USAID/SENEGAL HEALTH PROGRAM 2016–2021
Annual Report October 1, 2018–September 30, 2019 USAID/Neema Integrated Service Delivery and Healthy Behaviors
Preliminary version
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The “Integrated Service Delivery and Healthy Behaviors” project is one of the instruments of the USAID Health Program in Senegal for 2016–2021.
Cooperative Agreement No.: AID-685-A-16-00004 Project Dates: 1 September 2016 – 31 August 2021
Submitted to USAID/Senegal by: IntraHealth International
Senegal Country Office
Dakar, Senegal
Email: [email protected]
“Integrated Service Delivery and Healthy Behaviors” Project
IntraHealth International/Senegal
Cité Keur Gorgui, Immeuble El Hadji Bara Fall
Dakar, Senegal
Tel.: +221 33 869 74 94
Fax: +221 33 825 65 23
This document was prepared with the support of the American people through the United States Agency for International Development (USAID). The contents are the sole responsibility of IntraHealth International/Senegal and do not reflect the views of USAID or the United States Government.
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TABLE OF CONTENTS
BASIC INFORMATION ...... 5 ABBREVIATIONS AND ACRONYMS ...... 6 PROJECT DESCRIPTION ...... 9
‒ Introduction ...... 9
‒ Overall objectives and sub-objectives ...... 9
‒ Technical strategy ...... 10
Section 1: Outcomes achieved, by funding domain ...... 12
‒ 1. Maternal health ...... 12
Indicators ...... 12 Overview ...... 12 Technical approach and sustainability ...... 14 Barriers and constraints to achieving objectives ...... 16
‒ 2. Children’s health ...... 1
Indicators ...... 1 Overview ...... 1 Technical approach and sustainability ...... 1
‒ 3. Nutrition ...... 3
Indicators ...... 3 Overview ...... 4 Technical approach and sustainability ...... 5 Barriers and constraints ...... 7
‒ 4. Reproductive health and family planning (RH/FP) ...... 7
Indicators ...... 7 Overview ...... 8 Technical approach and sustainability ...... 9 Challenges/Constraints ...... 12
‒ 5. HIV/AIDS ...... 13
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Indicators ...... 13 Overview ...... 13 Technical approach and sustainability ...... 15 Barriers and constraints ...... 18
‒ 6. Malaria ...... 19
Indicators ...... 19 Overview ...... 19 Technical approach and sustainability ...... 20 Barriers and constraints ...... 22
‒ 7. Cross-cutting topics ...... 23
Health Systems Strengthening ...... 23 Gender equality and combatting GBV ...... 29 Water, sanitation, and hygiene ...... 2 Public-private partnership and synergy ...... 2 Science, technology, and innovation ...... 4 Section 2: Monitoring & Evaluation, Research, and Learning ...... 4
‒ 1. The project monitoring mechanism ...... 4
‒ 2. Study results ...... 1
‒ 3. Success stories ...... 4
‒ 4. Learning ...... 6
Section 3: Annexes ...... 9
‒ 1. Performance Monitoring Plan ...... 10
‒ 2. Summary of results of FP integration into vaccination services ...... 16
‒ 3. Summary of results for integrated mobile units (IMUs) ...... 17
‒ 4. Summary of VADI implementation ...... 18
‒ 5. Summary of CVAC implementation ...... 18
‒ 6. Summary of Tutorat 3.0 implementation ...... 19
‒ 7. Summary of CBO activities ...... 21
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BASIC INFORMATION
Project name: Integrated Service Delivery and Healthy Behaviors (ISD-HB) (Neema)
Start and End Date: 1 September 2016 – 31 August 2021
Primary implementation IntraHealth International, Inc. partner:
Contract number: AID-685-A-16-00004
Consortium partners: National Alliance of Communities for Health (ANCS) ChildFund Helen Keller International (HKI) ideas42 Johns Hopkins University/Center for Communication Programs (JHU/CCP) Réseau Siggil Jigéen (RSJ)
Coverage: Health Program Concentration Regions • Diourbel • Matam • Kédougou • Kolda • Saint-Louis • Sédhiou • Tambacounda PEPFAR sites: Dakar (Institute for Health Research and Pikine), Thiès (Mbour department), and Ziguinchor
Reporting period: October 1, 2018–September 30, 2019
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ABBREVIATIONS AND ACRONYMS
AMTSL ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOR
ARV ANTIRETROVIRAL
AYRH ADOLESCENT AND YOUTH REPRODUCTIVE HEALTH
BMWM BIOMEDICAL WASTE MANAGEMENT
CBO COMMUNITY-BASED ORGANIZATION
CCW COMMUNITY CARE WORKER
CDS HEALTH DEVELOPMENT COMMITTEES
CEM MIDDLE SCHOOL
CHA COMMUNITY HEALTH AGENT
CNLS NATIONAL AIDS COUNCIL
CPR CONTRACEPTION PREVALENCE RATE
CREN NUTRITION RECOVERY AND EDUCATION CENTER
CVAC COMMUNITY WATCH COMMITTEE
DAN DIVISION OF FOOD AND NUTRITION
DIPEC.COM INTEGRATED CARE APPROACH
DLSI DIVISION OF AIDS/STI CONTROL
DOT DIRECTLY OBSERVED TREATMENT
DSISS DIVISION OF THE HEALTH AND SOCIAL INFORMATION SYSTEM
DSME DIRECTORATE OF MATERNAL HEALTH AND CHILD SURVIVAL
ECD DISTRICT MEDICAL TEAM
ECR REGIONAL MEDICAL TEAM
EHA ESSENTIAL HYGIENE ACTIONS
EmONC URGENT OBSTETRIC AND NEONATAL CARE
ENA ESSENTIAL NUTRITION ACTIONS
EPI EXPANDED PROGRAM ON IMMUNIZATION
EPOA ENHANCED PEER OUTREACH APPROACH
FP FAMILY PLANNING
GBV GENDER-BASED VIOLENCE
HP HEALTH POST
HSS+ HEALTH SYSTEMS STRENGTHENING PLUS
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ICP HEAD NURSE iCVAC INTEGRATED COMMUNITY WATCH COMMITTEE
IMU INTEGRATED MOBILE UNIT
IO-CP INITIAL OFFERING OF CONTRACEPTIVE PILLS
IO-IMIC INITIAL OFFERING OF INTRAMUSCULAR INJECTABLE CONTRACEPTION
IO-SCIC INITIAL OFFERING OF SUBCUTANEOUS INJECTABLE CONTRACEPTION
IPT INTERMITTENT PREVENTIVE THERAPY
ITN INSECTICIDE-TREATED BEDNET
IUD INTRAUTERINE DEVICE
LLITN LONG-LASTING INSECTICIDE-TREATED BEDNET
LTPM LONG-TERM AND PERMANENT METHOD
MAM MODERATE ACUTE MALNUTRITION
MER&L MONITORING & EVALUATION, RESEARCH, AND LEARNING
MNCH MATERNAL, NEWBORN, AND CHILD HEALTH
MR MEDICAL REGION
MSAS MINISTRY OF HEALTH AND SOCIAL ACTION
ORS ORAL REHYDRATION SALTS
PAC POST-ABORTION CARE
PECADOM HOME-BASED CARE
PHF PUBLIC HEALTH FACILITY
PLHIV PEOPLE LIVING WITH HIV
PNA NATIONAL PROCUREMENT PHARMACY
PNLP NATIONAL MALARIA CONTROL PROGRAM
PPFP POST-PARTUM FAMILY PLANNING
PSP POLICIES, STANDARDS, AND PROTOCOLS
RB REGIONAL BUREAU
RENAPOP NATIONAL NETWORK FOR THE PROGRESS OF POPULAR ORGANIZATIONS
RMNCAH REPRODUCTIVE, MATERNAL, NEWBORN, CHILD, AND ADOLESCENT/YOUTH HEALTH
RESEAU NATIONAL DES PERSONNES VIVANT AVEC LE VIH (NETWORK OF PEOPLE RNP+ LIVING WITH HIV) SBCC SOCIAL AND BEHAVIOR CHANGE COMMUNICATION
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SDP SERVICE DELIVERY POINT
SP SULFADOXINE-PYRIMETHAMINE
STI SEXUALLY TRANSMITTED INFECTION
TLD TENOFOVIR/LAMIVUDINE/DOLUTEGRAVIR
UHC UNIVERSAL HEALTH COVERAGE
UNICEF UNITED NATIONS CHILDREN'S FUND
UREN RESUSCITATION AND NUTRITION EDUCATION UNIT
VADI INTEGRATED HOME VISIT
VL VIRAL LOAD
WHO WORLD HEALTH ORGANIZATION
WISN WORKLOAD INDICATORS OF STAFFING NEED
WRA WOMEN OF REPRODUCTIVE AGE
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PROJECT DESCRIPTION
Introduction
The concentration regions have reported weak health indicators compared to the country’s other regions for several decades. The maternal and child mortality rates are much higher in the concentration regions (neonatal mortality rate is 29.6‰ live births in the concentration regions compared to 22.1‰ in the consolidation regions; under-five mortality is 91.9‰ compared to 64.7‰). Use of family planning is nearly double in the consolidation regions. In addition, the consolidation regions report much higher numbers of births in health facilities and of fully vaccinated children. Lastly, rates of female genital cutting are five times higher in concentration regions than in consolidation regions, and young women age 15–19 are 35% more likely to have begun their reproductive lives.
Furthermore, women’s and girls’ unequal social status relative to men and boys and lifetime exposure to various forms of violence limit their opportunities and choices, as well as their capacity to access health services, to live a healthy life, and to contribute to the development of their communities and their country. Norms of masculinity influence men’s and boys’ health by increasing their vulnerability and have a negative impact on their adoption of healthy behaviors; these norms also negatively affect women and girls.
The “Integrated Service Delivery and Healthy Behaviors” (ISD-HB) project, called “Neema,” supports the efforts of the Government of Senegal to ensure health services are sustainably improved and effectively utilized to reduce maternal, newborn, and child mortality and morbidity and contribute to an AIDS-free generation.
The project is implemented in the USAID Health Program 2016–2021 regions of concentration: Diourbel, Kédougou, Kolda, Matam, Saint-Louis, Sédhiou, and Tambacounda. The project supports the Ministry of Health and the National AIDS Council (CNLS) in the fight against HIV through the four PEPFAR sites.
The ISD-HB project is implemented by IntraHealth in partnership with the National Alliance of Communities for Health (ANCS), Réseau Siggil Jigéen, ChildFund, Helen Keller International (HKI), Johns Hopkins University/Center for Communication Programs (JHU/CCP), and ideas42.
Overall objectives and sub-objectives
The project’s objectives and sub-objectives are outlined in the figure below.
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Goal: Support the efforts of the Government of Senegal to ensure health services are sustainably improved and effectively utilized to reduce maternal, neonatal, and child mortality and morbidity and contribute to an AIDS-free generation.
1: Increased access to and utilization of quality health Objective 2: Increased adoption of services and products in the public sector healthy behaviors
Sub-Objective Sub-Objective Sub-Objective 2.1: High- 1.4: Key Sub-Objective 1.1: Increased quality, Sub-Objective Sub-Objective populations in 2.3: Technical coverage and Sub-Objective targeted social 2.2: Public 1.3: Quality target areas are and operational utilization of 1.2: Linkage and behavior sector capacity services at tested, enrolled capacity of local evidence-based, between change to coordinate, household, on SBCC sustainable, community and communication design, and community, antiretroviral organizations high-impact facility interventions to advocate for and facility treatment, and to design, interventions at platforms is promote high- improved SBCC levels are provided implement, and the household, strengthened impact services at the national improved and quality care in evaluate SBCC community, and sustained and healthy and regional sustained alignment with programs and health behaviors levels the 90-90-90 improved facility level delivered at goals scale
Technical strategy
The project plans to accelerate access to evidence-based, high-impact reproductive, maternal, newborn, child, and adolescent health (RMNCAH) interventions across the continuum of care from households to facilities, increasing adoption of healthy behaviors, and strengthening the capacity of the Ministry of Health and Social Action (MSAS) at all levels to lead, plan, implement, monitor, and evaluate the health program, including social and behavior change communication (SBCC). It collaborates with local governments and civil society by using data to manage decentralized quality health services.
The proposed interventions build on existing systems implemented by the MSAS and lessons from past USAID programming. “Neema” uses participatory approaches to ensure all relevant stakeholders (members of the government, civil society organizations, and community actors) are engaged in supporting project activities and goals. The figure below summarizes the project’s technical approach.
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Figure 1: Project technical strategy
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Section 1: Outcomes achieved, by funding domain 1. Maternal health Indicators
Indicators Source Senegal Diourbel Kédougou Kolda Matam Saint- Sédhiou Tamba- overall Louis counda
Maternal DHS 2017 mortality rate 236 ND ND ND ND ND ND ND Neonatal c-DHS 2018 23 ND ND ND ND ND ND mortality rate Number of DHIS-2 women who had 4 or more ANC 173,093 20,103 2231 6462 6175 13,167 4339 9296 visits during their last pregnancy Number of women who had DHIS-2 4 ANC visits in 153,644 16,741 2147 6275 4981 12,096 4272 7848 accordance with standards Percentage of DHIS-2 women who had 86% 94% 126% 88% 94% 86% 77% 97% at least one ANC visit ANC completion DHIS-2 rate 51.2% 49% 44.4% 48.7% 39.7% 55.7% 52.8% 46.2%
Number of DHIS-2 deliveries under 334,151 40,233 4842 13,484 9168 16,893 8302 16,151 AMTSL Delivery/ DHIS-2 partograph rate 77.8% 70.6% 81.6 86.8% 66.9% 81.2% 79.1% 82.2%
Rate of deliveries c-DHS 2018 assisted by 74.2% ND ND ND ND ND ND ND qualified staff
Rate of deliveries c-DHS 2018 in health facilities 81.7% ND ND ND ND ND ND ND
Overview The Government of Senegal has prioritized maternal, newborn, and child, and adolescent/youth health. This priority has been reaffirmed in the National Health Development Plan (PNDS) 2019–2028. To achieve this priority sectoral objective, Senegal has developed an integrated strategic plan for maternal, neonatal, infant- child, and adolescent/youth health (the 2016–2020 RMNCAH Plan) to achieve the following priority objectives between 2015 and 2019: (i) to reduce maternal mortality from 392 to 285 deaths per 100,000 live births, (ii) to reduce neonatal mortality from 23 to 17 deaths per 1000 live births, and (iii) to reduce infant- child mortality from 59 to 42 deaths for 1000 live births.
