TableofContents EXECUTIVESUMMARY...................................................................................................................................4 I. Diarrhea .........................................................................................................................................................4 A. DiarrheaPrevention ................................................................................................................................................. 4 B. DiarrheaTreatment .................................................................................................................................................. 4 II. FamilyPlanningandReproductiveHealth ...................................................................................................5 III. Malaria ...........................................................................................................................................................6 IV.

. HIVandAIDS ..................................................................................................................................................6 V. CrossCuttingAchievements .........................................................................................................................7 A. CollaborationwithSantNet2 ............................................................................................................................... 7 B. Gender. .................................................................................................................................................................... 7 MONITORINGANDEVALUATION...................................................................................................................8 I. QualitativeResearch(ProjectFoQus) ...........................................................................................................8 II. TRaCkingSurveys(ProjectTRaC) ..................................................................................................................8 III. MappingSurveys(ProjectMAP) ...................................................................................................................8 IV. PrioritiesforLocalAIDSControlEfforts(PLACE) ..........................................................................................8 A. CurrentandCompletedResearchStudies ............................................................................................................ 8 1) NationalWomen'sTRaC2008FollowupSurvey.................................................................................8 2) PopulationatRiskofHIVFollowupTRaCSurvey................................................................................9 3) MysteryClientSurvey...........................................................................................................................9 4) FoQusonScalesforTRaCamongFemaleSexworkersandtheirclients.............................................9 5) MAPPhase2StudyFollowup.............................................................................................................9 6) FoQusonConceptDevelopmentSreau.........................................................................................10 B. OtherStudiesConductedDuringThisPeriod ..................................................................................................... 10 1) OperationsresearchwithPOUZN.....................................................................................................10 2) Determinantsofproviderproductivitysurvey..................................................................................10 3) Otherqualitativestudies...................................................................................................................10 C. SelectionofPlannedResearchStudiesApril2010September2010 ........................................................... 10 1) Outletandhouseholdmalariatreatmentsurvey..............................................................................10 2) FoQusstudyamongTOPReseausdoctors.......................................................................................10 3) FoQUsforTRACimprovementamongyouth1524..........................................................................10 4) PretestingTVspotsforProFemina(PSIsWHP)andforshorttermcontraceptivemethods............10 5) FoQusonsegmentationisplannedinthenextquarteramongusersofFamilyplanning...............11 6) Formativestudyaboutemergencycontraceptive,qualitativeresearchaboutthepackagingofthe emergencycontraceptiveandpretestingtoolsforcommunitybaseddistributionagent................11 7) ConceptTestingforthenewGasyBandyCoolCampaign................................................................11 8) PretestingflipchartonFPforcommunitybasedagents...................................................................11 9) PretestingLLINspotradio(educationalandpromotional)...............................................................11 10) Pretestingfilmaboutdiarrheapreventionandtreatment...............................................................11 11) Formativestudyonmalariacasemanagementatcommunitylevel................................................11

Page2

RESULTANDACTIVITYHIGHLIGHTS..............................................................................................................12 I. DiarrheaPreventionIncreasedcorrectandconsistentuseofSafeWaterSolution(SWS)amonglow incomeMalagasyhouseholds .....................................................................................................................12 II. DiarrheaTreatmentIncreasedcorrectandconsistentuseofDiarrheaTreatmentKittotreatdiarrhea athome ........................................................................................................................................................13 A. ActivitiesduringOctober2009March2010.................................................................................................... 15 1) Trainings ...........................................................................................................................................15 . 2) Communications...............................................................................................................................17 3) Distribution.......................................................................................................................................17 4) Research............................................................................................................................................18 I. SalesandDistributionofShortTermHormonalMethodsandNaturalMethods ....................................19 II. SalesandDistributionofEmergencyContraception..................................................................................20 III. AccesstoLongTermContraceptiveMethods ............................................................................................20 IV. ReproductiveHealth ....................................................................................................................................22 A. ExtensionofTOPRseauPlus ............................................................................................................................... 22 B. ExtensionofTOPReseaunetworktoMoramanga ............................................................................................ 22 I. MalariaPreventionIncreaseduseofinsecticidetreatedmosquitonets(ITNs)amonghighriskgroups (pregnantwomenandchildrenunderfive) ...............................................................................................23 A. Distributionactivities ............................................................................................................................................. 23 B. CommunicationActivities ...................................................................................................................................... 24 II. MalariatreatmentIncreasedappropriateuseofprepackagedantimalarialsamongchildrenunder fivethroughoutMadagascar .......................................................................................................................24 A. DistributionActivities ............................................................................................................................................. 24 B. CommunicationActivities ...................................................................................................................................... 26 I. KeyIndicatorAchievements/BaselineData ...............................................................................................27 A. Partnerreduction ................................................................................................................................................... 27 B. Condomuseamongsexworkers ......................................................................................................................... 28 C. Condomuseamonghighriskmen ....................................................................................................................... 28 II. IndicatorAchievement:STICaseManagement .........................................................................................33 CONCLUSION...............................................................................................................................................35 ANNEXA:OverviewofLogframeIndicators ANNEXB:ParticipantTrainingActivities ACTIVITYRESULTS WORKPLAN20092010StatusOverview

Page3

EXECUTIVE SUMMARY
The Social Marketing Program for Child, Maternal, and Reproductive Health Products and Services in Madagascar InJuly2008,PopulationServicesInternational/Madagascar(PSI)wasawardedafollowonitsearlier Cooperative Agreement. This Cooperative Agreement (CA # 687A00080003200) builds on PSIs socialmarketingandbehaviorchangecommunicationachievementsinfamilyplanning,maternaland childhealth,andSTI/HIVpreventionandtreatment.Thetotalprojectdurationisfiveyearsandthree monthsfromJuly14,2008throughSeptember30,2013.Thisreportcoversthesixmonthperiod fromSeptember2009throughMarch2010. Thegoalofthesocialmarketingprojectistoincreasetheuseofhealthproductsandservicesthrough commercialmarketinganddistributionstrategiesleveragingthestrengthoftheprivatesector.Where possible, PSI collaborates with NGOs at the community level to improve access to products and servicesinhardtoreachandunderservedareas.Forallhealthdomains,PSIcoordinatesandworks closelywiththepublicsector. AlthoughthepoliticalcrisisinMadagascarhasnotyetbeenresolved,operationshavebeennormal duringthereportingperiod.PSI/MunderwentalargeinternalreorganisationinAugust2009,which disrupted work plan execution and delayed implementation of several key activities including for research and communication during the second half of 2009. At present teams have been reconstituted,somenewpositionshavebeenfilledincludingforprocurement,whichhasbecomea separate department. A workshop washeld with a PSI/W procurement expert to ensure new team membersarefullyawareofexistingprocedures. The following is an overview of progress and achievements made on a number of indicators and importantactivities,including: I. DIARRHEA A. DiarrheaPrevention Despite challenges linked to supply problems, SrEau sales over the reporting period exceededobjectives(109%) Partner organizations requested to receive capacity building in social marketing and communications TheSrEauteamstartednewcollaborationstocreatedemandforbetterhygienepractices, includingconsistentuseofSrEauwith:Scouts/HIP,WFPandLandOLakes. PSIparticipatedintheWorldWaterdaycelebrationsinMahitsywiththeUSAmbassador B. DiarrheaTreatment Secondary analysis of TRaC data provided additional insights to develop communication strategiesforthetreatmentofuncomplicateddiarrhea PSI initiated new collaborations with partner NGOs for the distribution of DTK: MCDI, ASOS Sofia, Mercy Ministries, WCS, Aimbaovao: Over 1,000 community agents and over 2,000 medical/pharmacystaffhavebeentrainedduringthereportingperiod PSI contracted Grand Angle to design a nationwide communication campaign on DTK, particularlyHydrazinc

Page4

 Stepsarebeingtakentoaddresschallengesinrestockingcommunityagents Longprocurementdelaysmadeitchallengingtoappropriatelyfillthedistributionchannels Operational research on distribution channels and ORS & zinc use has been carried out in February/March2010byFocusDevelopmentAssociation(FDA). II. FAMILYPLANNINGANDREPRODUCTIVEHEALTH AttherequestofUSAID,PSI/Massumedtheresponsibilitytodistributeproductsoriginallydestined tothepublicsector.Thisincludesaprogesteroneonlyoralcontraceptiveaswellasadditionaldoses ofDepoproveraandDuofem.Inordertoensuresuccessintheseinterventionsaswellastheothers: PSI/M followed all the necessary preparatory steps to launch a new socially marketed progesteroneonly pill contraceptive Micropil (Microlut), mainly targeting nursing women, althoughnotexclusively.PSIMadagascarreceivedtheproductinJanuary2010butawaitsthe appropriatedocumentationfromthemanufacturerinordertoregisteritandlaunchit. BasedonthepreteststudyresultsforthenewPilplanandConfiancepackagingandprice,PSI madefinaladjustmentsthenlaunchedtheminFebruary.Aseparatepackagingwasproduced forcommunitybaseddistribution,tohelpavoidleaksintothecommercialsector. PSIprovidedaccessduringthisreportingperiodto:987,643cyclesofPilplan(38%ofannual projections, 94% pharmaceutical, 6% CBD); 459,584 doses of Confiance (46% of annual projections,96%pharmaceutical,4%CBD);7,596unitsofVakana(38%ofannualprojections, 100% CBD); 6,091 IUDs (61% of annual projections); and 754 implants (222% of annual projections). To expand the distribution of FP products and improve the counseling offered to target population, in partnership with 91 NGOs (including WCS) and Committees for Social Development(CDS),PSItrained: - 112communityhealthworkers(refreshertraining)inruralareas - 127privatesectorproviders - 143agentsofpharmaceuticalwarehouses(bothruralandurban). With the support of PSIs Womens Health Project, PSI trained 28 additional community health workersduringthisperiodtoreferclientstopharmaciesandfranchisedproviders,and46additional providerstoofferLTMs.Districtcoverageconsequentlyincreasedfrom50to90duringthisreporting periodwiththecreationof40newpointsofdistribution.Thiscoverageincludes72districtsreceiving supportfromtheSantNet2project. Addressingthetwobehavioraldeterminantshighlightedinthe2008TraCsurvey(selfefficacy and false beliefs), a 13mn film, two video spots, two radio spots, a radio program (Toky sy Antoka)wereproducedandairednationallyandregionally.Theyemphasizedtechniquesto improve use and correct false beliefs. Broadcasting of FP messages was expanded in rural areaswithaselectionofruralradiostations.AdditionalIECmaterialsarebeingdevelopedfor usebycommunityhealthworkers,aswellaspointofsalepromotionalmaterialsforincreased visibility. PSIstaffparticipatedintheUSAIDFPConferenceinKigaliandcontributedtoelaboratingan action plan to ensure that Madagascar meets unmet FP needs by 2015, therefore reaching oneoftheMDGindicators. With cofunding from PSIs WHP, 12 new medical and communication regional supervisors were recruited and trained in December 2009 to ensure the quality of services offered by franchisedproviders,andtosupportcommunitybaseddemandcreationactivitiesforFPand

Page5

LTMs in particular. After the annual QA evaluation conducted in 2009, action plans were developedwitheachprovidertoaddresstechnicalgaps. InDecember2009,PSIlauncheditsninthTopReseausiteinMoramanga.Sixnewproviders wererecruitedandtrained.InparallelIPCactivitieswerelaunchedwiththerecruitmentofsix youthpeereducators.Todate,theservicesareattractingmanyyouthwith369clientsinthe firstfewmonthsfollowingtheopening, III. MALARIA Massdistributioncampaignsof1,073,215LLINsinNovember1621,2009and580,000LLINs inDecember1419,2009.OnemillionoftheseLLINsarePMIprocured Following the revised US government position towards the government of Madagascar, PSI changedcampaignplanstotransportandstoreLLINsusingthepublicsectorandworkedwith localNGOsinstead. DuringtheAllianceforMalariaPreventionsannualmeetinginGeneva,Madagascarreceived special recognition from international malaria partners for its good work in the 2009 LLIN distributioncampaign A wide range of communication strategies were used at different stages of the 2009 LLIN campaigntoensureconsistentLLINuse The share of pharmaceutical distribution of Actipal keeps decreasing to the benefit of communitybaseddistribution. PSI was selected to be a subrecipient of the AMFm and will be in charge of designing communicationstrategiesforthisproject PSIstartednegotiationstoswitchprocurementofACTsfromcoblistertocombo IV. HIVANDAIDS The program distributed 11,781,299 units of Protector plus in 2009. Recent data demonstrate that approximately85%ofallmalecondomsdistributedinMadagascararethesocialmarketedProtector Plus. PSI distributed 6,102,742 male condoms during the reporting period for both family planning and STI/HIV programs. This equals to 92% of the semester objective. In November 2009, a new packagingwasintroducedalongwitha100%priceincrease.Athreeunitpacketnowsellstotheuser for 200Ar. Retail and wholesale margins were adjusted accordingly. Heavy pointofsale promotion accompaniedthenewpackagingincludingnewpointofsalematerialsandanimatedstandsatkiosks, gasstationsandothersmalloutlets. For the female condom, Feeling, 47,940 female condoms were sold in 2009 among female sex workers(FSW),correspondingto106%oftheannualobjective.Duringthereportingperiod,32,784 femalecondomsweredistributedthroughSWpeereducatorsandSWassociations.Weexpectnew USAID donated product to arrive in December 2010. The product will change as a result of the improved product material, and PSI will use this opportunity to review its current packaging and price. InJuly2009,PSIpurchased195,000Cura7and150,000Genicuretocoversocialmarketingneedsand avoidstockout.PSIownprogramincomewasusedtopurchasethemintheabsenceofWBorother funding. These quantities will cover 50 % of PSIs 2010 MBOs for STI kits. PSI will continue to seek externalfundingforthekits Followingadelayedstartofimplementation,activitiesundertheGlobalFundRound8HIVgranttook offformallyinMarch2010in8regions,withPSIsupportto10SubRecipients.GFHIVactivitiesare

