figure 10: iCCM in Nyamasheke district, 2020-2021 Key Accomplishment #8: Supported MOPDD to conduct refresher training on RapidSMS RapidSMS is a free and open-source framework for dynamic data collection, logistics coordination, and communication, leveraging basic short message service (SMS) mobile phone technology. Since September 2018, RapidSMS has been used by CHWs to notify referral facilities and central level severe malaria cases from the community as well as stock status of malaria commodities to prevent maternal, newborn, and child death in malaria case management. Health facilities are responsible for closely following up and quickly responding after receiving RapidSMS notifications from CHWs. During an audit conducted in 2020 by the Global Fund, problems linked to the web-based follow-up of malaria cases by CHWs through RapidSMS were noted. To address these concerns, IM Rwanda supported a refresher training on RapidSMS for health center and hospital staff from the two iCCM supported districts: Nyamasheke and Rusizi. The general objective of the refresher training was to increase the capacity of clinicians to use the RapidSMS web-interface and to equip them with advanced skills for the follow-up of severe malaria cases notified by CHWs and problems of stock-outs of malaria drugs and commodities that arise at the community level. The refresher training reached a total of 130 participants, including three staff from each health center and four staff from each district hospital. Staff included nurse clinicians, data managers, and CHW supervisors from health centers as well as a monitoring and evaluation officer, data managers, clinicians, and community health supervisors from hospitals. Objective 3: In support of Objective 1, provide global technical leadership, support operational research, and advance program learning Key Accomplishment #1: Supported malaria planning and TWG meetings During the reporting period, IM Rwanda provided technical and financial support to the MOPDD to conduct a quarterly reporting workshop with malaria stakeholders. Through this activity, IM informed

76% 77% 76% 78% 81% 75% 77% 81% 85% 83% 88% 87%

82% 85% 82% 83% 88% 89% 88% 92% 93%

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

Perc

ent o

f und

er-5

chi

ldre

n w

ith fe

ver

trea

ted

Period of iCCM implementation

Percentage of under five children with fever treated in iCCM, Nyamasheke district, 2020-2021

2020 2021


stakeholders of the project’s progress and quickly identified areas where the program was not performing according to its expected results. This provided an opportunity to assess how project objectives are being achieved through joint efforts from malaria partners. Key Accomplishment #2: Developed malaria and OPD division annual report 2020-2021 IM Rwanda supported the MOPDD/RBC to conduct a workshop to develop the MOPDD Malaria Annual Report 2020-2021 and discuss program priorities for the 2020 to 2021 reporting period. The workshop was attended by 34 MOPDD staff and partners during a five-day workshop from July 27 to 31, 2021. The validated and signed version of the 2020-2021 Malaria Annual Report was shared with malaria stakeholders by the MOPD Division’s Manager the following week to provide information on MOPDD’s fiscal year achievements, identify gaps in fighting against malaria, and identify actions points to be highlighted to better control malaria and set priorities. Table 5: Malaria Program Key Achievements # Indicators 2017-2018 2018-2019 2019-2020 2020-2021 1 Malaria Incidence per 1,000 persons per

year

389

321

198

114 2 Slide Positivity Rate (%) 47% 44% 35% 27% 3 Uncomplicated Malaria Cases

4,658,518

3,973,973

2,495,890

1,481,698 4 Severe Malaria Cases 10,984 7,035 4,358 2,592 5 Malaria Deaths 392 272 167 96 6 Case Fatality Rate (per 100,000 Malaria

cases ) 8.4 6.8 6.7 6.5

7 Proportion of malaria cases treated at community level

50% 57% 58% 54%

8 IRS District Coverage 5 10 11 12 Key Accomplishment #3: Supported the MOPDD to present malaria program results and lessons learned from Rwanda in a global forum From November 15 to 19, 2020, IM Rwanda supported the Director of the MOPDD Malaria Case Management Unit and the Director of the Malaria Epidemiology Directorate to participate in the ASTMH annual meeting, which was held virtually due to COVID-19 travel restrictions. The RBC Director of Epidemiology presented a poster entitled, “The Epidemiological and Projected Economical Impact of Indoor Residual Spraying in Ngoma District, Rwanda.” The abstract showed the measurable decrease of out- and in-patient malaria cases and an important cost benefit one year after IRS was conducted in the Ngoma district.



Quarterly integrated malaria supportive supervisions were delayed due to an MOPDD conflict activities, supervisors’ availability, and COVID-19 travel restrictions.

IM Rwanda proposed integrated malaria supportive supervisions to take place on a semi-annual basis. With digitization of the tool, this will help with data completeness and analysis.

COVID-19 restrictions and two lockdowns in January and July 2021 delayed or affected the implementation of some activities.

Remote follow-up and other social media platforms were used to continue activities where possible. IM Rwanda, in collaboration with iCCM supported districts, plan to conduct meetings by adapting approaches to align with national COVID-19 prevention measures with limited numbers of participants.

Delay in getting the TES approval from the Rwanda FDA, due to a lack of key documents from product manufacturers

IM Rwanda worked with TES stakeholders and submitted required documents, including the Good Manufacturing Practice for AL and obtained the Rwanda FDA approval. Remaining requested documents will be shared with the Rwanda FDA once available.

TES low enrollment rate The effectiveness of malaria control interventions, including IRS and HBMm have led to decreases in the number of malaria cases seen in health facilities. This is a positive result for the fight against malaria but a challenge for the TES. IM Rwanda has worked with MOPDD and the districts to involve CHWs from highly endemic villages to support the enrollment of patients for the TES. IM continues to explore additional solutions with study stakeholders.

Lessons Learned ● Though PMI staff are still working from home, monthly calls have been conducted to discuss activity

progress. This has helped IM Rwanda to keep PMI updated and to obtain PMI’s advice in addressing challenges.

● In line with measures in place to prevent the spread of COVID-19, each quarter malaria partners shared their activity plans. The MOPDD compiled them, gave feedback according to MOPPD priorities, and coordinated implementation planning according to the availability of project participants. This reduced field activity implementation delays, duplication of activities, and improved communication across malaria partners


IM Rwanda Indicator Table The data provided in the indicator table below are IM targets and activity results from October 1, 2020 – September 30, 2021. The data reflected work in IM Rwanda supported districts in Nyamaseheke and Rusizi districts, located in the Western Province of Rwanda. During this period, one MIP OTSS round was completed (during which 52 facilities were visited); a total of 733 individuals (including 426 CHWs) completed training (including on MIP, malaria microscopy, iCCM or rapid SMS training). Progress to Annual Target is calculated as actual result/target *100=progress to target. This provides an indication of how much progress has been made to meeting the annual target outlined in the country workplan.


(%)

Comments



99%

NA

NA

This indicator was introduced in HMIS system in March 2021. RBC is still proving orientation to health care provider in order to be reportable


90%

92.7%

103%

This indicator is collected during the SS visits. We targeted 90% after the 1st SS round (81.8%) and found a good progress exceeding the set target during the 2nd round, but we still need to support HFs so that they can continue to make progress on this indicator


95%

85.5%

90%

85.5% of trained microscopists performed 80% or greater during the post test. Post training follow up will be used to improve microscopists



(%)

Comments

performance, as this indicator target wasn’t achieved

Percentage of targeted facilities that meet standards (including appropriate materials, documentation, and qualified staff) for quality diagnosis of malaria

95%

94%

99%

This target was almost achieved at 100%

Percentage of targeted facilities with at least one provider trained in malaria diagnosis

100%

100%

100%


100%

100%

100%

Objective 1.2 Improved access to targeted quality malaria treatment

Percentage of children under 5 appropriately treated for fever according to iCCM or country algorithms by community health worker

99%

99.8% 101% CHWs are making good progress on treating appropriately children under 5 mainly due to the supportive supervision they are receiving from health centers

Percentage of confirmed uncomplicated malaria cases that received first-line antimalarial treatment according to recommended national guidelines

99%

99.4%

100.4%

This target was slightly exceeded probably due to the training of health care providers on the new treatment national guidelines

Percentage of targeted facilities that meet standards for quality malaria case management (including appropriate materials, documentation, and qualified staff)

90%

78%

86.6%

New Treatment guidelines were not available to all visited health facilities. Distribution was delayed due to the COVID-19 pandemic

Percentage of targeted HCWs demonstrating compliance to treatment

90%

86%

95%

This target wasn’t reached this year as the training of



(%)

Comments

according to national guidelines for cases with positive malaria test results

HCWs on the new treatment guidelines is still in progress and didn’t reach all health facilities

Percentage of targeted HCWs demonstrating adherence to negative test results according to recommended guidelines

100%

86%

86%

This target wasn’t reached this year as the training of HCWs on the new treatment guidelines is still in progress and didn’t reach all health facilities

Percentage of targeted facilities with national guidelines for malaria treatment that meet global standards

100%

77%

77%


Percentage of targeted health facilities that receive a supervisory visit

100%

100%

100%

Percentage of targeted health facilities regularly reporting routine malaria case data

100%

100%

100%


Percentage of pregnant women receiving an ITN during first ANC visit

80%

80.5%

100.7%

Percentage of pregnant women receiving an ITN during first ANC visit has slightly increased this is due to availability of nets at health facilities. This target was set during a period of nets stock out at health facility level

Percentage of targeted HCWs demonstrating competency in prevention of MIP

90%

82%

92%

This indicator didn’t reach the target showing the need of continuing supportive



(%)

Comments

supervision at facility level

Percentage of targeted HCWs demonstrating competency in treatment of MIP

90%

69.8%

77.5%

This target wasn’t reached this year as the training of HCWs on the new treatment guidelines is still in progress and didn’t reach all health facilities

Percentage of targeted facilities with recommended guidelines for prevention and treatment of MIP

100%

77%

77%



Contribution to national, regional, or global guidance/policy documents related to malaria (including reproductive health)

1

2

200%

Malaria Treatment Guidelines, Integrated Malaria Guidelines


2 1 50% Supported presentation of one abstract to ASTMH in 2020

Participation in targeted national, regional, or global level Working group(s) and/or taskforce(s)

2 2 100% Support TWGs

451 IM Senegal October 2020 – September 2021

Senegal

Background Senegal has made measurable progress in reducing malaria burden. The National Strategic Plan for the Fight Against Malaria in Senegal 2016-2020 states a goal of reaching malaria elimination by 2030, with a focus on improving malaria control in higher burden zones and initiating malaria elimination efforts in the lower burden zones in the country. Since 2008, national parasite prevalence has decreased from 5.9% in 2008 to less than 1% in 2017. From 2018 to 2019, total confirmed malaria cases decreased by 33.2%.1 However, these reductions have not been uniform due to the heterogenous transmission setting of Senegal. As of 2019, three administrative regions in the south make up 81% of the malaria burden in Senegal: in Tambacounda, Kolda, and Kedougou. Regions in the west and north, which include Saint Louis, Fatik, Louga, Thiès, and Kaolack have had the lowest incidence in the country.2 To accommodate Senegal’s varying transmission zones, the NMCP has implemented a tailored set of interventions according to each transmission stratum. In low transmission settings, generally located in the western and northern regions, the NMCP prioritized elimination activities which consist of case investigation and response measures. In higher transmission settings, generally located in the central and southern regions, the NMCP prioritized SMC and Prise en Charge à Domicile+ (PECADOM+, Home-based management of malaria+) a form of proactive case management of fever by CHWs who conduct weekly home visits during the high transmission months. Alongside the scale-up of SMC and PECADOM+ in control zones, Senegal will require additional interventions to reduce burden more aggressively in these zones and to reach the national malaria elimination goal by 2030. As such, in its 2021-2025 malaria strategic plan, the Senegal NMCP has added ITNs with the synergist piperonyl butoxide (PBO), mass drug administration (MDA) and indoor residual spraying (IRS) among their priority interventions and has an objective of reaching 95% coverage for MDA for the target population living in areas with high malaria transmission. To date, evidence regarding the effectiveness or acceptability of MDA in Senegal is not yet available.

1 The World Bank (2021). Incidence of malaria (per 1,000 population at risk) – Senegal. Retrieved August 20, 2021, from https://data.worldbank.org/indicator/SH.MLR.INCD.P3?locations=SN 2 MOH (2019). Bulletin Épidémiologique Annuel 2019 du Paludisme au Sénégal.

Figure 1: IM Senegal Geographic Scope

https://data.worldbank.org/indicator/SH.MLR.INCD.P3?locations=SN


MDA with dihydroartemisinin-piperaquine (DHA-PPQ) has generally been shown to lead to rapid and early reductions in the parasite reservoir.3 However, effects can be time-limited, depending on baseline transmission intensity and the presence of other malaria control interventions (e.g., strong community case management and surveillance, high coverage of effective ITNs). Recent MDA trials have included additional drugs that have malaria transmission-blocking activity, e.g., single low-dose primaquine or ivermectin, to explore whether these drugs may aid in sustaining the impact of MDA on transmission. With PMI support, IM is conducting a randomized trial to explore the hypothesis that time-limited MDA with DHA-PPQ and single low-dose PQ, in the context of an optimized control setting, including proactive community case management (PECADOM Plus) and universal coverage of effective ITNs, can reduce malaria transmission in moderate-low transmission settings of Senegal to the point where the NMCP can begin deploying pre-elimination activities (i.e., a target parasite incidence of <5 cases/1000).

IM, in collaboration with the NMCP, will also undertake a Malaria Elimination Readiness Assessment (MERA) with district and health facility teams and CHWs to prepare for implementation of elimination activities in ten priority elimination-focused districts (Bambey, Dagana, Foundiougne, Khombole, Mekhe, Niakhar, Louga, Podor, Saint-Louis, and Sakal), which are located in the north and west of the country. The assessment will identify key strengths and opportunities to strengthen Senegal’s malaria elimination strategy and activities through actionable recommendations to the NMCP.

Key Accomplishments – Mass Drug Administration Study (MDA) Objective 3: Provide global technical leadership, support operational research, and advance program learning Key Accomplishment #1: Conducted cross sectional survey to assess baseline malaria prevalence In December 2020, IM, with support from local health facility nurses and CHWs, conducted a baseline survey of malaria prevalence in the 60 study villages. A survey questionnaire was developed, and information collected on participant demographics, current fever, sample collection, detailed description of receipt of SMC rounds (if the child was less than 10 years-old), health seeking behavior, and use of malaria preventive measures. IM supported the NMCP to develop SOPs for implementing the 2020 cross-sectional survey. Staff involved in survey data collection were trained, including 20 enumerators. A one-day training for laboratory staff was held in Dakar, which included procedures on conducting fingerprick blood samples for testing of parasitemia by blood smear microscopy, molecular analysis, and rapid diagnostic testing (for febrile individuals only), preparation of slides for blood smear microscopy, and appropriate storage and labeling of samples. A field worker survey manual was also developed, and IM supported a training for head nurses and field workers in Tambacounda in December 2020. This training focused on data collection and using electronic data capture through android tablets.

The team conducted the survey starting on December 10, 2020, with six teams which included one laboratory-technician, one field worker, one head nurse, and one driver for each team. IM supported

3 Poirot, E., Skarbinski, J., Sinclair, D., Kachur, S., Slutsker, L., Hwang, J. (2013). Mass drug administration for malaria. Cochrane Database of Systematic Reviews.


development of a field supervision checklist, which was used by four supervision teams in the field throughout the ten-day survey.

The survey’s target sample of 2,400 people was designed to sample 40 people from each of the 60 villages. To reach the target sample size, eight households were randomly sampled from each village, with a maximum of five people per household. If 40 people were not reached per village, additional households were sampled and for villages with less than eight households, all household members were selected. Household randomization was based on a household list shared by the PMI VectorLink Project and developed during the PBO ITN distribution in the 60 study villages. The survey team conducted call-backs in cases where respondents were not available on the day of the survey data collection. Furthermore, IM tried to include households that were difficult to access, to provide an unbiased sample where all households were equally represented.

The survey included a total of 2,352 participants from 497 households from 60 study villages. The overall malaria parasite prevalence measured using blood smear microscopy was 7% but ranged from 0% to 31% across villages. Additional prevalence data from PCR, serology, and drug resistance markers, analyses of which are currently underway, will be used to inform effectiveness of the MDA intervention and to describe epidemiological changes affecting malaria prevention measures.

Key Accomplishment #2: Supported District Medical Teams (DMT) to expand coverage of PECADOM Plus across study villages Under the coordination of the DMT and with support of head nurses, IM recruited 42 new CHWs to conduct pro-active weekly household screenings of febrile cases in study villages. A total of 104 CHWs were trained on study procedures and collection of high-quality malaria morbidity data. A series of trainings were conducted between December 2020 and January 2021:

● From December 24-28, 2020, theory-based training of the 42 CHWs and two community supervisors was conducted in the Tambacounda District Health Center.

● On December 29, 2020, the 15-day hands-on training commenced. ● From January 11-17, 2021, CHWs were officially installed. ● From January 18-21, 2021, 104 CHWs were trained on project procedures and data collection at

the Tambacounda District Health Center.

Supervisory visits have been ongoing to monitor PECADOM+ activities and to assess quality and completeness of data collection.

Key Accomplishment #3: In collaboration with the NMCP and local health and administrative leaders, IM conducted community engagement campaigns to inform participants and stakeholders of the MDA campaign In October 2020, IM collaborated with the NMCP and local DMTs to create a community engagement plan. IM supported the NMCP, community health post nurses, and CHWs to implement sensitization activities in the 30 study villages randomized to the intervention arm and targeted to receive MDA. Informational meetings were held with village leaders and heads of households. IM also supported the organization of advocacy meetings with administrative, religious, and local authorities. Community radio stations conveyed MDA-related messages with quiz shows using local languages. Short videos were shared on social media and town criers reminded populations to stay home before the start of the campaign.


Home visits were performed by the health post nurses, CHWs, and the study team during the informed consent process and an information sheet was used to clearly explain and secure informed consent from all participants.