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According to the 2017 DHS, maternal mortality has seen a downward trend, going from 392 to 236 deaths per 100,000 live births between 2010 and 2017. Performance reported in 2017 exceeds the national goal for 2020, set at 285 deaths per 100,000 live births. On the other hand, changes in neonatal mortality saw ups and downs, going from 29‰ in 2010, to 19‰ in 2014, and 28‰ in 2017, and then to 23‰ in 2018, according to recent results in the c-DHS 2018. Neonatal mortality figures run the gamut, depending on the project intervention regions. Specifically, the c-DHS 2017 shows that neonatal mortality ranges from 23‰ in Kolda to 35‰ in Sédhiou. Monitoring pregnancy Figure 2: Change in antenatal care (ANC) completion rate
Change in ANC completion rate between 2018 and 2019 55% 56% 52% 51% 53% 51% 49% 49% 49% 51% 46% 44% 44% 45% 39% 40%
Ensemble Sénégal Diourbel Kédougou Kolda Matam Saint-Louis Sédhiou Tambacounda
DHIS 2 : Oct. 2017 à Sept 2018 DHIS2 : Oct. 2018 à Sept 2019
According to DHIS-2 data, the ANC completion rate (at least 4 ANC visits completed, according to standards) for the reporting period is 51.2% nationally, for an expected target achievement rate of 66% in 2019. The regions of Saint-Louis and Sédhiou are performing above the national average, with 56% and 53%, respectively. Although the national indicator is trending slightly downward, we have reported that four of the project intervention regions (Kédougou, Kolda, Saint-Louis, and Sédhiou) have improved their performance rates in comparison to 2018 rates. All of the concentration regions significantly increased the number of pregnant women who had four ANC visits that met standards between 2018 and 2019. Delivery surveillance According to data in the last c-DHS 2018 report, the rate of deliveries assisted by qualified staff is 74.2% nationally, or a 5-percentage-point increase compared to 2017. This achievement is close to the 2019 set target for this indicator, namely 76% (RMNCAH Plan). A comparative analysis of changes in trends by area between 2017 and 2018 shows an increase in the rate of deliveries assisted by qualified staff. However, by analyzing large geographic areas, we noted that the southern area (Kédougou, Kolda, Sédhiou, and Tambacounda-Ziguinchor) shows an overall performance rate of 57%, lower than the nationwide performance.
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Figure 3: Change in the rate of deliveries assisted by qualified staff
Similar findings were noted for the rate of deliveries performed in health facilities, with a national performance rate of 82%, or an increase of 6 percentage points according to the c-DHS 2018. The national rate for deliveries with the partograph improved slightly between 2018 and 2019, from 77% to 78%, according to the DHIS-2. Compared to performances for 2018, all project intervention regions significantly improved their performance for deliveries with the partograph. The project intervention regions far exceeded the national rate, with the exception of Diourbel (71%) and Matam (67%). In addition, the number of deliveries under active management of the third stage of labor (AMTSL) increased considerably between 2018 and 2019 for all project intervention regions. Postnatal follow-up For postnatal follow-up, c-DHS 2018 results show that 78% of births were followed by an initial postnatal exam within the first 48 hours, or an 11-percentage-point increase compared to 2017. Also related to prompt delivery of PNC, Figure 4 below shows a positive change in the percentage of newborns who had their first PNC consultation in the first hour following birth in all areas except in the north where the indicator remained unchanged between 2017 and 2018. Figure 4: PNC in the first hour after birth
84% 71% 70% 69% 58% 47%47% 46% 52% 37%
Nord Ouest Centre Sud Senegal
EDSc 2017 EDSc 2018
Technical approach and sustainability Strengthening delivery of maternal and newborn health services in hospitals, health centers, and health posts: The project supported the Ministry of Health and Social Action in the process to improve delivery of maternal and newborn health services through the following interventions:
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Tutorat implementation Teaching materials on ventouse delivery and newborn resuscitation through the Helping Babies Breathe (HBB) approach were used to strengthen the capacities of 61 tutors for package 1 (monitoring pregnancy from delivery to post-partum) to make the seven key services of basic urgent obstetric and neonatal care (EmONC) available in 57 service delivery points (SDPs). In addition, 137 tutor visits for package 1 were made overall. These visits helped provide coaching for 421 qualified providers (including 332 women) on the major themes, namely: Administration of preventive package, focused ANC, delivery/partograph, management of pre-eclampsia and eclampsia, delivery of post- abortion care (PAC), delivery under AMTSL, newborn resuscitation, ventouse delivery, and PNC. Final validation of the EmONC curriculum and development of the guide on managing obstetric and neonatal emergencies The EmONC curriculum was updated through project support. The guide on the management of obstetric and neonatal emergencies was also developed by the Directorate of Maternal Health and Child Survival (DSME) with project assistance. Maternal, newborn, and child health (MNCH) Supervision Supportive supervision conducted in 15 SDPs in Ranérou health district strengthened the skills of 17 providers (including 9 women) in the following areas: Essential Newborn Care (ENC)/resuscitation, AMTSL, and partograph. Gaps were identified in filling out the partograph and newborn resuscitation and were addressed. Strengthening delivery of maternal health services at community level and in households: The following achievements were reported at the health hut, community site, and household level: Continuation of the revised integrated home visit (VADI) resulted in training 1084 community health agents (CHAs) (including 581 women) in 474 huts and sites, bringing the cumulative coverage since the start of the project to 87%. Implementation of the VADI approach provided pregnant women and mother/newborn couples with community-based follow-up. Thus, 2283 pregnant women benefited from VADIs to monitor their pregnancies (ANC), and 1386 mother-newborn couples received a VADI from a CHA in the first 48 hours after birth. During the third year, the project supported completion of the process to harmonize the strategy to set up integrated community watch committees (iCVACs) that, in addition to maternal and newborn health, focus on epidemiological surveillance and promoting membership in mutual health schemes (mutuelles). Thus, 67 national trainers (including 24 women) and 290 providers (including 113 women) were introduced to the strategy. Since the start of the project, 1092 community watch committees (CVACs) have been set up overall, or 45% of forecasts. Training involved 8242 community members (including 6214 women) for the maternal and newborn health CVAC, and 2028 members (including 1334 women) for the iCVAC. Implementation of the community-based integrated care approach (DIPEC.Com) was continued in all 22 of the huts forecast for Year 3. Overall, 3285 CCWs (including 1566 women) are applying the DIPEC.Com approach in 2193 huts and sites, or 90% for the project’s overall forecasts. Thus, the essential needs of
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pregnant women, breastfeeding women, and newborns have been identified and are addressed using an integrated community-based approach. Implementation of integrated mobile units (IMUs) in the medical regions (MRs) of Saint-Louis, Diourbel, Kolda, and Sédhiou enabled 2942 pregnant women to receive their ANC. Among these women, 2292 took intermittent preventive therapy (IPT) under directly observed treatment (DOT), and 489 received a long- lasting insecticide-treated bednet (LLITN). Also, 736 women who had just given birth received PNC (see details in Annex 3). Promoting the use of maternal health services Implementation of the “Jàpp naa cì” campaign on health-promoting behaviors—such as early initiation of ANC, deliveries performed by qualified staff, and the use of post-delivery care services—was scaled up this year. The following achievements were reported: 289 TV spots and 391 radio spots were broadcast nationally on social support and the health card for pregnant women. Radio spots, infomercials, and shows were produced in the seven regions. Overall, 5313 inserted messages and 96 shows on health were produced, and 7853 spots were broadcast. Specifically in Matam region, men participated in high numbers in the interactive shows (approximately 30% of participants). These activities resulted in men making verbal commitments to ensure that their wives/spouses kept up with the ANC/PNC schedule and to help with referrals of pregnant women. Posters promoting social support were displayed on 38 TATA buses in the regions of Diourbel, Saint-Louis, Kolda, Tambacounda, and Sédhiou. Billboards were also displayed along the roads of the capitals of the seven concentration regions. Group discussions and VADIs led by community-based organizations (CBOs) on key themes related to maternal health reached 12,000 individuals in the seven regions. The mid-term evaluation of the longitudinal study of behavioral monitoring conducted by JHU/CCP found positive changes in the behavioral indicators, particularly completing all ANC visits and initiating ANC early on: this indicator rose from 64% in 2017 to 69.4% in 2019, or a 5.4% increase. This upward trend was also reported for deliveries performed in a facility, going from 83% in 2017 to 86% in 2019, or a 3-percentage- point increase. The mid-term evaluation also found that, on average, 73.2% women of reproductive age (WRA) stated having completed their first ANC visit in the first three months of pregnancy, compared to the baseline study, where this rate was 70% for WRA in the seven intervention regions. This increase was even higher in the regions of Tambacounda (83%), Saint-Louis (79%), and Kolda (74%). This support also had an impact on the indicator for newborns who received essential care immediately after birth. The mid-term evaluation also showed a positive change for this indicator for all seven regions: the indicator rose from 51% in 2017 to 75% in 2019.
Barriers and constraints to achieving objectives This year, few problems were encountered in activity planning; any constraints were primarily financial, due to frequent funding disruptions. Other constraints were noted in the supervision of CHAs during VADI implementation and the need to harmonize the process and coordination of partners during iCVAC implementation.
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Neema – Integrated Service Delivery and Healthy Behaviors
2. Children’s health Indicators
Senegal Saint- Tamba- Indicators Source Diourbel Kédougou Kolda Matam Sédhiou overall Louis counda
DHS Penta-3 Coverage 92.6 109.5 128.3 97.7 93.3 90 87.3 97.6 2017 Number of cases of diarrhea among children under 5 DHIS-2 356,921 41,175 7999 15,074 10,011 27,423 11,973 21,940 years treated with ORS/zinc Number of children under 5 years with malaria who received DHIS-2 13,073 111 1923 4452 95 5 70 5857 an artemisinin-based combination therapy Number of children under 5 years with pneumonia treated DHIS-2 150,662 11,451 3935 18,131 1847 10,322 3847 13,344 with antibiotics recommended by a provider or a CHA
Overview Senegal has made considerable progress in child health in recent years. An analysis of recent DHS data between 2015 and 2018 shows a gradual downward trend in the infant and child mortality rate, which went from 59 to 51 per 1000 in 2018 (c-DHS 2018). In the same period, child mortality also decreased significantly, from 21 to 15‰.
Between 2017 and 2018, child and newborn mortality declined, going from 42 to 37‰ and 28 to 23‰, respectively.
Based on c-DHS 2018 results, the country’s southern and central regions remain the most affected: infant- child mortality rates range from 89‰ in the southern area to 62‰ in the central areas.
The MSAS has prioritized reducing infant and child mortality in all its policy documents, especially the National Health Development Plan (PNDS) 2019–2028 and the integrated RMNCAH strategic plan 2016– 2020.
To achieve this goal, several strategies have been implemented, such as IMCI, vaccination, nutrition, management of pediatric emergencies, and improved access to care (universal health coverage; UHC). Therefore, during fiscal year 2018–2019, the USAID/Neema project supported the implementation of technical approaches to consolidate and sustain gains in child survival through MSAS services.
Technical approach and sustainability
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Neema – Integrated Service Delivery and Healthy Behaviors
Improved vaccination services: Implementation of the Tutorat 3.0 approach trained 14 new tutors on the disease control package, incorporating the Expanded Program on Immunization (EPI), thus bringing the number of package tutors to 54. These tutors coached 114 care providers, including 17 women and 57 qualified health workers on the EPI. The training sessions helped to improve management of the EPI, with monitoring of vaccination coverage and finding children whose vaccinations are not up to date.
In Diourbel, Saint-Louis, Sédhiou, and Kolda regions, 346 IMU visits were made, and 7323 children age 0–23 months were vaccinated.
Integrated Management of Childhood Illnesses (IMCI): In order to improve case management of diarrhea, fever, pneumonia, and malnutrition, the 54 package-3 tutors who are trained in IMCI in the project regions coached 444 care providers, including 263 women and 267 qualified health workers in IMCI, EPI, malaria, HIV, tuberculosis, and nutrition.
Supportive supervision on child survival and nutrition—focusing on observations of healthy and sick child consultation practices, the negotiation of best practices, care for children at the Resuscitation and Nutrition Education Unit (UREN) and the Nutrition Recovery and Education Center (CREN), biomedical waste management (BMWM), and medicine and commodity management—was conducted in Year 3 of the project in the MRs of Matam, Diourbel, Saint-Louis, and Kolda. Overall, 305 workers, including 168 women and 195 qualified providers, were supervised in 123 SDPs, including 17 health huts and 106 health posts (HPs). This supervision provided a framework to strengthen providers’ capacities on site and to develop action plans in each district, validated during meetings to present results. Also, the project supported supervision of CREN providers in Diourbel RM on the revised management of acute malnutrition. Overall, 45 CREN providers trained on the revised management of acute malnutrition guidelines were supervised in 7 SDPs (4 health centers and 3 public health facilities (PHFs)). This supervision addressed post-training gaps.
Community-based interventions improved access to care by bringing community services closer to clients by:
‒ Improving coverage in health infrastructure combined with capacity building for community actors: This strategy made 27 health huts operational, bringing the total number of functioning community structures to 682 for the target of 801 (or 86%) in the seven regions since the start of the project. During fiscal year 2019, community care workers (CCWs) confirmed and treated 43,967 cases of malaria; 5377 cases of diarrhea without dehydration, treated with oral rehydration salts (ORS) and zinc; and 6151 cases of simple pneumonia, treated with an appropriate antibiotic, according to DHIS-2 data.
‒ Implementing the integrated home visit (VADI) at household level: Overall, this involved 1841 of the 2638 planned huts and sites in the seven regions, or a 70% performance rate. Community actors conducted a total 18,200 VADIs this year, reaching 2860 healthy children, 2272 sick children, and 1528 malnourished children through their visits.