Page6

complementaryto,andbuildupon,thesolidfoundationPSIhasdevelopedasaresultoftheUSAID funded,targetedoutreach/interpersonalcommunication(IPC)activitieswithmostatriskpopulations (MARP). During the reporting period, five additional clinics in Antsirabe, Fianar and Morondava started offeringVCTservicesundertheTRPlusbrand,makingforatotalof21TRPlusclinicsinthecountry. Clientuptakehasbeengood,with131clientscomingforVCTatthenewsitesfollowingthe3months sincetheiropening. With assistance from PSIs senior marketing advisor and an external advisor from GW University in Washington/DC, PSI conducted a DELTA workshop to guide the 2010 HIV marketing plan development. The DELTA process considered results from various qualitative research such as the evaluationofthemasscommunicationcampaignGasyBandCool(July2009)andaphotonarrative with at risk men in urban areas. The Delta workshop resulted in a revised orientation of PSIs communication work with at risk men, shifting away from generic campaigns on partner reduction, condomuseandSTItreatmenttoatargetedcampaignthatwillfocusonriskreductionamongmen thatseekhighrisksexforthrillsandpleasure. TheTRACsurveyamonghighriskmenwasconductedinlate2009among508menin114hotspotsin eight urban areas with Top Reseau clinics. Early TRAC results from the 2009 survey among men in hotzones confirm that condom use with SW is inconsistent and that many of these men dont perceivethemselvestobeatriskforHIV. PSIassistedwiththeorganizationtheWorldAIDSDay,December1st2009inTana.Thetheme2009 WorldAIDSDaywas,Righttolife,accessforalltoHIVprevention.Adiscussionpanelwasorganized with mostatrisk populations and civil society partners including the Platform of Religious Leaders and Faithbased Organizations. The objective of this discussion panel was to highlight civil society mobilization and enable dialogue among civil society stakeholders united in the fight against HIV/AIDS. V. CROSSCUTTINGACHIEVEMENTS PSIsroleintheSanteNet2projectaimstostrengthenthecommunitybaseddistributionnetworkfor social marketing products within 500 New Generation Kaominina Mendrika (NGKM) and 300 Old Kaominina Mendrika. The collaboration between the two organizations and our partners remains strongduetoregularcoordinationmeetingsandjointplanningofactivities.PSIscoordinatorbased at the Santenet2 office facilitates this collaboration and contributes to the reinforcement of the distributionsystemandscaleupofthecommunitybasedDepoproveraservicedelivery. Quality assurance is an important overall component to all PSI activities under this cooperative agreement. This includes activities such as the communitybased provision of DepoProvera in partnership with SantNet2: PSI supplied SantNet2 partners with start up stocks of injectable contraceptivesandsharpboxestohelpthemmanagesyringeswastes.Also,PSIcontinuallyworksto improve access to qualitycontrolled reproductive health products and services via its franchised networksoftrainedprivatesectorhealthcareproviders(TopResearuandProfemina)withtechnical assistancefrompartnerssuchasJhpiego.Throughcomplementarysupportfromcostsharesources, thefirstofaseriesofindependentannualqualityassuranceauditsofthewasconductedduringthis period with the objective to ensure that PSIsupported providers deliver highquality RH services (specificallylongtermFPmethods)andthatwehaverobustsystemstomonitorandmaintainhigh qualityservices.ResultsofthisauditwillbeshareduponrequestfromUSAID. A gender audit originally planned to be conducted by PACT will be rescheduled before the end of 2010.

Page7

MONITORING AND EVALUATION

Tomeasureandimprovetheeffectivenessofsocialmarketinginterventionsacrossthehealthareaswhere PSIintervenes,significantresourcesareinvestedintheproductionoftimelyandactionabledata.Thesedata areusedtomakeevidencebaseddecisionsforongoingandfuturesocialmarketingactivities.PSIusesfour typesofstudiestogeneratedataforprogramplanningandevaluation: I. QUALITATIVERESEARCH(PROJECTFOQUS) Qualitative research is used for concept development, photo narrative, pretesting communication materialsand,ifnecessary,furtherexploringquestionsraisedinsegmentationusingfoqusonscales and foqus on segmentation (e.g. factors that differentiate users versus non users of a certain product/service). II. TRACKINGSURVEYS(PROJECTTRAC) PSI's TRaCking Results Continuously surveys collect data on evolving trends in logical framework indicators at the purpose, output, and activity levels with different target populations and for different health interventions. TRAC studies produce three sets of tables for program planners: 1) monitoring tables, which allow program planners to detect significant changes on logframe indicators;2)segmentationtables,whichallowthemtoexplorethedifferencesovertimeincertain behavioraldeterminantsbetweenusersandnonusersofaproduct/service;and3)evaluationtables, which provide them with evidence of the combined impact of PSI communication activities on the desiredbehavior. III. MAPPINGSURVEYS(PROJECTMAP) ProjectMeasuringAccessandPerformance(MAP)informsprogramplannersaboutthecoverageofa product, the qualityofthecoverageandtheequityofaccessamongthetargetpopulation.PSIhas started using geographic information systems to produce maps, as a way to assess among other indicators,equityofaccess. IV. PRIORITIESFORLOCALAIDSCONTROLEFFORTS(PLACE) PLACEstudiesusequalitativeresearchmethodssuchaskeyinformantinterviews,toidentifythesites wherepeoplemeetsexualpartners.PSIandINSPChaveconductedPLACEstudiesinlargeurbanareas with high concentration of groups most vulnerable to STIs/HIV, and has widely disseminated this informationtolocalHIVpreventiongroups. A. CurrentandCompletedResearchStudies During the period October 2009March 2010, we report progress on the following research studies and quality improvement activities. As in prior reports, key findings from TRAC and MAP studies availabletodatearesummarizedinAnnexA,whichalsopresentstheadjustedresearchresultsfrom twoperiods(baselineandfollowupsurvey).Asappropriate,AnnexAalsoshowsthesuggestedtarget forindicatorsforthenextroundofstudy.PSIwillsubmitproposedrevisedlogframeindicatorsinthe upcomingreportingperiod,whichwillincorporatebaselinedatafromtherecentlycompletedTRAC amongclientsofSWandSWs,andwillhavetargetsfortheyouthTRAC2010followupsurvey. 1) NationalWomen'sTRaC2008FollowupSurvey

Page8

Reportsbasedonthefivebehaviorsassessedareavailable:sleptunderaninsecticidetreatednetlast night; use of home based safe water systems; current use of modern contraceptives; use of anti malarial within 24 hours after symptoms at last case of fever for a child under five in the past two weeks; and use of Sur Eau and zinc during the ten days after first symptoms for the last case of diarrhea for a child under five in the past 2 weeks. Net use results were presented during the 5th Multilateral Initiative Malaria in Kenya in November 09 and during the 58th American Society of Tropical Medicine and Hygiene Symposium in Washington DC in November 09. Local dissemination wasdoneamongRollBackMalariateaminFebruary.Resultsonfamilyplanningwerepresentedin DecemberwithMoHamongfamilyplanningpartners. 2) PopulationatRiskofHIVFollowupTRaCSurvey The 2009 follow up survey focused on SWs and their clients; clients were defined as men who reportedhavinghadsexwithaSWduringthepastthreemonthsandwereselectedfromhotzones during peak slot times in eight Top Rseau sites using the TimeLocationSampling methodology1. Behaviors of interest for SWs include condom use during last sex and STI treatment; for clients, questionswereincludedonpartnerreduction.DatacollectionfortheTRACHIVfollowupsurveywas completed in December 2009. With separate funding from QMM, an oversampling among SWs in FortDauphinwasdonetogetresultsrepresentativetothesiteontwomainbehaviors:condomuse and STI treatment. Unofficial results are included in the current report. PSI will plan a more formal disseminationwithUSAIDandotherpartnersinthenextreportingperiod. 3) MysteryClientSurvey Inamajorchangefromthepreviousyears,withaneyetobeingmorecosteffective,PSItestedthe LQASapproachtoitsMysteryClientsurveysamongTOPReseauproviders.InAugust2009,19clinics among the 130 existing TOP Rseau clinics were randomly selected to arrive at a representative sample of all TOP Rseau clinics nationally. Results are available for FP and STI scenarios and are presented in the Reproductive Health section of the current report. PSI will analyse the advantage anddisadvantagesofusingLQASforproviderqualitysurveysforitsfuturesurveys. 4) FoQusonScalesforTRaCamongFemaleSexworkersandtheirclients QualitativestudyconductedinOctoberandNovember09togeneratenewmultiitemscalesand/or modifyexistingmultiitemscalesthatweresubsequentlyusedfortheTRaCamongSWsandclientsof SW. 5) MAPPhase2StudyFollowup This study gives information about coverage, quality of coverage, access and equity of access to sociallymarketedproducts,especiallythoseforhighlytargetedinterventionssuchascondoms. The MAP Phase 2 baseline was conducted in 2006 to assess access and availability to condoms in selectedurbanhighriskzones.ThefollowupcondomhotzoneMAPsurveywasconductedinparallel
Timesamplinglocationisawidelyusedsamplingstrategyforquantitativestudieswithhardtoreachpopulations.Hard toreachpopulationsarethosethatarenoteasilyaccessiblethroughhouseholdstudies,whichisthecaseforsexworkers andtheirclients.Themethodologyisalsooftenusedforclustersamplingofsocalledfloatingpopulations,whicharenot attachedtoaspecificsitebutmovefreelybetweensites.Siteshoweverareaccessibletoresearcherswhocanconduct interviewsonsite.Whenusingtimelocationsampling,theprimarysamplingunitforfloatingpopulationsisnotonlythe physicalsitebutalsothetimeofthemonth/week/daywhensamplingtakesplace.Respondentsforthesurveyswillbe chosenrandomlywithinselectedsamplingunits.
1

Page9

with the TRaC among clients of SW planned for the end of 2009 in the same hotspots. Results will helpprogrammersanddistributionteamsimproveweakspotsincurrentdistributionandpromotion efforts. 6) FoQusonConceptDevelopmentSreau A qualitative study using the photo narrative methodology was conducted among mothers and caregivers of children under five, users and non users of Sur Eau in periurban and rural area. The purpose of this qualitative study is to provide information that can be used to develop the brand, messageorcampaignpersonalityforSurEau.ResultswereavailableinFebruary2010. B. OtherStudiesConductedDuringThisPeriod 1) OperationsresearchwithPOUZN The POUZN project has been implementing an operations research study in Madagascar since February2010todeterminethemostefficientandeffectivedelivery/distributionmodelsforassuring accesstoandcorrectuseofzincandORS/ORTaspartofcommunitystandardcasemanagementof diarrheas in children under five years of age and to identify behaviors, attitudes and other factors thatmotivateandensurecorrectuseofzincasadiarrheatreatment,includingaffordability,access, packaging,media,andmessages.Analysisofthedataisongoing. 2) Determinantsofproviderproductivitysurvey UndercofundingwithPSIsWHP,PSIdevelopedaproviderperformancestudytoidentifycommon characteristics among high, medium and low performing providers. Study results will allow PSI to develop a screening system that predicts future provider productivity and develop training or any othertoolsthatimproveormaintainproviderproductivityovertime. 3) Otherqualitativestudies Several other qualitative studies were completed during the reporting period. They include: pre testing of the brand name, logo and packaging for Microlut and for the soon to be launched pneumoniaproduct;andpretestingofaradioseriesforlongtermfamilyplanningmethod. C. SelectionofPlannedResearchStudiesApril2010September2010 1) Outletandhouseholdmalariatreatmentsurvey 2) FoQusstudyamongTOPReseausdoctors Qualitative research among providers to determine what motivates them, what a typical highlow performerlookslikeandhowtobestsupportthem. 3) FoQUsforTRACimprovementamongyouth1524 Qualitativestudyusedtogeneratemultiitemscalesand/ortomodifyexistingmultiitemscalestobe usedforthenextTRaCSurveyamongyouth. 4) PretestingTVspotsforProFemina(PSIsWHP)andforshorttermcontraceptivemethods

Page10

5) FoQusonsegmentationisplannedinthenextquarteramongusersofFamilyplanning 6) Formative study about emergency contraceptive, qualitative research about the packaging of the emergency contraceptive and pretesting tools for community based distributionagent. 7) ConceptTestingforthenewGasyBandyCoolCampaign 8) PretestingflipchartonFPforcommunitybasedagents 9) PretestingLLINspotradio(educationalandpromotional) 10) Pretestingfilmaboutdiarrheapreventionandtreatment 11) Formativestudyonmalariacasemanagementatcommunitylevel .

Page11

RESULT AND ACTIVITY HIGHLIGHTS

Result1MaternalandChildHealth I. DIARRHEA PREVENTION INCREASED CORRECT AND CONSISTENT USE OF SAFE WATER SOLUTION(SWS)AMONGLOWINCOMEMALAGASYHOUSEHOLDS Likeinthepreviousreportingperiods,salesofSrEaubrandedpointofusewatertreatmentsolution exceed ambitious objectives (109%) despite challenges in managing the supplier whose cash flow problemsareaffectingstocklevels.DespitePSIsbesteffortstohelpSigmamanagetheircashflow (PSIplacedalargeorderof1.2millionbottlestoallowforSigmatoprocureenoughcapsandavoid stockoutofcaps,afrequentcausefornotbeingabletodeliversuppliesaccordingtotheschedule), thiscompanyhasgreatdifficultiestokeepupwithPSIsproductneeds.Astheircontractisupinthe nextreportingperiod,PSIispreparingacompetitivebiddingprocessforthesupplyofSrEau.Erratic supplynegativelyaffectssalesanditishopedthatthesupplierselectedthroughthisprocesswillbe abletoensuremoreconsistentdeliveries.

During this reporting period, the SrEau team has expanded the horizon of its collaborations. In November 2009 and January 2010, WSUP and WaterAid requested the SrEau team to build their capacityinsocialmarketing.UsingtheexampleoftheSrEauprogram,theteamhasbeenableto shareitsapproachofsocialmarketing,withaparticularfocusondistributionandcommunication.PSI hopestoextendthiscapacitybuildingroletootherorganizations.