Key Accomplishment #4: IM implemented all three rounds of the MDA campaign Prior to the start of MDA activities, IM coordinated with the NMCP to conduct a series of trainings for CHWs, drug distributors, supervisors, health post nurses, and DMTs to effectively distribute MDA drugs, conduct pharmacovigilance surveillance, and collect high-quality data for coverage estimates and adverse event reporting. In June 2021, IM, with support from the NMCP and PMI, implemented the first round of MDA in 30 intervention villages. MDA was delivered by 241 CHWs and 57 local supervisors who administered three doses of DHA-PPQ and single low-dose PQ to approximately 7,195 participants. Overall crude coverage of the first round of MDA was high (71-74% across the three doses) and the refusal rate was low (1-2%).

Findings from the acceptability study showed that community sensitization campaigns resulted in high coverage. Through passive pharmacovigilance, 46/7,195 (0.6%) of the study participants reported a total of 97 adverse events. Most adverse events were transient, and included headache, vomiting, abdominal pain, and fever. Similar adverse events were found through the active pharmacovigilance system. The

Figure 3: A health nurse prepares for drug administration, Saroudia Village

Figure 2: NMCP, PMI, IM, local health, and administrative leaders

Figure 4: A nurse distributes drugs to a participant during the MDA activity

Figure 5: Refresher training for CHWs in the Neteboulou Health Post


second MDA round was conducted August 6-9, 2021, and despite the challenges of working in a COVID-19 context, 74-76% coverage was achieved across the three doses and a refusal rate of 2%. The third and final round of MDA occurred on September 18-21, 2021. Rates of coverage were similar to Rounds 1 and 2 (72-76%).

The major reasons for non-coverage across all three rounds were due to absences, which ranged from 13-20%, and non-eligibility (e.g., 5-7% residents reported being too ill to receive MDA drugs). Analyses of pharmacovigilance data from Round 3 and mortality data across all three rounds are currently underway. In the coming project year, a one-year follow-up period will be conducted to observe whether MDA resulted in significant changes in malaria incidence as compared to the villages randomized to the control arm and who did not benefit from MDA, but rather from standard interventions.

Figure 6. Estimated Coverage of MDA rounds. Note: The denominator for crude coverage includes all participants in the target population. The denominator for operational coverage includes target populations who were present at the time of the campaign (i.e., excludes those absent).

Key Accomplishments – Malaria Elimination Readiness Assessment (MERA) Objective 3: Provide global technical leadership, support operational research, and advance program learning Key Accomplishment #1: Preparatory activities completed To support the NMCP’s priority to accelerate progress to elimination, the IM team supported preparations and secured funds for the MERA. IM worked closely with partners and the NMCP to develop the budget; finalize the assessment protocol; coordinate review by the NMCP and PMI Mission stakeholders; and identify the 10 districts to be included in the sample. IM submitted the study documents to the University of California San Francisco (UCSF) Institutional Review Board (IRB) for review and responded to feedback from the review committee. Approval by the UCSF IRB is expected by mid-


October 2021. IM also coordinated with the PSI Research Ethics Board to cede the review to the UCSF IRB. A short-term consultant was recruited and the approvals and contracting process was started. The consultant in Senegal will support preparations, conduct data collection, and assist with analysis, write-up, and dissemination.

Challenges and Solutions Challenges Solutions During the second round of MDA, a third wave of COVID-19 hit major cities in Senegal, including Dakar, where much of the study team is based. Though the number of COVID-19 cases remained low at the Tambacounda study site, multiple study staff members were unable to go to the field, limiting the number of supervisory teams that could provide study oversight.

Available supervisory teams were assigned multiple villages to oversee MDA delivery.

Competing yellow fever and polio vaccination campaigns resulted in delays in the census survey and training for MDA delivery.

The IM team worked closely with DMTs to adjust plans to support each stakeholder to reach objectives.

Negative rumors circulated regarding COVID-19 vaccination and its possible impact on the MDA activity, threatened to affect population adherence to the project.

The IM team developed a strong sensitization plan involving community leaders to clarify the difference between COVID-19 vaccination and the MDA campaign.

Lessons Learned ● The leadership of Tambacounda health and administrative authorities contributed to strong

community participation. ● Strong community involvement prior to the intervention and coordination with health authorities

have been helpful in proactively identifying relevant sensitization messages to use and helping the team to avoid rumors and misconceptions that could negatively impact participation in the study. This community and health authority engagement was especially critical in the context of spreading COVID-19 misinformation related to project activities.

● Although MDA is generally well appreciated and accepted by communities, a small number of refusals stemmed from rumors about MDA campaigns, including the reduction of women's fertility and men's virility, fear of adverse events, conflicts between village chiefs, and a lack of understanding for the random selection of beneficiary villages. Therefore, beyond the health dimension, MDA adherence could be improved by considering the socio-cultural and political dimensions of the localities involved.

● MDA coverage was hampered by frequent population movement and long-term absences during drug distribution months. In the future, teams should consider building in time during the preparation phase to better study population movement for the months in which drug distribution is planned. Doing so will help to quantify and reach all eligible persons in the population and understand reasons for absences.

457 IM Sierra Leone February 2021 – September 2021

Sierra Leone Background IM Sierra Leone supports the MOH and NMCP to implement malaria service delivery interventions at national and sub-national levels. IM Sierra Leone collaborates with the NMCP and DHMTs to strengthen malaria case management at community and facility levels, focused on improving measures to prevent malaria during pregnancy, bolstering the national laboratory diagnostics system, and building capacity of frontline HWs in the collection and use of data for decision-making. IM Sierra Leone seeks to improve case management and the provision of MIP services through two of three global IM project objectives.

• Objective 1: Improve quality of and access to malaria case management and malaria prevention during pregnancy

• Objective 3: In support of Objective 1, provide global technical leadership, support operational

research, and advance program learning Geographic Focus: From project inception to October 2020, IM Sierra Leone supported national level activities in close coordination with the NMCP and prioritized implementation in five districts: Port Loko in Northwest Province; Koinadugu and Falaba in Northern Province; and Bo and Pujehun in the Southern Province. In this reporting period, in consultation with the NMCP and PMI, IM Sierra Leone expanded its geographic scope to include Kono, Kailahun, and Kenema in the Eastern province; Bombali in the North; and Karene in the Northwest province. IM Sierra Leone also provides support for targeted interventions to all districts in Sierra Leone, including MIP refresher training, the roll-out of Artesunate Rectal Capsule (ARC), and laboratory OTSS+.

Figure 1: IM Sierra Leone Geographic Coverage


Key Accomplishments Objective 1: Improve the quality of and access to malaria case management and malaria prevention during pregnancy Key Accomplishment #1: Supported the NMCP and MIP TWG to fill HW MIP knowledge gaps through the organization of country-wide MIP training IM Sierra Leone collaborated with the NMCP and DHMTs to improve the uptake of MIP services since project start. IM Sierra Leone supported a revitalization of Sierra Leone’s MIP TWG; added an MIP module to the suite of OTSS+ checklists; and updated and distributed national guidelines and training materials.

During this project reporting period, feedback from OTSS+ visits, district in-charges meetings, and MIP TWG meetings indicated that a majority of HWs were not trained on the current MIP guidelines. In response, IM Sierra Leone supported the NMCP and DHMTs to train 1,822 HWs in all 16 districts. The training, based on WHO guidance for MIP, focused on proper distribution and use of ITNs, effective management of malaria in pregnant women, and strengthening ANC and IPTp delivery with SP. Cadres trained included the District Health Sisters, Malaria Focal Points, Hospital Midwifes, Hospital Matrons, and Maternal and Child Health Aid (MCHA) training coordinators.

The MIP training was evaluated via pre-and post-training assessments. Pre-tests helped instructors tailor the training to the needs of the participants, and post-tests helped instructors evaluate learning and guided Malaria Field Officers (MFOs) and other supervisors during subsequent facility OTSS+ and mentorship visits. As Figure 2 indicates, across all districts, the average post-test score increased by 15% compared to the pre-test, from 72% to 87%.

Figure 2: Average pre- and post-training test scores across districts and overall, showing a 15% increase in post-training test scores. Source: Pre- and Post-training Test Data


Key knowledge gaps identified during the training are listed below. These have been, and will continue to be, reinforced during OTSS+ and mentorship visits.

● SP should not be given to HIV positive women who are on cotrimoxazole. ● Pregnant women who are on five mg folic acid daily should not be given SP. ● mRDTs should only be used for suspected malaria cases. ● Pregnant women should receive at least three IPTp doses, commencing at 13 weeks and

continuing monthly up to delivery.

During the next reporting period, all HW who did not attend the classroom training will receive updates on the latest MIP guidelines during district and sub-district meetings. IM Sierra Leone will continue to reinforce MIP best practices through OTSS+ and mentorship.

Key Accomplishment #2: Improved HW knowledge of malaria case management, diagnosis, and MIP service delivery, through data-driven district and sub-district in-charges meetings In coordination with the NMCP and DHMTs, IM Sierra Leone has supported district in-charges meetings since 2019. These meetings have been an effective platform for promoting peer-to-peer learning and problem-solving for improved quality of malaria service delivery. Meetings also provide HWs with opportunities to share and discuss challenges and successes in malaria service delivery.

During this project period, to expand learning opportunities to a broader swath of HWs, and promote local problem solving, IM Sierra Leone introduced sub-district in-charges meetings at the chiefdom level. These meetings brought together a smaller number of local HWs to promote learning exchanges through role playing, presentations, and practical demonstrations.

At both district and sub-district in-charges meetings, the promotion of evidence-based decision-making was a key objective. IM Sierra Leone supported HWs and DMHTs to analyze progress made through key performance indicators for malaria case management and prevention of MIP, using both routine and OTSS+ data. Key malaria indicators that have been disaggregated by chiefdom or facility were presented to encourage the identification, discussion, and rectification of specific challenges in malaria service delivery in that locality.

Figure 3: MCHA conducting physical examination on a child with suspected uncomplicated malaria Photo credit: Mwangi Kirubi, IM


During this reporting period, IM Sierra Leone provided technical support to, and participated in, 25 data-driven district in-charges meetings in Bo, Falaba, Kailahun, Karene, Kenema, Koinadugu, Pujehun, Bombali, Kono, and Port Loko districts. In total, 2,199 HWs were reached, including 1,605 women and 509 men.

IM Sierra Leone also supported and participated in 46 data-driven sub-district in-charges meetings across the same set of districts. Overall, 1,385 HWs attended, including 1,136 women and 249 men. Personnel attending both district and sub-district meetings included peripheral health unit (PHU) HWs and DHMT team members.

Table 1: Number of district and sub-district in-charges meetings supported, disaggregated by cadre

Meeting Type

Number of Meetings

Number of HWs reached

Total Attendees State

registered nurses

Community health officers

Community health assistants

Mid-wives

State employed child health nurses

MCHAs Others

District in-charges meeting

25 0 364 145 62 551 1,072 5 2,199

Sub-district meetings

46 1 160 68 78 345 729 4 1,385

Total 71 1 542 213 140 896 18 9 3,584

Note: “Others” include CHWs, laboratory technicians, and nursing aides Key discussion items during the meetings included the importance of testing all suspected malaria cases before commencement of treatment. The figure below highlights the percentage of suspected cases tested across IM Sierra Leone--supported districts. Average percentages have remained high over the last four quarters, with slightly higher averages across districts working with IM Sierra Leone since 2018. These districts are Bo, Falaba, Koinadugu, Port Loko, and Pujehun. Bombali, Kailahun, Karene, Kenema, and Kono districts were added later in the reporting period.

Figure 4: Role play highlighting the role of male participation in improving IPTp uptake during ANC visits, facilitated by the IM MIP Technical Officer at a sub-district meeting, Photo credit: Deborah Boyma Deborah, IM


At the start of the reporting period, values for the indicator “Percentage of malaria cases confirmed with a parasitological test” exceeded the 100% target across most districts, which highlighted data quality challenges in reporting. For instance, the high rate of suspected cases recorded as receiving a confirmatory test may be attributed to providers only recording those cases for which the mRDT is positive. IM Sierra Leone supported district and sub-districts to engage HWs for correct data entry processes surrounding this indicator. This has led to a reduction to less than 100% in most districts, as presented in Figure 6, below.

Figure 6: Percentage of reported malaria cases confirmed with a diagnostic test, Source: MOH DHIS2

To monitor the effectiveness of district and sub-district meetings in sharing knowledge with HWs, tests are administered before and after each meeting. HW knowledge is assessed for mRDT, MIP, case management, and data quality. Across the 1,207 pre- and post-tests administered at district and sub-district meetings during the reporting period, HW scores improved by 19%.

Additionally, average pre and post-test scores were consistently higher in districts working with IM Sierra Leone since 2018. This indicates that IM Sierra Leone quality improvement (QI) interventions may have a lasting impact on quality of care (QOC). The average pre-test scores in existing operational and new districts are 62% (N=957) and 58% (N=359), respectively. Post-test scores of operational districts working

Figure 5: Percentage of suspected malaria cases that received parasitological tests


with IM Sierra Leone since 2018 were 81% (N=957) compared with new district post-test average scores of 75% (N=359). Figure 7 below indicates that assessment scores increased by an average of 19%, from 63% to 82% across all districts, regardless IM Sierra Leone engagement duration.

Figure 7: Average sub-district pre- and post-training test percentages, Source: IM Sierra Leone Training database

Key Accomplishment #3: Leveraged lessons learned from the paper-based round of OTSS+ to improve malaria service delivery through digitized OTSS+ OTSS+ is a key part of IM Sierra Leone’s QI approach. It is a process by which regular, ongoing support is provided to HWs to strengthen malaria service delivery at the PHU level. OTSS+ includes competency-based supportive supervision to identify areas that require improvement. It also offers on-the-job training, counselling, and troubleshooting to providers. Problems are jointly identified and resolved, promoting high standards of teamwork, and fostering two-way communication.

In the previous reporting period, IM Sierra Leone completed its first round of OTSS+ using paper-based checklists. To support national buy-in and sustainability, SL collaborated with the NMCP and DHMTs in the initial five operational districts to review and field test OTSS+ checklists. Feedback was used to update and improve the checklists, while ensuring that critical elements allowing IM to compare indicators across countries were maintained. Although the paper-based OTSS+ round was successfully achieved, manual calculation of results and hand-written action plans were time-consuming. While collecting data, skip logics were often not followed and required a high degree of cleaning. Manual data entry from the paper forms presented numerous data quality challenges, as well. During this reporting period, IM Sierra Leone worked with the NMCP and DHMTs to plan and commence implementation of a digitized clinical OTSS+ round using checklists in HNQIS. To reinforce effective implementation of OTSS+, IM Sierra Leone conducted a four-day HNQIS training for the NMCP, DHMTs, MIP TWG, and MFOs across 10 districts. The training covered all OTSS+ modules as well as HNQIS navigation and data submission. The final day of the training included a field exercise, followed by a debrief session where teams described and reflected on their experience. A total of 202 participants were reached


during these sessions including, 166 DHMT members, 23 MFOs, 10 NMCP staff, and three MIP TWG members. Of this total, 74 were female and 128 male. After the training and field exercise, IM Sierra Leone worked with its partners to implement digital OTSS+ across 10 districts. Teams administered checklists to assess clinical case management of suspected malaria cases, competencies in MIP at ANC, facility readiness, and mRDT use. The OTSS+ teams provided supportive supervision and on-the-job training to HWs in PHUs to address identified gaps. PHUs were also supported to develop action plans to address identified malaria service delivery challenges. Feedback was provided to health staff at the end of the visit, followed by discussions with health staff on how best to address these challenges. A copy of recommendations with responsible people and timelines were then shared with each facility.

During the reporting period, a total of 803 (90% of target) facilities received OTSS+ visits, reaching a total of 2,314 HWs. Of this total, 1,634 were female and 680 were male. Tables 2 and 3 show the number of PHUs and HWs reached during this OTSS+ round. Although most targeted facilities were reached, due to challenging terrain and absence of staff at some of the PHUs, about 10% of the PHUs did not benefit from the OTSS+ visit. These facilities will be prioritized during the next round of OTSS+.

Table 3: Facilities and HWs covered by OTSS+ by district

District Number of Facilities Targeted

Facilities Reached Percentage of Targeted Facilities Reached

Number of HWs Reached

Bo 148 139 94% 451 Bombali 79 76 96% 236

Falaba 43 39 91% 71 Kailahun 83 73 88% 268 Karene 59 55 93% 154

Kenema 138 106 77% 322 Koinadugu 49 45 92% 114 Kono 95 90 95% 191

Port Loko 100 94 94% 302

Pujehun 97 96 99% 205 Total 891 813 91% 2,314

Figure 8: MIP TWG members completing the MIP checklist during the HNQIS training in Kailahun district, Photo credit: Nelson S. Fofana, IM


Table 4: Targeted and number of HWs reached by district disaggregated by cadre and gender District

Number of HWs Reached by Cadre and Gender

Male

Female

Community Health Officer (CHOs)

State Registered Nurse (SRN)

Community Health Assistant (CHAs)

Mid-wives

State Enrolled Community Health Nurse (SECHN)

MCHA Others

Bo 52 1 25 32 102 230 9 66 385 Bombali 12 0 7 23 105 75 14 20 216 Falaba 3 0 5 7 18 35 3 14 57 Kailahun 21 0 16 9 84 117 21 97 171 Karene 12 0 5 12 37 74 14 40 114 Kenema 16 0 9 6 60 187 44 56 266 Koinadugu 4 0 5 5 22 40 38 38 84 Kono 12 0 5 13 35 99 27 25 166 Port Loko 21 2 7 12 66 149 45 37 265 Pujehun 16 0 17 8 17 140 7 31 174 Total 153 3 2 121 486 957 178 358 1,634

Note: “Others” include laboratory assistants, nursing aides, CHWs, Endemic Disease Control Unit assistants, and student nurses

Data from this round were not fully validated or presented to stakeholders via an LLW in time to be included in this report. A full analysis of 2021 OTSS+ results will therefore be presented in future reports. Anecdotally, IM Sierra Leone can report positive trends in QOC across all modules between the 2019 and 2021 OTSS+ rounds. Cumulative average QOC scores from districts that participated in both rounds have increased from 51.4% in 2019 to 72.4 % in 2021. QOC scores from the mRDT observation checklist increased from 73.3% in 2019 to 84.7% in 2021. A similar trend was observed in MIP service quality using


the ANC checklist, in which QOC scored increased from 43.7% to 65.7%. Likewise, for the clinical case management module, QOC rose from 43.1% to 62.3% during that period. Key Accomplishment #4: Supported rectal artesunate training, roll-out, and assessment across 14 districts The progression of uncomplicated to severe malaria is generally attributable to delays and failures in healthcare delivery and health-seeking behavior. To reduce severe

malaria deaths, IM Sierra Leone supported the NMCP to roll out ARC as a pre-referral intervention to peripheral health units (PHUs) in 14 districts. In previous reporting periods, PMI and its partners supported the NMCP to update national ARC guidelines and to procure 6,000 quality assured rectal artesunate capsules. IM Sierra Leone also took the leading role in supporting the NMCP to develop training materials and conduct trainings for national, district stakeholders.