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Neema – Integrated Service Delivery and Healthy Behaviors
Case management of pediatric emergencies: The project provided support to develop and validate the practical guide for the management of pediatric emergencies with technical assistance from the chair of pediatrics at Cheikh Anta Diop University (UCAD). This guide will supplement capacity building for providers from health centers and health posts in the management of pediatric emergencies. Following validation of the guide, 28 trainers (including 11 women) were trained in Diourbel MR, and a meeting to set up a regional pediatric emergency case management network was held in the region, chaired by the Governor. 3. Nutrition Indicators
Indicators Source Senegal Diourbel Kéd- Kolda Matam Saint- Séd- Tamba- ougou Louis hiou counda Number of children DHIS-2 under 5 years (0–59 months) affected by specific nutrition 910,395 93,538 15,402 41,040 19,624 63,050 34,985 39,846 interventions through a program supported by the US government Males 458,930 47,704 7855 20,930 10,008 32,156 17,842 20,321 Females 451,465 45,834 7547 20,110 9616 30,895 17,143 19,525 Number of children DHIS-2 under 2 years (0–23 months) affected by community-based nutrition 715,798 73,421 11,238 32,998 12,939 47,225 23,425 30,715 interventions through a program supported by the US government Males 360,834 37,445 5731 16,829 6599 24,085 11,947 15,665 Females 354,964 35,976 5507 16,169 6340 23,140 11,478 15,050 Number of Project individuals receiving data training on nutrition 18771 234 165 137 172 201 292 676 through a program supported by the US government Males 899 112 79 66 82 96 140 324 Females 978 122 86 71 90 105 152 352 Stunting DHS 19% 2018 Acute malnutrition DHS 7.8% ND ND ND ND ND ND ND 2018
1 For the 7 concentration MRs 3
Neema – Integrated Service Delivery and Healthy Behaviors
Exclusive DHS 46% ND ND ND ND ND ND ND breastfeeding 2018 Overview In Senegal, health and nutrition continue to be priorities at the highest level, as demonstrated by their inclusion in the Sustainable Development Goals (SDGs) and the development of a multisector strategic plan for nutrition 2017–2021. Nationally, stunting saw a 2-percentage-point increase, from 16.5% in 2017 to 18.9% in the c-DHS 2018. This situation is due to a significant increase in stunting in the Central (Kaolack, Kaffrine, Diourbel, and Fatick) and Western (Dakar and Thiès) major regions, in contrast to the Southern (Tambacounda, Kédougou, Kolda, Sédhiou, and Ziguinchor) and Northern (Matam, Saint-Louis, and Louga) major regions, which reported a significant decrease of 4 to 10 percentage points, respectively.
Figure 5: Stunting by major region
26%
21% 19% 17% 19%
16% 17% 17% 12% 9%
OUEST SUD NORD CENTRE NATIONAL EDS continue 2017 EDS continue 2018
The 2018 c-DHS showed a decrease in acute malnutrition prevalence, going from 9% in 2017 to 7.8% nationally. The decrease in acute malnutrition was also observed in all the major regions, except for the Southern region, which saw a 2-percentage-point decrease. It should be noted that this situation has gone up and down since 2015 at the national level. It went from 7.8% in 2015 to 7.2% in 2016, 9% in 2017, and then 7.8% in 2018.
Figure 6: Acute malnutrition by major region
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Neema – Integrated Service Delivery and Healthy Behaviors
National 9% 7.80%
CENTRE 10% 8%
NORD 12% 5%
SUD 8% 10%
OUEST 7% 6%
EDS continue 2017 EDS continue 2018
Moreover, an examination of A session to prepare fortified flour the determinants of malnutrition shows an improvement in the underlying indicators. Exclusive breastfeeding has increased, going from 42% in 2017 to 46% in the c-DHS 2018. This trend is based on data from the 2019 mid-term study of the USAID/Neema project showing a 77% rate for exclusive breastfeeding among surveyed women. In this same study, the rate for early initiation of breastfeeding increased from 67% in 2017 to 75% in 2019. It has been proven that one of the most effective ways to combat malnutrition is to implement prevention activities through a multisectoral and multidimensional approach. In this context, the USAID/Neema project has implemented holistic nutrition interventions to help improve indicators. Technical approach and sustainability Food diversity: Implementation of essential nutrition actions (ENA) and essential hygiene actions (EHA) through capacity building improved providers’ and community actors’ understanding of best practices for service delivery. In an effort to improve household food diversity, the project continued to support groups for community actors that are manufacturing and using fortified flour to prevent and/or to treat
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Neema – Integrated Service Delivery and Healthy Behaviors moderate acute malnutrition (MAM) among children. Thus, 366 members from 129 community groups were trained. This capacity building resulted in the production of 14 tons of fortified flour that was made available in 350 SDPs. Providing fortified flour for distribution made it possible to monitor 8304 children age 6–59 months with MAM, including 3853 females, and 1552 pregnant and breastfeeding women. A high number of healthy children also benefited from the fortified flour.
For operational aspects, emphasis was placed on formative supervisions and monitoring of routine vitamin-A supplementation. Thus, 409 workers, including 67 qualified providers, were supervised in 232 health facilities. This intervention was strengthened through mobile unit visits that supplemented 7383 children age 6–59 months in vitamin A in the hard-to-reach areas of Diourbel, Saint-Louis, Kolda, and Sédhiou regions. Infant and young child feeding and hygiene: Exclusive breastfeeding, complementary feeding for children 6–24 months, and continued breastfeeding until at least 24 months were widely promoted this year. Implementation of essential nutrition and essential hygiene actions (ENA/EHA) by providers and community actors helped improve delivery of prevention services for infant and young child feeding practices. These activities were accompanied by a social and behavior change communication campaign. Specifically, the project supported the DSME through the Division of Food and Nutrition (DAN) to celebrate National Breastfeeding Month in December 2018. The Minister of Health and Social Action and various stakeholders made commitments to support and protect children and newborns. At regional level, implementation of integrated communication plans resulted in broadcasting: 4024 spots, 23 radio shows, and 1293 inserted messages on early initiation of breastfeeding and exclusive breastfeeding. In addition, to boost the practice of appropriate complementary feeding, support was provided for the development and distribution of 1400 flowcharts on complementary feeding to strengthen providers’ counseling on this practice. Spots (671) and inserted messages on complementary feeding have been broadcast. In order to strengthen and maintain best nutrition practices, 937 group discussions were held on nutrition that led to enrolling 11,244 women on the issue of nutrition and hygiene. Capacity building in nutrition: The project continued to support capacity building for 1817 health workers and community actors, including 1450 women, in nutrition, hygiene, and SBCC through various approaches. 630 providers and community actors were trained in ENA/EHA to close gaps in the regions of Kolda, Tambacounda, and Matam. In addition, 32 new providers from CRENs and URENs, including 26 women, were trained on MAM in Saint-Louis. Also, 366 actors were introduced to fortified flour preparation to support management of acute malnutrition at community level. As part of Tutorat 3.0, 672 providers were coached on nutrition: 421 for package 3 (disease control) and 251 for package 1. This coaching helped improve delivery of nutrition services at SDP level. Routine vitamin-A supplementation coverage has increased. For malnutrition case management,
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data for the first half of 2019 (DHIS-2) showed UREN cure rates were higher than the performance threshold, set at 75%, in the regions of Kolda (92%), Tambacounda (82%), and Sédhiou (77.8%) where more package-3 tutor visits occur. Follow-up and supervision (monitoring): Monitoring of nutrition activities was a key activity this year at various levels using a range of techniques: regional nutrition/child survival supervisions, sentinel surveillance, and district-level supervisions to monitor implementation of ENA/EHA. For surveillance, the project supported the DSME/DAN to start surveillance in the new sentinel sites of Ranérou, Podor, Goudiry, and Bounkiling. Data showed high levels of malnutrition, thus justifying the urgent need to start nutritional surveillance in these sites. In addition, joint regional nutrition and child survival supervisions were conducted in the regions of Matam, Diourbel, Saint-Louis, and Kolda in collaboration with the DSME, under the coordination of the MRs and with participation from other partners working in nutrition (Action Against Hunger and the Malnutrition Control Unit in Matam; UNICEF in Diourbel; and the French Development Agency (AFD) in Kolda). At least 30% (123) of SDPs in these regions were visited, and 305 workers, including 168 women, improved their skills in the supervised domains. Monitoring of district-level ENA/EHA implementation through supervisions in intervention districts also made it possible to assess how well health workers are negotiating best practices in nutrition and hygiene as well as to what extent the nutrition services package has been incorporated into the various contact points and opportunities. Overall, 249 health posts, health huts, and sites were visited, and 341 workers, including 177 women, were supervised on the ENA/EHA package. This finding shows that workers have a greater understanding of nutrition and hygiene activities. Barriers and constraints ✓ Insufficient staff to properly monitor implementation of project activities ✓ Repetitive stops in activity implementation in Year 3, due to funding disruptions In terms of solutions, we propose strengthening synergistic arenas with UNICEF, the Malnutrition Control Unit, Kawolor, Heifer (Kolda and Vélingara), the hygiene department, and other partners to pool available resources.
4. Reproductive health and family planning (RH/FP)
Indicators
Indicators Source Senegal Diourbel Kédou Kolda Matam Saint Sédhiou Tamba- overall gou - counda Louis Contraceptive prevalence rate DHS 25.40% ND ND ND ND ND ND ND 2017
Couple-years of protection PRA 213,617 49,334 10,723 34,183 24,187 48,176 18,405 28,608 (CYP) through a program data supported by the US government
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Percentage of service delivery Super- 100% 100% 100% 100% 100% 100% 100% 100% points providing FP counseling vision and/or services supported by the US government
Average contraceptives stockout rate at service delivery points, DHIS-2 7.30% 3.80% 7.60% 2.60% 2.20% 2.90% 14.70% 5.30% by family planning method
Numerator 32 4 3 2 2 4 10 7 Denominator2 657 115 42 74 103 125 65 133 Male condoms 4% 1% 3% 5% 0% 1% 16% 6% Numerator 26 1 1 4 0 1 11 8 Female condoms 4.3% 2% 4% 1% 1% 3% 16% 5% Numerator 32 2 2 1 1 4 11 7 Calendar method 5% 1% 3% 2% 1% 1% 9% 4% Numerator 32 1 1 1 1 1 6 5 Implants 8% 6% 12% 0% 3% 3% 11% 3% Numerator 30 7 5 0 3 4 7 4 Injectable hormonal 7.9% 8% 15% 5% 3% 4% 19% 9% contraceptive Numerator 52 9 6 4 3 5 13 12 Intrauterine device 3% 3% 1% 0% 4% 2% 4% 6% Numerator 20 3 0 0 4 2 3 8 Oral hormonal contraceptive 7.8% 5% 15% 4% 3% 5% 29% 6% Numerator 51 6 6 3 3 6 19 8 Number of CHAs providing FP Map- information, referrals, and/or ping of 10,0953 1252 663 1821 1233 1462 927 2737 services supported by the US huts government during the year Percentage of individuals who Behav- 85% 66% 97% 89% 74% 93% 94% 87% remember hearing or seeing a ioral specific message on family moni- planning/reproductive health toring (FP/RH), with support from the US government survey
Numerator 3613 489 560 534 464 534 534 498
Denominator 4264 738 577 601 631 573 570 574
Overview With the goal of eliminating maternal, newborn, and infant-child mortality, Senegal has striven to bring the contraceptive prevalence rate (CPR) to 45% and to decrease unmet need among women in union to at least 10% by 2020 in its National Strategic Framework for Family Planning (CSNPF). Actions taken resulted in a steady increase in CPR between 2012 (16%) and 2017 (26%). Data from
2 This denominator is the same for all products 3 Concentration area total 8
Neema – Integrated Service Delivery and Healthy Behaviors the c-DHS 2018 show a CPR of 25%, or a one-percentage-point decrease compared to 2018. Despite this national decline in CPR, we noted an upward trend in the northern and central areas and stagnation in the southern area (Kédougou, Kolda, Sédhiou, Tambacounda, and Ziguinchor). However, the major western region (Dakar-Thiès) saw a 4-percentage-point drop between 2017 (39%) and 2018 (35%). This area’s demographic weight greatly influenced the decline in the national average.
Figure 7: Changes in the contraceptive prevalence rate between 2017 and 2018
39.1% 34.8%
26.3% 25.0% 22.8% 18.8% 19.6% 20.7% 19.5% 18.4%
ouest centre nord sud Senegal
2017 2018
Despite concerted efforts in family planning, unmet FP need continues to be too high in Senegal. According to the c-DHS 2018, close to 21% of Senegalese women who wanted to avoid or delay pregnancy, did not have access to modern contraception. This situation is primarily due to economic, social, and cultural barriers. However, disparities also exist between major regions and are more pronounced in the northern area (25%). These needs are very high among adolescents and youths (10–19 years) and among young adults 20–24 years, who account for 19% and 22% of the total population, respectively. Looking at adolescent fertility, the c-DHS 2018 showed that 15% of adolescents, 15–19 years, have already started their reproductive life. Approximately 18% of women 15–19 years, living in rural settings, have already begun their reproductive life, while in urban settings, the percentage is only 10%. This phenomenon is most pronounced in the southern area, where 26% of females age 15–19 years have already started their reproductive life. To support the MSAS to achieve the National Strategic Framework for Family Planning (CSNPF) goals, the project initiated high-impact interventions: scale-up of post-partum family planning (PPFP) combined with subcutaneous depot medroxyprogesterone acetate (DMPA/SC) via self- injection, and post-abortion family planning for youths. The project’s strategies also focus on enrolling new FP clients through integrated FP/vaccination, advanced strategies, IMUs, extension of community-based services, and open-door days.
Technical approach and sustainability
Scale-up of post-partum family planning
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The project supported training for 14 gynecologists (including 6 women), who, in turn, introduced 77 district and regional medical team (ECD and ECR) members (including 49 women) from the MRs of Saint-Louis, Matam, Tambacounda, and Kédougou to the approach. These regional trainers trained 217 providers (including 215 women). At the end of the year, PPFP delivery is available in 173 SDPs in the regions of Diourbel, Sédhiou, Saint-Louis, Matam, Kédougou, and Tambacounda, or 48% of the annual target. To foster effective application of acquired skills, 248 post-partum intrauterine device (IUD) insertion kits were distributed to the six regions. According to DHIS-2 data, during the reporting period, 10,700 women benefitted from PPFP, with 4330 (40%) of them from the concentration area MRs. Diourbel region, with 2896 clients, has the largest number of women who have benefitted from PPFP, or 67% of the concentration area and 27% nationally.
Extension of DMPA/SC via self-injection The project supported an orientation for ECD/ECR members from the regions of Diourbel, Saint- Louis, Matam, Tambacounda, Sédhiou, and Kédougou and training for 404 (including 319 women) of the 970 planned providers, or a performance rate of 42% for the annual target. For introduction at community level, the project supported the DSME to finalize the scale-up plan and implementation tools for DMPA/SC via self-injection. Sixty-five huts have been selected in Sédhiou and Diourbel regions to introduce community-level implementation.
Youth-friendly post-abortion care/FP (PAC/FP) The youth-friendly PAC/FP approach was implemented in Diourbel MR in the two hospitals in Touba and at the Mbacké health center. The approach involves training supervisors and providers on the tools and the Optimizing Performance and Quality (OPQ) process. Final evaluation results showed that 1257 clients received PAC from November 2018 to July 2019. Among these clients, 84% received FP counseling and 28% adopted an FP method, among whom 10% selected long-term and permanent methods (LTPMs). Roll-out of this approach increased the utilization rate of FP among PAC clients by 12 percentage points (16% at baseline up to 28%).