Page12

PSIparticipatedintheWorldWaterdaycelebrationsonMarch22inMahitsy,togetherwithUSAID funded organizations active in water treatment and hygiene promotion HIP, SantNet 2 et and the RanoHP consortium, in the presence of the US Ambassador in Madagascar. New collaborations are beingstartedandwillbeoperationalinthenextreportingperiod: Scouts/HIP/PSI:Allthreeorganizationswillsignaconvention.Afterhavingreceivedtrainings from HIP on water, hygiene and sanitation, scouts will conduct largescale sensitization sessions:464trainedscoutswillreach104,400peopleandPSIwillensuresupplyofSrEau: eachscoutwillbegivenaSrEaubottlefollowingthetrainingsession,andtheywilluseitfor demonstration. Trained scouts will work with wholesalers to sell SrEau following sensitizations. WFP/PSI:Throughthispartnership,PSIwillbuildthecapacityofWFPschoolcanteenagents in884schoolsintheSouthofMadagascar(Androy,AnosyandAtsimoAtsinanaregions).With WFP funding, PSI will conduct trainings on hygiene and communication techniques. This collaboration will help redyanmize and extend the Sekoly SurE approach in this part of Madagascarwherediarrheaisanimportantburden. PSI/LandO Lakes: PSI will train roadside restaurants (hotely) owners on hygine. This collaborationwillhelpexpandtheHotelySrEnetwork. These initiatives reinforce the community approach that aims to create demand for better hygiene practices, including consistent use of SrEau. Collaboration continues with Sant Net 2, through trainingofcommunityagentsthatreceiveastartupkitoncetheirtrainingiscompleted. Outside of SantNet areas, 284 community agents (151 women et 133 men) have been trained by PSIs trainers / promoters to prevention and management of uncomplicated diarrhea at the community.Thediarrheapreventionandmanagementtrainingpackageshavebeenintegrated. Research activities in the reporting period consisted in a Focus on Marketing Planning study. The objectiveofthisqualitativeresearchtoolistogaingreaterinsightsonthetargetaudiencetogenerate ideas and make marketing plan more centered on the target groups. Some of the outputs of this researchareaCategoryMapthatcomparesdifferentwatertreatmentmethodsastargetgroups viewthem,andasegmentationgraphthatsummarizesdifferentbarriersandmotivatorsforthe use of SrEau and identifies different archetypes to finetune target group profile and SrEaus positioningstatement.Basedonthisresearchandotherdataaccumulatedoverthelifeoftheproject, theSrEauteamwillwritethemarketingplanbasedonthenewDeltamodeldevelopedbyPSIs Globalcapacitybuildingdepartment.Sincethecommunicationstrategywillchangebasedonthisnew marketing plan, few communication activities took place during the reporting period. Counseling cardsforcommunityagentsarebeingupdatedtoincludemanagementofuncomplicateddiarrhea.In the next reporting period, a film including diarrhea prevention and treatment messages will be producedtobedhownduringMVUshows. Regarding the environment component of the program, the EMMS has been finalized and some environmental impact mitigation measures such as collection of expired SrEau bottles have been implemented: 33,760 expired SrEau bottles have been returned during the reporting period. This quantityhasbeendiscountedfromsales.PSIgavetheMinistryofHealth2,000SrEaubottlestobe distributedintheSouthEast,aregionthathasbeenbadlyaffectedbytheHubertcycloneinFebruary 2010. II. DIARRHEATREATMENTINCREASEDCORRECTANDCONSISTENTUSEOFDIARRHEATREATMENT KITTOTREATDIARRHEAATHOME

Page13

Secondary analysis of TRaC 2008 data has been carried out to better identify determinants to be addressed.Thisanalysishelpedunderstandwhattreatmentsarebeingusedbymotherswhentheir childhavediarrhea(seetable1),theprescriberofantidiarrhealsorantibioticsusedtotreatchildren with diarrhea (table 2), and mothers knowledge of correct ORS + zinc use (table 3). The results demonstrate that this project is at its starting point. That there is still a lot to do to address misconceptionsondiarrheatreatmentandtoestablishthesimultaneoususezincandORSasthenew referencetreatmentprotocolforchildrenwithdiarrhea. Table1:Methodsusedfordiarrheatreatment(in%)

Thereisa widespreadperceptionthat diarrheaisnotsevere.Indeed,80.5% ofmothersgavesome kindoftreatmenttotreattheirchild,whichleavesnearly20%whodidnotseekanytreatment.There is still a lot to be done to address the perceived severity of diarrhea and get those who do not do anythingtotreatdiarrheatoseekpropertreatmentandhopefullythecommunicationcampaignto promoteHydrazincwillcontributetoraisetheawareness. Amongthosewhosoughttreatment,zincisbyfarthelowestusedsolution.Simultaneoususeofzinc and ORS was not even mentioned once by respondents. It is important to note that these results weregatheredbeforePSIhadlauncheditsDiarrheaTreatmentKit(DTK),hencereflectingabaseline priortoproductlaunch.However,thepublicsector,throughUNICEFdonations,hadbeendistributing zincandORSin90districts.Resultsshowthatthisprogramhashadlittleimpact.Thereisoveralllow knowledgeaboutzincandORS,bothwiththegeneralpublicandwithprescribers. Table2:PrescriberofantibioticsusedtotreatchildrenwithdiarrheanottreatedwithORSor1/8

This graph shows that, despite training provided in health centers to promote ORS and zinc use, healthcentersandhospitalscontinuetobethemainprescribersofantibioticstotreatdiarrhea.

Page14

Table3:MothersknowledgeofcorrectORS+zincuse

Whileanimportantportionofmothers(yetrepresentingonlyatotalof39%,leavinglotsofroomfor improvement)areabletocorrectlyexplainhowtoadministerORS,knowledgeofzincadministration isnonexistent.ItisimportanttocomplementoverallknowledgeofORS+zincasanefficientwayto treatdiarrheawithknowledgeofzincadministration,asitisdemonstratedthatfollowingthe10day treatmentcourseisrequiredtoobtainsignificantlongtermbenefits. Data from this secondary analysis has been important to guide strategic decisions regarding the program,particularlytrainingsandsensitization.Trainingandcommunicationshavebeenfocusedon creatingawarenessforORSandzincastherecommendedmethodtotreatuncomplicateddiarrhea forchildrenunder5,andonlimitingtheprescriptionofantibioticsandantidiarrheals A. ActivitiesduringOctober2009March2010 1) Trainings InadditiontoitscollaborationwithSantNet2,whosecommunityagentsarealreadytrainedtousing ORS and zinc to treat uncomplicated diarrhea at the community level, PSI granted a 9 months (JanuarySeptember2010)subcontracttoMCDItointroducethismuchneededtreatmentinrural communitiesoftheSouthWestofMadagascar.Thissubcontractensuredcontinuousservicedelivery by community agents of an area particularly affected by diarrhea. To expand the reach of the programtowardsnationalscaleupoftheuseofzincandORSbycommunityagents,PSIpartnerswith otherNGOswhooperateoutsideofSantNet2areas: ASOSSofiathatcomplementsmalariarelatedactivitiesofitscommunityagentswithViasr in6districtsoftheunderservedSofiaregion. MercyMinistriesthataddedViasrtothebasketofproductsofitscommunityagentstrained toIMCIcandwhooperatein22ruralhealthcentersoftheTamataveIIdistrict WCSintheMaroantsetradistrict(Analanjiroforegion)andtheAndapadistrict(Savaregion). Its community agents have been trained to management of uncomplicated diarrhea in childrenunder5. Aimbaovao,anNGOthatworkedinmalnutritioninsuburbancommunesofAntananarivoand that has now enhanced the capacity of its community agents with the management of

Page15

uncomplicated diarrhea in children under 5 and that now sensitizes the population to diarrheatreatment. Thetablebelowsummarizesthetotal numberand typeofagentstrainedbydistrict,withdifferent partnerNGOs(AprilSeptember2009). NGOs/Partners # of trained agents perType Districts gender MCDI MERCYMINISTRIES 556 (354H/202F) 20 (9H/11F) 2H 486 (146H/340F 14 (11H/3F) 25 (13H/12F) 27 (15H/12F) 25 (08H/17F) 1139 (545H/594F) 16 (13H/3F) 1155 Communityagents Communityagents Trainers Communityagents Trainers Communityagents TularII,Ankazoabo, Morombe,Ampanihy TamataveII Antsohihy,Port Berger,Bealanana, Mandritsara, Ambanja,DiegoII Maroantsetra

ASOS

WCSMAKIRA WCSAndapa ONGAimbaovao Subtotal

Communityagents Communityagents Communityagents Trainers

Andapa ManjakaAvaradrano Tan

TOTAL

NGOs reported in this table have had their community agents trained for 2 days to diarrhea preventionaswellasmanagementofuncomplicateddiarrheainchildrenunder5atthecommunity level.Toensureproperreplicationoftrainingsandaccuratedeliveryofinformation,trainersinthese partnerNGOs,oncetheyhavebeentrained,receivesupportfromthePSIteamtodelivertheirfirst seriesoftrainings. Medical doctors are being targeted with continuous medical training sponsored by Hydrazinc, and organizedincollaborationwithregionalmedicalassociations(CROMConseilRgionaldelOrdredes Mdecins).Duringthereportingperiod,continuoustrainingsessionsinformingmedicaldoctorsthat ORSandzincistherecommendedtreatmentprotocol(WHOandUNICEF)foruncomplicateddiarrhea tookplaceintheAtsinanana,BoenyandSavaregions.Thesesessionsfocusparticularlyonthetheme ofabusiveprescriptionofantibioticsandantidiarrheals. In addition to this, PSIs training and promotion team has trained counter staff of pharmacies and dptsdemdicaments, whoareanimportantsourceofadviceformothersseeking treatmentfor theirchildrenwithdiarrhea.ThetrainingfocusedontheimportancetoprescribeORSandzincasthe firstlineoftreatmentforuncomplicateddiarrhea. ThetablebelowsummarizesthenumberofagentstrainedbyPSIinmanagementofuncomplicated

Page16

ORSandzinc(Octobre2009March2010). NGOs/Partners CROM Pharmacists/Counter staff PSI(Med.promotion dept.) TOTAL 2) Communications Given the very low knowledge and use of ORS and zinc, training alone is not enough to change behaviors and a largescale communication campaign including mass media and interpersonal communication is necessary to reach the projects ambitious objectives. PSI worked with Grand Angle, a reputable advertising agency selected through a competitive bidding process, to design a communicationstrategythatwillcontributetochangingbehaviorsrelatedtodiarrheatreatment.The followingcommunicationmaterialshavebeenproducedtosupportthesocialmarketingstrategyof bothHydrazincandViasr: Type Number Users Videospots 2 MVUCROMTVStations Audiospotsinnationalandlocallanguages 3 MVUCROMRadiostations Brochures Pointofsalematerials Bannerforstands/presentations Duringthisdiarrheaseason(November2009March2010),PSIaired441radiospotsatthenational leveland98inlocaldialect,intheTularIetIIlocalradiostations.Somepromotionalmaterials(tee shirts, pens, keyrings) have been produced to support regional minilaunches organized in collaboration with the CROM. Other sensitization support materials (counseling cards) and training support materials for community agents (IMCIc algorithm) and pharmacy counter staff (simplified brochures)arecurrentlybeingproducedandwillbedisseminatedinthenextreportingperiod. 3) Distribution WhileHydrazincispresentinanestimated90%ofpharmaciesand80%ofdptsdemedicaments, sales have been slow (25% of 2nd quarter objectives). Since availability is very high, this is mostly a problem of lack of product knowledge. Hopefully, communication campaigns (more precisely the massmediacampaignsplannedinthenextreportingperiod)andregionalminilaunchesshouldhelp addressthisproblem.However,prescriptionbehaviorslongengrained(antibioticsandantidiarrheals) aredifficulttochange,particularlyamongpharmacystaff,asprofitmarginsgainedwiththesaleof Hydrazinccannotmatchthoseofantidiarrhealsandantibiotics. 3,000 300 4 CROMPSIFARMAD Pharmacies PharmaciesDpts PSIPromoters #ofpeopletrained 309 158 Type Mdecins Pharmacists/staff Regions Atsinanana,Boeny, SAVA Tana,Diego, Tamatave,Antsirabe, Tular,Majunga National

1,691 2,158

MD

Page17

During several field visits, PSI staff noted that Hydrazinc movement in dpts de medicaments was veryslow,mostlybecauseoftheproductcostswhichisrelativelyhigh(2,000Ar)comparedtoother productssoldintheseoutlets.ItisthereforerecommendedthatHydrazincbereplacedwithViasr (whichcosts500Ar)indptsdemedicaments.Thatway,communityagentsinremoteareaswillbe able to get their products from these outlets. This new system should help increase availability of highquality ORS and zinc treatment in remote areas. Hydrazinc will be mostly sold in urban areas wherethepriceoftheproductislessabarrier. Thesupplychainsystemputinplacein72districtsaspartofthecollaborationbetweenPSIandSant Net 2 is operational. However, most communelevel distribution points have had difficulties restockingatthedistrict,giventheimportantdistancebetweenthedistrictandthecommune.Cash flow is also an issue, since communebased distribution points often do not have sufficient cash in handtoprocuretherequirednumberofprepackagedtreatmentstorestockallcommunityagentsin their area. A coordination and informationsharing workshop is planned in April to improve this communitybased distribution system. PSI has setup the same distribution system in communes outsideofSantNet2interventionareas. ProcurementhasbeenchallengingandthisstronglyaffectsViasrsales.ProcurementofViasrwas launchedinNovember2009,afterobtainingawaivertoprocureORSfromsourcesoutsidetheUnited States. In addition to the timeconsuming bidding process, it took suppliers a long time to send productsfortastingandtogetthefinalproductdesignright.ORSisexpectedtoarriveinMadagascar in May. This has limited the supply of ViaSur during the 20092010 diarrhea season to the small amonts received the previous year. These delays will affect training plans for the next reporting period, forcing PSI to organize several simultaneous trainings in June, which will require recruiting extratrainerstohandlethisworkload.Thissupplyproblemwillprobablymakeitchallengingtomeet training and sales objectives in the next reporting period, but teams are prepared to react quickly oncetheproductgetsintoMadagascar. 4) Research Operational research on distribution channels and ORS & zinc use has been carried out in February/March 2010 by Focus Development Association (FDA). Results are expected in June 2010. Thisqualitativeandquantitativeresearchwillprovideadditionalevidencetoguidetheprogram.

Page18

RESULT AND ACTIVITY HIGHLIGHTS

Result2FamilyPlanningandReproductiveHealth I. SALESANDDISTRIBUTIONOFSHORTTERMHORMONALMETHODSANDNATURALMETHODS PSIreceivedtheshipmentofprogesteroneonlypill(Microlut)inJanuary 2010.Thebrandname,packagingandpricewerepretestedandfinalized, leading to the selection of the following brand logo, packaging. The product is positioned as the progesteroneonly pill that is easy to use, healthy and effective, adapted to nursing women, and brings peace of mind. MicropiladoptedthesamepricestructureandgenerallookasPilplantoencouragewomentokeep using modern FP methods after nursing ends. PSI is currently awaiting the appropriate documentationfromthemanufacturertoregisteritandlaunchitonthemarket. The new Pilplan and Confiance packagings were launched in February. A separate packaging was produced for communitybased distribution to avoid leaks into the commercial sector. Significant improvementsweremadetothePilplanpackagingtomakeitmoreuserfriendlyandcostefficient. Both products now also benefit from added exposure via branding on the prsentoir that was adjustedtobedisplayedonwallsatpointsofsale. All products were subbranded by the umbrella family planning brand ProFemina, to create a perception of a family of quality modern methods that women can freely choose from. This also allows PSI to overcome the regulatory challenge limiting the promotion of prescriptionbased productsonpointsofsale.