During this past reporting period, IM Sierra Leone continued its support for this activity to further train 2,452 HWs across 14 districts at the PHU level (2,000 female and 452 male). These trainings focused on equipping providers to recognize danger signs, administer ARC, effectively refer patients to higher levels of care, and record data correctly in their registers. Following the training, referral forms, job aids, and posters were distributed to HWs to take back to their respective facilities.

All participants underwent pre- and post-test evaluations of their knowledge. Participants had an average pre-test score of 53%, which increased to 86% post-test, showing a 33% percent improvement. Figure 11 below shows overall average pre- and post-test scores, disaggregated by district.

Figure 9: IM Chief of Party, Kwabena Larbi and M&E Officer Nelson Fofana reviewing the under-five health facility register during an OTSS+ visit at Matenneh MCHP, Bombali district, Photo credit: Alex Momoh Amara, IM

Figure 10: Recap session by participants during ARC training in Koinadugu District, Photo credit: Mohamed Saiddu Kamara, IM


Figure 11: Average performance in pre- and post-test during ARC HW trainings

After the trainings, IM Sierra Leone supported the NMCP to assess the roll-out of this intervention to quantify appropriate ARC practices for both administration and referral, and to document health outcomes of patients who received the pre-referral intervention. IM Sierra Leone reviewed a convenience sample of 134 records from 69 facilities in five districts. All 109 patients who met severe malaria case criteria were administered ARC and were referred. Approximately 11% of family members or guardians refused the referral. Record review data did not indicate reasons for refusal. Of the 65 patients who were admitted to a referral facility, five (8%) died in a hospital and at least 52 (80%) were discharged. Records for seven admitted patients were not located. Ambulances were used as the transportation method in 75% of referrals. About 96% of referral forms made it to the referral facility, but only 7% made it back to the referring facility. While 72% of ARC administration took place in Community Health Posts and Maternal and Child Health Posts, which are often remote and offer basic care, 92% of patient deaths occurred in patients who were referred from these PHUs.


Figure 12: ARC Record Review Assessment Cascade

While the above analysis highlights key successes of the ARC roll-out, challenges were observed that need to be addressed. IM Sierra Leone, together with the NMCP, will collaborate with PMI’s SBC implementing partner, Breakthrough ACTION to understand and address caretaker refusal challenges. IM Sierra Leone will also continue discussions with DHMTs on how best to engage referral centers to reinforce the sending of referral forms back to the referring facilities upon discharge. IM Sierra Leone plans to support the implementation of a community level supervision round in the next reporting period, which will focus on recognition of danger signs, ARC administration, referral form completion, and referral. Furthermore, IM Sierra Leone will support the NMCP to conduct a severe malaria training aimed at inpatient providers followed by OTSS+ for inpatient providers to bolster QOC for severe malaria and related complications.

Key Accomplishment #5: Supported MDRT to improve and strengthen malaria diagnostic capacity among microscopists The findings of the Sierra Leone Laboratory Needs Assessment carried out in March, 2019 by the NMCP, Central Public Health Reference Laboratory (CPHRL), and IM Sierra Leone, indicated major gaps in malaria diagnosis, including: poor laboratory infrastructure; shortages of laboratory staff according to recommended staffing norms across all levels of health care system; shortages of microscopes; low coverage of refresher training in malaria diagnostic testing; infrequent supportive supervision; and only a few health facilities performing malaria parasite species identification and parasite counting. To respond to identified gaps, IM Sierra Leone supported the NMCP and CPHRL to conduct three one-week bMDRT for 54 laboratory personnel (13 females and 41 males), a one-week aMDRT for 20 laboratory personnel (six females and 14 males), and a one-week nECAMM for nine laboratory personnel (three female and six male) with the highest performance during the preceding aMDRT. This suite of training was arranged so that only the most successful laboratory personnel from the basic training would continue to the advanced training. Trainings included public and private laboratories as well as uniformed personnel, including the military and police.


The goal of each training was to equip participants with knowledge and skills to competently diagnose malaria through microscopy. The bMRDT provided an overview of key malaria microscopy competencies, with a focus on parasite detection. The aMDRT and nECAMM trainings included parasite detection but expanded their scope to emphasize building species identification and parasite counting skills. High performing laboratory personnel from these trainings will comprise a pool of supervisors who will lead future laboratory OTSS+ visits.

bMDRT trainings

Results of the bMDRT pre-workshop theory test showed a mean score of 33%, which improved to 51% at post-test. None of participants scored 90% at pre-test while two (4%) scored above 90% at post-test. All laboratory technician, regardless of whether they received an IM Sierra Leone-supported training, will be provided with basic background information in malaria parasitology during OTSS+ mentorship visits.

Each group of bMDRT participants demonstrated improvement from their pre- to post-training assessments, which tested for skills in parasite detection, species identification, and parasite quantification (Figure 14). Parasite detection is the number of positive and negative training slides indicated by a

Figure 13: Practical sessions during the bMDRT training, Photo credit: Fay Chalobah, IM

Figure 14: bMDRT pre- and post-test results


participant to align with the true results of the slides. However, performance for all participants was below the >80% score recommended by the project. IM Sierra Leone will address these deficiencies through planned laboratory OTSS+ rounds and will conduct mentorship visits on a quarterly basis to strengthen laboratory technician microscopy competency skills using proficiency testing (PT) slides.

aMDRT training aMDRT scoring was classified as level A, B, C, and D for all categories: parasite detection, species identification, and parasite counting from pre- and post-tests on days two, three, and four using version two of WHO’s Malaria Microscopy Quality Assurance Manual.

Table 4: Summary of participants performance in aMDRT training Level Number of

staff attaining level

Level target

Level A 0 Parasite detection- ≥ 90%, Species identification- ≥ 90%, Parasite counting- ≥ 50%

Level B 2 Parasite detection- 80%-89%, Species identification-80%-89%, Parasite counting- 40%-49%

Level C 1 Parasite detection- 70%-79%, Species identification-70%-79%, Parasite counting- 30%-39%

Level D 17 Parasite detection- <70%, Species identification- <70% Parasite counting- <30%

Table 4 shows the post-test malaria competencies, indicating low performance compared with WHO standards. As this was the first aMDRT in Sierra Leone, low scores were not surprising. Poor performance in parasite quantification is attributed to the fact that participants do not routinely conduct parasite quantification during their regular workday. Additionally, personnel lack tally counters in their workplaces, which is a key component for quantification. Participants of the aMDRT improved their scores from pre- to post-test in all malaria microscopy competency areas. Average scores for: parasite detection increased from 63% to 83%; sensitivity increased from 66% to 87%; specificity increased from 56% to 78%; parasite identification increased from 20% to 57%; and parasite counting (density) increased from 5% to 30%. However, the post-test scores for all competencies tested during after the aMDRT, while increased from their pre-test values, remained lower than desired. IM Sierra Leone will work with laboratory personnel to improve these competencies through future trainings, OTSS+ and mentorship visits to improve malaria microscopy competencies.

nECAMM training As noted in the aMDRT training section above, even the most highly skilled participants rarely incorporate parasite counting into their daily work. This lack of experience is reflected in their relatively low scores. The nECAMM was held immediately after the aMDRT, so participants did not have the opportunity to practice parasite quantification under real-world conditions at the time of the nECAMM.


Table 5: Summary of participants performance in nECAMM training Level Number of staff

attaining target Level target

Level A 0 Parasite detection- ≥ 90%, Species identification- ≥ 90%, Parasite counting- ≥ 50%

Level B 1 Parasite detection- 80%-89%, Species identification-80%-89%, Parasite counting- 40%-49%

Level C 4 Parasite detection- 70%-79%, Species identification-70%-79%, Parasite counting- 30%-39%

Level D 4 Parasite detection- <70%, Species identification- <70% Parasite counting- <30%

In Figure 15, nECAMM participants show improvement in their scores in the post-test in each competency area except P. falciparum identification. The ability of participants to identify very-low-density slides (66-108 ul/L of blood) proved to be difficult, hence most of these slides are reported as negative. Mentorship and on-the-job training through OTSS+ with PT slides will improve this skill. The greatest improvement was seen in specificity, which increased by 34%. Showing that participants were able to increase their capacity in confirming negative slides.

Figure 15: Summary of NECAMM competency performance


Key Accomplishment #6: Supported the first round of Laboratory OTSS+ in 53 health facilities across 15 districts to strengthen laboratory capacity During this reporting period, IM Sierra Leone, in collaboration with the NMCP and CPHRL, finalized and incorporated the laboratory OTSS+ modules into HNQIS. To reinforce effective implementation of laboratory OTSS+ and skillful mentorship during fieldwork, IM Sierra Leone conducted a five-day training on navigation of OTSS+ supervisory skills and HNQIS for 20 MOH laboratory supervisors (six female and14 male). Field testing was conducted in five health facilities in the Western Area Urban and Western Area Rural districts. After field testing, team members provided feedback reflecting their experiences and relevant adjustments to the HNQIS application were made.

IM Sierra Leone, in partnership with the NMCP, supported the CPHRL to conduct the first round of laboratory OTSS+ in 53 facilities (11 private hospitals, 10 community health centers, three military hospitals, and 29 government hospitals) across 16 districts, reaching a total of 202 laboratory staff (53 female and 149 male). Selection of the facilities was done in collaboration with the NMCP and the CPHRL. The OTSS+ round found a general lack of essential supplies, laboratory equipment and low PT scores. Stock-outs of one or more malaria microscopy supplies was observed in many of the health facilities that were visited. Approximately 74% of health facilities visited lacked buffer tablets and distilled or deionized water. As a result, HFs used tap water for preparation of stains, which resulted in poor quality of stained slides. In addition, HFs lacked methanol (58%), filter paper (51%), lens cleaning fluid (58%), and microscope slides (43%). Giemsa stock solution was available at some facilities (38% of HFs), but staff had not been trained on use of Giemsa solution for staining. All facilities visited had stock-outs of one or more essential consumables and reagents for malaria microscopy contributing to poor quality results and service interruption.

To support delivery of quality and timely diagnostic results, laboratory equipment must be available, of high quality, and context appropriate. Most facilities had staining racks, but no staining troughs nor dishes. At the time of laboratory visits, some HFs lacked some equipment for malaria microscopy procedure. Of the 53 facilities visited, only 8% (N=4) of HFs had a PH meter, 19% (N=10) had a blood roller/mixer, 34% (N=18) had a weighing balance, 38% (N=20) had tally counters, 45% (N=20) had timers, and 92% (N=49)

Figure 16: Representatives from PMI, NMCP, DLDBS, and IM Sierra Leone with participants at IM Sierra Leone supported NECAMM training, Photo credit: Cyril Pat-Cole, IM


of had at least one functional microscope. A total of 109 microscopes were available during the time of OTSS+ visits in 53 facilities. Only 72% (N=78) were functional and 28% (N=31) were non-functional. None of the HFs had any microscope spare parts available. Daily maintenance of microscopes is not carried out and no system for microscope maintenance is in place.

During this reporting period, as part of EQA, IM Sierra Leone collaborated with the NMCP and CPHRL to conduct PT in 51 health facilities using slides from a WHO-validated slide bank. The team used 10 validated slides comprising negative and positive slides with P. falciparum, P. malariae, P. ovale, and mixed infections. HF results were compared against the validated slides, the percentage if parasite detection was determined, and feedback was provided to the laboratory technicians.

The minimum standard competency agreement between the laboratory technicians and the reference results is set at 80% or more for parasite detection, 80% or more for species identification, and 40% or more for parasite densities. Among laboratory technicians, 15% (n=8) and 4% (n=2) met the minimum standard for parasite detection and parasite counting, respectively. None of the health facilities met the requirement for species identification.

Figure 17 shows the average PT scores by districts, based on the results from the 51 facilities where PT testing was conducted.

Figure 17: Comparison scores for parasite detection, species ID and parasite counting in PT at the 52 health facilities across 15 districts

Average PT scores were 41.4%, which is below the WHO standard of 90%. To boost scores, IM Sierra Leone will conduct quarterly mentorship visits to very low- and medium-performing health facilities and conduct additional MDRT trainings in the next reporting period to build microscopy competency. Additionally, IM Sierra Leone has successfully collaborated with PMI to support the procurement of one year’s worth of laboratory supplies. This will support trained laboratory technicians to be able to conduct malaria microscopy, thereby retaining and improving their skills.


Objective 3: In support of Objective 1, provide global technical leadership, support operational research, and advance program learning Key Accomplishment #1: Supported the NMCP to develop a symposium proposal and presentation to the ASTMH annual meeting IM Sierra Leone supported the NMCP Case Management Focal Point to present at the virtual ASTMH annual meeting in November 2020. The symposium presentation focused on Sierra Leone’s experience of rolling out and assessing uptake and utilization of ARC in 14 districts across the country. The objectives of the presentation were to provide context for the malaria burden in Sierra Leone, a description of the roll-out of ARC in selected districts. and an exploration of a record review assessment, which was designed to capture learnings from the roll-out. Further information is included in Key Accomplishment #4 above. Additionally, IM Sierra Leone collaborated with the NMCP and PMI to develop an abstract titled “Assessing the roll-out of ARC as pre-referral intervention in five districts in Sierra Leone” which has been accepted as a poster for the ASTMH annual meeting in November 2021. Finally, IM Sierra Leone collaborated with the CPHRL and NMCP to develop an abstract titled “Optimization of Laboratory OTSS+ in Sierra Leone” based on the successful rollout of the first laboratory OTSS+ in the country.” The abstract has been accepted by ASTMH as a poster presentation and will be presented at the November 2021 annual meeting. Key Accomplishment #2: Supported planning for a TES to assess the safety and efficacy of first-line antimalarials WHO recommends that all countries monitor the safety and efficacy of their first line antimalarials to quickly identify and monitor the emergence and spread of parasite resistance. In 2017, the Sierra Leone NMCP conducted a TES to test the safety and efficacy of three antimalarials: AL, first-line treatment; Artesunate-Amodiaquine (ASAQ), (alternate first-line treatment), and DHA-PPQ, back-up first-line treatment. After correcting for recrudescence or reinfection with PCR tests, all three antimalarials were found to be over 95% efficacious in the treatment of uncomplicated malaria caused by P. falciparum.

During this reporting period, IM Sierra Leone supported the NMCP to prepare for a TES evaluating the efficacy and safety of AL and ASAQ for the treatment of uncomplicated malaria caused by P. falciparum in three study sites: Bo, Bombali, and Kenema. IM Sierra Leone, in collaboration with the NMCP, engaged DHMTs and hospital management to support the identification and evaluation of readiness of the proposed TES sites. All sites were assessed using a standard guide and five study centers have been identified across three sites: two in Bo, two in Bombali, and one in Kenema. In collaboration with the NMCP, PMI, WHO, and CDC, the TES protocol was reviewed to include the confirmed sites, finalized, and submitted to the Sierra Leone Ethics and Scientific Review Committee for approval. The ethics committee approved the TES protocol in July 2021. IM also supported a review of microscopist availability and competency to understand how many met the requirements for the TES. A training plan was developed to strengthen and refresh the skills of the 13 microscopists chosen for the study. Furthermore, IM Sierra Leone has initiated the procurement of supplies for the TES and has identified a subcontractor to refurbish all areas allocated to the study at the various sites. Enrollment is expected to begin by Q1, 2022 and will be completed within six months of commencement.


Challenges and Solutions Challenges Solutions The outbreak of COVID-19 delayed most of the planned activities during the reporting period. National MOH counterparts were occupied with responding to the epidemic. This meant IM Sierra Leone had limited opportunities to engage with them. Additionally, the national restrictions and safety measures introduced limited the number and frequency of activities that could be implemented without jeopardizing the health of communities and IM staff.

IM Sierra Leone encouraged the NMCP to include other health experts in supporting IM Sierra Leone activities as opportunities arose. This reinforced that country-wide trainings, like the MIP refresher training, were implemented with the involvement of MIP TWG members in ten districts over a relatively short period. Going forward, IM Sierra Leone will promote this strategy with the NMCP Case Management Unit.

Key stakeholders were unavailable for the implementation of planned activities as they are involved in other activities, which were sometimes even targeting the same group of HWs.

IM Sierra Leone will continue to share its work plans with the DHMT and other stakeholders well ahead of planned activities, as well as continuously engage with stakeholders to achieve a common perspective.

In early 2021, the NMCP suffered the passing of the NMCP Manager and Deputy Manager. These key positions have remained vacant throughout the project year. Lack of official leadership within the NMCP has led to some delays in the coordination and prioritizing of IM Sierra Leone activities.

IM Sierra Leone will continue to maintain open and frequent communication with the NMCP. IM Sierra Leone will also increase emphasis on developing and sharing detailed implementation plans to enhance their ability to plan and coordinate with the NMCP.

ARC procurement was delayed. The PMI-approved procurement of 1,000 recto-caps as a stop-gap measure will not meet national needs.