Information sessions during vaccination and integrated advanced strategies These strategies have been incorporated into the deliverables for fixed obligation sub-grants to facilitate health-district buy-in. Throughout this year, 392 information sessions incorporated into vaccination sessions were held, exposing 14,005 individuals (including 12,720 women) to FP messages. These sessions enrolled 3249 new users of an FP method, or an average enrollment rate of 26% (see Annex 2). In parallel, 173 integrated advanced strategy visits enrolled 1588 new users.
Strengthening outreach services through integrated mobile units Transferring the management of the IMUs to the medical regions resulted in making 346 visits. Overall, 1863 FP clients were seen, including 855 new clients enrolled in the program. A total of 3447 youths age 10–24 years benefited from services. (see Annex 3)
Extending initial offering of contraceptives at community level
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During Year 3, 210 CHAs (including 122 women) were trained in initial offering of subcutaneous injectable contraception (IO-SCIC), and 36 were trained on initial offering of contraceptive pills (IO- CP). This brings the availability of injectables to 90% with the enrollment of 123 of the planned 137 IO-SCIC huts; and brings IO-CP availability to 67%, with 20 of the 30 remaining huts. At the end of three years, IO-SCIC is available in 705 huts, initial offering of intramuscular injectable contraception (IO-IMIC) is available in 151 huts, and the IO-CP platform has been boosted with 140 additional huts, of which 120 huts are new and 20 huts were previously in operation. These performance rates bring the number of huts that offer IO-SCIC and IO-IMIC to 859 and 847, respectively, since the start of the project. For IO-CP, 934 huts have been enrolled since the start of the project. Except for Kédougou, all regions exceeded 90% coverage.
Organization of open-door days This year, six days were organized in the regions of Tambacounda, Kédougou, and Kolda. During these activities, 247 new users were enrolled, including for 173 implants, 72 injectables, and 2 IUDs.
Strengthening providers’ capacities in FP through on-site coaching Package-2 (Family Planning) tutors from seven regions were able to coach 185 qualified providers (including 155 women) and 105 community actors, (including 79 women) on FP counseling and delivery. This improved availability and delivery of FP services, contributing to a rise in CPR. Monitoring compliance with FP regulations: The Tiahrt poster has been revised and printed. In total, 1500 posters are available and have been distributed to SDPs by the regional bureaus.
Delivery of youth-friendly services The USAID/Neema project, in collaboration with the Ministry of Education, Ministry of Youth/adolescent counseling centers, and the MSAS, developed and implemented strategies, such as: Delivery of client-friendly services in facilities 90 providers (including 47 women) were trained in the health districts of Vélingara, Médina Yoro Foulah, Saraya, and Salémata on the “Construire son avenir” (or “Build Your Future,” in English) curriculum. Also, an exploration conducted by Alioune Diop University in Bambey identified the medical department as a hosting site for FP services delivery. In Kolda, the Diaobé health post was also selected to provide client-friendly services. The health development committee began building construction for staff and adolescents and youths. Behavioral research A preliminary test of the model to deliver preventive services to adolescents and youths age 15–24 years was conducted in four SDPs in Tambacounda health district in the region of the same name, in order to assess the model’s feasibility and acceptability. Thus, 17 providers were trained on content for the intervention package. In addition, eight information sessions were held to present the services package to youths, put them in touch with a provider who will listen to them and share essential health messages with them in a fun and appealing way. These sessions reached 224 youths age 15–24 years (including 126 women) from 22 associations and the distribution of 221 vouchers
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Neema – Integrated Service Delivery and Healthy Behaviors valid for 15 days for them to receive a health check free of charge in an SDP. (See the Monitoring- Evaluation section for the first test results.) Delivery of the youth- and adolescent-friendly community-based services package: In Year 3, delivery of the adolescent and youth reproductive health (AYRH) service package was introduced in 482 of the 544 planned sites and huts (or an 89% performance rate) with 909 trained CHAs (including 447 women). Since the start of the project, the service package has been available in 3436 of the 3853 huts and sites (or an 89% increase), with the training of 7753 CHAs (including 3964 women). Also, in order to strengthen the community, 2156 additional CHAs, made up of unmarried adolescent/youth relais (736) and CHAs from previously enrolled facilities were trained on the package. All regions have a coverage of at least 80%. Implementation of the VADIs/iCVACs, incorporating gender and youth issues, at the hut and site level was continued with training for 1084 CHAs (including 575 women) in 474 huts for the slated 357 huts and sites, or 133% of forecasts, bringing the cumulative coverage to 87%. Implementation of the VADI approach provided pregnant women and mother/newborn couples with community- based monitoring of pregnancy and the postnatal period. Overall, 2283 pregnant women were monitored during their pregnancy.
Support in middle schools (CEMs) A total of 1862 facilitated sessions on AYRH and life skills were held, reaching 35,604 students, including 19,167 girls from 32 middle schools in the regions of Kolda, Sédhiou, Tambacounda, Kédougou, Diourbel, and Saint-Louis. These activities enable students to avoid some high-risk situations while giving them good attitudes and behaviors to maintain their own health. Activities targeting out-of-school youth Throughout this year, 62 group discussions, 14 film screenings, 4 discussion cohorts, 2 social mobilizations, 1 theatrical event, and 2 “Génies en Herbe” (Budding Geniuses) contests on AYRH were rolled out by adolescent counseling centers in Mbacké, Matam, Kolda, Vélingara, Tambacounda, Bakel, and Kédougou; the Saint-Louis youth space; and the adolescent counseling bureau in Diourbel. These activities sensitized 4244 individuals, including 2274 girls, on early pregnancy, child marriage, excision, female genital cutting, sexual abuse, sexually transmitted infection (STI)/HIV/AIDS, sexuality, and violence.
Social and behavior change communication The project provided technical support to the DSME to develop the national FP communication plan. It also supported the development of communication tools and organized the launch of FP and AYRH campaigns. Also, through contracts signed with media outlets and implementation of the integrated communication plans, 11,091 spots, 41 shows, 1689 inserted messages, 17 news coverage reports, and 279 sponsorships were produced in the seven regions.
Challenges/Constraints The main challenges are: - A delay in PPFP scale-up due to a scheduling conflict for trainer training
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- Unavailability of youths for community-based AYRH activities during the school year - Inadequate buy-in from medical regions for some interventions (FP/vaccination integration) - Providers’ boycott of training activity during the union strike
5. HIV/AIDS
Indicators
Indicator SEX Indicators MSM TOTAL codes WORKERS
Number of individuals from key populations KP_PREV 1790 1466 3256 who could benefit from HIV prevention services
Number of individuals who benefited from HIV HTS_TST testing services (HTS) and who received their 1456 1263 2719 test results
Number of individuals from key populations HTS_TST_POS 182 42 224 who tested positive
YIELD Positivity rate (yield) 12.5% 3.3% 8.2%
Number of individuals recently put on TX_NEW 168 41 209 antiretrovirals (ARVs) LINKAGE % of linkage to treatment 92% 98% 93%
TX_CURR Active file on ARVs 465 247 712
Number of individuals from key populations TX_PVLS (D) 155 64 219 whose viral load (VL) was measured
Number of individuals from key populations whose VL is suppressed and documented in the TX_PVLS (N) 85 47 132 last 12 months (demonstrated by the medical record <1000 copies/mL). Percentage of individuals from key populations whose VL is suppressed and documented in the % PVLS (N) 55% 73% 60% last 12 months (demonstrated by the medical record <1000 copies/mL).
Overview The HIV epidemic in Senegal is concentrated, with a 0.5% prevalence4 in the general population and a high prevalence in key populations (17.8% among men who have sex with men (MSM), 9.2%
4 DHS 2017 13
Neema – Integrated Service Delivery and Healthy Behaviors among injecting drug users, and 6.6% among sex workers). The most recent UNAIDS estimates show a gradual decline in HIV prevalence, for people age 15 to 49 years since 2005. This trend could be attributed to the early, targeted investments in response to HIV. When looking at specific categories, HIV prevalence among registered sex workers, meaning those listed in the file who work legally, went from 23.8% in 2010 to 8.7% in 2015. The estimated HIV prevalence for MSM went from 21.8% in 2007 to 27.9% in 20175 and is most pronounced for the 18–19-year-old age group. Similarly, variations were observed in the epidemic’s prevalence, with peaks as high as 41.9% for MSM in Dakar. Distribution of HIV prevalence among MSM show disparities depending on geographic region, with a predominance in Dakar and in the northern regions. Senegal is committed to eliminating the HIV epidemic by 2030 through implementation of the TATARSEN (Test All, Treat All, and Retain) strategy, with improved, scaled-up interventions based on the treatment cascade.
Figure 8: Evolution of the 90-90-90 goals cascade between 2016 and 2018 in Senegal 71% 72%
54% 63% 54% 46% 49% 41% 37%
2016 2017 2018
PVVIH connaissant leur diagnostic PVVIH sous TARV Suppression virale
An analysis of the results of the treatment cascade over the last three years found that the number of people living with HIV (PLHIV) who were tested improved considerably from 2016 to 2018, from 54% to 72%. This indicates a significant reduction in gaps for the first “90,” from 46% in 2016 to 28% in 2017, or an 18-percentage-point increase in two years.
In terms of treatment, the number of PLHIV on ARVs also rose between 2016 and 2018. In 2018, the estimated number of PLHIV on ARVs was 26,454. Efforts are still needed to improve care retention for PLHIV to further reduce this gap.
Regarding VL measurements, few PLHIV on ARV therapy have a VL <1000 copies/mL (viral suppression), despite a slight increase from 37% in 2016 to 49% in 2018. Despite considerable efforts, work remains around viral load VL assays, focusing on ensuring VL devices are interconnected and functioning, samples are properly routed, and results are appropriately reported.
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Despite these numerous efforts and outcomes, challenges persist, particularly in reaching key populations. This requires new approaches and major shifts in how the epidemic is monitored. In this context, Senegal has incorporated the PEPFAR West African program model into its approach through the USAID/Neema project, which focuses on three strategies for key populations: • Redirecting institutional and technical support more toward support for medical and community teams responsible for services dyelivery in intervention sites • Refine epidemic control tools at priority geographic and health sites • Targeting testing interventions in locations with high numbers from key populations (Dakar, Mbour, and Ziguinchor)
Figure 9: PEPFAR intervention site
Technical approach and sustainability First “90”:
Community level: At community level, the project supported recruitment of 60 mediators, 40 of whom were outreach mediators and 20 who work on site. Among the recruited mediators, 55% are MSM (24 outreach and 9 on-site), and 45% are sex workers (16 outreach and 11 on site). All 60 mediators were trained on: demedicalized screening at community level using rapid diagnostic orientation tests (TRODs), the enhanced peer outreach approach (EPOA), index testing, and micro-planning. Mapping of hot spots and an estimation of size of key populations were completed in Ziguinchor and Mbour. This identified 28/ hot spots—including 19 sex worker sites, 6 MSM sites, and 4 injecting drug user sites—in Ziguinchor. There were 63 hot spots in Mbour, including 44 sex worker sites, 40 meeting points for MSM, and 18 meeting points for injecting drug users. Mapping of hot spots
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Neema – Integrated Service Delivery and Healthy Behaviors made it possible to develop micro-plans for each mediator with a key population target to reach for each hot spot in order to avoid duplicated activities and data. Facility level: With the goal of improving actors’ capacities on PEPFAR approaches, the USAID/Neema project trained 82 providers, including 73 women, from four PEPFAR sites and the national level (CNLS and Division of AIDS/STI Control (DLSI)), and regional level on index testing and the EPOA. With the goal of meeting the minimum requirements for PEPFAR and to avoid overlap, the project worked in collaboration with the Institute for Health Research, Epidemiological Surveillance, and Training (IRESSEF) and Gaston Berger University to revise the SENCAS platform (an electronic reporting system) with a “Neema profile” to provide a unique identification code for anyone receiving HIV services in sites. In total, 33 providers from sites, including 16 women, were trained to use the platform. They will be supported by four data management interns to improve information management. Outcomes: Overall, 3256 individuals from key populations, including 1790 MSM and 1466 sex workers benefited from the prevention package. For screening, 2719 individuals, including 1456 MSM and 1263 sex workers, were tested, and 224 individuals (182 MSM and 42 sex workers) tested positive. The overall positivity rate for tests is 8.2%, with outcomes of 12.5% for MSM and 3.3% for sex workers. With index testing, 10 PLHIV agreed to use the services and referred 20 contact cases, among whom 10 tested HIV positive, or a 50% seropositivity rate. The overall testing yield is satisfactory despite disparities between sites: 13% for South health district in Dakar and 4% for Ziguinchor health district. It is also low for sex workers, with 3%, despite the number tested. Second “90”: The project also supported the DLSI to revise the sex worker monitoring guide in accordance with the 2018–2022 National Strategic Plan guidelines. Four themes were included in the new guide: monitoring procedures for sex workers at all levels, medical-social follow-up for sex workers, community case management, and enrollment of clandestine sex workers into the sex worker monitoring system. As part of the transition to tenofovir/lamivudine/dolutegravir (TLD), the Neema project supported training for 33 trainers (including 14 women) on the new treatment guide, the TLD transition, and national procedures for viral load measurements. The DLSI received support to review and validate the therapeutic education module for the skills- based approach. In the sites, 31 therapeutic education sessions reaching 310 PLHIV, including 221 women, were held to improve monitoring and treatment support. To ensure treatment retention for PLHIV, 60 activities to locate patients lost-to-follow-up found 143 PLHIV, including 112 women.