Duringthereportingperiod,PSIdistributed:987,643cyclesofPilplan(38%ofannualprojection,94% pharmaceutical, 6% CBD), 459,584 doses of Confiance (46% of annual projection, 96% pharmaceutical,4%CBD)and7,596unitsofVakana(38%ofannualprojection,100%CBD).

Page19

 II. SALESANDDISTRIBUTIONOFEMERGENCYCONTRACEPTION StepsweretakenthisperiodtoplanforthelaunchanewemergencycontraceptionpillinFY10. III. ACCESSTOLONGTERMCONTRACEPTIVEMETHODS Support from USAIDs FP program is complemented by the Womens Health Project (WHP) to increasetheuseoflongtermfamilyplanningmethods(LTM),suchasIUDsandimplants.Underthe WHPproject,PSI/Madagascarfocusesonadvocacyofkeystakeholders,promotionanddistributionof intrauterine devices(IUDs)andimplantsintheprivatesector,behaviorchangecommunicationsfor providers,anddemandgenerationforIUDsandimplants. AsofMarch2010,76certifiedproviders(68clinics)offeredonaregularbasisallreversiblemodern methods including LTMs. Partners for LTM service delivery include 44 Top Rseau clinics. With technical assistance from Jhpiego, PSI builds private sector capacity through regular training and refreshertrainings,monitoringandcomplicationmanagement,throughanetworkofreferralcenters andofapoolofindependenttrainers/supervisorsintargetregions. PSIprovidedaccessduringthisreportingperiodto6,091IUDs(61%ofannualprojections);and754 implants(222%ofannualprojections).

Output1:ImprovingtheOpportunityoftheTargetGrouptoPracticeModernFamilyPlanning PSIMadagascarsfamilyplanningstrategyfocusesonincreasingavailabilityofcontraceptiveproducts toreachcommercialmarketsandviaanetworkoftrainedcommunitybasedhealthworkersagentsin ruralareas. PSIs training teams promote socially marketed products by visiting new pharmacies and private

Page20

providers to increase their capacity to offer FP products and services, and to maintain a constant availabilityofstocksandtraintheirsalesstaff;throughtrainingcommunitybasedhealthworkers;and througheducatingtargetgroupswitheducationalsessionsonfamilyplanning. Duringthisreportingperiod,thetrainingteam: Educated1,057womenandmenaboutFPandproducts Trained23providersonbasicFP Providedcontinuousmedicaleducationforonfamilyplanningto104providers Trained112communitybasedagentsonfamilyplanningandprovidedaninitialstartupstock topromoteanddistributeFPproducts Trained 64 Youth Peer Educators and 28 FP Counselors to mobilize demand for franchised providers Trained 143 pharmaceutical warehouse agents (dpts de mdicaments) to ensure proper storageandincreasetheknowledgeaboutsociallymarketedproducts Trained46providersonLTMs. Districtcoverageincreasedfrom50to90duringthisreportingperiod,including72districtsreceiving supportfromtheSantNet2project,and2fromWCS.Intotal40newcommunitybaseddistribution pointswerecreated. PSI supplied 720 sharp boxes to the community health workers trained on Depoprovera in the SantNet2 areas of intervention to allow for the implementation of the communitybased service provisionofConfiance. Output 2 & 3: Improve the Ability and the Motivation of the Target Group to Practice Modern FamilyPlanning PSIs 2008 TRaC results identified two determinants as a having significant impact on the use of modern contraceptives for both urban and rural women: self efficacy (ability to use pills and injectables); belief (incorrect belief regarding infertility and safety of pills and injectables). Study results on BCC exposure also led PSI to strengthen its communication activities in rural areas, and expanditscommunicationwiththesecondarytargetgroups(providersandpharmacists). Duringthisperiod,PSIproduced3TVspots,1TVfilm,3radiospots,6educationalprograms(Tokysy Antoka) focusing on the two determinants for FP (self efficacy and belief) and on belief, outcome expectation and social support for LTMs specifically. PSI broadcast, aired and featured 607 radio spots,72educationalprograms,172TVspots,11radiospecialreports,and11films.Moreover,103 Mobile Video Unit education sessions, reaching 37,569 people, helped promote modern family planninguse. To further support the expansion of the communitybased approach, PSI is developing new IEC materials specifically for rural areas, including health booklets (under the lead of SantNet2), flipcharts,postersandmore.PSIisintheprocessofdevelopingnewpromotionalmaterialsforpoints ofsaleandprovidersclinicsfocusingonthetwodeterminantsforFP,andonLTMs.

Page21

IV. REPRODUCTIVEHEALTH PSIwouldliketohighlighttwoissuesinReproductiveHealththatpertaintothefranchisednetworkof privateclinics,TOPRseau: A. ExtensionofTOPRseauPlus InNovember2009,PSI/MselectedfivenewclinicstoofferVCTservicesin3TRsites.PSI/Mprovided training support and equipment to the clinics confirm national standards for quality VCT service delivery.Trainingwasorganizedincollaborationwiththepublicsector.Toensureeffectivepromotion oftheservices,ashortrefreshertrainingforyouthpeereducatorswasorganizedinthesethreesites. The total of TR+ clinics is now 21. During the reporting period, 4,110 clients were tested with 11 positivecases,allreferredforcare.PSIusesitsownfundstosupporttheprovisionofVCTservicesfor mostatriskgroups.RefinedtargetingandstronglinkagewithMSMandSWpopulationshelpensure thosewhomostneedit benefitfromsubsidizedaccesstoqualityVCT.The newclinicsareattracting clientsfromriskgroups,with37clientsreportedduringtheperiodJanuaryMarch2010. B. ExtensionofTOPReseaunetworktoMoramanga In December 2009, PSI launched its ninth Top Reseau site in Moramanga. Moramanga was chosen basedonthelocalcontext,itspositionasacrossroadcitywheredifferenthighriskactivitiesaretaking place, the presence of a mining project and the potential private clinics to support our activities. In addition,itisaccessiblefromTanaanditsnetworkmembersandpeereducatorswillinitiallyreceive supportfromtheTanabasedTRstaff.Sixprivateprovidersfromfiveclinicswererecruitedandtrained onyouthfriendlyRHserviceprovision.Sixyouthpeereducators(PEs)weretrainedoninteractiveBCC usingPSIstrainingcurriculumforyouthPEs.Giventhesensitivepoliticalenvironment,PSIorganizeda small launch event that included youth and the newly franchised members; no health or local authoritieswereinvitedsoastomaintainalowprofile. DuringthereportingperiodresultsfromthenineTRsitesindicateitsimportanceinworkingwithatrisk youthandbringingyouthinforqualitycounselingandservices: Atotalof66,176youthclientscameforRHservices(STI,FP,RHservices); Atotalof23,542youthclientscameforFPcounselingandservices; Morethan12,000youthvisitedforSTIcounselingandservices; More than 37,000 youth clients were referred to TR clinics by the team of 92 youth peer educatorswithdiscountcoupons.

Page22

RESULT AND ACTIVITY HIGHLIGHTS

Result3Malaria I. MALARIA PREVENTION INCREASED USE OF INSECTICIDETREATED MOSQUITO NETS (ITNS) AMONGHIGHRISKGROUPS(PREGNANTWOMENANDCHILDRENUNDERFIVE) A. Distributionactivities Duringthisreportingperiod,PSIhasbeenbusytakingpartinthe2009distributioncampaigns,thefirst wave of the campaigns that will bring universal LLIN coverage in Madagascar, thus generating unprecedented health impact in the country. In constant collaboration with RBM and the National CoordinationCommittee(CNC),PSIhasplayedaleadingroleinmakingthiscampaignarealitydespite thenumerouschallenges. Inadditiontotheherewasverylittletimetoorganizethiscampaign.EffectiveplanningstartedinJuly 2009, after the PSI expatriate team returned from evacuation in South Africa. Given the revised US government position towards the government of Madagascar following the sociopolitical crisis, it became impossible to follow the original plan that was to transport and store LLINs using the public sector. USAID/Madagascar advised its partners to work with NGOs in mass distribution areas to organize transportation and storage of LLINs. Restrictions also included supervision of activities by public sector health staff and any other activity involving the public sector. Because of the lagged delivery of LLINs, the CNC decided to organize 2 campaigns, one in November 2009 in the Atsimo AtsinananaregionandonedistrictoftheAnosyregion,andoneinDecember2009intheAtsinanana region.ThetablebelowsummarizestheLLINsdistributedbysource. Table:SourceofLLINsdistributedin2009inmassdistributioncampaigns PMIFY08RoutineLLINsreprogrammedforcampaign PMIFY09(*) GF4(PSI) UNICEF2008RoutineLLINsreprogrammedforcampaign UNICEF IFRC(*) TOTALpartnercontributions 500,000 500,000(*) 100,000 418,000 55,215 80,000(*) 1,653,215

(*):LLINsdistributedinDecember2009intheAtsinananaregion Atotalof1,073,215LLINshavebeendistributedinNovember1621,2009and580,000inDecember 1419,2009.Numbersarestillestimates,asfinaldataisexpectedfromtheNMCPtoconfirmtheexact numberofLLINsdistributed.Themainchallengeofthesecampaignswasthelackoftimetoplanand executeallrequiredsteps.Trainingsparticularlysufferedfromthislackofpreparation,andsupervision visitsdemonstratedthatmostissuesencounteredduringthecampaignstemmedfromthis.Inaddition totheworkofallPSIdepartments,internationallogisticsconsultantsAlainDaudrumezandNorredine Zenatihaveplayedanimportantroletokeeppartnersmobilizedandcreatemomentum.Recruitment oftemporaryfulltimesupervisorystaffdedicatedtothecampaignhelpedresolvemanyissuesinthe field.Severalmeetingstookplacefollowingthecampaignstogatherlessonslearned. Overall,2009campaignswereasuccess,asLLINsarrivedtoeventhemostremotedistributionpoints, and community participation and involvement has been good. Recurring issues included lack of local

Page23

ownershipoverthecampaign,lackofcollaborationbetweenimplementingNGOsandthepublicsector inPMIareas,logisticaldifficultiestoaccessremoteareas,weakIECcomponent,weaklocaladvocacy, inadequate filling of campaign forms, inadequate storage in some areas, unclear definition of household, and insufficient understanding of postcampaign activities (hangup). Several lessons learnedworkshopswereorganizedandinformationfromtheseworkshopswasusedtoredesign2010 campaigns. Unfortunately, in February 2010, the Hubert cyclone severely hit the region where the 2009 campaigns took place. The extent of how the 2009 mass distribution campaign was affected is unknownatthistime. WithGlobalFundmonies,ateammadeofonePSImemberand2SLPmembersrepresentingtheCNC took part in the annual Alliance for Malaria Prevention (AMP) meeting in Geneva in February 2010. During this workshop, the team received a special recognition with Nigeria for the good work undertaken in Madagascar to reach the Abuja universal coverage targets. This recognition from the international malaria community means a lot to PSI and gave the team extra motivation for the arduous upcoming 2010 distribution, when 5.5 million LLINs will be distributed in difficult regions of Madagascar.Inthenextreportingperiod,nearlyallpreparatorystepsforthelargestLLINdistribution campaigneverorganizedinMadagascarwillbecompleted. B. CommunicationActivities During the reporting period, 90 video spots including malaria prevention messages have been aired and 153 MVU shows took place with 18,581 people reached. The objective of these communication activities was to promote correct and consistent LLIN use in order to address the increasing gap betweenLLINownershipanduse.Duringthereportingperiod,trainers/promotershavetrained462 counterstaffand257privatesectorhealthstaffonmalariaprevention. TherewasalsointensecommunicationduringtheLLINcampaignstosensitizethepopulationintarget areastotheLLINcampaignsaswellastopromoteconsistentLLINuse.388spotsaudiohavebeenaired duringthe2009campaign,andthedistributionteamused16,230posters,2,527hats,1,260advocacy flyers, 5,600 leaflets and 83 banners during the campaign. Social mobilization has been another important way to communicate directly with the target audience, and an estimated 198,392 people have been reached during interpersonal communication sessions with mobilizers during the 2009 campaigns. This multifaceted exposure was complemented by communication activities that took place during the hangup phase. During door to door visits, mobilizers have been able to motivate householdstousetheLLINstheyreceivedforfreeduringthecampaign.Bymakingindividualcontact with households and help them hang LLINs on sleeping places, mobilizers strongly contributed to closingthegapbetweenLLINownershipanduse. II. MALARIA TREATMENT INCREASED APPROPRIATE USE OF PREPACKAGED ANTIMALARIALS AMONGCHILDRENUNDERFIVETHROUGHOUTMADAGASCAR A. DistributionActivities While Actipalbranded ACTs (launched in October 2008) have made their way through the different intendedtargetgroups(distributors,prescribersandgeneralpublic)asthenewfirstlinetreatmentof malaria,salesarestillslowandtakeoffnotasfastasexpected.Duringthereportingperiod,PSIsold 155,710 individual doses of Actipal, 71% of which had been distributed through pharmaceutical distributors,and29%throughtrainedcommunityagents.Therehasbeenasharpincreaseintheshare ofcommunitybaseddistributionthatalmostdoubledcomparedtothepreviousreportingperiod. Oneofthepossibleexplanationsforthislackofperformanceofthepharmaceuticalsectorisprobably

Page24

thelowsellingpriceofActipaltoendusers(thepricewasimposedbytheMinistryofHealth),makingit difficultforallactorsinthedistributionchaintocoverthecostofstockingtheproduct.Thereislittle incentivefortheprivatesectortoensureconsistentstockingofActipal.PSIisworkingwithFARMAD, itsmaindistributionpartner,toaddressthisimportantissue.Duringthereportingperiod,Madagascar hasmadesignificantprogresstowardsobtainingAMFm,whichshouldbesignedinthenextreporting period.Thisprojectwillincludeaheavycommunicationcomponenttowardsthepublicsectoranditis hopedthattheimportantinfluxofACTswillcontributetoaddressresistancefromtheprivatesector.In parallel to this, IMCIc scaleup, mostly through Sant Net 2, creates needs for community agents to restockinActipal. Thegeneraltrenddoesnotleantowardsanincreaseinthedemandformalariatreatment.Theshare ofconfirmedmalariacasesinoutpatientvisitskeepsdecreasing,withadropfrom5%to3.9%inayear. More consistent use of Rapid Diagnostic Tests (RDTs) will also contribute to a less systematic use of ACTstotreatfever.MassdistributionofLLINswillalsostronglyimpactthenumberofmalariacases. ActipalSales:October2009March2010

ACTIPAL
35,000 30,000 25,000 20,000 ralisations 15,000 10,000 5,000 0 oct09 nov09 dc09 janv10 fvr10 mars10

PSI started negotiating with UNITAID and UNICEF (the procurement agent for Actipal) so PSIs next procurement order includes combo ACTs rather than coblister. The public sector, through UGP, already distributes combo ACTs and it is important that the pharmaceutical and community sectors alignwiththisoffer.Negotiationsarelongandcomplexasproductcustomizationisrequired,andthere isonlyoneWHOpreapprovedsupplierofcomboACTs.PSIismonitoringtheprogressofthesituation verycloselysothattheorderisplacedassoonaspossibleinthenextreportingperiod. To complement distribution activities and get all target groups to use or prescribe ACTs to treat uncomplicated malaria, numerous trainings took place during the reporting period. PSIs trainers / promotersteamcarriedout24trainingreachingouttoanestimated224peopleincluding: 20pharmacystafftrainingstotaling143participants.Trainingsessionsfocusedontherisksof prescribing chloroquine as opposed to the benefits of ACTs, and on the type of advice that canbegiventoapatientseekingcareinapharmacy. 3 community agents training sessions focused on management of uncomplicated malaria in thecommunity,reachingoutto72communityagents 1trainingof9staffofapartnerNGO.