IM Sierra Leone will continue to engage GHSC-PSM and NMCP to adequately quantify the national requirements and expedite their procurement

Several data-related challenges persist. At the PHU level, severe malaria data elements are not captured in the revised MOH tools. In the DHIS2, there is no data element to differentiate microscopy test results as severe versus uncomplicated malaria. Additionally, malaria treatment indicators only account for malaria treated with ACTs but do not include severe malaria-specific elements. At the inpatient level, the drugs used to treat severe malaria are not captured in the summary form that feeds into DHIS2. Finally, revised facility summary forms do not capture IPTp4, IPTp5, and beyond.

IM Sierra Leone will continue its engagement with the NMCP for further discussion with the Directorate of Policy, Planning, and Information (DPPI) to include these key data elements in subsequent updated DHIS2 forms. IM Sierra Leone proposed to the NMCP and DPPI that HWs be asked to find space in the ANC register or forms to record IPTp4. In the meantime, IM Sierra Leone will collect data from a sample of health facilities through an audit of source registers where all IPTp data are recorded. This will provide stakeholders an indication of the coverage of IPTp4, IPTp5, and beyond.

The vendor identified for the international procurement of TES supplies required up to eight weeks to stock supplies before shipping them, which meant many critical items would not arrive in time for the planned study launch.

IM worked with the NMCP, PMI, and CDC to identify alternate sources, locally and through PSM to secure enough of the items and allow for study launch according to the proposed timeline, while waiting for the remainder of the supplies to arrive later.


Lessons Learned

● It is important for IM Sierra Leone to work with PMI implementing partners to share best practices during the COVID-19 pandemic and further investigate how best to sustain project activities considering this challenging situation.

● IM Sierra Leone should verify that HWs attending routine meetings and trainings are rotated. This will support equitable gender representation as well as attendance from less represented personnel. The rotation of HWs can be verified through the review of attendance lists from previous meetings with key DHMT personnel before invitations are sent to participants.

● It is important for IM Sierra Leone, the NMCP, and DHMTs to have joint planning meetings for approval of planned activities. Continuous engagement of DHMT leadership on planned activities is also key in ensuring successful implementation.

● IM Sierra Leone should continue to engage with DHMTs to reduce the number of HWs permitted to attend district and sub-district in-charges meetings at a single time. This will support adequate time and space for effective knowledge sharing, skills transfer, and peer-to-peer learning.

● IM Sierra Leone, together with NMCP should collaborate with Breakthrough ACTION to understand and address the caretaker refusal of rectal artesunate.


IM Sierra Leone Indicator Table The data provided in the indicator table below are IM targets and activity results from October 1, 2020 – September 30, 2021. Please note that since May 2021, there have been challenges with national DHIS2 (transmission of data from subnational to national level). Therefore, HMIS data from May through Sept 2021 may have been underreported. The report covers ten (10) districts and four (4) regions, Kono, Kenema and Kailahun (Eastern Region), Bo and Pujehun (Southern region), Bombali, Falaba and Koinadugu (Northern region) and Porto Loko, and Karene (North-West region). During this period, one round of OTSS was completed, reaching 813 health facilities and 202 health care providers were trained.



Progress to

Annual Target

(%)

Comments

Objective 1.1 Improved access to quality malaria

diagnosis


100% 100% 100%

IM in collaboration with NMCP-supported DHMTs and health facilities conducted district and sub-district meetings to refresh HWs on malaria control guidelines and policies with the support from partners having contributed to sustained high adherence to policies. Data for this indicator is derived from the country’s own DHIS2 platform. Although IM Sierra Leone has supported the NMCP to increase the percentage of malaria cases confirmed with a diagnostic test, it is possible that the value of this indicator, as reported, is inaccurate.


100% 95.70% 96%

Despite the high testing rate recorded in DHIS2, IM Sierra Leone believes that the rates are lower. This is due to documented reports of periodic mRDT stock-outs and the temporary suspension of testing during the initial phase of the COVDI-19 pandemic. These challenges were expected to have negatively affected the testing rate. IM Sierra Leone will engage with PMI Measure Malaria, the NMCP, and DPPI to further improve reporting skills of HWs at facility and district levels.

Percentage of observed HW demonstrating competency in correctly classifying cases

25% 65% 260%

IM Sierra Leone was requested by the MOH and PMI to expand to five more districts, beyond the initial target, this is the reason for exceeding target.



Progress to

Annual Target

(%)

Comments

as not malaria, uncomplicated malaria, and severe malaria Percentage of HW demonstrating competency in malaria RDTs

100% 43% 43% A total of 1,266 HWs were supervised, of which 544 HWs scored 90% or greater in the preparation and reading of RDTs.

Percentage of HW demonstrating competency in malaria microscopy

40% 11% 28%

A total of 54 HWs were supervised, of which six HWs scored 90% or greater demonstrating competency in malaria microscopy.


40% 2% 5%

Laboratory OTSS+ data results that only the Ebovac Laboratory in Kambia meets standards. The remaining Laboratories across the remaining districts did not meet standards. IM Sierra Leone will continue to engage PMI, the NMCP, and CPHRL to improve skills and reinforce availability of supplies to the laboratories. In addition, PMI Sierra Leone is procuring a limited number of laboratory supplies for these labs.


100% 53% 53%

From the 54 facilities supervised, 29 have at least one provider trained in malaria diagnosis. IM Sierra Leone has plans to train more health workers during planned laboratory trainings in FY22.

Percentage of targeted HW trained in malaria diagnostics

100% 75% 75% A total of 72 HWs were targeted, of which 54 were trained.


100% 100% 100% A total of 20 supervisors were targeted and 20 were trained.

Percentage of targeted districts with

100% -- -- The Laboratory OTSS+ conducted during the project period did not have any



Progress to

Annual Target

(%)

Comments

national malaria diagnostic supervision tools that adhere to national standards

checklist for this indicator, thus no data was generated to measure this indicator.

Percentage of targeted districts with national guidelines for malaria diagnosis that meet global standards

100% 100% 100% All IM supported districts have guidelines that meet standards.

Objective 1.2: Improved access to targeted quality malaria

treatment


-- --

Severe malaria OTSS+ was not conducted in this reporting period. IM Sierra Leone plans to conduct training and OTSS+ for health workers on severe malaria in FY22.


99% 101% 102% The reason for the overachievement is related to presumptive treatment due to stock-outs of mRDT kits.

Percentage of observed HW demonstrating competency in management of uncomplicated malaria

4% 7% 57%

The overachievement of this target is due to the expansion to more districts by IM Sierra Leone, which was not planned in the workplan for the current reporting period.

Percentage of observed HW demonstrating compliance to treatment according to WHO guidelines for

90% 95% 106%

IM Sierra Leone on-going rounds of OTSS+, mentoring, coaching, and regular supportive supervision have increased HWs capacity and adherence to national treatment guidelines.



Progress to

Annual Target

(%)

Comments

cases with positive malaria test results Percentage of observed HW demonstrating adherence to negative test results according to global standards

100% 81% 81%

IM Sierra Leone ongoing rounds of OTSS+ data shows non-compliance observed from few health care staff not withstanding mentorship and supportive supervision will improve compliance to national treatment guidelines.


50% 1% 2%

The underperformance of this indicator is due to the lack of materials and documentation. Most facilities have qualified staff but lack materials and documentation.


100% 89% 89%

Sierra Leone’s national DHIS2 has not been updated since June, due to challenges in retaining district M&E staff. Some staff are currently not at post.


100% 99% 99%

A total of 889 facilities were targeted and 803 were reached. IM will prioritize the unreached HFs during the next OTSS round of visits.

Percentage of HW trained in management of severe malaria

100% N/A N/A This activity was not conducted in the year under review.

Percentage of HW trained according to national guidelines in malaria case management with ACTs

100% N/A N/A

There were no IM-supported case management trainings this year. However, HW received updates on malaria case management through OTSS+ visits, district meetings, and mentoring visits



Progress to

Annual Target

(%)

Comments

Percentage of IM-supported districts/health facilities with national guidelines for malaria treatment that meet global standards

100% 100% 100% The five districts initially planned for IM interventions were supported with malaria treatment guidelines.

Objective 1.3: Improved access to quality

prevention and

management of MIP


100% 85% 85% DHIS2 has been updated recently but few district are yet to submit complete data.


N/A --

The elements for the numerator for this indicator are not currently captured in the Sierra Leone DHIS2. This is a priority for review during the upcoming year.


64% 67% 104% This is because IPTp doses above four are not captured separately in the DHIS2. The national HMIS system captures IPTp3.


99% 82% 82% DHIS2 has not been updated since June 2021 due to retention of M&E, staff by the government.


100% 88% 88% DHIS2 has not been updated since June 2021, due to the retention of M&E staff by the government.

Percentage of observed HW demonstrating competency in treatment of MIP

63% 19% 19%

Few HWs meet the competency score (90%) in the treatment of MIP. IM Sierra Leone will support the NMCP to provide refresher training for HWs and scale-up regular mentorship and supportive supervision in HFs

Percentage of observed HW demonstrating competency in prevention of MIP

40% 16% 40%

Few HWs meet the competency score (90%) in the treatment of MIP. IM Sierra Leone will support NMCP to provide refresher training for HWs and scale-up regular mentorship and supportive supervision in HFs.

Percentage of HW trained in IPTp

100% 96% 96% A total of 2,811 HWs were targeted and 2,705 were trained



Progress to

Annual Target

(%)

Comments

Percentage of IM-supported districts with national guidelines for prevention and treatment of MIP that meet global standards

100% 100% 100% All IM Sierra Leone-supported districts have been provided with MIP national guidelines.

Functional/ active RMNCH/MIP/ANC/ community health Working Group

4 4 100% IM Sierra Leone supported and participated in two TWG meetings for MIP (2) and M&E (1).


1 1 1

IM Sierra Leone supported the NMCP to prepare a presentation regarding the value of OTSS+ in promoting the uptake of MIP services.



4 4 4

IM Sierra Leone supported the NMCP to submit two abstracts for presentation at ASTMH annual meetings in 2020 and 2021. Both abstracts were accepted as poster presentations.

Participation in targeted national, regional, or global level Working group(s) and/or taskforce(s)

2 2 100% IM Sierra Leone participated in two MIP TWG meetings and one M&E meeting.

482 IM Tanzania October 2020 – September 2021

Tanzania Background

The entire population of Tanzania is considered at risk for malaria, although transmission varies significantly among and within regions. Prevalence varies by region from <1% in Zanzibar and areas in a “corridor” running from northeast to southwest of mainland Tanzania covering approximately one third of the country and its population. At the same time, high transmission areas are consistently found in the Lake and Western Zones at 24% prevalence and in the Southern Zone at 15% prevalence. Results from the 2017 Malaria Indicator Survey (MIS) key indicator report

showed that 7.3% of children under five years of age in mainland Tanzania and Zanzibar had tested positive for malaria by mRDT, down from the 2011-2012 MIS (9%) and the 2015-2016 Tanzania Demographic Health Survey -MIS (14%).

During the reporting period, IM Tanzania supported two out of 11 regions which have previously been supported by PMI in mainland Tanzania, Lindi and Mtwara; one new mainland region, Katavi; and two regions in Zanzibar, Pemba and Unguja islands (Figure 1). IM Tanzania activities covered 867 health facilities in total: Katavi (99), Lindi (262), Mtwara (261), which is 622 on the mainland, and Zanzibar (245), as shown in Table 1.

Table 1: List of IM Tanzania regions with type and number of health facilities per region

Region Hospital Health Center

Dispensaries Clinics Primary

Health Care Unit

Primary Health Care

Unit Plus Total

Katavi 4 16 79 N/A N/A N/A 99 Lindi 10 24 228 N/A N/A N/A 262

Mtwara 9 30 222 N/A N/A N/A 261 Zanzibar 15 N/A 53 14 132 31 245

Grand Total 38 70 582 14 132 31 867

IM Tanzania supported the NMCP and Zanzibar Malaria Elimination Programme (ZAMEP) to improve malaria service delivery through two global IM project objectives:

● Objective 1: Improve the quality of and access to malaria case management and prevention of malaria during pregnancy

● Objective 3: Provide global technical leadership, support operational research, and advance program learning

Figure 1: IM Tanzania focus regions


COVID-19 Preventive Measures IM Tanzania has remained committed to project staff and stakeholder safety against COVID-19. In collaboration with regional and council health management teams IM Tanzania established that, during

activities, participants observe social distancing, wear face masks, and use hand sanitizer (Figure 2). IM Tanzania provided preventive measures to staff, facilitators, training participants, and Malaria Service Delivery and Quality Improvement (MSDQI) supervisors during activity implementation. IM Tanzania supported the availability of hand-washing stations in training and meeting venues and optimized the use of digital applications such as Microsoft

Teams to replace physical meetings, for example for the Joint Partner Planning Meeting and weekly project level meetings.

IM Tanzania adhered to COVID-19 safety protocol guidance from USAID as well as from the MOH Community Development, Gender, Elderly and Children (CDEC).

Key Accomplishments


Key Accomplishment #1: Supported the introduction of the IM Tanzania project in the targeted implementation regions IM Tanzania worked with the NMCP and President’s Office Regional Administration and Local Government (PO-RALG) to introduce the IM Tanzania project and team in the three mainland Tanzania focus regions of Katavi, Lindi, and Mtwara. Based on requests from regional authorities, IM Tanzania developed a memorandum of understanding (MOU) with consultations from the regions to commit to implementing activities as per the project’s scope of work. The signed MOU outlined the commitments for both IM Tanzania and the regional authorities, including their support toward meeting the project objective and goals.

Figure 2: Basic refresher microscopy training in Zanzibar, Photo credit: Mariam Kiwale, PSI

Figure 3: IM COP, Lindi RC and Finance Administrator signing the Lindi MoU (Photo credit by Michael Kimario).


Key Accomplishment #2: Supported the updating of malaria diagnostic policy documents and reference materials for ZAMEP and the NMCP IM Tanzania supported ZAMEP and the NMCP to organize a five-day stakeholder workshop to review and update the guidelines for malaria diagnostic testing as well as the Malaria Diagnosis Refresher Training (MDRT) curriculum for Zanzibar and mainland Tanzania. The updated guidelines serve as a reference document for standardization of malaria diagnostic training through a standard MDRT curriculum and policy direction for malaria quality assurance procedures. The workshop brought together 10 attendees from ZAMEP, the Laboratory Practitioners Board, and the Directorate of Diagnostics Services from the MOH in Zanzibar and another 10 from mainland Tanzania, including national trainers and representatives from the NMCP, PO-RALG, and National Public Health Laboratory (NPHL). After the workshop, IM Tanzania shared a draft of the updated malaria diagnostic testing guidelines with stakeholders for inputs; the guidelines were still under review at the time of writing of this report. Key Accomplishment #3: Supported national TOTs on the new Electronic Data Systems (EDS) application IM Tanzania participated in the orientation workshop for the new EDS application to create a pool of national trainers to lead TOT workshops. A refresher training was needed to update users and build capacity for them to use Tanzania’s new EDS, which has more advanced functions compared to the previous version of EDS. IM Tanzania supported the NMCP to train regional and council MSDQI supervisors on data cleaning and the use of the new EDS MSDQI application. In the three implementation regions, IM Tanzania oriented regional and district supervisors on the app. The app is currently being used and the activity sought to increase the accuracy of data that supervisors submit through the app. Key Accomplishment #4: Supported development and dissemination of the national guidelines for malaria diagnosis, treatment, and preventive therapies IM Tanzania supported the NMCP to develop a moderator’s guide for the orientation of Regional and Council Health Management Teams (R/CHMT) on the new guidelines for malaria diagnosis, treatment, and preventive therapies for 2020. The moderator’s guide was used for the dissemination of the new guidelines to two IM Tanzania project regions in Katavi and Lindi as well as seven regions which are not supported by IM, including Mwanza, Shinyanga, Kagera, Tabora, Singida, Arusha, and Tanga. In addition, the NMCP conducted cascade trainings for the updated guidelines, to health providers in the three IM-supported regions. IM Tanzania supported the NMCP to develop the HF orientation package to fit health service providers’ needs. The 20 Council teams in the IM-supported regions led orientation meetings that covered 536 HFs (98 in Katavi, 260 in Lindi and 158 in Mtwara), supported by IM Tanzania. IM Tanzania also supported the NMCP to revise reference material and incorporate changes for improved quality of malaria care.

Figure 4: Slide sorting, Photo credit: Said Mgata, IM


Key Accomplishment #5: Strengthened malaria slide banks in Zanzibar and mainland Tanzania During the reporting period, IM Tanzania facilitated the implementation of External Quality Assurance services at HF level and malaria microscopy training in Zanzibar and mainland Tanzania by assisting in the selection of health facilities for participants who had not yet received the training. IM Tanzania procured 356 non-P. falciparum slides for ZAMEP to strengthen the malaria slide bank in Zanzibar. Based on the needs identified from slide sorting at the National Health Laboratory in Dar es Salaam, IM Tanzania supported the NMCP to procure 220 non-P. falciparum slides (60 P. malariae, 60 P. ovale, and 50 P. falciparum/P. malaria, 50 P. falciparum/P. ovale) that were added to the national malaria slide bank. Furthermore, IM Tanzania supported the renovation of the room in the ZAMEP Pemba office that was already storing the ZAMEP Pemba slide bank. IM provided benches and furniture, including cabinets for slide storage to enable ZAMEP to host the malaria slide bank. In addition, IM Tanzania supported the NMCP to procure and install a computer server at the National Health Laboratory Quality Assurance and Training Centre to facilitate slide bank maintenance.