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At community level, 60 mediators were trained on: the continuum of care, therapeutic education, sexual health, gender-based violence (GBV), and human rights. The training supported psychosocial monitoring, treatment retention, and GBV case reporting. Overall, 141 individuals from key populations of the 149 who tested positive were put on ARV therapy, including 103 MSM and 38 sex workers, or a 95% linkage to treatment, with 93% for MSM and 100% for sex workers. Third “90”: Outcomes: The project provided support to collect and measure VL for 219 individuals from key populations in the 4 PEPFAR sites, of whom 132 (or 60%) obtained a suppressed VL. However, efforts will be made to advocate for starting TLD treatment in PEPFAR sites; this treatment reduces/suppresses VL more quickly. Support activities:
Coordination: Project coordination takes place at two levels: the central level and site level. At central level: The USAID/Neema project provided support to the CNLS and the DLSI to harmonize HIV interventions by collecting data and information from civil-society and the public- sector partners. To do this, 16 partners from civil society and the public sector met to map funding and interventions. This activity laid the foundation for a plan to ensure synergy between the various partners working under CNLS and DLSI leadership. To the same end, a mapping of PEPFAR and Global Fund interventions was prepared as well as mapping of resources and objectives for the four sites with the goal of harmonizing and pooling the two funding sources. The project participated in two coordination meetings of the various partners at the national level. During these meetings, participants shared progress on PEPFAR implementation and the various achievements based on the cascade. Recommendations from these meetings sped up achieving some challenges (unique identification code and the strategy to improve the yield for sex workers). With the goal of harmonizing practices, a PEPFAR implementation guide for sites, three standard operating procedures guides (index testing, EPOA, and mobile clinic), and four job descriptions for site staff (site coordinator, data manager, community supervisor, and mediator) were developed and shared with the various stakeholders in PEPFAR implementation. At site level: Organization of 53 weekly coordination meetings for the site treatment team allowed participants to regularly share information about PEPFAR, monitor implementation of project activities, and synthesize and validate weekly data. Also, for TATARSEN-plan coordination and monitoring, the Neema project supported payment for two deliverables in project intervention regions (Dakar, Thiès, and Ziguinchor). These sub-grants enabled: 6 integrated supervisions of ECRs in 3 MRs, 30 integrated ECD supervision missions, and 24 TATARSEN quarterly reviews in Dakar, Thiès, and Ziguinchor. As part of institutional strengthening, support was provided to the networks and associations of key populations (The
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National Network for the Progress of Popular Organizations (RENAPOP) and RNP+, a network of PLVIH) in the form of office, IT, and teaching supplies and equipment. Monitoring & Evaluation: For the PEPFAR set-up process, a situational analysis was conducted in four selected sites (Pikine, DLSI/IHS, Mbour, and Ziguinchor), and an action plan was developed for each site. In order to meet PEPFAR requirements, the Neema project developed/adapted the management tools, both at the community and facility level. These were: the index testing register, session reporting notebook/sheet, counseling and testing register for the CCD/V HIV laboratory, and GBV case reporting sheet and register. All tools were printed and made available to sites to better manage information. The project hired four supervisors, assigned to the sites, to improve monitoring of community activities. They were trained on the revised PEPFAR management tools and weekly data transmission and reporting. The project supported holding a national review of STI treatment and key populations. The review took stock of STI treatment at the medical region level, a quality assessment of key populations (MSM and sex workers) monitoring, and an assessment of the level of TATARSEN implementation among key populations. Lastly, two project staff members were trained on the “Data for Accountability, Transparency and Impact Monitoring” (DATIM) platform for regular reporting of PEPFAR data.
Social and behavior change communication
The USAID/Neema project contributed to printing and distributing communication materials to promote testing and project branding. This involved providing various project stakeholders with 1000 pens, 3000 two-colored shirts, 300 multi-pocket Sols Wild vests, 300 sports water bottles, and 300 tactical solar LED flashlights with stands.
Lastly, a training workshop for leaders of key populations on transformational leadership and self- esteem was held. Overall, 30 leaders from key populations, including 20 MSM and 10 sex workers, were trained.
Barriers and constraints For the first “90”: The major constraint at this level is still the low screening yield for sex workers, due to the problems reaching those who work outside of association networks. Implementation of the EPOA approach could help to reduce this gap. For the second “90”: The lack of free follow-up physicals in some sites and the delay in transitioning to TLD are still barriers to quality treatment. The chosen solutions were enrolling PLHIV into health mutuelles to reduce informal “user fees” and implementing the TLD transition at the four sites. For the third “90”: At this level, noted constraints are related to: weak programming of VL- measurement activities, delayed reporting of VL results, and activity planning. With the goal of mitigating the identified constraints, emphasis will be placed on programming a VL measurement
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Neema – Integrated Service Delivery and Healthy Behaviors campaign and setting up an early-warning and monitoring system to reduce the time need to deliver results.
6. Malaria Indicators
Indicators Source Senegal Diourbel Kédou- Kolda Matam Saint- Sédhiou Tamba- overall gou Louis counda Number of malaria- DHIS-2 368 12 21 99 3 10 14 25 related deaths 0–5 years 69 3 10 27 0 0 1 2 ≥ 5 years, excluding 297 9 11 72 3 10 13 23 pregnant women Pregnant women 2 0 0 0 0 0 0 0 Number of children DHS 66% ND ND ND ND ND ND ND under 5 presenting a 2017 fever in the last two weeks who took an antimalarial treatment
Percentage of children DHS 60.7% 66.7% 49.9% 63.8% 74.0% 61.5% 73.7% 37.2% under 5 who slept 2017 under an insecticide treated net (ITN) the night before the survey Percentage of pregnant DHS 61.8% 68.5% 53.9% 59.3% 73.1% 70.8% 80.4% 37.9% women who slept under 2017 an ITN the night before the survey
Overview
Malaria, a potentially deadly parasitic disease, is a public health problem in Senegal. The epidemiological situation of malaria in Senegal is characterized by a low incidence in the general population. According to DHIS-2 data, it went from 30 per 1000 in 2016 to 19.9 per 1000 in 2019. This decrease was also noted among children under 5 and pregnant women, considered to be the populations most vulnerable to malaria. However, the incidence levels still vary considerably, depending on the region. Kédougou, Tambacounda, and Sédhiou regions reported the highest incidences, exceeding 200 per 1000, while incidence rates below 1 per 1000 have been observed in the north.
A sharp decrease in parasite prevalence among children under 5 was reported between 2012 and 2017, according to the continuous-DHSs results when prevalence dropped from 3.4% in 2012 to 0.9% in 2017 (DHS). This downward trend was observed in the project concentration regions except
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Neema – Integrated Service Delivery and Healthy Behaviors for Kolda, where prevalence remained stable. Nevertheless, there were significant variations between regions. In the regions of Louga, Saint-Louis, and Matam, the disease prevalence (via rapid diagnostic test and microscopy) is almost zero in 2017, while it remains high in the regions of Tambacounda (4.8%; 1%), Kolda (2.9%; 2.9%), and Kédougou (15.3%; 7.3%). These three regions also report the highest incidence rates and the lowest availability and utilization rates for insecticide-treated nets (ITNs).
According to the DHIS-2, malaria-related mortality reported a downward trend between 2017 and 2019, from 3.7% to 1.5% in 2018 and to 0.02% in 2019. This same downward trend is observed among vulnerable groups and in concentration regions. However, the percentage of malaria-related deaths during these three years is higher in the concentration regions, ranging from 64% to 75%. For these regions, Diourbel, Kédougou, and Kolda reported the highest number of deaths for children under 5 and people older than 5 years, excluding pregnant women. This situation could be due to the high parasitic incidence and prevalence levels in these regions. Added to this, Kédougou and Kolda regions report the lowest ITN availability and utilization rates, according to the DHS 2017.
Technical approach and sustainability
The mid-term review of the strategic plan 2016–2020 resulted in repositioning the malaria control strategy toward elimination. The USAID/Neema project supports the National Malaria Control Program (PNLP) to implement this plan through improved malaria case management, prevention, behavior change communication, monitoring, and coordination.
Malaria case management
As part of malaria case management at health facility level (health posts, health centers, and PHFs) this year, the project supported training for 574 providers, including 415 women, on the new malaria prevention and treatment guidelines, bringing the number of trained providers to 1467 (including 944 women) since the start of the project. The high percentage of trained midwives (331 state registered midwives (SFEs), or 61%) is in response to the identified gaps in case management for pregnant women and the continuum of care for malaria. The training sessions improved the quality of malaria case management through better application of new guidelines (for example, using ACT for pregnant women and artesunate to treat serious cases at the hospital and health center level).
In addition, 14 new tutors were trained on the disease control package, including malaria, bringing the number of package tutors to 54. These tutors coached 191 providers (including 83 women) and 110 community actors during the first visit on malaria case management; 62% of coached providers are qualified health workers.
Post-training follow-up for 57 providers, including 19 women, in Tambacounda and Diourbel regions helped address noted gaps in malaria case management in the 35 visited health facilities.
At the community level, malaria case management involved enrolling new community-based facilities, consisting of selecting community actors; training them; providing them with equipment, supplies, and inputs; and conducting post-training follow-up/supervision. This strategy helped to get 27 health huts up and running, bringing the total number of functioning community structures
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Neema – Integrated Service Delivery and Healthy Behaviors to 682 for the target of 801 (or 86%) in the seven regions since the start of the project. Thus, 46 community care workers (including 20 women) were trained in malaria case management in 2019. During fiscal year 2019, CCWs confirmed and treated 43,967 malaria cases, thus improving people’s inclination to seek early care, which can have an impact on the number of malaria-related deaths (DHIS-2).
At all levels of the health system, the project continued to support ECDs/head nurses (ICPs) in logistics supervision in 132 SDPs, including 1 health center, 26 health posts, 95 health huts, and 10 home-based-care (PECADOM) sites in Goudomp, Podor, and Kolda. The logistics supervision, which includes PNLP tracer products, resulted in strengthening the on-site capacities of 132 stock managers, providing SDPs with stock sheets, and formulating recommendations for ECDs and ICPs to improve medicine management.
Malaria prevention
Intermittent preventive therapy (IPT) and social and behavior change communication (SBCC) are effective ways to prevent malaria.
Intermittent preventive therapy: The DHS-2017 data show a 94% IPT-1 coverage rate compared to 63% for IPT-2 and 22% for IPT-3. Despite an upward trend the last three years, IPT-3 coverage remains low, leading to the development of a stimulus plan in the concentration regions. Thus, the following actions were taken through project support for the IPT stimulus plans:
‒ Evaluation and updating of IPT stimulus plans in 11 districts in concentration regions
‒ Provision of 45 new buckets (520 since the start), bringing bucket coverage to 84% for health facilities. Providing buckets improves Sulfadoxine-Pyrimethamine (SP) intake under DOT
‒ IPT training for 291 CHAs (777 since the start), including 125 men (367 since the start), in the districts of Goudomp, Médina Yoro Foulah, and Saraya
‒ Documentation of IPT in Goudomp health district showed several increases: SP3 coverage rose between 2016 and 2017, from 43% to 79%; the number of women who completed 4 ANC consultations went from 650 to 1268; and the number of deliveries assisted by a qualified staff member also rose.
Social and Behavior Change Communication (SBCC): Malaria is one of the key themes in the national communication campaign, “Jàpp naa cì.” This campaign focuses on social support to promote healthy behaviors, emphasizing early recourse to care in case of fever, following the SP intake schedule, and using LLITNs. The campaign has been implemented at the central level in the seven project intervention regions.
At the central level, support for the PNLP covered the organization of a national malaria campaign that broadcast 61 television spots and 160 national radio spots, reaching approximately 5,068,000 individuals, including 2,580,000 women (estimates based on the BDA audimat).
In addition, signage about malaria was displayed in conjunction with the national campaign on 17 LED panels (14 in Dakar, 1 in Mbour, 1 in Saint-Louis, and 1 in Kaolack) for two weeks.
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The 500 group discussions about LLITNs and IPT held across the seven regions reached 12,553 individuals. Also, group discussions during VADIs on the sociocultural factors related to malaria prevention reached 23,813 individuals.
The partnership with community radio stations in the seven concentration regions resulted in broadcasting 39,846 spots radio spots on LLITNs (15,478), IPT (14,998), and seeking early care (9480). These radio stations also hosted 100 shows, inserted messages during shows with large audiences, sponsored 100 radio programs, and produced 25 news reports on themes related to malaria.
Coordination and monitoring
Support to coordinate and monitor malaria control was primarily implemented with the PNLP central unit and at the MR and district level. The project supported the following activities:
‒ Technical support through five regional malaria advisors in the medical regions of Kédougou, Tambacounda, Diourbel, and Kolda at the central level to monitor the implementation of malaria control plans for medical regions and health districts.
‒ Technical support for the universal LLITN coverage campaign in concentration regions with mobilization of five regional program managers.
‒ Technical support for the seasonal malaria chemoprevention campaigns in the regions of Diourbel, Tamba, Kédougou, Sédhiou, and Kolda with mobilization from four regional program managers.
‒ Organization of 3 coordination meetings with the PNLP to monitor action plans. These meetings helped redirect project support toward the country’s central and northern regions where funding gaps were noted.
‒ Participation in the statutory meeting of the consultation framework for partners in malaria control (CCPLP) to reactivate and facilitate commissions.
‒ Development of malaria control plans based on each region’s epidemiological profile. Overall, 10 districts in the regions of Diourbel (Bambey), Saint-Louis (Saint-Louis, Richard Toll, Dagana, Pété, Podor), and Matam (Thilogne, Matam, Ranérou, and Kanel) developed malaria elimination plans. In addition, 10 malaria control acceleration plans were developed in 10 districts in the regions of Diourbel (Diourbel, Touba, and Mbacké), Sédhiou (Goudomp, Sédhiou, and Bounkiling), and Tambacounda (Koumpentoum, Makacoulibantang, Bakel, and Diankhe Makha). The malaria control acceleration plans include hospitals for proper case management of severe malaria.
Barriers and constraints Constraints observed during implementation of malaria control activities involved frequent Sulfadoxine-Pyrimethamine (SP) stockouts at the SDP level reported during supervisions and other monitoring activities.
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Recommended solutions suggest conducting advocacy among local and health officials to mobilize funding from Health Development Committees and from mayors’ commitments to purchase SP.
7. Cross-cutting topics
Health Systems Strengthening Overview The health system has worked hard in the areas of maternal, newborn, child, and adolescent health as well as malaria prevention and treatment. During Year 3, the Neema project implemented interventions to strengthen the health system’s management and performance. Programming approach The implemented approaches are described below: Governance: The key achievements in this area are summarized below: - Through the implementation of health development committees (CDSs), the project supported training for CDS members on the procedure manual that sets the conditions for this body’s organization and operations. This training helped to set up and get CDSs up-and-running in 363 SDPs (342 HPs and 21 health huts), or 61% of the relevant facilities (HPs and health huts). - Continued support to hold coordination meetings within all project intervention regions. These meetings are an opportunity to review the Annual Work Plans and intervention monitoring. The same was done at the health district level. - All project intervention regions received support to hold Annual Coordination Reviews (RACs) to improve the planning and monitoring of interventions. - As part of strengthening the integration of community health into the health system, the project supported: o Capacity building for local officials on community health management through training for 340 officials (including 89 women); 114 joint monitoring visits with local municipalities (43% of forecasts) in huts and sites in collaboration with administrative and health officials; development and sharing of a technical sheet for harmonizing the approach and documenting the joint monitoring. o Development of tools for health post teams (midwife, nurse, and assistant nurse) to implement a bolstered format of the advanced strategy. This format capitalizes on lessons learned from the itinerant midwife strategy and conventional integrated advanced strategies. It takes into account strengthening the maternal, newborn, and child health (MNCH) package, streamlining visits, and systematic coaching for CHAs. o The PSNSC 2014–2018 evaluation process and development of the PSNSC 2019–2023: availability of the PSNSC development report and the draft of the new plan. Health financing: Achievements included awarding sub-grants to medical regions and health districts and the mobilization of domestic resources.