Page25

B. CommunicationActivities FollowingACTWatch/TRaC2008datademonstratingthatpharmaciesarethefirstpointofcontactof mothersseekingtreatmentformalaria,PSIhasdevelopedaseriesofpromotionalmaterialstoaddress this issue. The objective of these promotional materials is to motivate mothers to seek treatment in health centers to treat fever. Private sector doctors are also targeted with specific Actipalbranded promotional materials to generate Actipal prescription instead of other treatments not based on artemisinin (with 2/3 of all malaria treatments prescribed, Sulfadoxine Pyrimthamine is the most commonlyused). During the reporting period, 153 MVU shows took place, reaching an estimated 57,370 people including 18,581 women. With a total of 107 communes visited, an average of 17 communes per monthhavebeenreached.Sensitizationsessionsorganizedbytrainers/promotershavereachedout toanestimated1,262peoplein21groupsessions.Radiospotshavebeenaired5,036times. NewevidencefromtheDHSshowsthatrapidcareseekingbehaviorformalariatreatmentisstilllow (8%inrural areas,11%inurbanareas).Therefore, messagesfocusingontimecareseekingbehavior arebeingdevelopedandwillbelaunchedinthenextreportingperiod.

Page26

RESULT AND ACTIVITY HIGHLIGHTS

Result4HIVandAIDS Madagascar continues to be characterised as a low HIV prevalence country, but with a significant burden of disease for STIs. STI and HIV rates are highest among groups most vulnerable to infection includingSWs,MSM,andIDUs. Youth, especially those in peri urban areas, constitute a population segment characterised by early unsetofsexualactivity,highratesofmultipleconcurrentpartners,andhighincidenceofunprotected sex. PSIs work focuses on specific atrisk groups and is concentrated on improving access to and availability of male and female condoms in hotspots; reaching at risk groups with key STI/HIV prevention messages through mass media and targeted IPC activities in peri urban sites; and encouraging use of qualified providers for STI treatment and VCT including through its network of franchisedprivateproviders,TopReseau. Unofficialresultsfromthe2009TRACstudyconductedinNovDec2009amongclientsofsexworkers andsexworkersinsevenTopReseausiteswillbereportedfortwokeybehaviours,partnerreduction andcondomuse.OfficialresultsareexpectedbyMay2010,andwillbedisseminatedamongpartners. At that time, newly obtained baseline data will be inserted into the logframe (Annex A), and PSI will monitorprogressagainstbaselineresultsinthenextsurveyplannedfor2011. InparallelwiththeTRACsurvey,PSIcollecteddatafortheMAP(MeasuringAcccesandPerformance) surveyoncondomavailabilityinurbanhotspots.ResultsfromtheMAParebeinganalysedandwillbe reportedinthenextsemesterreport. I. KEYINDICATORACHIEVEMENTS/BASELINEDATA A. Partnerreduction Due to a change in the sampling strategy for at risk men2, the 2009 TRAC monitoring table provides baselinedataforthreemainbehaviorsincludingpartnerreduction,asindicatedbelow. Fromthedataweseethatcommercialsexisveryprevalent,andthatnearly94%ofrespondentsvisit SWinadditiontohavingaregularsexualpartner. Thelargenumberofrespondentswhowereexcludedbecausetheycouldnotgivethenumberofnon regularpartnersisanotherindicationofthehighprevalenceofconcurrentmultiplepartnerships. Aswillbediscussedfurtherinthissectionofthereport,PSIproposestochangethebroadlydefined targetgroupofatriskmentoclientsofSWs,andtofocusitskeymessagesmostlyoncondomuse. Thisimpliesthatweanticipatelittleimprovementinthebelowindicatorforthecomingyear.
2

In 2006 sampling was done among men with specific occupations such as truck drivers, pousse pousse drivers, fishermen,meninuniform,minersetc.In2009,samplingwasdoneinperiurbanhotspotswheremalerespondentsina certainagebracketwhoansweredyestothequestionhaveyouhadsexwithaSWduringthepastthreemonthswas includedinthesample.

Page27

INDICATORS BEHAVIOR/USE Hadtwoormorenonregularsexualpartnersduringthepast12 months(casualandcommercialpartners) Hadtwoormoresexualpartnersduringthepast12months NEED/RISK Hadregularsexualpartnerduringthelast12months Hadnonregularsexualpartnersduringthelast12months1 Hadcommercialsexualpartnersduringthelast12months

1 2

2009 N=508 % 49.2 100 93.7 63.5 100

ThosewhowereunabletogivethenumberofnonregularpartnerswereexcludedN=474 ThosewhowereunabletogivethenumberofallsexualpartnerswereexcludedN=398 B. Condomuseamongsexworkers

Comparingdatafromthe2006TRACwiththosefromthe2009TRACamongsexworkers,wenotea highly significant increase in reported condom use with clients: whereas in 2006, nearly 72% of SW respondentsindicatedconsistentcondomusewithclients,in2009thispercentageincreasedtonearly 81%. We note a firsttime inclusion of data on anal sex, with nearly 44% of 117 SW who engaged in analsexreportingitwasunprotected.Quantitativedataonfemalecondomusewascollectedalsofor the first time, with 23% of SW reporting use during the last 12 months. PSI started distribution of Feeling, thefemalecondom,in2007. Distributionishighlytargeted tosex workers,andiscombined withinteractivetrainingandIPConcorrectuse. INDICATORS BEHAVIOR/USE Usedacondomatlastsexwithclients Usedcondominmostofthetimeoralwayswithclients Had an unprotected anal sexual relation with a man during the last 12 months (among FSWs who had anal sexualrelation) Used female condom with their clients in the last 12 months C. Condomuseamonghighriskmen Asshowninthetableundercondomusebelow,only37%ofthosewhohadsexualrelationswithanon regularpartnerusedacondom;only63%reporteduseofacondomwithasexworker.Thisillustrates the importance of continued promotion of protected sex among men who visit sex workers. The segmentation table, which shows behavioral determinants that distinguish behavors from non behavorsandtheneedtohighlightprotectionoftheirhealthandthatoftheirregularpartnerasakey drivertochangebehavior. 2006 N=1061 % 86.1 71.7 n/a n/a 2009 N=696 % Sig.

*,**,or *** 86.2 ns 80.8 *** 43.6 23.1

Page28

INDICATORS BEHAVIOR/USE UsedacondomatlastsexwithFSW Usedacondomatlastsexwithnonregularpartner1 Used condom in most of the time or always with nonregular partner1 Used a condom at last anal sex with a male partner in last 12 months(amongthosewhohadsexualrelationwithaman)2

2009 N=508 % 63.4 37.3 26.3 45.5

Output1:Increaseopportunityoftargetpopulationstoadoptsafersexualbehaviors Activitiesimplementedunderthisoutputwerebaseduponthebehavioraldeterminantsidentifiedin previousTRaCsurveysintheabsence offinalizeddatanowpresentedforthefirsttimein thetables above. The new Protector Plus packaging and price structure was launched in November 2009. The design reflects a more modern look, a fresh color and updated tag line. The price of the threepack was increased by 100% (from 100Ar to 200Ar). Research with consumers indicates that this price is still largelywithintherangeofwhattheyexpectandcanaffordtopayforthreecondoms.Sofarfeedback fromthedistributionteamconfirmsthatthepriceincreasehasnotbroughtnegativeeffectstosales. Consumers and retail agents appear to appreciate the new packaging, and continue to be loyal consumers. A communication plan for extensive promotion of the new Protector Plus packaging was developed during the reporting period. The main objectives of this promotional launch were to increase brand visibilityandbrandawarenessandtoincreasethereachofthetargetedconsumerbyusingmidmedia interventions.ThecampaignutilizedmassmediaaddsonradioandTV,pointofsaleprintedmaterials, stickers on buses and taxis and live promotion at bus and gas stations. As part of the new brand presentation,PSIintroducedaneightpackatareducedunitprice,toallowconsumertostockup thiseightpackhasadifferentformatthanthestandardthreepack.Wealsointroducedatwopackto useforpromotionalpurposes. ThenewPPpricestructureispresentedinthetablebelow: Format Packof2 Packof3(normalsales) Packof8(boostersales) In2010PSI/MhopestoconductacomprehensiveTotalMarketAnalysisofthecondommarket,given the presence of new higher priced brands and the larger availability of the free condom. While PP+ remainsthecondomofchoiceformany,withitsmarketshareestimated85%(ref:PSI/M2009total market share analysis, CNLS partner forum 2009), such an analysis will help PSI determine the opportunityandneedforasecondsociallymarketedcondom,tobeintroducedatahigherpricethan PP+.Wewillinviteanexternalmarketingexperttoassistwiththisexercise. Price 100Ar 200Ar 400Ar Channel MVUdirectsalestohighriskmenandfree samplesduringshow Allpointofsale(retailersandwholesalers) Gasstationshop,hypermarket

Page29

In addition, for the first time ever, the TRAC survey included a section on brand equity, which is intendedtohelpPSI/Mstrengthenbrandpositioningandbrandperceptionsamongconsumers.With assistance from a professor from GW University in DC, a series of questions were included that intendedtomeasuretheperceptionofPP+versustheperceptionofothercondombrands.Dataare currentlybeinganalysedandwillbeusedtorefinethePP+positioninganditsappealtoconsumers.In future PSI/M may decide to include such a series of questions in other product TRAC surveys to determinetheforceoftheirbrandsvisavisthecompetition. ActivitiesduringSept09March2010 Tokeep up withfemale condomdemandandtoincreasetheinvolvement andownershipoftheSW community, SW peer educators started to involve SW Leaders (SWL) more actively for IPC purposes. SWLareopinionleadersamongSWandholdagreatdealofinfluenceovertheSWpopulation. PSIsSWpeereducatorsworkedwithSWLinseveralsitestoencouragetheirparticipationincondom salesandpromotion,includingnegotiationskills.Interestandparticipationwashigh. Through regular sales, SWLs serve as a sales point for female condoms at the community level. This increasesaccesstotheproductforSWswhowouldnotbeabletopurchasefromPSIspeereducator teams. DuringthereportingperiodPSIproducedandairedacommunicationcampaignonfourmainthemes: to improve the selfefficacy of young men to use condom in any circumstance; to negotiate condom usewithpartner;toimproveselfefficacyofyoungmentorefusesexwithanotherpersonthantheir partner;andtoimproveselfefficacyofyoungwomenonpillsuse.A30secondTVandradiospotwere producedforeachofthesethemes,includinginlocaldialects. To raise awareness of the campaign, a teaser ad was developed and aired to start each behavior campaign. Youth comic books and drama were also produced to complement the TV and radio productionsandtoreinforcethekeymessages.Atotalof8radiospotsand8TVspotsofthepopular ANS(itismylife)showwereproducedandbroadcast136and116timesrespecttively.Broadcastingis donewherepossibleinlocaldialect. While it was initially planned to rotate messages each three to four months to cover all four key behaviors within a single year, due to PSI/Ms internal reorganization, the capacity of the communicationteamtoproducethespots,andthecapacityoftheresearchteamtopretestthemwas hampered.Asaresult,theambitiousmediaplanfortheentirecampaignhadtorescheduled. The campaign is now set to end in December 2010, at which time PSI will conduct a post campaign evaluationtomeasuretheeffectivenessandimpactofthecampaignamongurbanyouth. A total of 14 youth events were organized in the 8 TOP Rseau sites to support the communication campaign. The events were in the form of leisure activities such as sketch competition or sports activities,andweredesignedasanopportunitytoinvolveyouthcommunityleadersandassociationsin reproductivehealthwork,andtopromotetheTRnetwork. Theproductionofnewcommunicationactivitiesforhighriskmen,orclientsofSWs,willcommencein thecomingmonths,followingtheanalysisofTRACdata. IntheDELTAworkshopsomedecisionsweretakenwithregardtothecontentandformatofthenew campaign,including:

Page30

 The high risk men BCC brand Gasy Band Cool (GBC) has been repositioned for clients of SWsasthelifestylechoicethatprovidesRatoma3(thetargetgroup,describedasasexual thrill seeker) the excitement and adventure he craves while protecting his sexual health. The revised brand will associate GBC with Xtreme sports in order to draw a parallel with sexual risk taking. To the uniniated outsider, Xtreme athletes might look like they are recklessandrisktakers.Inactuality,though,theyarehighlyskilledathleteswhotakeevery precautiontominimizetheirrisksothattheywillnotgetinjured. Possiblewaystousethisconceptwillincludetheproductionofvideostobedistributedvia MVU, in bars, etc. using purchased Xtreme sport footage. Beyond this, only a presenter is requiredtoexplainhowXtremeatheletesreducetheirriskandtomakethelinkwithsexual risktaking.Noactorsoractingwillberequired. The videos should easily pass the Stop, Understand & Feel Rewarded test in that the they will 1) be extremely attentiongetting since such programs are not common in Madagascar (the stop test); 2) be easy to relate to the promoted behaviors of condom use during commercialsexandSTItreatment(i.e.,understandthebenefitpromised);and3)rewardthe viewerwithinformationhewasnotprivytobeforeabehindthescenesunderstandingof howtheseathletesprepareforandexecutetheirstunts(feelrewarded).Theconcepteasily lendsitselftomanyepisodes,sincetherearesomanyXtremesportstoexplore. PSI/Mintendstopretestthebrandconceptofthecampaignandsomeofitsearlyoutputs,e/gTVclip and DVD material, to ensure that it is getting the attention of the target group, that it can communicate brand positioning and personality, and make the link with sexual health, and that the targetgroupenjoysandunderstandsit.KeyattitudesrelatedtothenewGBCbrandwillbemeasured andtrackedovertime,e.g.,whetherornotsomeonecanhaveanexcitingandadventurouslifewhile protecting his sexual health (the brands positioning). If this is not the case, PSI/M will redesign the next phase of the GBC campaign to include concepts that do speak to the brand positioning and personality. Giventhereorientationofitsprogramactivitiestoincludemenwithmanysexpartnersinhotzones, PSI/M has also decided to focus less on partner reduction in its mass media campaigns. While IPC workers will continue to present integrated messages, it is clear that broad media campaigns on partner reduction will have little to no impact on high risk thrill seekers such as Ratoma who pride themselvesonhavingmanydifferentsexpartnersandliveinaculturalenvironmentwherethisismore orlessaccepted.Insubsequentphasesofthecampaign,oncetherelationshipbetweenthenewbrand andthetargetgrouphasbeenestablishedandprioritybehaviorshavebeenaddressed,theideawould betoslowlyintroduceotherkeybehaviorsthatarenotoriouslydifficulttoaddress(partnerreduction amongclientsofSW). A new pretest format will be used and introduced in the months to come. It will include both a quantitative and a more traditional qualitative component. The new GBC campaign is well suited to pretestthenewresearchtoolasitisakeycampaignofhighimportance,willinvolvemultiplemedia channels, has a direct link with a brand (PP+ condom) and a very clear behavioral message (condom use).
TheGBCcampaignwillfocusonhighriskmeninurbanhotspots,andRatomawillserveasthebrandspokespersonto reinforceitspositioningwiththetargetgroup.Inourworkondeterminingtheaudienceprofile,Ratomastandsoutasa typical Malagasy low to middle income guy who craves sexual pleasure and is attracted by the thrill of having many exciting sex partners. Qualitative research confirmed that such men visit SWs often, have multiple concurrent partners andareatthehighestriskofcontractingSTIs/HIV.Theyarealsonumerous,asconfirmedthroughtherecentTRACsurvey which indicated the high prevalence of multiple partners, the low consistent condom use even with SWs and the low perceivedriskRatomashave.
3

Page31

In October 2009, with funding from JICA, PSI Madagascar produced a short edutainment film that discussestheriskandinconveniencesofmultiplepartnerships,demonstratesafunandeffectiveway todiscussandnegotiatecondomuse,andshowstheriskandcostsofhavingSTIs.Anoutsideagency wasrecruitedtoproducethefilm.ThefilmfeaturestwocelebratedMalagasysingersandwasshoton locationinTular,whereitwillbeextensivelyusedduringMVUandIPCpresentations.PSIwillconduct ashortposttestofthematerialsixmonthsafteritsinitialintroductiontothetargetaudience(menat risk;generalmalepopulation). Output2:Increaseabilityoftargetpopulationstoadoptsafersexualbehaviors ActivitiesduringSept09March2010 Since2007,PSIhasbeenworkingwithpeereducatorteamsonriskreductionstrategiesinthreeTop RseausitesformenatriskforSTI/HIV.Duringthereportingperiod,thePSIpeereducatorteams(in Antananarivo, Toamasina, Antsiranana) reached 13,814 highrisk men with STI/HIV prevention messages. Interest in their activities is high and they are often actively solicited to hold educational sessionsintruckstops,teashopsandotherplaceswhereworkingmengather. InadditiontoansweringquestionsaboutSTI/HIV,thepeereducatorsalsopromoteVCTforHIVatTop Rseau Plus clinics using discounted coupons. During the reporting period, they distributed 1158 coupons, with 596 men going for VCT. Recognising the need to bring men in for regular STI consultations,inthecomingreportingperiodPSIwillintroducediscountedservicesforthisgroupfor STI diagnosis and treatment at TOP Rseau clinics. In each of the three sites, providers who are interestedinthiswillbeselectedandintroducedtothevouchercomponent. Theoutreachteamshaveconducted4trainingsforatotalof30TopRseauprovidersintheprovision of MSMfriendly services in 4 sites (Fort Dauphin, Tamatave, Majunga, Diego). MSM peer educators provide coupons during their outreach/IPC sessions for discounted STI and VCT services. During the reporting period, MSM peer educators reported 1733 individual contacts with peers, 1304 coupons distributed and 322 MSM going for VCT services and 287 receiving STI treatment or counseling at selectedTOPRseauclinics. The focus of the MSM program in 2010 will continue to be on finding new members of this largely hidden and difficult to access community, through PSI/Ms team of ten peer educators. In addition, withGFround8HIVsupport,PSIwillworkwithtenSubRecipientsineightregionsofthecountryon MSMrelatedactivities.ItisgenerallyacknowledgedthatPSIisaleaderinthisfieldinMadagascarand hence,capacitybuildingandtransferofskillsandknowledgeareamongthemainprioritiesintheinitial startupphaseofGFRound8. PSIiscommittedtobuildingthecapacityoflocalassociationsincludingtheMSMassociation,Solidarite desHSH.WithPSIsupport,SolidariteHSHhasbeenselectedforasmalloneyearPAFgrant(UNAIDS). ThegoalofthisprojectistoimprovetheaccessanduseofSTI/HIVpreventionandtreatmentamong MSM people. In addition to providing indirect administrative and technical support, PSI worked with Solidarite on the recruitment and initial training of MSM peer educators in 3 intervention sites, Mahajanga,FianarantsoaandSteMarie. Duringthelastmonthsof2009,andinanticipationofalargerorderthroughtheGFround8HIVgrant, PSIhasinitiatedprocurementofgellubricant.Atotalof200,000unitswillarriveinmid2010,andwill be distributed free of charge to MSM. We consider packaging the gel with a brand name associated with PP+, in Malagasy and according to MSM preferences. This would indirectly reinforce the PP+ brandandserveasaremindertoalwaysusecondoms.

Page32

PSI continues to improve and expand its sex worker peer education program. The program is run in seven TOP Rseau sites and involves 21 trained peer educators. Peer educators serve as a point of contact for information, support and access to products/services for their community. During the currentreportingperiod,peereducatorsreported5725individualcontactswithpeers,sharingSTI/HIV prevention messages with more than 8956 sex workers, convincing 1536 sex workers to seek VCT servicesandsellingmorethan13560femalescondomsand27002maletotheirpeers. FollowingtheOctoberDeltamarketingplanningworkshop,PSI/MdecidedtoreorientitsSWprogram activitiestoincludeother,nonSRHrelated,topicsinitsoutreachworkwiththisgroup.Theprogram wasrepositionedtobemorerelevanttoSWswhodefinethemselves,asqualitativeresearchshowed, often was mothers and care takers. Feedback from the field indicated that PSI Peer Educators and trainersarestartingtoexperienceaudiencefatigueforHIV/STIrelatedmessageswhenencountering membersofthetargetgroup.Wedecidedtotestwhetheranentrypointthatiscenteredaroundtheir desire to be good mothers and to take care of their children would make access easier and help PSI peereducatorsreachnewSWs.Thepositioningstatementoftheprogramhasevolvedto:ForOlga, theFelanaprogramisthethatgiveshertheinformation,skillsandopportunitytoimprovethehealth ofherchildandthesexualhealthofherself.Throughthecourseofthisandnextyear,activitieswillbe expanded accordingly and synchronized with other PSI/M programs (e.g., malaria prevention, safe water, loyalty programs where a free doctors consultation for her child can be earned if she gets STI/HIV tested four times a year, etc.). The new program kicked up unofficially in December with a Christmas party for more than 300 of these women and their children using funds provided by the AmericanactressAshleyJudd. II. INDICATORACHIEVEMENT:STICASEMANAGEMENT In20082009,PSIpurchasedatotalof352,000Cura7and295,000Genicuretocoversocialmarketing needsandtoavoidproductstockout.Asaresultofthecurrentpoliticalsituationandtheabsenceof World Bank funds, the MOHFP is no longer supplying STI treatment kits. In late summer 2009, PSI utilized program income to purchase 195,000 Cura7 and 150,000 Genicure to avoid stock out. However, products arrived a few months later than expected, in February and March 2010 respectively, which accounted for a product shortage in early 2010. During the reporting period PSI sold 89,063 Cura7 and 75,606 Genicure, well below the period objectives. Given the difficulty in attracting funding for the kits, PSI/M will monitor the field situation to assess real needs, and in collaboration with its DC headquarter staff, decide on use of project income to cover 2010 needs. A costanalysisofbothproductsisplannedforthecomingtrimester. PSItrained134pharmaceuticsagentsandother27communityagentsonuseofthePPTkitsduringthe currentreportingperiod.TrainingoncorrectproductuseremainsanimportantcomponentofPSI/Ms workinSTIprevention,andwithanewlyrecruitedandtrainedteamoftrainers/promoters. ActivitiesduringSept09March2010 PSIsSWpeereducatorsencouragetheirpeerstoseekeffectivediagnosisandtreatmentservicesfor STIs at qualified providers. This is accomplished through the provision of coupons for discounted STI servicesatTOPRseauclinics.Anestimated5844couponsweredistributedduringSWpeeroutreach; 3096SWreceivedSTIservicesatTOPRseauclinics. PSIcontinuestoaddressaccessrelatedbarrierstoSTIservicesthroughitsyouth,SW,MSMandHRM peer worker teams and the TOP Rseau providers. On the distribution side, medical detailers will continue their advocacy work to encourage use of the prepackaged treatment kits in public and privatehealthfacilities.Duringthisreportingperiod,TOPRseaudoctorsprovidedatotalof12,098STI consultationstoyoungpeople.

Page33

ResultsfromtheTRACsurveyamongclientsofSWwhohadsexwithaSWinthelast3monthsindicate the high prevelance of STIs among this population. As the table indicates, 39% of respondents self reported an STI in the past year. Approximately 76% of this group said they received treatment, includingselftreatmentwithprepackagedtreatmentkitorotheroverthecounterdrugs,with71%of thosewhohadasymptomreportingvisitingadoctor.Wenotethat83%knowwheretofindservices andthatnearly86%ofthisgroupofmenknewaboutTOPReseauclinics.Thebelowarebaselinedata againstwhichwewillmeasurechangeinthenextTRACHRG(2011). INDICATORS NEED/RISK HadaSTIinthepast12months BEHAVIOR/USE SoughtSTItreatmentfromaqualifiedproviderifSTIsymptomswereexperienced inthelast12months(AmongclientsofFSWwhohadSTIsymptomsinthelast12 months)1 Received any STI treatment if STI symptoms were found in the last 12 months (AmongclientsofFSWwhohadSTIsymptomsinthelast12months)1 OPPORTUNITY Availability ReportedthattheyknowwheretofindSTItreatmentservices AwareofSTIservicesprovidedbyTopRseauclinics ABILITY Socialsupport ReferredtheirregularpartnerforSTItreatment(AmongclientsofFSWwhohadSTI symptomsinthelast12months)1 SelfEfficacy Reported that they can go to the doctor to get treated when they have STI symptoms Completed their treatment (Among clients of FSW who had STI symptoms in the last12monthsandreceivedtreatment)2 MOTIVATION Belief BelievedthatSTItreatmentservicesareexpensive 2009 N=508 39.3 % 70.9 75.9 % 83.2 85.6 % 45.7

97.6 96.0 % 45.7

Page34

CONCLUSION
In July 2008, Population Services International/Madagascar (PSI) was awarded a new Cooperative Agreement(CA#687A00080003200)whichallowsPSItoexpanditssuccessfulsocialmarketingand behavior change communication interventions in family planning, maternal and child health, and STI/HIVpreventionandtreatment.ThetotalprojectdurationisfiveyearsandthreemonthsfromJuly 14, 2008 through September 30, 2013. This report provided an overview of the main achievements duringtheperiodSeptember2009March2010. Despite a period of continued political turmoil, operations have run more or less normally thanks to the continued support of USAID; PSIs internal reorganization in the fall of 2009 did hamper timely implementationofplannedactivitiesespeciallyforresearchandcommunication.Theyear2010isoff toagoodstart,andPSI/Mispleasedtoreportseveralimportantachievementsthatweremadeduring thesemester,asfollows: Through increasing collaboration with partners and enhanced communications messaging based on TRACresults,diarrealpreventionandtreatmentactivitiescontinuedtogrow,includingthedistribution of SurEau surpassing its targets for the period and the training of over 1000 community agents and 2000medical/pharmacystaffontheappropriatemessagesrelatedtoanduseofdiarrhealtreatment kits. WorkingincollaborationwithRBMpartnerssuchasPMI/USAID,DELIVERandothers,PSIcontributed to the distribution of more than 1.5 million LLINs in the period through two massdistribution campaigns, for which the country received special international recognition from the Alliance for Malaria Prevention (AMP). Progress towards greater distribution of ACTIPAL at the community level wasseenaswellduringthisperiodthankstocollaborationwithpartnerssuchasSantenetandothers. Based on evidence from qualitative and quantitative studies conducted, PSI changed the Pilplan and Confiance packaging and price to promote increased use. Increase partnership with NGOs and CDS resulted in the training of 112 community health agents, 127 private sector providers and 143 pharmaceutical warehouse agents. This in turn improves urban and rural reach of FP products and messagesandrelatedclientcounseling. FollowingthesignatureoftheGlobalFundRound8HIVgrant,activitieshavestartedforrealinthefirst trimesterof2010.PSIanditspartnerPrincipalRecipient,theCNLS,areworkingwith12SubRecipients in8regions,whoareimplementingIPCandservicestoatriskpopulations.Thestartupphasehasbeen verytimeconsuminganddemandedcontinuousinvolvementandfollowupfromPSIsHIVteam,both inTanaandinthefield.ManyoftheSRshavenevermanagedagrantnorbeensubjectedtorigorous monitoringandevaluationprocedures,providingbothPRswiththeimportanttasktointroducesuch procedures and related tools. Skills transfer and capacity building of these local organizations, which includesmallnetworksofSWandMSMassociations,isatoppriority.TheworkPSIhasdonewiththese marginalized groups is providing a solid foundation to expand successful activities, to introduce relevantandeffectiveapproachesandtodocumentresults.PSI/Miscommittedtocontinuingtoserve thesepopulationswithqualitysexualandreproductivehealthinformationandservices.