Figure 5: Proficiency testing Health Facility performance in Pemba


In collaboration with ZAMEP, IM Tanzania worked to reinforce the competency of the facility microscopists, who will be mentoring others on PD and ID especially in low-scoring facilities. To support the monitoring of health facility performance to meet quality requirements, proficiency testing was conducted in Unguja and Pemba islands by IM in collaboration with the ZAMEP Laboratory, with a focus on the identification of non-P. falciparum species. Results showed that more than half of the facilities in Unguja and Pemba performed well in PD defined as scores greater than or equal to 80% (Level A & B),

Figure 6: Proficiency testing Health Facility performance Round 1 in Unguja

Figure 8: Participants in the bMDRT Training at the National Health Laboratory Quality Assurance and Training Centre in Dar es Salaam, Photo credit: Saidi Mgata, IM

Figure 7: Participants of bMDRT Training in Unguja, Zanzibar, Photo credit: Saidi Mgata, IM


while ID remained an area for further improvement with level scores below 70% (Level D) (Figure 5 shows results from Pemba and Figure 6 Unguja). During the project reporting period, IM Tanzania supported the NMCP and ZAMEP to conduct malaria diagnosis refresher training for 89 facility microscopists and 9 reference microscopists, including 60 from Zanzibar and 38 from mainland Tanzania, to improve skills in PD, ID, and PC. Basic MDRT (bMDRT) and re-certification improve the quality of services and accuracy of diagnostic results in routine malaria testing. Advanced MDRT (aMDRT) aims at increasing the pool of competent supervisors and trainers. The aim of the bMDRT training was to support microscopists to meet minimum competency levels of ≥80% for PD and ID, and greater than 40% for PC, per WHO recommendations. Thirty microscopists who demonstrated the strongest performance in PD, ID, and PC, including 15 from Zanzibar and 15 from mainland Tanzania, were invited to attend a five-day aMDRT. As a result of the aMDRT four participants out of 15 in mainland Tanzania achieved the national level of B, which is equivalent to the WHO level 2 certification. In Zanzibar, 10 participants achieved level B or higher, with six participants achieving level A and four participants achieving level B. IM Tanzania worked with the NMCP to develop the national malaria microscopist re-certification protocol; provided guidance on training, assessment, and certification procedures; and provided inputs on the duration and reasons for re-training or re-certification of malaria microscopists. IM Tanzania then supported the NMCP to conduct a re-certification assessment for 17 national Malaria Microscopy Quality Assurance trainers. Four out of 17 achieved the national competency level B equivalent to WHO level 2. In general, after post- test assessment there were improvements in the participants’ performance in key areas of PD, ID and PC compared to the pre-test results, which suggest knowledge gain and skills improvement after training.

Figure 9: aMDRT Aggregate Microscopy Results with Standard Deviations, Zanzibar


Figure 11: Malaria microscopy Trainers Re-certification Assessment Results, Tanzania mainland Key Accomplishment #6: Supported MSDQI Baseline Implementation in Zanzibar In the past project year, IM Tanzania supported the MSDQI strategy. Like OTSS+, this strategy is also a facility-level approach aimed at improving health facility and provider competency through on-site supportive supervision, troubleshooting, and on-the-job training. IM Tanzania supported ZAMEP to complete baseline MSDQI visits. IM Tanzania trained 93 supervisors, including 55 in Unguja and 38 in Pemba, on MSDQI-EDS. IM Tanzania then accompanied the supervisors to complete the baseline

Figure 10: aMDRT Aggregate Microscopy Results with Standard Deviations, Tanzania mainland


assessment and disseminate the results. IM Tanzania worked with ZAMEP and district supervisors to visit 245 facilities, covering all seven facility coverage checklists (Table 2). Out of the 245 health facilities, 162 were on Unguja and 83 on Pemba. During the visits, 28 facilities were noted to be closed or non-functioning. Some facilities were using malaria microscopy rather than mRDTs. For this reason, the number of OPD facilities assessed was greater than the number of facilities assessed for mRDT. Table 2: Zanzibar MSDQI baseline supportive supervision coverage

Facility Coverage Checklist

Location Visited HFs ANC OPD IPD SME mRDT Microscopy Logistics

Unguja 162 101 158 9 160 155 75 162

Pemba 83 66 83 5 83 80 23 83

Total 245 167 241 14 243 235 98 245

The findings of this round of MSDQI identified that at OPD, 54%-94% of facilities scored >75% across the nine indicators on managing patients, with the three related to history taking, danger signs and physical examination being most problematic. Across the eleven steps of providing injectable artesunate, 74%-100% of admitting facilities were competent. While reporting tools were available at 88% of the 245 facilities, at the IPD none had the standard reporting tools. The biggest weakness identified in facility readiness was staff training, with only 7% of IPD staff and 24% of OPD staff having been trained on malaria in the last two years. Half the facilities did not have adequately trained laboratory staff based on the Health Ministry’s requirements per level of facility. The eight indicators related to malaria microscopy scored the lowest of the components assessed with 54%-68% of facilities scoring >75%. ZAMEP and the facilities have started addressing the gaps identified by implementing quality improvement plans at all levels. Follow up MSDQI rounds will be conducted to determine progress and guide further actions to improve the quality of malaria services. Key Accomplishment #7: Supported training of mentors on severe malaria and MIP During the current reporting period, IM Tanzania, in collaboration with the NMCP and PO-RALG, supported the training of mentors in Katavi, Lindi, and Mtwara regions. The training focused on both severe malaria and MIP, as these were two areas highlighted as particularly weak during the MSDQI supervision. For example, many pregnant women with suspected malaria identified at ANC were systematically referred to OPD for treatment, which caused delays and risked loss to follow-up. MOH policy is that suspected malaria can and should be addressed directly during the ANC visit. The training was conducted for five days in each region. Mentors came from the councils within the regions and from the regional hospital. The total number of mentors trained was 66, (i16 in Katavi, 21 in Lindi, and 29 in Mtwara). Trained mentors have been supported to conduct on-site training on clinical aspects of malaria when they are identified as challenges during an MSDQI round. After this training, the mentors address inpatient department/severe malaria and ANC/MIP challenges in their councils, specifically dilution and administration of Artesunate Injection, assessment of danger signs in pregnant women, and data quality audits. Given the traditional profile of MSDQI supervisors, these are competencies that are sometimes


outside of the expertise of the supervisors. This is not just a problem in Tanzania, but in many countries, there are questions about how confident malaria focal points for example are at providing on-the-job training to ANC providers. MIP is an interdisciplinary endeavor. The same is true for inpatient care of severe malaria patients which tends to be limited to higher level hospitals, whereas district health authorities like malaria focal points are often more confident at the primary care level. Key Accomplishment #8: Transitioned Katavi from paper based to electronic MSDQI During the current reporting period IM Tanzania, in collaboration with the NMCP and PO-RALG, supported the Katavi region to transition from paper-based to electronic MSDQI. Using MSDQI paper checklists limited timely reporting and analysis in Katavi, while other regions were already using EDS-MSDQI. IM Tanzania trained regional and council MSDQI supervisors on using EDS-MSDQI application. The three–day supervisor training reached 35 supervisors, including five regional supervisors and six supervisors from each of the five councils. The project also issued 13 tablets to the regional secretariat in Katavi to support MSDQI supportive supervision using EDS-MSDQI. IM Tanzania managed to support MSDQI supportive supervision to 98 out of 99 health facilities in the region (98%). Summary IM Tanzania worked with the NMCP and PO-RALG to support Katavi, Lindi, and Mtwara regions to conduct MSDQI supportive supervision in health facilities using the EDS-MSDQI application. Overall, a total of 608 out of 622 (98%) health facilities received supportive supervision visits, including Katavi (98), Lindi (259), and Mtwara (251) as indicated in Figure 13.

Figure 12: The IM Medical Data System Specialist, issuing 13 tablets to the Katavi Regional Medical Officer, Photo Credit: Katavi IT, IM


Supportive supervision also included on-the-job training and mentorship for health workers: 1,069 on case management related to injectable artesunate and ACTs, 578 on IPTp, and 1,097 on mRDT out of 1,555 trained on malaria diagnostics. The remaining 58 attended training in the classroom on malaria microscopy) (IM Tanzania Indicator Table). At the council level, before MSDQI supportive supervision, IM Tanzania oriented supervisors on the appropriate use of the checklists, EDS-MSDQI, and data cleaning. At the end of MSDQI in each council, supervision teams conducted post-MSDQI feedback meetings to share feedback with all CHMTs, including those who did not participate during supervision. This provided an opportunity to resolve outstanding issues encountered during implementation. The meetings were also a call to action for issues including the registration of facilities for malaria microscopy proficiency testing and using electronic logistics management information system (eLMIS) in re-distributing commodities to minimize stock-out and expiry. Below are key findings following MSDQI supportive supervisions at the facility level in the three regions. Reproductive and Child Health (RCH): Through MSDQI activities, IM Tanzania observed low performance in RCH department readiness in facilities in all three regions and assessed the data quality to be below standard. This included the absence of reference materials, such as the current ANC guidelines, fever case management algorithm, and job aids, as well as outdated HMIS tools that did not capture the current tracked indicators. In addition, most facilities did not have functional Hemoglobinometer machines and cuvettes. Documentation of RCH services in the ANC registers was also inadequate in some facilities, including recording of malaria testing and IPTp services. The incompleteness of Child health registers

Figure 13: MSDQI supportive supervision coverage in IM Tanzania regions- 2021


(HMIS book #7) was common among health facilities that received MSDQI visits, with data inconsistencies noted for child health services between summary reports and HMIS registers.

Supervisors observed that providers serving pregnant women during ANC visits lacked competency in malaria diagnosis and treatment. Instead, ANC providers referred pregnant women testing positive for malaria to the OPD. The internal referral increased client-waiting time and increased risk of loss to follow up.

Additional gaps included providers not inquiring whether the pregnant woman was using an ITN and not actively inquiring about fever during history taking (Figure 16). Similarly, clinicians at OPD relied on clients to disclose fever. Supervisors conducted on-site mentorship to health providers to address these gaps.

Figure 14: RCH Core Indicators Performance for 521 HFs in IM Regions, 2021

Figure 16: Health Care Provider Competence in Managing Pregnant Women Indicator Performance for 300 HFs in IM Regions, 2021

Figure 15: RCH Site Readiness Indicators Performance for 521 HFs in IM Regions, 2021


Inpatient Services: The management of severe malaria cases in inpatient departments (IPD) through the reconstitution and administration of injectable artesunate was adequate especially on dose calculation and dilution. Another area at the inpatient department which was low performing was on data completeness and consistency as most of the standard documentation tools were missing (Figure 17). IM Tanzania continued to strengthen skills among providers in managing severe malaria cases through support to district mentors who shared knowledge and best practices in high malaria burden facilities. However, weaknesses remained in the support system for services. For example, malaria reference materials, essential equipment, and emergency care medicines were not sufficiently stocked in health facilities which received MSDQI (Figure 18).

In addition, facilities scored poorly in data quality assessments. (Figure 19). This was likely related to several factors: inadequate documentation due to absence of individual treatment and observation charts to facilitate register review, insufficient documentation of deaths due to malaria, and weaknesses in monitoring of the patients using blood smear. Weaknesses in using blood smears for the monitoring of patients likely stemmed from two problems: some facility clinicians did not order blood smears and some clinicians ordered a blood smear, but laboratory technicians performed an mRDT instead of malaria microscopy as recommended. IM Tanzania continued to work collaboratively with CHMTs and admitting facilities to establish proper data management practices in IPDs, including updating the death registry, and reinforcing communication between laboratory staff and clinicians for managing severe malaria cases.

Figure 17: IPD core indicators Figure 18: IPD site readiness indicators


Logistics: Assessment results indicated that 50% of health facilities were performing well in logistic observation, DQA, and availability of malaria commodities. The main challenge observed was the weakness of the Integrated Logistics System to support CHMTs to know facility levels of stock on hand as needed for re-distribution. As a result, medicine and supplies were expiring in some of the facilities, while other facilities were out of stock. During the logistics and supply component of MSDQI, supervisors observed under-stock and over-stock of malaria commodities, including ITNs and SP in various health facilities. In response, IM re-distributed these commodities from overstocked to understocked facilities through the government system by using a project vehicle to create a balance of malaria commodities in health facilities. Staffing levels contributed to poor performance of the site readiness indicator. Most health facilities did not have enough pharmacists. This led supervisors to compare performance between unqualified and qualified staff in this module. Despite this gap, HFs were effectively using available staff to build capacity through staff training. Figures 20 and 21 depict logistics and supply indicator performance during the reporting period.

Figure 19: IPD-DQA indicators


Microscopy: A shortage of Giemsa stain, low competency among laboratory personnel, and inadequate understanding of the importance of malaria microscopy in managing severe malaria patients contributed to generally low levels of performance, particularly related to quality assurance and quality control (QA-QC), for malaria microscopy across all project-supported regions. Figures 22 and 23 illustrate the performance status of microscopy diagnostic tests.

Figure 20: Logistics & Supply Core Indicators Performance for 497 HFs in IM Regions, 2021

Figure 21: Logistics & Supply Site Readiness Indicators Performance for 497 HFs in IM Regions, 2021

Figure 22: Microscopy Core Indicators Performance for 53 HFs in IM Regions, 2021

Figure 23: Microscopy site readiness indicators


Challenges included the fact that few health facilities received proficiency testing slides from the national laboratory. IM Tanzania also did not receive documentation on whether internal quality control was done as the facilities lacked documentation if they were conducting the internal quality assessment as required. During the reporting period, IM Tanzania conducted refresher training on malaria diagnosis for 38 laboratory technicians. These trained laboratory technicians then served as mentors and reinforced competency development across other laboratory facilities to conduct and perform malaria microscopy according to national standards. IM Tanzania also involved them in MSDQI supervision to provide mentorship to fellow technicians.

mRDTs: During MSDQI (which was done by CHMTs) the facilities achieved high scores in performing mRDTs, documentation, and quality control of the stored cassettes. Most facilities adhered to proper documentation of mRDT use, using HMIS tools. Staff were also trained in mRDT testing. Testing site availability performed lower as most facilities did not have a specific mRDT testing site, meaning that in OPDs, the clinician’s desk was used for both testing and consultation which is considered bad practice according to the MSDQI scoring system 30% of the facilities were missing the standard reporting tool for mRDT (Figures 26 and 27).

Figure 24: Microscopy Observation Indicators Figure 25: Quality Assurance & Quality Control Indicators Performance for 53 HFs in IM regions


In addition, some providers did not adhere to guidance of wearing gloves and using safety boxes at the testing sites. 42% scored below 50% on the steps in performing the mRDT as well. Most (99%) HFs adhere to the mRDT quality control requirement of labeling ‘Invalid’ on used defective mRDT device which did not show control line when the testing was conducted.

Figure 27: mRDT Site Readiness Indicators Performance for 553 HFs in IM Regions, 2021

Figure 26: mRDT Core Indicators

Figure 28: mRDT Testing Accuracy and Quality Control Indicators Performance for 553 HFs in IM Regions, 2021


OPD: More than half of health facilities performed well in the core parameters of the OPD module. 20% of the facilities scored below 50 on the availability of reference materials and 18% on the availability of the SBCC materials (Figures 29 and 30). IM Tanzania helped the CHMTs to correct this weakness as part of the Quality Improvement Plan by distributing available SBC materials in Mtwara and Lindi regions and printing and distributing 1,500 copies of the new malaria guidelines to all supported health facilities in Katavi (300), Mtwara (600), and Lindi (600).

When a clinician member of the CHMT conducted the observation portion of MSDQI, providers performed well on malaria testing and diagnosis. Almost two thirds of clinicians observed did not score adequately on performance of a physical examination, with history taking and patient satisfaction also emerging as problem areas. High patient volumes and staff shortages may be contributing to underperformance of these areas. Facilities performed well on injectable artesunate dilution with only 3% scoring below 50%. (Figure 32). The project has trained mentors on management of severe malaria and by using these MSDQI data, the least performing facilities will be prioritized to be visited by the mentors during on-the-job training visits.

Figure 29: Health Care Provider Competence in Managing Clients Attending OPD Indicator Performance for 413 HFs in IM Regions, 2021

Figure 30: OPD Site Readiness Indicators


Figure 31: Health Care Provider Competence in Managing Clients Attending OPD Indicator

Figure 32: OPD Severe Malaria Management: Pre-Referral Treatment Indicator Performance for 509 HFs in IM Regions, 2021


Challenges and Solutions Challenges Solutions Electronic device incompatibility with the new EDS-MSDQI application. Malaria focal points in the regions and districts had 5.1.1 android devices that did not support the new application, which was a barrier to future EDS-MSDQI supportive supervisions.

In collaboration with the NMCP, IM Tanzania engaged system developers who revised the new application's properties to fit in the minimum available android version. Temporarily, this addressed the barrier of delayed MSDQI supervision using the new application. In the next project year IM will procure 40 new devices compatible with the new application which should be a lasting solution.

Some supervisors did not have access to the MSDQI group in DHIS2 and/or were not aware of the data synchronization function, so they collected data but could not synchronize them successfully.

IM Tanzania advised the NMCP and system developers to strategize on approaches to communicate the limitations with supervisors and provide them direct support for effective MSDQI supervision and synchronization of data.

The current MSDQI checklists do not reflect the new guidelines for malaria treatment, diagnosis, and therapies.

IM Tanzania recommended that the NMCP review the current MSDQI checklists to reflect the new guidelines for malaria treatment, diagnosis, and therapies. This has been shared and discussed with the NMCP and there is a plan to address this.

Technical difficulties with the MSDQI EDS application hindered successful data cleaning of some health facilities that had duplicate entries since their data downloaded in mobile devices that were not used during supportive supervision.

IM Tanzania advised and provided technical support to supervisors to use the new MSDQI EDS application, which is designed to minimize this challenge.

Lessons Learned ● A well-coordinated joint plan with local government authorities enabled access to and use of

government vehicles during project implementation, which enabled MSDQI supervision teams to complete activities on time. For example, the Katavi regional authority provided one vehicle to support MSDQI alongside the IM Tanzania project vehicle. This allowed supportive supervision in two councils of Nsimbo and Tanganyika simultaneously. Similarly, the Lindi regional office dedicated one vehicle to support MSDQI supportive supervision in the districts. IM Tanzania covered fuel expenses and allowances for supervision teams.