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As part of support for medical regions and districts, the project continued collaborative efforts through sub-grants in the execution of deliverables, thus: (i) 29 amendments were signed with health districts in the concentration areas; (ii) 7 amendments were signed with medical regions in the concentration areas; (iii) 3 amendments were signed with medical regions with HIV hot spots; (iv) 2 contracts were signed with the medical regions of Tambacounda and Kolda to hire 20 qualified providers; and (v) a total 260,151,822 FCFA ($442,776) was disbursed to pay for deliverables completed by medical regions and health districts. The strategy to enroll mayors through advocacy was continued this year with 36 mayors. The project supported the mobilization of domestic resources for health for a total 43,766,000 FCFA ($74,490) for a commitment of 88,046,000 FCFA ($149,854), or a 49% recovery rate. This amount was used to purchase ultrasound machines and to renovate the maternity wards in Podor and Bakel districts, build housing for the midwife and ICP in Richard Toll district, pay for an enclosure for the health center in Salémata in Kédougou region, enroll 250 women into a health mutuelles in the districts of Médina Yoro Foulah and Koumpentoum, and purchase medicines for health huts in Kanel and Bambey districts. Human resources: The project helped strengthen human resources in health through: − Official launch of the MSAS online portal. To date, 842 providers have enrolled onto the platform (www.formation.sante.gouv.sn), and courses with the highest enrollment are: IMCI, Sayana Press, and FP counseling. − Support to train MSAS senior staff on leadership and management through the Organization and Methods Office (BOM) in synergy with HRH2030, GoTAP, and Health Systems Strengthening Plus (HSS+). This training strengthened participants’ leadership skills to guide health teams toward significantly improving health outcomes and to be able to lead their teams to address challenges. • Testing of the Workload Indicators of Staffing Need (WISN) approach in Saint-Louis district to assess health staff workload: This activity provided work standards for the socio-professional categories of SFE and state registered nurse (time required for a well-trained, motivated, and competent staff member to perform an activity according to professional standards in response to local circumstances). − Set up national health workforce accounts: the project supported the MSAS to prepare a concept note to establish national health workforce accounts. Pharmaceuticals management: As part of improving health commodity availability, the project continued to support MSAS entities through: - Logistics supervision of 132 health facilities—including 1 health center, 26 HPs, 95 health huts, and 10 PECADOM sites—in the districts of Goudomp, Podor, and Kolda provided 95 health huts with inventory sheets and helped resupply 32 huts in Goudomp with essential medicines and commodities. Recommendations were made for the various stakeholders. - Technical support was provided to develop the Contraceptive Procurement Tables to quantify the country’s contraceptive needs through the DSME, the DLSI, and the Marketing and Social Development Agency (ADEMAS) and to plan procurements for 2019, 2020, and 2021.
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Health services delivery: The project supported strengthening service delivery in terms of availability, quality, and implementation of innovative approaches: Availability of services: As part of strengthening services delivery, the project supported the following interventions: − 10 new health posts up and running (Tambacounda and Kolda regions) by installing equipment and covering one state registered nurse and one SFE for each health post. These new posts improved services availability in the districts of Diankhé Makha, Médina Yoro Foulah, Kolda, and Vélingara. After nine months of operations at these new huts, 5821 individuals were seen for a primary care consultation, 524 women were seen for an ANC visit, 92 deliveries assisted by qualified staff were performed, 123 new clients were enrolled in FP, 1724 children were vaccinated, 621 children received vitamin A supplementation, and 158 cases of diarrhea were treated for children 0–5 years in these 10 new posts. Overall, 9834 services were delivered in these new facilities. − 164 community infrastructure facilities in operation (27 huts and 137 sites) with training for 736 CHAs (including 461 women). The newly operational huts and sites received equipment and supplies (revised management tools; and care and infection prevention supplies, including handcrafted incinerators, cooking demonstration supplies, and furniture). The total number of community health facilities put into operation since the start of the project is 97 new health huts (out of 61 planned huts) and 424 new community sites (74% of the project’s overall forecast). − Establishment of a comprehensive system to organize emergency transportation in 300 new additional communities in 20 health districts. These communities mobilized 467 means of transport (158 vehicles, 129 carts, 80 ambulances, 2 canoes, and 98 other types of transportation, such as motorbikes) and 12,019,860 FCFA ($20,457) for expenses. By the end of three years, 576 communities had organized emergency transportation (or 99.77 % of projections). This system was used by 576 beneficiaries (including 435 females), the majority of whom were WRA (70%, including adolescents age 10–19 years), children 0–5 years (26%), and newborns (3%). The reasons for referrals are obstetric and neonatal emergencies (51% cases), childhood illnesses (27%), other medical conditions (18%), and trauma and injuries (4%). − Evaluation of referral system functioning at all levels (hospital, health center, health post, health hut, and site) using RSAM tools for Saint-Louis MR. This support made it possible to produce and share a plan to improve referral/counter-referral system functioning and emergencies management in Saint-Louis region. − The project also supported the Directorate General of Health Services (DGS) and the National Emergency Medical Service (SAMU) to finalize the technical validation of the emergency response improvement plan. Quality of service delivery: In the context of improving quality service delivery, the main achievements are: − Distribution of Policies, Standards, and Protocols (PSP) for RMNCAH (PSP/RMNCAH): During Year 3, 866 providers (including 589 women) were introduced to using the PSP, for an annual target of
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818 individuals, or an annual performance of 106%. In addition, 318 sets of PSP were delivered to SDPs, and 897 USB keys were distributed to providers. Since the start of the project, 1089 providers (747 women) have been introduced to using the PSP. Sharing this information made the RMNCAH PSP available in 415 SDPs (381 HPs, 25 health huts, and 9 PHFs), or 68% of SDPs in the concentration area. • Support to share job aids on maternal and child health: the project supported the DSME to make six tools available, namely: Case management of post-partum hemorrhage; newborn resuscitation; the IMCI approach, definitions of FP concepts; counseling steps; and accidental diseases and poisoning among children. • Maternal death surveillance and response: The DSME developed an implementation guide for maternal death audits with project support. Also, nine auditing session were supported at the district level in Bounkiling and at the PHF level in Tambacounda and Diourbel. Overall, 33 cases of maternal death were reported in the audit, of which 20 cases were secondary to direct causes. In the 20 audited cases of maternal death, 10 were possibly or definitely preventable. In addition, 6 cases of neonatal death were reviewed, and most were due to asphyxiation. Most of the auditing committees analyzed the avoidability of death. Factors leading to the deaths were: late diagnosis and delayed care due to a failure to identify high- risk situations during ANC and labor. Shortcomings were noted in filling out patient files, problems with patient conditioning, and ensuring adequate communication between peripheral SDPs with reference structures. Encouraging points were noted in the organization of the maternal death reviews with the actual presence and involvement of permanent members of the audit committees and facility heads, and the audits of most of the deaths that occurred in these SDPs during the reporting period. After the auditing sessions, recommendations were formulated following identification of negative points that contributed to the deaths. − Supervision of maternal death audits: The project supported the DSME to monitor the implementation of maternal death audits in the health districts of Sédhiou, Goudomp, and Bounkiling through a supervision visit. This visit revealed satisfactory planning for the maternal death surveillance and response reviews, formalization of auditing committees, availability of auditing reports, monitoring, and regional coordination that ensured recommendations were carefully monitored. − With the development of the biomedical waste management (BMWM) plan for Saint-Louis, all seven MRs now have a BMWM plan. Similarly, 74 ECR/ECD members (including 14 women) and 148 providers (including 74 women) were trained in BMWM. This brings the number of trained providers to 317 (including 153 women) since the start of the project. This training strengthened ECR/ECD and provider skills and understanding of the environmental impact of biomedical waste and introduced them to USAID environmental compliance. − Implementation of BMWM equipment in 514 SDPs (342 HPs, 21 health huts, and 11 PHFs), or 84% of SDPs in the intervention area. This equipment improved collection, storage, and treatment/elimination in compliance with the laws and regulations in force.
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− Support for the celebration of Global Integrated mobile unit activity package Handwashing Day in Tambacounda and Diourbel MRs and the health districts of Saraya, ✓ Antenatal Care Salemeta, Médina Yoro Foulah, and Kolda. ✓ Family planning ✓ Postnatal consultations Innovative approaches: The project ✓ Growth monitoring and promotion, and vaccination introduced and implemented several for children approaches that all have an impact on services ✓ Adolescent/youth services delivery delivery and utilization at the SDP and ✓ HIV screening community levels. These were: ✓ Health promotion Integrated Mobile Units: With Marie Stopes ✓ Breast cancer screening by specialized providers (upon MR request) International’s retirement from the Outcomes of IMU visits consortium, the project—in collaboration with - 2942 ANC consultations, including 2292 women who the medical regions of Kolda, Sédhiou, Saint- received IPT under DOT Louis, and Diourbel—set up integrated mobile - 736 PNC visits units (IMUs) to deliver care. Each mobile unit is - 1963 FP clients seen, including 855 new clients - 3447 adolescents and youths age 10–24 consulted run by a team made up of the coordinator, two - 1063 individuals tested for HIV qualified providers (a nurse and a midwife), - 1074 women screened for cervical cancer and one support staff (a driver). IMU visits - 2289 screened for breast cancer target hard-to-reach areas or places with weak - 1095 pelvic ultrasounds - 931 breast ultrasounds infrastructure and low levels for indicators in - 25,641 individuals reached through SBCC activities the priority programs to help improve maternal and child health. The IMU service package includes several components (see box). This year, these units made 346 visits. An analysis of results in the four intervention regions show greater use of preventive services. People greatly appreciate these services, stating that they have facilitated their access to other services, as illustrated in Madame D.T.’s testimonial. She is 30 years old and lives in a village served by the Sol Bok health hut of the Mboussobé HP in Touba district. “The services that I received here gave me access to a contraceptive method: a long-desired need after my cesarean. This health vehicle has been a boon to us, way before my last pregnancy. It helped us save money on buying the ticket and travel.” The same finding was also made about specialized services, especially cervical and breast cancer screening. Jàpp naa cì Game Show The Jàpp naa cì Game Show is a communication activity based on the “Divertir pour Eduquer” (Have Fun While Learning) approach that helps change social norms related to girls’ and women’s identities, making reproductive health choices, and maternity norms. Its purpose is to raise awareness about maternal and child health and birth spacing, dispel negative myths and taboos about maternal and child health, and also promote a couple’s relationship. The idea was presented at the National Education and Health Information Service (SNEIPS) and other MSAS directorates and medical regions in the intervention areas to instill buy-in. The first edition was played in
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Kédougou district with participation from all sectors: health, education, youth, and community development. Strengthened intervention districts The situational analyses and evaluations along with the various review and supervision reports show significant differences in health indicators between districts in the same region and between concentration regions. This type of district contributes to keeping performance low in their umbrella regions. Boosting interventions could significantly improve health indicator levels in these districts, and in turn, in these regions. Dianké Makha and Pété are among the districts with the country’s lowest health indicators. In this context, the project supported the entire design process for a plan to strengthen interventions in Dianké Makha district in Tambacounda region: identification and justification of the need to design a plan for strengthened interventions, preparation and holding of workshops to plan and validate the plan, and consolidation of an action plan. Local actors have taken clear ownership of the initiative with the effective participation of administrative and local officials, representatives from other sectors (education, youth, and community development) and community leaders (village chiefs, imams, GPF president, etc.). Health information system: In order to improve the availability and utilization of quality data, the project supported the Division of the Health and Social Information System (DSISS) to: − Print and distribute management tools in 29 districts (9094 registers and 4 reporting tools for health centers and health posts; for the community level, 18,850 notebooks and a reporting tool in huts and sites) − Train 82 ECR/ECD members and 386 providers (including 224 women) on using the information system for management (ISM) tools, including community level tools revised for districts − Organize routine data quality audits in 26 of the 29 districts to prepare the Statistics Yearbooks − Capitalize on community-level data (huts and sites) with validation of community-level indicators and configuration of data-entry forms in the DHIS-2 Barriers and constraints to achieving results The main constraints are: - Scheduling conflicts in the implementation of the deliverables of fixed obligation sub-grants awarded to medical regions and health districts. The project performed regular monitoring to deal with these constraints. Meetings with administrative officials and local municipalities addressed infrastructure gaps in new HPs. - The main challenges to keeping huts and sites in operation are supervision of services delivery in huts and sites done by health post providers and ongoing availability of tracer medicines and products.
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- The main issue facing the comprehensive system to organize emergency transportation is keeping these systems up and running through the renewal of financial resources, maintenance for transportation vehicles, strengthening the link with referring structures, and documentation.