Page35

ANNEX A: ADJUSTED LOGFRAME INDICATORS

Result One: Family Planning and Reproductive Health

Goal: Reduce maternal and child mortality and morbidity by improving reproductive health of Malagasy women and reducing unintended pregnancy. Purpose: Increased use of modern family planning methods among targeted women Indicator
Increase the % of sexually active 15-24 old females in urban project sites currently using modern family planning methods Increase the % of rural communes with at least one point of sale that sells Pilplan Increase the % of rural communes with at least one point of sale that sells Confiance Maintain the % of urban communes with at least one pharmaceutical outlet and one other point of sale that sells Pilplan Maintain the % of urban communes with at least one pharmaceutical outlet and one point of sale that sells Confiance Increase the % of Top Reseau doctors who score at least 20 on minimum standard for FP counseling in mystery client evaluations

Method of measurement
Behavioral tracking surveys (TRaC) 2008, 2010, 2012

Baseline 2006

Baseline 2008

Result 2009

TARGET 2010

TARGET 2011

TARGET 2012

33.2%

TBD

TBD

MAP surveys 2010 and 2012

46%
MAP surveys 2010 and 2012

55%

65%

42%
MAP surveys 2010 and 2012

55%

65%

4 5

n/a
MAP surveys 2010 and 2012

60%

70%

n/a
Mystery Client Report 2008-2012

55% 4.58% n/a 65% 70%

60% 75%

Significant increase in the mean score for self-efficacy indicators with regard to oral contraception for female youth ages 15-24 in urban areas Increase the % of female youth 15 to 24 in urban area who cite correctly side effects of modern contraception. Significant increase in the mean score for belief indicators regarding pills and injectable contraception among female youth 15-24 in urban areas Number of socially marketed oral contraceptives sold in the last 12 months through the social marketing system Number of socially marketed injectable contraceptives sold in the last 12 months through the social marketing system Number of clients (15 24) seen in the past 12 months through the Top Reseau sites for family planning, Number of IUDs or implants inserted in the past 12 months in Top Reseau sites

Behavioral tracking surveys (TRaC) 2008, 2010, 2012

3.02

TBD

TBD

Behavioral tracking surveys (TRaC) 2008, 2010, 2012

n/a

TBD

TBD

Behavioral tracking surveys (TRaC) 2008, 2010, 2012

Oral : 2.34 TBD Injectable: 2.62 TBD

10

PSI monthly sales monitoring system

1,548,560

887,559

Pill: 2,601,000 Micropill: 80,000 995,000

Pill: 2,862,000 Micropill: 102,000 1,084,000

TBD

11

PSI monthly sales monitoring system

542,782

324,097

TBD

12

PSI monthly sales monitoring system

38,071

22,726

27,763

30,540

33,594

13

PSI monthly sales monitoring system

Implant : 388 IUD: 5,557

Implant : 307 IUD: 7562

Implant : 500 IUD: 10,000

Implant : 125 IUD: 3,400

TBD

14

Increase in the number of community based sales agents who are trained to promote and sell oral contraceptive Increase in the number of community based health workers who are trained to inject Confiance Increase in the number of private sector providers trained in quality reproductive health services and socially marketed contraceptive products (Top Reseau sites, Pharmaceutical Outlets, other) Number of MVU shows held related to family planning Number of radio spots aired related to family planning Number of TV spots aired related to family planning

PSI monthly sales monitoring system 106 PSI monthly sales monitoring system 0 PSI monthly sales monitoring system 278 514 n/a 158

600

200

TBD

15

16

490

490

TBD

17 18 19

PSI monthly sales monitoring system PSI monthly sales monitoring system PSI monthly sales monitoring system

204 4,824 163

142 63 1

192 TBD TBD

192 TBD TBD

192 TBD TBD

Result Two: Malaria Logical Framework

Goal: Reduce malaria related mortality Purpose: Increase use of effective methods of prevention for malaria among vulnerable groups (pregnant women and children under five)

Indicator
Increase percentage of households owning at least one insecticide treated mosquito net (ITN): a)National b)Rural c)Urban Increase percentage of households owning at least two ITNs. a)National b)Rural: c) Urban Increase percentage of pregnant women reported sleeping under an ITN the previous night: a)National b)Rural c)Urban Increase percentage of children under 5 reported sleeping under an ITN the previous night: a)National b)Rural c)Urban

Method of measurement
Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

Baseline 2006

Baseline 2008 a) 79.8% b)78.8% c)85.6%

Result 2009

TARGET 2010 a) 60% b)52% c)68%

TARGET 2011

TARGET 2012 a)90% b)79% c)100%

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

a) 39.9% b)37.4% TBD c)57.0% TBD

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

a) 57.6% b)56.1% c)71.1%

a) 47% b)44% c)50%

a) 85% b)77% c)93%

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

a) 69.1% b)68.1% c)78.8%

a) 55% b)48% c)62%

a) 85% b)77% c)93%

Significant increase in the mean score for availability related to malaria prevention (ITNs & IPT) among 15 to 49 Year old pregnant women.

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

Within grocers: 2.48 Within Health center : 2.48 a) 78.6% b)77.6% c)83.9%

TBD

TBD

Increased percentage of pregnant women and mothers/caregivers of CU5 who know where to obtain ITNs Increased percentage of rural communes which have at least one source of ITNs Increase from 56% to 65% in 2010, and to 80% in 2012 mothers/caregivers of CU5 who cite that fever is a sign of malaria for their children under 5 a) national: b). rural: c) urban: Significant increase in mean scores for beliefs related to prevention methods among caregivers of children under five and pregnant women.

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

TBD

TBD

7 8

MAP Surveys

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

a) 81.7% b)81.7% c)82.1%

a) 68% b)68% c)69%

a) 74% b)74% c)75%

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

On negative effects: 3.27 On periodicity : 3.04 On Cause of malaria: 2.92

TBD

TBD

10

Increase the percentage of pregnant women and caregivers of CU5 who do not believe that treated insecticide mosquito net should be used only during rainy seasons. a)National b)Rural c)Urban Increase the percentage of pregnant women and others/caregivers of CU5 who do not believe that insecticide on insecticide treated mosquito net have ill effects on health. a)National b)Rural c)Urban Mean scores related to willingness to pay for ITN among caregivers of children under five are not significant with regards to use. Percentage of caregivers of CU5 & pregnant women that consider ITNs affordable. a)National b) Rural c)Urban Number of socially marketed treated mosquito nets sold through the social marketing system Number of ITNs distributed or sold

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

a) 75.1% b)74.9% c)74.8%

a) 53% b)52% c)81%

a) 59% b)58% c)86%

11

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

a) 72.3% b)71.9% c)80.7%

a) 41% b)43% c)96%

a) 47% b)49% c)98%

12

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

6665

TBD

TBD

13

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

a) 86.0% b)85.6% c)86.4%

a) 86.0% b) 83% c) 88% 145,311 1,620,00 1,500,000

a) 91% b)88% c)93% TBD

14

Project MIS System

353,747

15

Project MIS System

353,747

145,311

1,620,00

1,500,000

TBD

16

Number of ITNs distributed in country that were purchased or subsidize with USG support Number of people trained in malaria prevention or treatment with USG funds Number of treatments with ACT drugs purchased and distributed to malaria patients under five years of age (with GFATM support) Increase in the number of CBDAs who are trained to promote and sell ITNs and ACTs Increase in the number of private sector providers trained in malaria prevention and treatment following the national policy (Pharmaceutical Outlets, depots de mdicaments, other) Number of MVU shows held related to prevention or treatment of malaria Number of radio spots aired related to malaria Number of TV spots aired related to malaria

Project MIS System

353,747

145,311

17

Project MIS System

369

2004

2,563

2,691

TBD

18

Project MIS System

419,449

299,610

1,200,000

1,080,000

950,000

19

Project MIS System

127

1837

TBD

TBD

TBD

20

Project MIS System

369

2004

2,563

2,691

TBD

21

Project MIS System

685

416

288

288

288

22 23

Project MIS System

6,605 0

3751 0

TBD TBD

TBD TBD

TBD TBD

Project MIS System

Result Three: HIV/AIDS Communications/Condoms Logical Framework

Goal: Reduce the transmission and impact of STI/HIV/AIDS Purpose: Expand correct and consistent use of methods and products to prevent STI/ HIV/AIDS among youth 15-24 years, and high risk populations in project areas

Indicator

Method of measurement
Behavioral tracking surveys (TRaC) among urban youth in project sites 2008, 2010, 2012 Behavioral tracking surveys (TRaC) among urban youth in project sites 2008, 2010, 2012
To be measured by bilateral project 15-24 year old Youth

Baseline 2006

Baseline 2008

Result 2009

TARGE T 2010

TARGET 2011

TARGET 2012

Increase the % of never married 15-18 year old youth in urban areas in project sites reporting never having engaged in sexual intercourse Increased age at first sex among urban youth in project target sites

73.3%

TBD

TBD

17.4

TBD

TBD

Percentage of young people (15 -24) in USAID focus communes who report not having had sex with a nonregular partner in the last 12 months Decrease the % of sexually active 15-24 year old in urban areas in project sites who report having two or more sexual partners during the past 12 months

Behavioral tracking surveys (TRaC) among urban youth in project sites 2008, 2010, 2012

32.9%

32.7%

TBD

TBD

Decrease the % of sexually active 15-24 year old youth in urban areas in project sites who reported having had two or more sexual partners at the same time during last month (last 4 weeks) Increase the % of sexually active 15-24 year old youth in urban areas in project sites who report having used a condom with their last non-regular partner

Behavioral tracking surveys (TRaC) among urban youth in project sites 2008, 2010, 2012

39.4%

TBD

TBD

Behavioral tracking surveys (TRaC) among urban youth in project sites 2008, 2010, 2012

a) regular partners 29.0% b) occasional partners 51.1%

a) regular partners 21.4% b) occasional partners 35.8%

TBD

TBD

Percentage of young people (15 -24) in USAID focus communes who report having used a condom in their last sexual relation with a nonregular partner Decrease the % of HRM who report having had two or more sexual partners during the past 12 months Decrease the % of HRM who reported having had two or more sexual partners at the same time during last month (last 4 weeks)

To be measured by bilateral project 15-24 year old Youth

Behavioral tracking surveys (TRaC) among high risk groups 2009 & 2011 Behavioral tracking surveys (TRaC) among high risk groups 2009 & 2011

73.2%

68%*

63%

n/a

TBD

TBD

Target

10

Increase the % of High Risk Men (HRM) who report having used a condom with their last non-regular partner Increase the % of FSW (Female sex workers) who report having used a condom with their last client Increase the % of FSW who report having used a female condom in the past 6 months

Behavioral tracking surveys (TRaC) among high risk groups 2009 & 2011 Behavioral tracking surveys (TRaC) among high risk groups 2009 & 2011 Behavioral tracking surveys (TRaC) among high risk groups 2009 & 2011
To be measured by bilateral project

62%

67%*

72%

11

86.2%

90%*

94%

12

n/a

45%*

48%

13

14

Significant increase in mean score for social norm indicators for youth 15-18 related to abstinence Increase in % of youth 15-18 who report that it is normal for people their age to abstain from sex

Behavioral tracking surveys (TRaC) among urban youth in project sites 2008, 2010, 2012 Behavioral tracking surveys (TRaC) among high risk groups 2009 & 2011 Behavioral tracking surveys (TRaC) among high risk groups 2009 & 2011

93.3%

TBD

TBD

15

Significant increase in mean score social norm indicators for HRM related to condom use Increase in % of HRM who report that their friends always use condoms with non-regular partners

3.15

3.35*

3.51

16

n/a

TBD

TBD

Target

10

17

Significant increase in mean score social norm indicators for FSWs related to condom use Increase the % of FSW who report that other sex workers always use condoms with their clients Significant increase in mean score for social norm indicators for sexually active youth 15-24 related to condom

Behavioral tracking surveys (TRaC) among high risk groups 2009 & 2011 Behavioral tracking surveys (TRaC) among high risk groups 2009 & 2011 Behavioral tracking surveys (TRaC) among urban youth in project sites 2008, 2010, 2012 Behavioral tracking surveys (TRaC) among urban youth in project sites 2008, 2010, 2012

3.53

3.69*

3.81

18

n/a

TBD

TBD

19

2.49

TBD

TBD

20

Increase the % of sexually active 15-24 year old youth in urban areas who thought that the majority of their friends had less than two sexual partners in past 12 months Significant increase in availability mean score for HRM related to condoms

21.3%

TBD

TBD

21

Behavioral tracking surveys (TRaC) among high risk groups 2009 & 2011 Behavioral tracking surveys (TRaC) among high risk groups 2009 & 2011

3.50

3.66*

3.78

22

Increase the % of HRM in urban areas who report that condoms are always available when needed

64%

74%*

79%

Target

11

23

Increase the % of urban highrisk zones that meet the MAP minimum coverage standard of at least 50% of all outlets that sell condoms

MAP PHASE II Condom 2009-2011

80%

TBD

TBD

24

Increase the % of rural communes that meet the MAP minimum coverage standard of at least one outlets that sells condoms (33% in 2005) Increase the % of sexually active 15-24 year old youth in urban areas who both correctly identify ways of preventing the sexual transmission of HIV/STI Significant increase in the mean score for knowledge indicators with regard to prevention of HIV/STI among sexually active 15-24 urban youth. Significant increase in mean score for self-efficacy among 15-24 sexually active urban youth related to partner reduction and condom use

MAP PHASE I 2010-2012

TBD

TBD

25

Behavioral tracking surveys (TRaC) among urban youth in project sites 2008, 2010, 2012