● Limited means of transportation hindered regional and council supervision teams from visiting hard-to-reach health facilities. For example, in the last quarter of the reporting period, IM Tanzania supported the Lindi municipal council with a car and driver to conduct MSDQI supportive supervision in three dispensaries that CHMTs could not visit due to poor road infrastructure and lack of a reliable vehicle. The Lindi municipal council team had previously used a car from the regional malaria information focal points office, which could not reach these health facilities.

● Availability of newer devices with advanced applications enabled smooth implementation of the MSDQI checklist. IM Tanzania procured new Android devices and issued them to MSDQI supervision teams to conduct supportive supervision. Once completed, the group passed the devices to the teams in the next council. With the availability of reliable means of transportation and Android devices in each council, MSDQI could occur in parallel across all councils within a region.


IM Tanzania Indicator Table The data provided in the indicator table below are IM Tanzania targets and results from October 1, 2020, to September 31, 2021. The data in the indicator table reflect activities in the IM-supported areas in Tanzania which include three regions in Mainland Tanzania: Katavi, Lindi and Mtwara and two regions in Zanzibar (Unguja and Pemba Islands). Progress to Annual Target is calculated as actual result/target *100=progress to target. This provides an indication of how much progress has been made to meeting the annual target outlined in the country workplan.

Objective Indicator Target Result Progress to

Annual Target (%)

Comments



100% 97%

97%

648,351 reported malaria cases confirmed with a diagnostic test, out of 669,471


100% 99% 99% 1,481,403 suspected malaria cases received a parasitological test, out of 1,481,481

*Percentage of observed health workers demonstrating competency in correctly classifying cases as not malaria, uncomplicated malaria, and severe malaria

100% 94% 94% MSDQI supportive supervision in 560 health facilities for 413 HWs

*Percentage of supervised health facilities that meet 75% or greater on mRDT (lab evaluation) checklist

90% 93% 103%

MSDQI supportive supervision in 553 health facilities for 471 HWs; Facilities adhered to proper documentation, using the HMIS tools, and staff were trained on mRDT use.

*Percentage of supervised facilities that meet 75% or greater on microscopy (lab evaluation) checklist

90% 64% 71%

MSDQI supportive supervision in 53 health facilities A shortage of Giemsa stain, low competency among laboratory personnel, and inadequate understanding of the importance of malaria microscopy could



Annual Target (%)

Comments

explain the low performance in some facilities.

*Percentage of supervised facilities that meet standards (including appropriate materials, documentation, and qualified staff) for quality diagnosis of malaria

80% 40% 50%

MSDQI supportive supervision in 53 health facilities The lack of documentation and low competency among laboratory personnel in some facilities are the main reasons for this low performance. IM Tanzania conducted refresher training for 38 laboratory technicians on malaria microscopy to improve the skills of technicians in microscopy.


100% 88% 88%

IM Tanzania conducted on-job training during MSDQI supportive supervision. The training was in the form of mentorship rather than classroom sessions.


100% 95% 95%

IM Tanzania conducted on-job training during MSDQI supportive supervision. The training was in the form of mentorship rather than classroom sessions.



100% 17,657 / 17,657=

100% 100%


100%

648,273/648,27

3= 100%

100%

*Percentage of observed health workers demonstrating

90% 63% 70%

MSDQI supportive supervision in 560 HF OPDs. Malaria testing and diagnosis performed well. However, most clinicians did not



Annual Target (%)

Comments

competency in the management of uncomplicated malaria

conduct complete physical examinations on patients and clinical history-taking was limited only to patients’ complaints.

*Percentage of observed health workers demonstrating compliance to treatment according to WHO guidelines for cases with positive malaria test results

90% 87% 97%

MSDQI supportive supervision in 560 HF OPDs; 280 HWs demonstrated compliance, out of 322 total

*Percentage of observed health workers demonstrating adherence to negative test results according to global standards

90% 93% 103%

MSDQI supportive supervision in 560 HF OPDs; 210 HWs demonstrated adherence, out of 226 total

*Percentage of supervised facilities that meet global standards (including appropriate materials, documentation, and qualified staff) for quality malaria clinical management

80% 66% 83%

MSDQI supportive supervision of 560 OPD HFs. OPD site readiness performance was inadequate in some facilities, due to limited staff training in malaria case management, scarce reference materials, and the absence of SBC materials

Percentage of expected malaria reports from IM-supported facilities received

100% 100% 100%

Percentage of targeted health facilities that received a supervisory visit for malaria case management and/or MIP and/or diagnosis/lab

100% 98% 98%

608 of 622 targeted HFs received a supervisory visit for malaria case management and/or MIP and/or malaria diagnosis/microscopy



Annual Target (%)

Comments


100%

88% 88%

IM Tanzania conducted on-the-job training during MSDQI supportive supervision. The training was in the form of mentorship rather than classroom sessions.



100% 100%% 100% In terms of coverage, performance of this indicators is on track.


80% 89% 111% In terms of coverage, performance of this indicators is on track


90% 71% 79%

In the previous project year, there was reported stock out of SP in Project supported regions, MSD and Prime vendors.

*Percentage of observed health workers demonstrating competency in the treatment of MIP

80% 56% 70%

MSDQI supportive supervision of 169 HWs out of 300, demonstrated competency in the treatment of MIP.

*Percentage of observed health workers demonstrating competency in the prevention of MIP

80% 89% 99%

MSDQI supportive supervision with 260 HWs out of 292, demonstrated competency in the prevention of MIP


90% 69% 138%

IM Tanzania conducted on-the-job training during MSDQI supportive supervision. The training was in the form of mentorship and informal training, rather than classroom training.

Objective 3: Project technical leadership contributes to PMI-led


1 1 100%

IM Tanzania contributed in three ways for the dissemination of updated 2020 national guidelines for diagnosis and treatment of malaria: to national TOT participants; to three project regions via 1,500 reprinted copies of new guidelines;



Annual Target (%)

Comments

global policy development and OR

to HFs in collaboration with the NMCP.


2 0 0%

IM Tanzania submitted two late-breaker abstracts for the 2021 ASTMH Meeting.

Participation in targeted national, regional, or global level Working group(s) and/or task force(s)

2 2 100%

Per the IM Tanzania workplan, IM Tanzania will attend malaria case management and MIP national TWGs, with the NMCP and ZAMEP.

*For the MSDQI indicator, the competency score threshold is 75% in Tanzania

506 IM Zambia October 2020 – September 2021

Zambia

Background Zambia’s National Malaria Elimination Strategic Plan (NMESP) 2017–2021 was launched to achieve a malaria-free Zambia by eliminating indigenous malaria infections and preventing the importation and reintroduction of malaria into areas where the disease has been eliminated.1 To achieve this goal, the NMESP lays out tailored malaria control strategies and milestones by geographic strata based on malaria burden. Zambia’s 2018 Malaria Indicator Survey (MIS) showed measurable progress in reducing malaria infections over the past decade through intensified control efforts. These include the expansion of case management through private sector health facilities and community case management, alongside effective vector control through ITN distribution. At the national level, malaria infection in children under the age of 5 decreased from 17% in 2015 to 9% in 2018.2 However, malaria continues to be a major health burden, particularly in border areas. Zambia’s MOH receives funding from PMI and is in its eleventh year as a PMI-focus country. PMI supports the MOH by providing equitable access to innovations in malaria prevention and control.

IM Zambia worked with the MOH and NMEC to improve malaria service delivery through appropriate case management in the Copperbelt and Central provinces. The project supported improving and strengthening malaria diagnosis, treatment, and management of malaria in pregnancy in accordance with national and international guidelines through PHOs. Despite the COVID-19 pandemic, IM Zambia supported the NMEC to improve the quality of malaria services by conducting OTSS activities in 16 high- and moderate-burden districts and six low-burden districts in Central and Copperbelt provinces. In Central Province, IM Zambia supported all 12 districts: Chisamba, Chibombo, Chitambo, Kabwe, Kapiri-

1 Republic of Zambia MOH (2017). National Malaria Elimination Centre, National Malaria Elimination Strategic Plan 2017-2021: Moving from accelerated burden reduction to malaria elimination in Zambia. 2 Republic of Zambia MOH (2018). Zambia Malaria Indicator Survey 2018.

Figure 1: IM Zambia Geographic Focus Areas


Mposhi, Luano, Ngabwe, Mkushi, and Serenje, including the three low-burden districts of Itezhi-Tezhi, Mumbwa, and Shibuyunji, to improve and update malaria skills. In Copperbelt Province, IM Zambia supported all 10 districts: Mufulira, Kitwe, Luanshya, Chingola, Chiliabombwe, Mpongwe, Lufwanyama, Masaiti, Kalulushi, and Ndola. In addition to OTSS, IM Zambia supported Lusaka District in Lusaka Province to strengthen malaria surveillance through data review meetings with hospital and health center representatives; routine supportive supervision for all 58 health facilities including hospitals, health centers, and health posts. This included reinvigoration of active case detection through CHWs in 10 HF catchment areas. Year 4 was notable for expansion of the scope of OTSS beyond the typical focus on public sector facilities to include private sector facilities as well as community-level health workers. In the context of OTSS, IM Zambia supported PHOs to improve skills and competencies of private sector health workers to align with national malaria guidelines targeting 10 private health facilities for OTSS on the Copperbelt. Additionally, as part of the national iCCM strategy, IM Zambia supported the NMEC to monitor the implementation of harmonized community case management of malaria by trained CHWs and provided on-site supportive supervision to strengthen CHW skills. According to the 2018 Zambia MIS, only 20% of children with fever were promptly brought for care, and only 32% of caregivers sought care within 24 hours. A more proactive approach is needed to improve access to quality case management services and care seeking behaviors. The protocol for IM’s proposed ProAct study hypothesized that proactive case detection and treatment in moderate burden areas where CHWs visit homes to identify persons with fever and test them and other febrile household members for malaria, treating those who test positive—will lead to a greater reduction in parasite prevalence and case incidence compared to standard iCCM. Because of the COVID-19 pandemic, the implementation of the ProAct study was postponed. As a result, data collection will extend beyond the length of this project. Therefore, in consultation with PMI, IM transitioned study implementation to another partner in 2021.

Key Accomplishments - OTSS Objective 1: Improve the quality of and access to malaria case management and malaria prevention during pregnancy Key Accomplishment # 1: Supported the NMEC to improve the quality of and access to malaria case management by improving access to national guidelines To standardize malaria case management and MIP interventions in Zambia, the NMEC has developed policies and guidelines. These include: the national Malaria Quality Assurance Diagnostic Manual, which PMI endorsed and MOH printed in 2020; the ANC contact schedule for IPTp; and the MIP treatment algorithm. During this reporting period, IM Zambia supported the NMEC to print 750 copies of the ANC contact schedule for IPTp to help health workers to have quickly accessible references and to update their knowledge in managing MIP according to Zambia and WHO guidelines.


IM Zambia also has supported Central and Copperbelt provinces to improve the quality of malaria case management and prevention in pregnant women. In Central Province, the percentage of health facilities that meet global standards for quality MIP case management improved from 82% from the October 2019 to September 2020 to 86% from October 2020 to July 2021. In Copperbelt Province, results improved from 55% in the previous reporting period to 73% in the current reporting period (EDS-DHIS2). These improvements are attributed to the continuous distribution of MIP prevention guidelines in the two provinces as well as on-the-job training during OTSS visits.

Figure 3: Percentage of health facilities that meet global standards for quality malaria in pregnancy case management, Source: EDS- Malaria in Pregnancy checklist, provincial and district OTSS annual rounds Figure 4 shows that from October 2019 to September 2020, competency, and knowledge in prevention of malaria in pregnancy among health workers in Central Province remained high at above 98%. Copperbelt Province recorded an improvement from 91% from October 2019 to September 2020 to 99% from October 2020 to July 2021 (EDS-IM Data Hub). Similar to the MIP case management standards above, this improvement in the competency and knowledge among health workers for the prevention of malaria in pregnancy may be attributed to continuous, on-the-job coaching by midwife supervisors during OTSS visits in the two provinces as well as the increased availability of MIP prevention guidelines.

Figure 2: The PHO Clinical case management specialist and MCH Coordinator for the Copperbelt province receiving the IPTp ANC uptake schedule.


Figure 4: Percentage of targeted health workers demonstrating competence/knowledge in prevention of MiP, Source: EDS-Malaria in Pregnancy checklist, provincial and district OTSS annual rounds Key Accomplishment #2: Strengthen supportive supervision capacity by training new supervisors in malaria case management, diagnosis, and advanced Electronic Data Systems (EDS) OTSS is a key strategy in ensuring continuous quality improvement of malaria case management at service delivery points in Zambia. IM Zambia supported the NMEC to organize and facilitate provincial and district OTSS supervisor trainings with the aim of increasing the number of trained supervisors and scale-up to other health facilities. During this reporting period, IM Zambia supported trainings to further improve the competencies of provincial supervisors. Sixteen OTSS supervisors (eight from each province) participated in an MDRT and 18 (nine participants from each province) in a training of trainers for OTSS from October 2020 to July 2021. To sustain gains made during the previous three years of the project implementation and ensure reliability of data, IM Zambia supported the process of upgrading the existing EDS application to Advanced EDS and the virtual training of 40 super users on the Advanced EDS. The upgrading followed a process to identify challenges with the previous system, including data not uploading, duplication of data, unreliability of internet connectivity, and other issues. The additional features in the Advanced EDS, which utilizes HNQIS software, include the Plan, Assess,

Figure 5: PHO and District Health Office (DHO) OTSS supervisor case management training, Photo credit: Chipo Kachali, IM Photo by Patrick Sichalwe


Improve, and Monitor modules. Furthermore, the updated app provides an action plan that enables both service providers and supervisors to address gaps before the next OTSS visit. Additionally, Advanced EDS includes iCCM assessments of CHWs and facilities. The MIP OTSS checklist was also migrated to Advanced EDS. The advanced EDS (HNQIS) is scheduled to start its full functionality in Q1 of the following project year. Key Accomplishment #3: Improved health workers’ clinical competencies in malaria classification and treatment through OTSS The classification of malaria as either uncomplicated or severe (complicated) informs clinicians for treatment decisions. IM Zambia supported on-the-job coaching during OTSS visits to reinforce clinicians’ skills for the classification of malaria. The percentage of health workers demonstrating competency in malaria classification by severity remained high at 94% in the previous reporting period and 93% in the current reporting period in Central Province. In Copperbelt Province, it remained constant at or above 90%, as observed in Figure 7 below. This high performance can be attributed to on-the job coaching during OTSS visits and availability of job aides. To sustain and improve these competencies, IM Zambia supported and encouraged the display of mRDT job aides in the outpatient department and improved access to laboratory services for internal quality controls performance of mRDT. In addition, IM Zambia plans to include continuing medical educational sessions for health workers, especially those at higher-level facilities during OTSS visits. OTSS activities will also reinforce adherence to guidelines for the management of fever, including management of malaria and other causes of fever.

Figure 7. Percentage of health workers demonstrating competence in correctly classifying cases as malaria, not malaria, uncomplicated malaria and complicated malaria, Source: EDS-clinical observation checklist, provincial and district OTSS annual rounds

Figure 6: Clinician assessing a child at new town clinic, Luanshya district, Photo credit: Deborah Lukote, Laboratory OTSS+ supervisor


According to the WHO, all suspected cases of malaria must be tested prior to treatment, and treatment must be administered to only those who test positive. IM Zambia and the NMEC reinforced this policy during OTSS visits to support clinicians to adhere to test results. Figure 8 shows that the rate of participating health workers in both provinces who treat patients based on a positive test result is close to 100%, with only slight variations by province or by reporting period. The percentage of health workers refraining from treating malaria-negative patients is also high, with a slight decrease by 2% in Central Province from the previous reporting period. To ensure that competency remains high, and that clinical staff further improve adherence to test results, IM Zambia printed and distributed national guidelines on malaria treatment and diagnosis algorithm in the two provinces. In addition, IM Zambia also coordinated with PHOs to ensure availability of drugs at service delivery points in both provinces.

Figure 8: Percentage of targeted HCWs demonstrating compliance to treating malaria cases according to WHO guidelines by test results, Source: EDS-clinical observation checklist, provincial and district OTSS annual rounds Key Accomplishment #4: Strengthened health facilities’ competency in malaria microscopy through outreach training and supportive supervision (OTSS) Quality assured malaria microscopy remains the gold standard for malaria diagnosis; however, there are numerous challenges associated with poor malaria microscopy competencies including a lack of the latest training in microscopy for new personnel, equipment, and access to reagents, among others. In this reporting period, IM Zambia supported the NMEC, PHOs, and DHOs in Central and Copperbelt provinces to conduct OTSS in health facilities with laboratory services to ensure accurate malaria microscopy test results. In FY 2021, 66 microscopy health facilities (56 public and 10 private health facilities) were reached out of the target of 66 health facilities at the provincial level in 22 districts in both provinces compared to the previous year (FY2020) where 76 health facilities were reached out of a targeted 74 microscopy health facilities targeted in 19 districts.


Figure 9: Percentage of Health Facilities demonstrating competence (90% or greater) in malaria microscopy, Source: EDS-laboratory observation checklist (provincial OTSS annual rounds). Figure 9 above shows that out of the 65 health facilities that were visited in FY20, 48 reached the target of 90% and above in microscopy competencies in both Central and Copperbelt Provinces. In FY21, 31 health facilities reached the target of 90% and above out of 42 visited in both provinces. Central Province recorded a decline in malaria microscopy competencies by 11% while competencies improved by 8% in Copperbelt Province, when comparing the previous report period with the current reporting period. The improved microscopy competencies among laboratory health workers in Copperbelt are attributed to the recently completed MDRT. In Central Province, it is believed that competency declined because of deployment of new laboratory staff, attrition, and stock-outs of laboratory reagents, such as methanol. As a result, IM Zambia, in conjunction with the NMEC and PHO, has enacted mechanisms to ensure that staff who benefit from MDRTs and nECAMM carry out on-the-job training at their respective districts and provide orientation to newly employed staff or to staff who were transferred from other health facilities, which helps guarantee continuity.