Gender equality and combatting GBV Overview An analysis of social relations between men and women in Senegal reveals inequalities that negatively affect access to health care, and more generally, the well-being of various population categories. Similarly, GBV has been on the rise over the years. Sociocultural and religious beliefs are used to justify certain acts of physical and psychological violence toward women (particularly in the context of marriage). Hence, 46% of Senegalese women 15–49 years believe that it is justified for a man to beat his wife for at least one of the reasons mentioned in the survey (DHS 2017). In addition, recent data on GBV shows that close to one-third of women 25–49 years (32%) had already entered into a first union before reaching age 18, indicating persistently high levels of early marriage. Furthermore, among women age 15–49 years, 24% have been excised. Programming approach Interventions rolled out in 2019 by the USAID/Neema project that deal with gender equality and combatting GBV are listed in the government’s line of action. The thinking is to develop service delivery and SBCC activities as much as possible that promote equitable access to health care and well-being for men, women, and young people, whatever their specific characteristics. Interventions related to gender and GBV are described below: Achievements in gender equality and women’s empowerment The following interventions were developed: Support for the Ministry of Women, Family, and Gender to implement the National Gender Equality and Equity Strategy The project supported celebration of the 2019 International Women’s Rights Day under the leadership of the Ministry of Women, Family, and Gender. - Free consultations, depending on the area, offering MNCH/FP, breast and cervical cancer screening, and HIV screening (Kolda and Sédhiou) resulted in enrolling 50 new FP users, screening for 89 women for cervical and breast cancer, and delivering 18 ANC consultations. - Extensive communication through caravans to raise awareness, panels, and community fairs on the theme for March 8, 2019—“Think fairly, build intelligently, innovate for change”—and specific topics such as early marriage and pregnancy, post-partum infections, women’s decision-making power, and their empowerment. They raised awareness among at least 1612 individuals, including 1343 women. - Integrate gender and youth issues at the health services and household levels Implementation of this intervention resulted in strengthening care providers’ capacities on gender mainstreaming:
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- The manual on mainstreaming gender into the provision of care was completed; it comprises five modules (general information, Gender and RMNCAH; GBV case management; Gender and disease control; and Gender and WASH). - A user guide for trainers was also developed, and a pool of 12 national trainers was set up. - 66 ECR and ECD members (including 34 women) from Diourbel, Tambacounda, and Sédhiou were trained on the manual. - Scale-up began in the four districts in Diourbel MR with four training sessions for 60 care providers, including 31 women. The coverage rate for participating SDPs is 60%. - Implementation of the Nurturing Connections approach to incorporate gender into nutrition activities The process aims to foster women’s empowerment, particularly their ability to make the necessary decisions to improve their own, and their children’s, nutritional status; and encourages greater participation from men in child care and in negotiating with women about the well-being of the entire family and the community. In 2019, 726 individuals, including 392 women, took part in these meetings, for a target of 620 participants, or a participation rate of 117%, due to community members’ interest in this approach—one that lets people share their experiences. Achievements in combatting gender-based violence The USAID/Neema project’s contribution is organized around three intervention areas: Capacity building as part of combatting GBV A module on case management for victims of GBV was added to the guide on mainstreaming gender into the provision of care. The trainer user guide also includes sessions on this topic. Thus, the ECRs and ECDs of Diourbel, Tambacounda, and Sédhiou were trained in case management for victims of GBV. Community-based strategies for the prevention and management of GBV The Community Action Cycle for gender-based violence (CAC/GBV) is a participatory approach to educate, mobilize, and empower communities aimed at preventing and managing GBV at the community level. At the end of this fiscal year, the following achievements were made: - Orientations for the remaining three pools of regional trainers - Holding 25 sessions for districts (100% of the annual target) reaching 547 trainers (318 women), comprised of ECD members, providers, and project facilitators - Training for 1317 CAC/GBV groups (or 61% of the planned number of groups), reaching 20,952 members (including 14,598 women) to lead activities to combat GBV in their communities SBCC activities on GBV Celebration of 16 Days of Activism combating violence against women and children Communication activities were developed in the seven concentration regions in collaboration with MRs, health districts, and local actors to prevent GBV. These activities reached 8293 individuals (including 3795 women) as well as those reached via media and social networks. More than half of those reached were adolescents and youths (5920 young people, including 2916 girls). Development of a communication plan on GBV
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• Development of the GBV campaign concept with USAID/Neema project partners: the MSAS Gender Unit, medical regions, the Young Leaders Network, Bajenu Gox, and other partners. • A communication firm was hired to finalize the campaign slogan and propose scripts and audiovisual products for the national campaign. • Five TV spots were produced, including on domestic violence and early marriage. Constraints and barriers Inadequate human resources at the ministry unit level to ensure proper coordination of activities with medical regions and districts.
Water, sanitation, and hygiene Washing hands with soap and water at critical times helps reduce diarrheal episodes by 45%, according to the World Health Organization (WHO), making it an inexpensive, highly cost-effective intervention for improving people’s health. The USAID/Neema project supports installation of handwashing stations in vulnerable households and facilities to promote adoption of handwashing behavior at critical times to prevent diarrheal infections and diseases. It also serves to remind or alert family members about handwashing. In a drive to foster sustainability and synergy, the project supported the hygiene department’s quarterly work plan to install devices in households and monitor their use. Since the start of the project, 11,686 of the planned 11,836 devices have been installed, or a performance rate of 98.73%. This success was due to the strategy to support the hygiene department for the installation and collaboration with ACCES and Tambacounda region. The project’s mid-term survey reported a positive trend toward adopting favorable behaviors to prevent infections and control diarrheal diseases in the project intervention regions, with over 90% washing their hands after using toilets, before cooking, and after eating. This year, approximately 100,000 individuals were reached through the hygiene department’s interpersonal communication efforts that accompany the installation of handwashing stations and the monitoring of their use. Public-private partnership and synergy
Technical approach
Synergies: Synergy with other projects are summarized below, by topic.
Human resources management
‒ Synergy with the HRH 2030 project, GoTAP, and HSS+ to implement the Workload Indicators of Staffing Need (WISN approach), strengthen capacities in central MSAS directorates and departments on leadership.
Malaria control
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‒ In synergy with USAID-GOLD, a regional advocacy workshop was held in Tambacounda for local officials to increase the involvement of technical advisors in SP availability as part of improving IPT coverage for pregnant women.
‒ In synergy with USAID-GOLD, awareness-raising activities on malaria in Tambacounda and Kolda regions were held with 332 mobilized individuals, including 156 women.
Nutrition/WASH
‒ A planning meeting to build synergies with Naatal Mbay, Kawolor, and ACCES and to discuss ways to collaborate
‒ Trainer training for 16 staff on ENA/EHA in Kaffrine with funding from the USAID Kawolor project and USAID/Neema technical support.
‒ Distribution of hand-washing stations in Goudiry
Governance/Planning
‒ Development of 3 plans to build internal synergy in the Regional Bureaus (RBs) of Kolda, Tambacounda, and Saint-Louis and 1 plan to build external synergy
‒ Support organization of workshops to develop Local Government Operational Plans (POCLs) for municipalities in Kolda medical region through the health districts
Public-Private Partnership
‒ In the context of public-private partnership, the project completed the final version of the PSP that were used by SHOPS+ to introduce private SDPs
‒ The project supported SHOPS+ through Tutorat 3.0 to organize on-site supervisions in private SDPs by providing mannequins for packages 1 and 2
Support to develop the health-Local Government Operational Plans (POCLs) made it possible to:
‒ Reduce the financial costs for implementation for each project
‒ Provide Annual Work Plans in the intervention regions
Meetings to build synergy facilitated sharing results and identifying common activities and their harmonized implementation. The following was done:
‒ Training of a pool of trainers in Kaffrine who facilitated the harmonization of approaches to implement ENA/EHA in Kawolor and Neema intervention areas.
‒ Synergy with HSS+ and GOLD resulted in training on women’s role in improving health services delivery in the GOLD partnering municipalities in Tambacounda and Kédougou. Pooling efforts will help increase the target population’s demand for care.
‒ Support for the DSME to revise the PSP made the document available to SHOPS+ so that services could be provided in private SDPs that comply with MSAS PSP.
Barriers/constraints
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The main barriers are listed below.
‒ Contributions to activities to promote people’s buy-in and enrollment were minimal due to the unavailability of financial resources to support health mutuelles in the concentration regions.
‒ The lack of harmonization of procedures between partners within the Regional Bureaus limited the implementation of some activities in the field. Science, technology, and innovation The key achievements are summarized below. - Support for health huts for medicine stock management and stockout early warnings with the deployment of a mobile application to report births and deaths, appointment reminders for pregnant women, and monitoring ANC and PNC - Use of the mHero RapidPro technology for awareness raising, supervision of actors, and mass SMS campaigns - The project also supported the MSAS to redeploy and update the iHRIS software - In terms of monitoring appointments for PLHIV, the project launched a mobile application that allows social workers and physicians to monitor patients and receive SMS alerts in case of no-shows. The application also sends an SMS reminder to patients before their appointment to pick up ARVs. With the CNLS, another initiative is being tested with the DHIS-2 by its Tracker module.
Section 2: Monitoring & Evaluation, Research, and Learning Monitoring and evaluation are important components in a project’s management cycle that play a key role in the decision-making process. Since emphasis is increasingly on resources, monitoring and evaluation are particularly important in determining which interventions are more effective. These processes allow individuals and organizations to assess whether a project is achieving its objectives, to monitor the use of funds, to identify challenges, and to create a database needed to clarify decision making and to improve future efforts. The main mission of the Monitoring & Evaluation, Research, and Learning (MER&L) component is to monitor project activity implementation, support integrated supervision, ensure the production of quality data, and document interventions for better decision-making. This section will focus on four main points:
1. The project monitoring mechanism
2. Study and evaluation results
3. Success stories
4. Issues related to learning 1. The project monitoring mechanism The monitoring process involves routine collection of quality data using specific indicators to measure results. The main activities completed this year are: quality assurance of generated data; quarterly reviews of project data; and support for integrated supervision of SDPs and community facilities.
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Data quality assurance: The relevance of decisions depends first and foremost on the quality of the data. The USAID/Neema project set up mechanisms to guarantee data quality, meeting the five criteria for quality (Validity, Reliability, Timeliness, Precision, and Integrity). Data quality assurance is conducted on the two types of data used to measure project performance: - At the project data level: The MER&L team developed standardized data collection tools used by all program staff. The performance monitoring table was also put online, which allows the various monitoring and evaluation officers from the three RBs and the Diourbel Coordination Unit to capture data collected by technicians in real time. In order to provide quality data, the MER&L team at the central level conducts a quarterly data audit at each RB and the Diourbel Coordination Unit. - At the service data level: The DHIS-2 is the main data source used by the project to prepare its Performance Monitoring Plan (PMP). Thus, the project supported the MSAS in several activities with the goal of providing quality information for decision-making purposes. Organizing a regular data quality audit in 26 districts was one form of support. (See the section on health system strengthening for other examples of support). Quarterly project data reviews: For monitoring project performance, periodic reviews were organized at the regional and national level. The regional bureaus organize quarterly reviews to ascertain progress on planned activities and to identify constraints and challenges that arise along with the recommended solutions. A national data review is also held at the central level to prepare the quarterly or annual report submitted to the donor. This meeting is an opportunity for project staff to discuss achievements and identify the way forward for the next quarter. In addition, the project also supported the 2018 services data review in 26 districts. Integrated supervision of SDPs and community structures: Each quarter, the project provides support to districts to allow them to conduct a supervision visit to assess the quality of services offered and to verify data completeness. During this year, 320 SDPs, 176 health huts, and 68 community sites were supervised by ECDs with USAID/Neema project support. These supervisions helped strengthen providers’ capacities. 2. Study results The project conducted a mid-term evaluation to monitor behaviors to support the implementation of some interventions. The goal of this study is to monitor changes in the behavioral determinants related to each of the themes. It also assessed the impacts of the Jàpp naa cì campaign. In addition, as part of the behavioral study with ideas42, a preliminary test of a model to provide preventive services for adolescents and youths was carried out in Tambacounda. Key results are described below:
Mid-term evaluation: • Safe motherhood is fairly well managed: Overall, 69.4% (compared to 67% at baseline) have stated having had four visits. Gaps were noted when comparing regions. The highest completion rate was in Saint-Louis, where 78.1% of WRA were in compliance with the WHO standard, while Diourbel region reported the lowest percentage, with 52.5%. Also, 30.4% of WRA stated having had at least three doses of SP/Fansidar during their last pregnancy, or an 11-percentage-point increase compared to 2017. • Data also show that increasingly more communities are adopting the practice of exclusive breastfeeding. The rate for exclusive breastfeeding in the seven regions went from 42% to 77% 1
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between 2017 and 2019. In some regions, the rate exceeded the 80% mark (Kolda 95% and Sédhiou 88.9%). However, in a region like Tambacounda, work still needs to be done (62.2%). • For childhood illness, the results show an overall improvement in indicators compared to the 2017 baseline survey. The percentage of WRA who administered an ORS-based treatment increased from 70.8% to 72.1%. Moreover, the percentage of WRA who administered a zinc-based treatment rose from 70.8% to 78.9%. • Family planning prevalence among women who have had at least one child in the last five years rose from 28% to 34% in 2019. Comparing data from 2017 to data from 2019 for the most commonly used methods shows an increase in LTPMs, such as the implant (34% to 42.4%), and a decrease in the use of short-term methods like the pill (20% to 15.9%) and injectables (40% to 31.2%). • Bednet use among women and children was also assessed during the study. For children, 90% (compared to 83% at baseline) of them use a bednet; children in rural settings show a slight advantage (91%) compared to those in urban settings (85%). In Sédhiou, nearly all children use a bednet (98%). Regional differences are not obvious. For pregnant women, the average value for WRA who slept under a bednet is 89% (compared to 83% at baseline). Looking at individual regions, Sédhiou and Kolda report the highest rates with 98% and 94%, respectively. • Regarding early marriage, the majority of women interviewed (59%) stated they supported denouncing and challenging these marriages. The vast majority (90%) of them state they are also ready to oppose early marriage of their daughters/nieces/sisters. The results also show that the vast majority of women surveyed (65%) refute the idea that early marriage is a way to protect girls. A communication program called Jàpp naa cì was developed to stimulate behavior change, using the baseline study results, The midterm evaluation results point out that 26% of interviewees state having heard about it through television, with percentages ranging from 57% in Saint-Louis compared to 7% in Matam; 24.4% heard about it via radio, with 37% in Sédhiou compared to 12% in Kédougou; 11% via publicity posters, with 26% in Kolda compared to 5% in Kédougou; and 7% through newspapers and magazines. Overall, we noted an improvement in behavioral indicators.
Figure 10: Changes in selected indicators between 2017 and 2019 89% 83% 77% 67%69%
42% 34% 34% 28% 19%
4 CPN AME PF TPI3 Moustiquaire(FE) Baseline Mi-parcours
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Behavioral research: A preliminary test of an innovative service delivery model for adolescents and youths outside of school settings was conducted in four SDPs in Tambacounda health district, to assess the model’s feasibility and acceptability. The intervention package content includes: (i) enrollment sessions, (ii) a preventive health exam (physical exam; condom provision; screening for risk behaviors; and counseling on nutrition, physical activity, and prevention of high-risk pregnancies and STIs and AIDS) and (iii) the health information program via the “Ado Santé” SMS Inbox. The mystery client survey conducted during implementation and the monitoring survey of 40 young people who had participated in the information sessions showed positive results for the intervention’s acceptability and feasibility as well as for the knowledge and behaviors related to reproductive health for young people. Key results of the preliminary test: ▪ 90 youths completed a health exam (including 51 women) with 64%, age 15–19 years. ▪ 15 out of 18 youths who had a health exam stated having changed their behaviors after the exam. “I am more prepared to avoid STIs and early pregnancy.” ▪ This exam also demonstrated that this system could be effective for: (1) Improving communication and interaction between young people and health providers; (2) Normalizing frequent use of health services to mitigate the social costs related to contraception; and (3) confirming that providers needed regular training on delivery of youth-friendly services. ▪ The youths demonstrated keen interest in the approach and on the topics covered, especially preventing pregnancies and STIs. (Mystery Client Survey). ▪ Providers unanimously agreed that (1) the intervention should be deployed across Senegal; and (2) the intervention could help reduce unintended pregnancies and STIs. (Provider questionnaire, monitoring survey). ▪ Lessons learned: (1) Behavioral interventions are still needed to help providers change their behaviors in this area. (2) Care providers found that the intervention was both feasible and effective in achieving health objectives. ▪ Recommendations: (1) Clarify explanations and change attitudes toward young people regarding issues of sexual health; (2) Support young people to cover the costs of purchasing some medicines; and (3) Extend the validity of vouchers. ▪ Challenges: Help providers to systematically create a welcoming environment for young people.