9.5%

TBD

TBD

26

Behavioral tracking surveys (TRaC) among urban youth in project sites 2008, 2010, 2012

5.24

TBD

TBD

27

Behavioral tracking surveys (TRaC) among urban youth in project sites 2008, 2010, 2012

Partner reduction: 2.92 Condom use: 3.18

12

28

Increase the % of urban youth 15-24 who report they are able to refuse sex with someone other than their partner

Behavioral tracking surveys (TRaC) among urban youth in project sites 2008, 2010, 2012 Behavioral tracking surveys (TRaC) among urban youth in project sites 2008, 2010, 2012 Behavioral tracking surveys (TRaC)among high risk men 2009 & 2011

83.7%

TBD

TBD

29

Increase the % of 15 to 24 year old in urban/rural areas who are confident in their ability to use a condom

71.8%

TBD

TBD

30

Significant increase in mean score for self-efficacy among HRM in urban areas related to partner reduction from 3.28 in 2006 to 3.44 in 2009 and to 3.6 in 2011 and condoms from 3.42 in 2006 to 3.58 in 2009 and to 3.7 in 2011 Increase % of HRM who report they are able to limit the number of their sexual partners Increase the % of HRM who state that they can always persuade casual partners to use condoms Significant increase in selfefficacy mean score for self efficacy among FSW in urban areas related to condoms

a)partner reduction : 3.28 b)condom: 3.42

a)partner reduction : 3.44 b)condom: 3.58

a)partner reduction: 3.6 b)condom : 3.7

31

Behavioral tracking surveys (TRaC)among high risk men 2009 & 2011 Behavioral tracking surveys (TRaC)among high risk men 2009 & 2011 Behavioral tracking surveys (TRaC)among high risk men 2009 & 2011

TBD

TBD

32

72%

77%*

82%

33

3.52

3.68*

3.8

Target

13

34

Increase the % of FSW who state that they are able to convince all their clients to use a condom from 84.5% in 2006 to 89% in 2009, 92% in 2011 Number of Socially marketed condoms sold through the last 12 months through the social marketing system

Behavioral tracking surveys (TRaC)among high risk men 2009 & 2011

84.5%

89%*

92%

35

Project MIS System

Male condoms : 9,450,480 Female condoms : 22,387

Male condoms : 5,850,336 Female condoms : 14,514

Male condoms: 20,274,50 0 Female condoms: 31,500

Male condoms: 22,026,30 0 Female condoms: 33,000

Male condoms: 23,939,50 0 Female condoms: 34,600

36

Number of individuals trained to promote HIV/AIDS prevention through abstinence and/or being faithful (A, B only) Number of individuals trained to promote HIV AIDS prevention programs through other behavior change beyond abstinence and being faithful (A, B, C) Number of individuals reached through community outreach that promotes STI/HIV/AIDS prevention through abstinence and/or being faithful (A, B only)

Project MIS System

n/a

37

Project MIS System

208

653

678

TBD

38

Project MIS System

n/a

Target

14

39

Number of individuals reached through community based outreach that promotes STI/HIV/AIDS prevention through other behavior change beyond abstinence and/or being faithful (ABC)

Project MIS System

216439

341,683

344,702

TBD

15

Result Four: HIV/AIDS STI Case Management LOGICAL Framework

Goal: Reduce the transmission and impact of HIV/AIDS Purpose: Increased use of high quality STI services and products and VCT services Indicator 1
Increase % of sexually active 15-24 year old youth in urban areas in target sites with an STI in last 12 months who sought a treatment from qualified provider. Increase % of HRM in urban target sites with STI symptoms in last 12 months who sought a treatment from qualified provider Increase the % of FSW in urban target sites with STI symptoms in the last 12 months who sought a treatment from a qualified provider Significant increase in mean score for sexually active youth 15 - 24 year old in urban target areas with regard to availability of STI services Increase the % of sexually active youth 15 -24 in urban target areas who report that they know where to find STI treatment services

Method of measurement
Behavioral tracking surveys (TRaC) among urban youth 15-24 (2008, 2010, 2012)

Baseline 2006

Baseline 2008

TARGET 2009

TARGET 2010

TARGET 2011

TARGET 2012

57.0%

TBD

TBD

Behavioral tracking surveys (TRaC) among high risk groups 2009 & 2011 Behavioral tracking surveys (TRaC) among high risk groups 2009 & 2011

82%

87%*

92%

87%

92%*

96%

Behavioral tracking surveys (TRaC) among youth (2008, 2010, 2012)

3.10

TBD

TBD

Behavioral tracking surveys (TRaC) among youth (2008, 2010, 2012)

83.3%

TBD

TBD

Target

16

Significant increase in mean score for HRM in urban target areas with regard to availability of STI treatment

Behavioral tracking surveys (TRaC) among high risk groups 2009 & 2011 Behavioral tracking surveys (TRaC) among high risk groups 2009 & 2011 Behavioral tracking surveys (TRaC) among high risk groups 2009 & 2011 Behavioral tracking surveys (TRaC) among high risk groups 2009 & 2011

3.52

3.72*

3.88

Increase the % of HRM in urban target areas who report that they know where to find STI treatment

73%

76%*

79%

Significant increase in mean score for FSW in urban target areas with regard to availability of STI treatment

3.72

3.88*

3.96

Increase the % of FSW in urban target areas who report that they know where to find STI treatment services from 88% in 2006 to 90% in 2009 and 92% in 2011

88%

90%*

92%

10

Maintain the % of rural communes with at least one point of sale that sells STI PPT kit Cura 7 Increase the % of urban Fokontany with at least one point of sale that sells STI PPT kits Cura 7

MAP surveys (2010, 2012)

74%
MAP surveys (2010, 2012)

75%

80%

11

30%

50%

65%

Target

17

12

Increase the % of rural communes with at least one point of sale that sells STI PPT kit Increase the % of urban Fokontany with at least one point of sale that sells STI PPT kit Genicure Increase the % of Top Rseau medical providers who can correctly diagnose and prescribe correct treatment to patients with STIs Increase the % of Top Rseau Plus counselors who meet the minimum pre and post test counseling standards Significant increase in selfefficacy mean score for HRM in urban areas with regards to STI services Increase the % of HRM reporting that they can go to the doctor to get treated when they have STI symptoms Significant increase in selfefficacy mean score for FSW in urban areas

MAP surveys (2010, 2012)

28%
MAP surveys (2010, 2012)

40%

50%

13

30%
Mystery Client Surveys

50%

65%

14

25.68%

55%*

60%

65%

70%

15

Mystery Client Surveys

9.09% 60%* 65% 70% 75%

16

Behavioral tracking surveys (TRaC) among High risk group 2009 & 2011 Behavioral tracking surveys (TRaC) among High risk group 2009 & 2011 Behavioral tracking surveys (TRaC) among High risk group 2009 & 2011

3.64

3.8*

3.92

17

93%

95%*

97%

18

3.72

3.88*

3.88

Target

18

19

Maintain the % of FSW reporting that they can go to the doctor to get treated when they have STI symptoms Significant increase in belief mean score for sexually active youth 15-24 in urban areas related to STI treatment Increase the % of sexually active 15-24 year old youth in urban areas who believed STI must be treated medically to be cured. Number of socially marketed STI kits for ulcerative infections sold through the social marketing system in the last 12 months Number of socially marketed STI kits for the treatment of gonorrhea and Chlamydia sold in the past 12 months through the social marketing system Number of people (by target group) treated for STI at Top Reseau USAID supported sites

Behavioral tracking surveys (TRaC) among High risk group 2009 & 2011 Behavioral tracking surveys (TRaC) among youth 20082010-2012 Behavioral tracking surveys (TRaC) among youth 20082010-2012

97%* 95.8% 98%

20

2.54

TBD

TBD

21

95.1%

TBD

TBD

22

Project MIS System

184,415

109,062

303,000

318,000

330,000

23

Project MIS System

242,359

151,408

330,750

350,000

357,000

24

Project MIS System

Youth 15 to 24 :

Youth 15 to 24 :

22,638

24,902

27,392

18,478
CSW:

15347
CSW:

7,439

2827

Target

19

25

Number of people (by target group) counseled and tested for HIV at Top Reseau USAID supported sites.

Project MIS System

Youth 15 to 24 :

Youth 15 to 24 :

6,655

7,321

8,053

4,697
HRM:

530
HRM:

435
MSM:

296
MSM:

139
CSW:

209
CSW:

2,851 26
Number of individuals trained to promote HIV AIDS prevention programs through other behaviour change beyond abstinence and being faithful (A, B, C) Number of individuals reached through community based outreach that promotes STI/HIV/AIDS prevention through other behavior change beyond abstinence and/or being faithful (ABC) Project MIS System

2,332 653 208 678 TBD

27

Project MIS System

216439

341,683

344,702

TBD

20

Result Five: Maternal and Child Health: DIARRHEAL DISEASES Logical Framework
Goal: Improved health and nutrition status of Malagasy children under five Purpose: Increase the use of proven lifesaving interventions that address one of the major killers of children under five in Madagascar, diarrhea disease Indicator 1 Increase % of mothers and caregivers of CU5 who report using SrEau in the past month. a) national b) rural c) urban Increase % of caregivers with CU5 who have already used SurEau. a) national b) rural c) urban Increase % of households with treated (including chlorine, boiling, filtering, etc) water prior to consumption in the last 24 hours d) national Method of measurement Behavioral tracking surveys (TRaC) 2008, 2010 and 2012 Baseline 2006 Baseline 2008 TARGET 2009 TARGET 2010 TARGET 2011 TARGET 2012

15.0 12.0 28.8 Behavioral tracking surveys (TRaC) 2008, 2010 and 2012 35.8 34.2 54.6 Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

16.0 14.0 19.0

20.0 18.0 23.0

30.0 25.0 36.0

34.0 29.0 41.0

e) rural f) urban

35.8 34.2 43.5

TBD

TBD

21

Significant increase in mean scores related for availability among mothers and caregivers of CU5 with regard to Sur Eau. National

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012 n/a TBD TBD

Increase % of mothers and caregivers of CU5 who know where to buy SurEau a) national b) rural c) urban Significant increase in mean scores related to social norms among mothers and caregivers of CU5 with regards to Sur Eau. - National

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012 74.4 67.9 93.7 Behavioral tracking surveys (TRaC) 2008, 2010 and 2012 n/a TBD TBD 74.0 67.0 83.0 78.0 72.0 87.0

Increase % of mothers and caregivers of CU5 who think that people in their community use water treatment product a) national b) rural c) urban

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

45.1 42.4 58.1

30.0 25.0 35.0

34.0 29.0 40.0

22

Increase % mothers and caregivers of CU5 who can cite SurEau as way to prevent diarrhea. a) national b) rural c) urban Increase % of mothers and caregivers of CU5 who can cite that hand washing with soap is a way to prevent diarrhea a) national b) rural c) urban Increase % mothers and caregivers of CU5 who can cite that use of latrine is a way to prevent diarrhea a) national b) rural c) urban

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012 29.5 26.2 46.3 Behavioral tracking surveys (TRaC) 2008, 2010 and 2012 70.0 60.0 83.0 74.0 65.0 87.0

34.6 31.4 49.5

TBD

TBD

7.5 7.2 9.2

TBD

TBD

10

Significant increase on mean scores related to self-efficacy among mothers and caregivers of CU5 with regards to Sur Eau. National

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012 n/a TBD TBD

23

11

Increase % of mothers and caregivers of CU5 who feel confident to use SurEau correctly a) national b) rural c) urban Mean scores among mothers and caregivers of CU5 for willingness to pay remains insignificant with regards use of Sur Eau

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012 69.9 66.6 86.2 Behavioral tracking surveys (TRaC) 2008, 2010 and 2012 n/a TBD TBD 68.0 58.0 77.0 72.0 63.0 81.0

12

DIARRHEA TREATMENT 13 Increase % of CU5 that had diarrhea in the last 2 weeks who received ORS or ORT and ZINC to treat diarrhea Increase % of CU5 that had diarrhea in the last 2 weeks who received ORS and/or recommended home fluids Increase % of CU5 that had diarrhea in the last 2 weeks who were treated with zinc supplements Increase % of CU5 with diarrhea in past two weeks, reported to have received increased fluids during the illness Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

0.1

TBD

TBD

14

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

58.2

TBD

TBD

15

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

0.1

TBD

TBD

16

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

71.6

TBD

TBD

24

17

Increase % of CU5 with diarrhea in the past two weeks, reported to have received the same amount or more food during and after the illness Significant increase in mean scores related for availability among mothers and caregivers of CU5 with regard to diarrhea treatment kit Increase % of mothers and caregivers of CU5 who know where to buy diarrhea treatment kit Increase % of mothers and caregivers of CU5 who can state at least two recommendations for home case management of diarrhea Increase in the % of mothers and caregivers of CU5 who state that exclusive breastfeeding during first 6 months reduces childs risk of diarrhea Increase % of mothers and caregivers of CU5 who know that CU5 with diarrhea need more food

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

38.6

TBD

TBD

18

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012 n/a TBD TBD

19

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

n/a

TBD

TBD

20

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

99.5

TBD

TBD

21

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

92.4

TBD

TBD

22

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

83.8

TBD

TBD

25

23

Increase % of mothers and caregivers of CU5 who know that CU5 with diarrhea need more fluids Increase in % of mothers and caregivers of CU5 who can correctly explain ORT/ORS preparation Increase in % of mothers and caregivers of CU5 who can explain correct zinc administration and duration Significant increase on mean scores related to outcome expectations among mothers and caregivers of CU5 related to diarrhea treatment kit Increase % of mothers and caregivers of CU5 who state that ORS/ORT administration is an effective treatment for dehydration caused by diarrhea Increase in the % of mothers and caregivers of CU5 who state that a complete a 10 day course of zinc treatment will reduce the duration and severity of a diarrhea episode Increase % of mothers and caregivers of CU5 who state that Zinc will prevent future episode of diarrhea

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

99.3

TBD

TBD

24

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

38.6

TBD

TBD

25

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

0.3

TBD

TBD

26

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

n/a TBD TBD

27

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

96.7

TBD

TBD

28

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

96.9

TBD

TBD

29

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

97.3

TBD

TBD

26

30

Mean scores among mothers and caregivers of CU5 for willingness to pay remains insignificant with regards use of diarrhea treatment kit

Behavioral tracking surveys (TRaC) 2008, 2010 and 2012

n/a

TBD

TBD

27