Figure 10 shows that laboratory staff performed well in parasite detection (>90%), but the scores for slide preparation and slide staining were lower. Slide staining scores were below 80% through the two periods in both provinces. Slide preparation and slide staining are skills that are deemed more complex than PD as they require very specific steps to be done successfully. It is therefore more difficult to reach high competency scores in these two skills. Stock-outs of essential items, such as methanol, and lack of internal quality control (QC) also contributed to low scores. To improve skills for smear preparation and staining for malaria microscopy, IM will support the NMEC lab unit through OTSS to provide practical on-the-job session to the HF microscopists. IM was in discussions with the PMI Zambia mission and will continue to advocate through all malaria stakeholders in the supply chain to provide consistent malaria microscopy commodities.


Figure 10: Percentage of health facilities demonstrating competence in parasite detection, slide preparation and slide staining average score, Source: EDS-laboratory observation checklist (provincial OTSS annual rounds) Key Accomplishment #5: Strengthened provider competency in malaria RDTs through OTSS

IM Zambia supported the NMEC, PHOs, and DHOs in Central and Copperbelt provinces to conduct OTSS and ensure the provision of high accuracy mRDT services among end users. The selection of HFs is incremental especially at the district level and this limits the expectations of improved performance and an opportunity to re-visit those that are preforming poorly. The results in Figure 12 show that there was a steady trend of ≥80% in health workers demonstrating competency in using mRDTs in Central Province. In Copperbelt Province, however, a decline in the percentage of HWs demonstrating mRDT competency dropped from 82% during the previous reporting period to 72% in the current period. The decline observed in Copperbelt Province is likely due to trained HWs having been assigned to other duties and having been done by non-HW to assist with the mRDT testing. Additionally, the criteria for including HFs in OTSS rounds tends to limit the expectations of improved performance

indicators. Not all HFs participate in the rounds and therefore are not revisited to track a stable cohort year after year. Instead, participating HFs are rotated in and out, and lower performing HFs have priority for inclusion. As a result, IM Zambia supported PHO to take appropriate measures by providing on-the-job coaching to workers involved in mRDTs testing procedures.

Figure 11: A community health assistant using mRDTs to diagnose children presenting with malaria symptoms in Lufwanyama District, Photo credit: Dr. Jacob Ngambi, Clinical OTSS+ Supervisors


Figure 12. Percentage of health workers demonstrating competence in mRDT (attaining 90% or greater), Source: EDS-RDT observation checklist, provincial and district OTSS annual rounds Key Accomplishment #6: Supported PHOs to strengthen and assess malaria microscopy capacity through nECAMM in two provinces A reliable, well-trained microscopist is an essential resource for correct malaria diagnosis in low-resource settings, especially in case of point-of-care mRDT commodity shortages.

Figure 13: Percentage scores in pre and post-test of malaria microscopy competency assessment, Source: Malaria competency training reports, during the previous and current reporting periods IM Zambia worked with NMEC WHO-certified microscopist to support three bMDRTs and six nECAMMs since 2019. In this reporting period, IM Zambia supported the NMEC to conduct a week-long nECAMM for 18 participants (nine per province), which resulted in scores >80% at post-test for all three-assessment criteria PD, ID, and PC (Figure 13). Based on this assessment of competency, IM Zambia


prepared a training for microscopist supervisors to provide oversight during OTSS visits at provincial level in both provinces. This added to the pool of malaria microscopists already assessed in nECAMM in the previous reporting period and is contributing to the national training targets. IM supported training a total of 112 laboratory microscopists to date: Copperbelt Province had 59 laboratory staff trained and 53 laboratory staff trained from Central Province. Based on this assessment of competency, IM Zambia prepared a training for microscopist supervisors to provide oversight during OTSS visits at provincial level in both provinces. The NMEC did not provide a target number but has indicated that the national goal is for 100% of microscopists to participate in trainings and assessments. Key Accomplishment #7: Strengthened malaria diagnosis capacity by equipping the national slide bank with well-characterized slides Malaria slide banks serve as sources of high-quality and well-characterized malaria slides, which are validated for training, competency assessment, and quality assurance in malaria diagnosis. IM Zambia support of the Zambia National Malaria Slide Bank enables the NMEC to use standardized and validated slides for quality in- and pre-service malaria microscopy training, national competency assessment of microscopists, and on-the-job laboratory coaching. Supporting the slide bank also provides a platform for malaria microscopy proficiency testing (PT). IM support for the EQA program also reinforces competency in malaria microscopy to detect, identify, and quantify malaria parasites at HF level. IM Zambia supported the NMEC in identifying non-plasmodium falciparum species in the two provinces to expand the slide bank with additional slides from different species, including all which are known to be found in the country. Since 2017, the NMEC laboratory unit documented the target number of slides in the slide bank as 15,000 a year. During the reporting period, 8,128 slides (54%) were collected, 4,969 validated, and 3,159 awaiting validation (Table 1). The slides are used for refresher training and proficiency testing.

Figure 14: nECAMM assessment in Kabwe district for laboratory health workers from the two provinces. Photo credit: Bright Sikaala, IM

Figure 15: Malaria slide generation for non-pf species at Roan General Hospital, Luanshya District. Photo credit: Patrick Munyimba (Lab OTSS+ Supervisor)


Table 1: Number of slides generated for P. falciparum and non-P. falciparum species

Slide generated by composition Previous reporting period

Current reporting period

Provinces

P. falciparum 300 740 Central P. ovale 1,089 1698 Copperbelt P. malariae 1,188 2231 Copperbelt P. falciparum and P. ovale 512 100 Copperbelt P. falciparum and P. malariae 600 200 Copperbelt Not classified 1,388 3159 Copperbelt Total 5,077 8,128

Key Accomplishment #8: Strengthened malaria case management in private microscopy facilities As part of efforts to improve malaria service delivery, IM Zambia, in collaboration with the NMEC, supported the Copperbelt PHO to engage private health facilities and conduct a two-day guideline-dissemination meeting in October 2020. The meeting addressed malaria indicator gaps; disseminated malaria policy guidelines and protocols; familiarized and updated private providers on current malaria treatment guidelines; and shared best practices in malaria case management. Thirty participants attended the meeting, including 15 participants each from the districts of Kitwe and Ndola. The participants included six nursing officers, seven medical doctors, nine clinical officers, and eight laboratory scientists. Private health facilities had not received OTSS visits from PHOs.

During the reporting year, IM Zambia supported PHOs to implement the first- ever OTSS activity. IM Zambia will continue advocacy with the PHOs to extend this to the rest of the private health facilities in the two districts through the future engagement with the private medical health sector organization. The advocacy shall include training of their health facility staff in a class and contribute to PHO to provide support supervision. Figure 17 demonstrates that adherence to both negative and positive test results improved from Round 5 to 6 in private health facilities. The results show a 100% adherence to positive and negative malaria test results in Round 6. All the five observed health facilities visited in Round 6

met the WHO requirement while in Round 5, only one (25%0 health facility out of the four adhered to positive and negative malaria test results. This improvement is attributed to on-the-job coaching, and provision of malaria case management guidelines by supervisors during OTSS visits and dissemination meetings.

Figure 16: OTSS+ activities at Company Clinic in Kitwe District of the Copperbelt Province. Photo Credit: Mable Chewe, PHO MCH Coordinator


Figure 17. Percentage of private facilities adhering to positive and negative malaria test results-Copperbelt, Source: EDS-RDT observation checklist, provincial OTSS annual rounds Key Accomplishment #9: Strengthened support for integrated OTSS for CHWs linked to health facilities In Zambia, CHW involvement in community case management of malaria is a well-recognized intervention for reducing morbidity and mortality in high-burden areas as it focuses on improving access to prompt diagnosis and treatment. CHWs serve as links between HFs and the community and play an essential role in coordination.

IM Zambia supported the NMEC and PHOs to monitor the implementation of harmonized iCCM with trained CHWs and provide on-site supportive supervision to improve and strengthen the skills of CHWs in four districts: Kapiri-Mposhi, Lufwanyama, Masaiti, and Mpongwe. The NMEC briefed PHO and DHO staff on the approved monitoring checklist for CHW supportive supervision. DHO clinical and District CHW Coordinators then carried out an orientation for HF health staff who in turn trained CHWs in their catchment area on use of iCCM monitoring tools. In March 2021, DHO and HF staff conducted supportive supervision in the four districts, targeting 30 CHWs per district for a total of 120 CHWs, 75 male and 45 females. During this

activity DHO supervisors observed CHWs in RDT testing, treatment, and case referral at the community level. DHO supervisors observed CHWs using the OTSS checklist and provided feedback on areas of

Figure 18: CHWs receiving on-the job support supervision from the Masaiti CHW coordinator and PHO laboratory OTSS+ supervisor. Photo credit: Michael Kasonde, PHO OTSS+ supervisor


improvement according to iCCM national standards. The CHWs also received on-the-job coaching for the correct use of mRDTs and administration of antimalarial and pre-referral treatment. The main findings from this activity were that:

• CHWs were able to identify clients’ problems, perform mRDTs, administer ACTs correctly and were able to refer clients found with danger signs.

• CHWs were able to send monthly reports on malaria activities even though some phones for malaria rapid reporting were not working and new phones were not readily available for some CHWs to send reports.

• Some trained CHWs had not been able to practice in the community due to the lack of commodities such as mRDT and ACTs; this led to some CHWs forgetting specific skills, like putting the right drops of buffer on mRDT cassettes.

• There was a high dropout rate of CHWs trained in iCCM due to a lack of practice with mRDTs (due to lack of available commodities) and incentives.

• CHWs had good adherence to positive and negative mRDT results. • Each of the CHWs visited had passive and active registers, though they were not used at the time

of the visit due to the non-availability of commodities. • Facility staff were generally unable to visit CHWs due to lack of transport, however integrated

visits were done with universal child immunization campaigns on a few occasions. • CHW supervisors lacked monitoring tools such as iCCM supervisory checklist HFs for use during

supportive supervision.

To reinforce the efficiency of data captured during the supportive supervision of the CHWs, in August 2021 IM Zambia also supported the NMEC to digitize the approved national CHW monitoring checklist in the Advanced EDS, which will enable IM to aggregate and analyze quantitative data on this activity in FY22.

Key Accomplishments – Lusaka Surveillance Objective: Improve the timeliness and accuracy of health facility malaria data through enhanced malaria surveillance Key Accomplishment #1: Improved the quality of malaria surveillance data by initiating consistent monthly malaria data reviews and supportive supervision During the reporting period, IM Zambia supported the Lusaka DHO to improve malaria surveillance at HF level by hosting routine malaria data review meetings at the sub- district level and by conducting supportive supervision visits for underperforming health facilities. Routine data review meetings targeted data personnel at first-level hospitals and urban health centers; facility malaria focal points; and facility in-charges from all the five first-level hospitals and 27 urban health centers.


The reviewed data included weekly malaria-specific HF reports from the NMEC’s Malaria Rapid Reporting System (MRR) and monthly reports to the MOH HMIS. On a monthly basis, IM Zambia provided in-person or remote support to the data personnel, malaria focal points, and facility in-charges in at least 12 facilities. Also, because some gaps identified included pharmacy and laboratory data, some of the meetings included laboratory and pharmacy representatives. Additionally, IM Zambia provided supportive supervision to all first-level hospitals and health centers included in the monthly data reviews as well as to health posts to improve data capture and data quality in the Lusaka District. During the supportive supervision meetings, MRR and HMIS data were examined in detail, gaps were identified, and recommendations for improvement were discussed. Some of the common gaps included missing data elements, missing reports, discrepancies on data submitted to the MRR and HMIS, discrepancies between recorded and treated cases, and poor case definition. Routine data review meetings and supportive supervision contributed to improved HF reporting to the MRR systems and data quality as shown below. Improvement in MRR reporting The chart below shows HF reporting rates for two similar periods: October 2018 to September 20193

and October 2020 to September 2021. Before IM support in October 2018, HF reporting was at 36%. Facility reporting rates have reached 100% in April, May, and July of 2021. In June 2021, the reporting rate decreased due to an upsurge of COVID-19 cases, which caused some HFs to convert to COVID-19 response centers. The gains in HF reporting can be attributed to the feedback and guidance provided to HFs by the Lusaka DHO and IM Zambia. These activities provided an opportunity for HFs to identify existing gaps in reporting practices, troubleshoot facility-specific challenges, and improve understanding of data use at clinical, pharmaceutical, and laboratory levels within their facility. Data quality, reporting, and understanding of the malaria situation in the Lusaka District improved notably.

3 Impact Malaria support began in early 2020 and included clearing a backlog of data entry.

Figure 19: CHW and EHT staff map active malaria cases on the malaria surveillance map provided to the facility with IM support, Photo credit: Lusaka Surveillance staff


Figure 20: Lusaka district facility weekly reporting to MRR Improved identification of local malaria transmission Due to improved data capture on the locality of malaria transmission, malaria hot points have been identified as shown in the map below. Health facilities and the DHO are using these data to prioritize interventions, such as indoor residual spraying.

Figure 21: Lusaka district local malaria cases, Aug 2020 to July 2021


Improving MRR reporting at health posts Reporting rates at the health-post level also improved significantly. Before IM Zambia support in October 2018, only ten out of 27 health posts in Lusaka District, or 37%, were reporting to the MRR system; however, reporting has improved to 100%. Furthermore, three other health posts already listed on MRR but never having reported, began submitting weekly reports to the MRR system.

Figure 22: Health posts MRR reporting rates Objective: Support reactive case detection (RCD) in the 10 health facility catchment areas Key Accomplishment #1: Reinvigorated reactive case detection in Lusaka In the period under review, IM Zambia supported the Lusaka DHO to train or reorient CHWs on the government's reactive case detection (RCD) protocols and, through supportive supervision and data top-ups, assist them in conducting RCD4 visits. To ensure that CHWs have the required competencies, the below activities were conducted: Update of RCD training materials IM Zambia in conjunction with the Lusaka DHO updated the training materials as follows:

1. RCD workflow and protocol: CHWs in Lusaka are using a different protocol from the one used in rural areas due to population size and density in urban areas. CHWs in Lusaka only test members of the index household and do not follow the 40-meter radius when conducting community case follow-up activities.

4 Reactive case detection is a surveillance method that was designed to take advantage of the spatial and temporal clustering of asymptomatic individuals within “hot spots” by using passively detected cases as triggers to initiate screening and treatment of individuals living in proximity to those cases.


2. Diagnosis and treatment: Since most HFs are easily accessible by community members, CHWs in the Lusaka District do not provide treatment to positive cases but instead refer them to the HF for treatment; therefore, IM removed the treatment section from the training materials.

3. Mapping: When CHWs conduct case follow-up activities, they map positive cases found at the index household only. IM added training content on mapping that provides information on how to map cases in community areas where CHWs find active cases.

One-day RCD refresher training for CHWs previously trained in iCCM To update CHWs on iCCM and ensure competency, IM Zambia supported the Lusaka DHO Malaria Unit to activate RCD at the 10 Lusaka District HFs through a one-day refresher training for 28 CHWs who were trained earlier in iCCM at six of the ten health facilities. The training provided the already trained CHWs with an opportunity to refresh their skills and knowledge gained from the 2019 iCCM training which included malaria testing using mRDTs, completing registers, and reporting to MRR with mobile phones.

Two-day RCD orientation for CHWs not yet trained in iCCM Since some of the CHWs haven’t had iCCM training, IM Zambia organized a special training to ensure acquisition of knowledge and skills on both RCD and iCCM. Twenty-seven CHWs were oriented on how to conduct RCD activities, and then HFs received between two to four mobile phones for MRR, depending on the number of CHWs trained per HF.

Thirty-four CHWs) from among the 55 CHWs who participated in the two above-mentioned IM-supported trainings received phones and MRR system login credentials enabling them to submit monthly reports for their community case management activities.

After training the CHWs, IM began supporting the Lusaka DHO in RCD implementation. During supportive-supervision visits, the team noted several challenges preventing RCD from restarting, including commodity stock-outs, HFs treating cases from outside of the HF catchment area, and COVID-19-related disruptions. Currently, RCD activities are active in seven out of the 10 targeted health facilities (Figure 23). IM Zambia supported the Lusaka DHO with data top-ups for CHWs who submitted monthly reports to the MRR system through an automated top-up system.

IM supported the Lusaka DHO to engage with neighboring DHOs, under the auspices of the PHO, to discuss how to resolve cross-border transmission issues. Figure 23 below also shows an unusual surge in local malaria cases in June 2021. Local malaria cases are positive cases that do not report travel outside of the district within the past one month and having spent at least one night. During this period, two facilities reported challenges with a particular batch of mRDTs which led to the recording of more positive cases than usual. IM Zambia and the NMEC are working with the DHO to better understand the situation.


Figure 23: Recorded local cases vs followed cases (MRR January to July 2021)

The activation of RCD activities will help the district follow up on index case contacts, as a way of reducing the spread of malaria among community members. However, as Figure 23 shows, there are still many cases that would benefit from follow-up across the district. Being able to scale RCD to additional health facilities would help in reducing transmission in Lusaka.

Key Accomplishment #2: Identified Government of the Republic of Zambia (GRZ) staffing structure for RCD and built their capacity for continued implementation after IM support IM Zambia supported the Lusaka DHO in identifying the staffing structure for RCD activities. The malaria focal points from all six sub-districts were identified as staff who will take on the responsibility of RCD implementation by supporting facility-led RCD activities in their respective sub-districts. However, the identified staff did not have skills to support this activity. IM therefore supported the Lusaka DHO to host a one-time RCD orientation meeting for the six sub-district malaria focal points. The RCD orientation meeting was helpful in ensuring the development of a sustainable knowledge base and skills among the identified staff as IM prepared to wrap-up support to the Lusaka DHO.

Objective: Support mapping of community malaria surveillance data to inform intervention prioritization in the Lusaka District

Key Accomplishment #1: Systematized zonal mapping of local malaria cases to support intervention planning During this reporting period, IM built base maps with marked zonal boundaries for the 10 HFs implementing RCD and uploaded the shape files into the NMEC DHIS2. IM also produced wall maps for each facility and integrated a simple, tally sheet-based mapping approach into the RCD training package for the Lusaka District. IM supported the Lusaka DHO to print detailed HF catchment area maps) for CHWs and a larger map for posting to a wall within the HF. The Environmental Health Technologist (EHT) is HF staff responsible for community activities, including RCD activities. This map includes a small chart where the EHT, or other designated HF staff, can make a ‘tick mark’ each time a locally acquired malaria case is identified within a zone. On a monthly basis, HFs will begin seeing which zones include the highest number of cases and can use this information to target indoor residual spraying, MDA, and other community-based follow-up activities to combat malaria in Lusaka with more efficiency and a higher degree of precision.


Figure 24: Mandevu UHC, Community malaria surveillance

Figure 25: Facility map with data on malaria hot spots


During this reporting period, IM reinforced sub-district activities using a supportive-supervision platform to ensure that the 40 CHWs at seven of the 10 supported facilities were capturing data on the location of locally acquired malaria cases identified within their facility catchment areas during RCD activities. The EHT/facility malaria focal points are responsible for updating the captured data on the wall map tally sheet. The map in Figure 25 below was generated using this hot-spot data, per the request of the Lusaka DHO and in support of the planned indoor residual spraying activity. Objective: Sustainably transition all activities to the Lusaka district Key Accomplishment #1: Provided cross-cutting support to the sub-district and district officers to sustainably transition support for monitoring malaria surveillance to their teams During this reporting period, IM Zambia supported the Lusaka DHO to implement activities aligned with district needs and consistently reinforced ownership by the DHO and sub-district levels. The Lusaka DHO teams took on leadership roles during the meetings. In January 2020, IM initiated the transition process through meeting discussions with the Lusaka DHO. The Lusaka DHO assigned the sub-district malaria focal point person to continue leading the implementation of IM-supported activities while the Lusaka DHO Malaria Unit staff took on the supervisory role. IM shared the transition and sustainability plans with the LDHO. Training needs for both facility-based malaria surveillance and RCD were identified. In April 2021, IM provided the Lusaka DHO with MRR and RCD orientations and transferred some of the tasks to staff at the six sub-districts who were oriented. IM Zambia continued to strengthen the capacity of the six sub-district staff in data reviews and identified underperforming facilities that required support. As the IM Zambia support to the Lusaka DHO in Lusaka Province is set to conclude, it was important to implement all activities and to confirm that sub-district staff capacity was strengthened for continued sustainable activity implementation by the PHO and the Lusaka DHO. IM staff members paired up with sub-district team members to oversee the execution of each of the tasks they are expected to take over at the end of Impact Malaria support. This included overseeing data processing and review, conducting all data review meetings and supervision visits together (with the sub-district leading), and providing one-on-one mentorship after each meeting.

Key Accomplishments - Zambia ProAct Study More than a decade after the introduction of mRDTs and ACTs, a small proportion of children with fever are tested for malaria and appropriately treated. Promoting the active detection of symptomatic malaria infections by CHWs on a weekly basis may be an effective way to improve the uptake of malaria detection

Figure 26: Chilenje District malaria focal point person with) during a facility support visit at the Lusaka Central Prison UHC, Photo credit: IM


and case management and, thus, reduce malaria mortality and transmission. The ProAct Study will determine the feasibility and impact of weekly active detection of symptomatic malaria cases at the community level on malaria morbidity and transmission. This data will help inform future policy decisions. Study Overview The study is a two-arm, cluster-randomized controlled trial, and districts will be selected based on eligibility criteria, such as malaria burden, CHW deployment, and vector control status, based on similar levels of vector control interventions in control and intervention areas of the study, among other factors. The Chadiza District in the Eastern Province was selected, and Katete, Senga, and Chipangali districts are under review. Randomization for the study will occur at the CHW level and 30 clusters will be enrolled in each arm for a total of 60 clusters (i.e., 30 control and 30 intervention clusters). Progress Update The IM project, along with other stakeholders, supported the Government of Zambia on the ProAct Study. Since inception, IM had reached successful milestones in the preparation for implementation of the ProAct Study including development of a detailed budget, study matrix, finalization of the study protocol, and obtention of the necessary IRB approval. However, in October 2020, IM was informed of the decision to handover the Zambia ProAct Study in its entirety to PATH’s PAMO Plus project. In this reporting period, IM collaborated with partners to efficiently transition all study activities to PAMO Plus.

Challenges and Solutions – Zambia OTSS and Lusaka Surveillance Challenges Solutions

OTSS Lack of updated malaria charts at health facilities

IM will liaise with the NMEC to distribute charts to health facilities during OTSS.

Malaria RDTs are conducted in laboratories with microscopy facilities

IM to support the NMEC to ensure that mRDTs are only conducted in an outpatient department (OPD) laboratory.

No internal quality control (IQC) in laboratories

IM will support the NMEC to ensure on-the-job coaching during OTSS for IQC implementation.

Difficult to access, hard-to-reach facilities IM supported the PHOs and DHOs to target hard-to-reach health facilities before the rainy season.

Reaching a portion of all eligible HFs in each activity (OTSS round, CCM HSS activity)

IM applied selection criteria for HFs participating in activities, rotated HFs between rounds, developed generalizable methods and tools, among other strategies.

Lack of IPTp performance charts in facilities IM supported PHO midwife supervisors to coach and encourage HF in-charges to ensure IPTp data is analyzed and displayed at MCH offices.

Stock-outs of malaria commodities such as mRDT, ACT and rectal artesunate including

IM is working with other stakeholder through bi-weekly commodity meeting looking at malaria commodity


Challenges Solutions microscopy supplies frosted slides, Giemsa stain powders.

supply, is liaising with NMEC to improve malaria commodity supply in the country.

Delays in activity implementation at provincial and sub district level due to conflict in MOH activities such as COVID priorities and NMEC priorities.

Engaging and informing PMI mission to engage and obtain high-level guidance with MoH – NMEC on activity implementation.

Trained staff in malaria case management both Clinical and Laboratory reassigned to high priorities such as COVID assignments.

IM to support PHO and DHO to provide continued on the job coaching to cadres other than health workers in the mRDT training.

Lusaka Surveillance The COVID-19 pandemic caused delays in the implementation of some planned activities. Also, both facility staff and CHWs were exposed to COVID-19, and it became a challenge for CHWs to conduct RCD activities in households.

IM Zambia conducted virtual meetings when in-person meetings were not possible due to the COVID-19 pandemic. Once the COVID-19 situation improved, micro- meetings were held, observing MOH and IM safety protocols, at the sub-district level. IM Zambia also supported facilities to update missing reports.

Stock-outs of malaria commodities, including ACTS, mRDTs, Artesunate, and ITNs.

IM Zambia liaised with the NMEC, and other stakeholders, to ensure availability of malaria commodities at service delivery points. IM moved ahead to implement other activities, such as training of CHWs in readiness for the availability of malaria commodities. IM also supported the sub-districts and Lusaka DHO in resolving this issue through initiating discussions at different levels.

Poor internet connection affected virtual meeting attendance and participation.

IM Zambia encouraged participants to identify which service providers work best for their area and assessed options for returning to small gatherings as the COVID-19 situation improved.

Lack of HMIS login credentials at HF causing missing and late reports as the sub-district staff were overwhelmed with other tasks.

IM Zambia worked closely with the sub-district and Lusaka DHO staff to get login credentials for facilities that have computers, to enable them to submit reports in a timely manner.

HMIS challenges and the change of reporting tools affected reporting rates and data quality as some of the data staff were not oriented.

IM Zambia provided orientation to untrained staff during in-person supportive supervision visits.

E-first facilities struggling with data quality issues due to Smartcare5 system challenges.

IM Zambia guided HFs to maintain and consistently update hard copies records. IM Zambia guided HFs to request the Smartcare5 support team to visit affected facilities.

Locally acquired malaria cases from other facility catchments are not followed by CHWs,

IM Zambia provided guidance to EHTs to document communication leadership with the respective HFs.

5 Smartcare is the electronic health record system developed and deployed by the Zambia MOH in collaboration with the CDC to provide

continuity of care and as a national M&E system.


Challenges Solutions and once transferred to the respective facility, there is no way of tracking if follow-up activities are done The CHWs fall inactive because they are not well supplied with ACTs and RDTs for community surveillance.

Engaging CHWs in other facility tasks, such as malaria testing and data capturing, when it becomes impossible for them to conduct community activities, is an effective way of maintaining their skills and support HF staff.

Lessons Learned: Zambia OTSS and Lusaka Surveillance

● Consistently engaging PHO leadership in planning and providing support to the provinces has helped the provinces improve malaria case management.

● Postponement of activities due to increase of COVID-19 cases in FY22 Q2 delayed activities such as trainings, OTSS visits and meetings. Consistently engaging NMEC and PHO leadership for alternate planning and implementation strategies such as virtual training and meetings and OTSS activities implemented by sub district and overseen by provincial instead of national level.

● Use of virtual meetings and trainings in planning and implementation of activities is necessary during Covid 19 pandemic to avoid postponement of activities.

● Collaborating closely with the NMEC supports timely activity implementation and allows flexibility in case of overlapping MOH activity commitments.

● Following up virtually and consistently with OTSS supervisors during HF visits helps in improving data uploaded into IM Data Hub.

● Continuing mentorship provided to CHWs during OTSS visits reinforces continuity of quality improvements in case of transfers or reassignments of trained personnel to COVID-19 centers. This will enable the facility to continue conducting activities, such as CHW adherence to testing and treatment, malaria slide generation, and MIP after the end of the project.

● Identifying and engaging government staff to lead activities during closeout will assist in strengthening their capacity.

● Building capacity with multiple staff, as opposed to only one, reinforces sustainability and mitigates the loss of institutional knowledge even in case of transfers, illness, or competing activities, which was experienced during this reporting period.

● Quickly identifying and switching to alternative methods that provide an opportunity for activities to safely continue during situations when in-person activities become impossible. Virtual meetings were helpful in ensuring the continuity of activity implementation during the previous two waves of COVID-19.


IM Zambia Indicator Table The data provided in the indicator table below are IM targets and results reflect activities from the period October 1, 2020 – September 30, 2021 in the IM supported areas, Central and Copperbelt Provinces. Rounds 4 and 5 of district OTSS and rounds 5 and 6 provincial OTSS were done in FY21. A total of 716 health facilities have been observed through OTSS during the life of the Impact Malaria Project and a total of 108 health workers have been trained in case management and microscopy competency trainings combined.

Objective #

Indicator Target Results

Progress towards Annual Target

Data source

Comments

Objective I: Improve the quality of and access to malaria case management and prevention of MIP

Percentage of confirmed malaria cases

N/A 50.6% (1,337,939/2,643,692)

N/A HMIS

50% were confirmed malaria cases because every patient that visits the health facility with suspected malaria is subjected to a parasitological test (mRDT or microscopy) to confirm malaria.


100% 100% (2,643,692/2,643,692)

100 HMIS

All suspected malaria cases were subjected to malaria test by microscopy or mRDT.

Percentage of health facilities demonstrating competency in malaria microscopy

84% 57% (31/52)

68 EDS

The Central Province experienced staff attrition, which affected reporting period achievement. However, nECAMM and ECAMM trainings have been scheduled for 2022 to improve parasitological diagnosis by microscopy

Percentage of observed health workers demonstrating competency in mRDT observation

85% 78% (248/319)

92 EDS

Staff attrition affected this achievement. nECAMM and ECAMM trainings have been scheduled for 2022 to improve parasitological diagnosis by mRDT


Objective #



Data source

Comments

Percentage of health workers demonstrating competency in correctly classifying cases as not malaria, uncomplicated malaria, and severe malaria

97% 92% (242/263)

95 EDS

HFs achieved sustained high levels of competency in classifying malaria correctly from the previous to the current reporting period. This is a result of training staff in case management and reinforcing positive practices through OTSS.


100% 100% (47/47)

100 EDS

Trainings were conducted as planned; all targeted supervisors were trained in malaria diagnosis.

Percentage of targeted facilities with at least one provider trained in malaria diagnosis

70% 70% (227/324)

100 EDS

Due to staff attrition in the reporting period, not all targeted HFs had trained staff in either mRDT or microscopy.

Percentage of facilities with malaria quality assurance manual (microscopy guidelines)

30% 60% (21/35)

200 EDS

The project printed diagnosis and treatment guidelines and distributed them in supported facilities. The target was agreed upon prior to the printing of QA manuals.

Percentage of targeted health workers demonstrating compliance with treatment according to WHO guidelines for cases with positive malaria test results

90% 98% (302/307)

109 EDS

HWs achieved sustained high levels of competency for treating confirmed malaria cases in the last and current reporting period, due to on-the- job coaching through OTSS visits.


Objective #



Data source

Comments

Percentage of health workers demonstrating adherence to negative test results according to global standards

90% 95% (105/111)

106 EDS

HWs achieved sustained high levels of competency for adhering to negative test results in the last and current reporting period, due to on-the- job coaching through OTSS visits.

Percentage of targeted health workers demonstrating competency in management of severe malaria according to national guidelines

97% 94% (18/19)

97 EDS

Due to staff attrition during the reporting period, competency for the management of severe malaria reduced slightly. On-the-job coaching will be intensified during OTSS to improve staff competencies.

Percentage of targeted health workers demonstrating competency in management of uncomplicated malaria according to national guidelines

100% 92% (283/308)

92 EDS

Competency in management of uncomplicated malaria improved from the last and current reporting period due to on-the-job coaching through OTSS visits.

Percentage of targeted health facilities that received a semi-annual supervisory visit

100% 108% (502/466)

108 EDS

The percentage of HFs visited was greater than anticipated because OTSS supervisors also reached newly opened health facilities during OTSS rounds that were not counted in the original target.

Percentage of pregnant women who received three or more doses of IPTp

60% 51% (74139/146102)

85 HMIS

Knowledge and competency in preventing MIP between the last and current reporting period increased largely due to


Objective #



Data source

Comments

according to national guidelines

case management strengthening during OTSS on-the-job coaching by supervisors.

Percentage of targeted MCH health workers mentored in MIP

100% 100% (338/358)

100 EDS

Safe motherhood activities continued with mentorship of health workers at MCH clinics.

Percentage of targeted health workers demonstrating competency/knowledge in prevention of MIP

80% 96% (314/327)

120 EDS This improved due to on-the-job coaching on the printed SOPs for MIP.

*The IM Zambia Annual Report has achievements up to July 2021 because August 2021 data are not yet in HMIS, and IM is conducting district OTSS using Advanced EDS.

Lusaka Surveillance Indicator Table The data provided runs from the period October 1, 2020 to September 30, 2021 in the targeted HFCA in Lusaka District, Lusaka Province.



Data Source Comments

Objective #1:

Percentage of reported malaria cases in LDHO facilities that are confirmed with a diagnostic test (mRDT or microscopy)

90% 92% 113% HMIS Baseline: 75% Result is an 11-month average (October 2020-August 2021)

Total numbers of antimalarial treatments provided in LDHO facilities

100% 108% HMIS

After the change in tools for HMIS reporting in February 2021, some data staff still have challenges using the new HIA one and two forms. There are gaps in current HMIS data. Total confirmed cases =





15,678. Total antimalarial treatments provided = 16,929. Baseline: 50%. Result includes 11 months of data (October 2020-August 2021)6

Travel versus locally acquired malaria cases in LDHO facilities

5% 20% -8% MRR

Baseline: 19%. Note that the level of support provided to the 10 RCD health facilities is not sufficient to influence local case incidence to this degree. Suggest eliminating indicator. Result is an 11-month average (October 2020-August 2021)

Objective #2:

Time from confirmed case reported at HFs to follow-up in facilities with active RCD

7 days 7 days 100%

All cases in the seven facilities submitting data are followed within seven days of being confirmed. Baseline: No follow-up. Result includes eight months of data (January 2021-August 2021)

Total locally acquired cases applicable for follow-up which received follow-up in ten facilities identified for RCD support

90% 17% 19%

Note that the 17% represents cases from ten facilities supported by IM and receiving RCD implementation support. RCD activities have not started at three of the ten IM-supported facilities. (Number of local malaria cases followed up 99) / (Number of local cases recorded at the 10 RCD supported facilities 589). Baseline: No follow-up. Result includes 8 months of data (January 2021-August 2021)


85% 99% 200%

After the change in tools for HMIS reporting in February 2021, some data staff still have challenges using the new HIA one and two forms. There are gaps in current HMIS data. Baseline: 71%. Result is an 11-month average (October 2020-August 2021)

Percentage of targeted health facilities regularly

95% 97% 104%

Reporting rates for the current period were affected by COVID-19 related tasks as well as exposure by facility staff to

6 The Progress to Annual Target entry was intentionally left blank due to HMIS reporting gaps following a national level change in the reporting tools.





reporting routine malaria case data - MRR

COVID-19. Baseline: 44%. Result is an 11-month average (October 2020-August 2021)

Percentage of targeted health facilities regularly reporting routine malaria case data - HMIS (Health Information Aggregation Form #1)

95% 81% 59%

Reporting to HMIS this reporting period was affected by the change in the reporting tools. Some of the data clerks have not been trained in the use of the new tool. Also, HMIS developed system challenges after upgrades implemented in January and February 2021. Reporting rates were also affected due to competing activities at the sub-district level where reports for HFs that do not have computers are submitted. Baseline for HIA1: 61%. Baseline for HIA2: 50%. The result is an 11-month average (October 2020-August 2021).

Percentage of targeted health facilities regularly reporting routine malaria case data - HMIS (HIA2)

95% 91% 92%

Objective #3:

Number of malaria-related supervision visits conducted

144 152 106%

Number of DHMT meetings which include review of HF malaria indicators

4 3 75%

U.S. President's Malaria Initiative Impact Malaria Project ...

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