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3. Success stories
Inspired by the USAID/Neema project, a mayor provides UHC to 300 constituents... and saves lives! Senegal launched universal health coverage on September 20, 2013. The USAID/Neema project has led ongoing advocacy for universal health coverage. Community dialogues piqued the mayor’s concern in Thilogne. He decided to allocate a portion of the municipality’s funding to protect and provide access to care for the most vulnerable.
Her name is Ndiabou Niang. She is 30 and from Diabe Salla, a neighborhood on the outskirts of Thilogne municipality. She is a housewife, living with her husband and two children. The family strives to make ends meet. Ndiabou runs a small business selling seasonal fruits to help provide for the family. She could have contributed more but her closely-spaced births kept her from doing so. For her last prenatal visit, the midwife asked her for 39,000 FCFA for tests, prescriptions, and an ultrasound. A fortune!! She confides sadly that the prescriptions and test orders laid tucked away in the back of a drawer for a long time.
In the meantime, here pain persists, and she doesn’t know exactly why, nor what to do. “Of course, I’ve heard of this famous universal health coverage that lets a family get medical care at a lower price or even for free. I was never able to join... lack of resources,” she exclaims, worried. “If I can no longer take care of my family because of my health, who is going to take care of them?” Senegalese from the informal sector are not required to join or pay into health insurance. Close to half of them live below the poverty threshold and couldn’t afford quality health care even if they wanted it. Associations support setting up community health mutuelles, run by volunteers. But it always ends with discouragement: there is no reason to pay into a mutuelle when it only covers 20% to 50% in a health post, one of the local establishments offering limited services, found throughout the country. Admittedly, the consultations do not cost more than 1000 FCFA and are, therefore, affordable. By contrast, expensive treatments and medicines are not obtainable. Whether insured or not, people still have to go to the pharmacy, where they have to pay—and a lot: between 5000 and 12,000 francs FCFA for a box of antibiotics. So, they’re saving up money when they’re healthy, and once they become sick, go see whichever professional they want and walk through the door of whatever establishment they choose. Or they’re turning to traditional medicine, even if the plant dosage poses risks, when they don’t have enough to pay for modern medicine. Recognizing this, USAID/Neema began extensive advocacy. Community mobilization involving people and local municipalities was what got people to support UHC. After several meetings to discuss ongoing advocacy, the mayor of the municipality of Thilogne decided to fund UHC for close to 300 women and children. Including more members proved advantageous for Ndiabou, the mother of the family. “Recently, I was referred to the Ourossogui Regional Hospital (CHRO) for x-rays, prescriptions, and tests costing 75,000 FCFA. I only paid 15,000 FCFA. If I hadn’t had UHC, I couldn’t have paid all that.” Ndiabou is very grateful for the strong advocacy carried out by USAID/Neema staff and is committed to do whatever it takes to get her two children, ages three months and
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International Women's Day 2019 International Women's Day has special significance for everyone at USAID Neema. Today, through Helen Keller International (HKI), a project consortium member, we celebrate an exceptional woman of change from Senegal. Brigitte Malou is a health worker and leader who gives her time, energy, and service with all her heart to improve the lives of women and children and to build stronger communities. USAID's Neema Project works to ensure that communities have sustainable access to high-quality, routine health and nutrition care, even in the most remote villages. The woman we celebrate in this story received training through the Neema project and the project now supports her work. Brigitte Malou Nurse Brigitte Malou's office at the health post in Sinbandi Balante may as well have a revolving door. Just as one mother and child leaves, another pair enters. The nurse welcomes them all with a tireless and 100%- genuine smile. “Some women travel here from very far away, even all the way from outside the district—some even come from Guinea Bissau,” she said. “Regardless of where they come from, we take them into our care.” See this link for more details of Brigitte’s story: https://youtu.be/tAjFaZIzBY4
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4. Learning
The learning plan is a forward-looking, interactive tool that ensures that project staff can learn from implementation. USAID/Neema recognizes that learning from information gained from program implementation increases project impacts. The main goal of the learning plan is to identify key issues, lessons, and knowledge that could be used to improve a project’s performance. Learning is emphasized throughout the project’s cycle. This year, the following interventions were documented to draw lessons for possible scale-up: Community-based distribution strategy for Sulfadoxine-Pyrimethamine (SP) under DOT in Goudomp health district: As advocated by the WHO, this strategy recommends administering SP through intermittent preventive therapy (IPT) for pregnant women. The efficacy of this alternative prevention strategy on reducing the Plasmodium falciparum placental infection rate, low birth weight, and severe anemia during pregnancy has been demonstrated in several studies conducted in Africa. In Senegal, this strategy has been implemented at the operational level (health posts and health centers), but the expected results for coverage (SP3) have not been reached yet. Problems and constraints reported in implementation are: SP stockouts and pregnant women’s unavailability due to their workload and the isolated areas where they live, especially during the rainy season. Aware of these problems and constraints, USAID/Neema supported Goudomp health district through the Safane and Karantaba health post to initiate an innovative approach called “community-based SP under DOT” to improve SP3 coverage and to achieve the fixed targets. The approach relies mainly on the relais (community actors), who are called home-based SP distributors. The approach first involves leading activities to raise public awareness about the new strategy and to also advocate among municipal officials. With support from health committees and mayors through endowment funds, SP inventories were strengthened to prevent stockouts. Using a follow-up notebook, the distributor relais conducts a monthly check on the status of enrolled pregnant women who have taken the first dose of SP at the health post or health center. The distributor gives the second dose on the appointment date noted in the health card and then checks off SP2; the follow-up will be done in the same way for SP3, SP4, and SP5, and the administered dose must be recorded in the daily collation tables (TACOJO). The next step is to select distributors based on their availability and expertise, led by the ICP/SFE and assisted by the village chief, with preference placed on relais from the community. The strategy helped improve the SP3 coverage rate, the assisted delivery rate, the ANC completion rate, and the LLITN coverage rate for pregnant women. Documentation showed an increase between 2016 and 2017 for SP3 coverage from 43% to 79%; for the number of women who completed four ANC consultations, increasing from 650 to 1268; and for the number of deliveries assisted by a qualified staff, which rose from 2028 to 2150. In terms of lessons learned, we highlight: • Involving village chiefs and women leaders makes it possible to reach a large number of women about SP intake and keeping ANC appointments.
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• The ongoing contact between the pregnant woman and the relais distributor created by the strategy encourages and motivates the woman to complete the series of ANC consultations and to deliver in a health facility. • Ownership of the strategy by community actors
Nurturing Connections: A transformative gender-relations approach can improve women’s health. The project has taken an approach that mobilizes and challenges power relations between men and women and the gender norms that drive unfair and discriminatory behaviors in households and communities. Nurturing Connections is a behavior change program that aims to transform community norms through a participatory approach involving various decision makers and influential people at the household and community level. It is a process that fosters women’s empowerment, particularly their ability to make the necessary decisions to improve their own, and their children’s, nutritional status; and encourages greater participation from men in child care and in negotiating with women about the well-being of the entire family and the community.
The intervention sets up the necessary foundations for behavior change and mainstreaming a gender perspective within households. To illustrate this, we offer the following accounts from a couple in the village of Mbane: In Mbane village, Amadou Niang, a 33-year-old farmer, lives with his wife Oumy Niang, age 23 and mother of two children under 5 years and six-months pregnant. The couple’s last abortion occurred one year ago, caused by the painful task of fetching water for the household. Water is a very difficult problem in the village, leading to many abortions. Oumy Niang told her story. “I’ve had two abortions, and we were thinking about gossipers and judgmental glances, but with Nurturing Connections, my husband changed and since then, he gets water and dead wood for me. Thank God I’m relaxed about my pregnancy at six months.” Her husband explains further, “This program came at the right time and opened our eyes. All that we regret is not having had it for so long; we were in the dark, and now with Nurturing, we are in the light.”
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“Beyond my problem with abortion, Nurturing Connections helped us women because today we defend our points of view without disrespecting our husbands or creating drama. Everything gets discussed, and very often we find solutions together with our husbands,” adds Oumy Niang. For Amadou, women have become more aware and avoid spending on ceremonies where a lot of money was being wasted and which was a problem in the village. Today, there are rules that ensure people adhere to the promised changes with the support of the village chief and the imam. In all the villages, participants in Nurturing Connections activities (women, men, and leaders) are very committed and satisfied with the activity’s outcomes. Men say that they like these activities and are eager for a new day. “We’re very busy in the fields, but we always find time for these activities.” They are unanimous in saying that they were somewhat apprehensive and afraid at the start but, in the end, “gained a lot from these meetings.” “We learned how to communicate with our family members, especially our wives and children; we show understanding toward the other person, and we help with household chores, especially fetching water.” Other changes for Amadou Niang: “I was very nervous, but now I’m learning to manage myself”; “I even became a mediator to resolve conflicts in the community, whereas before, that was not my problem.” He adds: “Men tend not to realize that women have too much to do and that they must help lighten their load by communicating with them to know how to help them, and especially practicing family planning.” There always has to be communication between husband and wife and between community members. “These activities have changed us a lot; before, I made decisions alone in my home, telling myself that I was the head of household. Now I talk it over with my wife and consult her before making a decision.”
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Section 3: Annexes 1. Performance Monitoring Plan 2. Summary of results of FP integration into vaccination services 3. Summary of results for integrated mobile units (IMUs) 4. Summary of VADI implementation 5. Summary of CVAC implementation 6. Summary of Tutorat 3.0 implementation 7. Summary of CBO activities
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1. Performance Monitoring Plan
Data used to prepare the Performance Monitoring Plan for this year are from the following sources:
1. The DHIS-2 platform for services data. The annual data completion rates in the DHIS-2, measured on 22 October 2019, appear in the table below.
Medical region DSME: Monthly report Child nutrition and health
Diourbel 79.8 68.3
Kédougou 65.7 59.6
Kolda 78.8 58.2
Matam 73.8 45.6
Saint-Louis 80 71.1
Sédhiou 69.4 61
Tambacounda 68.7 54.6
Overall rate 73.50% 59.70%
1. The National Procurement Pharmacy (PNA) database (Yeksi Naa data) for the stockout indicator. 2. The Regional Procurement Pharmacy (PRA) databases to calculate CYP, based on distribution data. 3. Supervision data: Data used to prepare the Performance Monitoring Plan for this quarter are from the following sources: 4. Mid-term monitoring survey of health-promoting behaviors for the handwashing indicator.
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SOURCE/ ACHIEVEMENT Pro- Comments DESCRIPTION OF COLLEC- REP. BASE- FY19 gress No. DESAG. INDICATORS TION FREQ. LINE OBJEC- Q1 Q2 Q3 Q4 FY19 METHOD TIVES Goal: Support the efforts of the Government of Senegal to ensure health services are sustainably improved and effectively utilized to reduce maternal, neonatal, and child mortality and morbidity and contribute to an AIDS-free generation. Objective 1: Increased access to and utilization of quality health services and products in the public sector 1.1.4 Couple-years of Diourbel 31,780 48,633 24,651 11,254 13,429 49,334 101% PRA data are not Regional protection (CYP) Kédougou 20,883 11,250 2871 3209 4643 10,723 95% available yet for this Procure- through a program Kolda 40,781 34,619 14,434 5841 13,908 34,183 99% quarter (Q4). We are ment HL.7.1-1 supported by the US Every Matam 25,408 18,500 296 10,174 13,717 24,187 131% waiting for PRA-level Pharmacy government 3 mos Saint-Louis 69,375 58,892 10,206 19,621 18,349 48,176 82% data. (PRA) Sédhiou 21,960 17,119 7772 3145 7488 18,405 108% distribu- Tambacounda 53,700 35,000 7382 8675 12,551 82% tion data 28,608 TOTAL 263,887 224,013 67,612 61,919 84,086 213,617 95% 1.1.10 Number of children Diourbel 27,633 18,306 3800 3374 2033 2244 11,451 63% under 5 years with Kédougou 5380 3922 934 1399 706 896 3935 100% This year, 62,877 cases pneumonia receiving Kolda 33,085 25,310 4209 5692 3592 4638 18,131 72% of children with antibiotics 3.1.9.2-3 pneumonia received recommended by Every Matam 7254 3525 527 491 510 319 1847 52% DHIS-2 the recommended providers and CHAs 3 mos Saint-Louis 17,148 13,793 2374 3557 2372 2019 10,322 75% antibiotics, achieving trained through a Sédhiou 12,838 7230 1178 1064 684 921 3847 53% 70% of the annual program supported by Tambacounda 15,528 17,651 3986 4293 2544 2521 13,344 76% the US government target for the year. TOTAL 118,866 89,739 17,008 19,870 12,441 13,558 62,877 70% 1.1.12 Number of children Diourbel 33,325 36,098 8329 15,995 7422 9429 41,175 114% under 5 years with Kédougou 5937 6431 729 3294 2300 1676 7999 124% diarrhea treated 135,595 childhood HL.6.6-1 Kolda 27,025 29,274 1445 6946 2770 3913 15,074 51% according to national cases of diarrhea were DHIS-2 Every Matam 17,116 18,540 2694 3016 1923 2378 10,011 54% guidelines (ORS/zinc) treated with ORS/zinc, 3 mos Saint-Louis 32,754 35,479 5442 9340 5903 6738 27,423 77% through a program or an increase of 87% supported by the US Sédhiou 12,665 13,719 1923 4770 2425 2855 11,973 87% for the annual target. government Tambacounda 15,557 16,851 3316 8998 4692 4934 21,940 130% TOTAL 144,379 156,392 23,878 52,359 27,435 31,923 135,595 87% 1.1.18 Number of qualified Diourbel 154 216 75 94 45 20 234 108% Throughout this year, community providers Kédougou 48 149 0 2 100 63 165 111% 1877 workers were trained in nutrition Kolda 44 165 0 12 24 101 137 83% trained in nutrition, or HL.9-4 through a program Project Every Matam 0 119 93 0 34 45 172 145% 131% of the annual supported by the US archives 3 mos Saint-Louis 372 314 108 24 24 45 201 64% target. government Sédhiou 91 153 0 87 10 195 292 191% Tambacounda 0 318 23 167 131 355 676 213% TOTAL 709 1434 299 386 368 824 1877 131% 1.1.19 Percentage of providers Situational Every Diourbel 33% 75% 64% 64% 85% Supervision data who comply with analysis 3 mos Kédougou 44% 75% 63% 63% 84% collected in 320 health 11
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SOURCE/ ACHIEVEMENT Pro- Comments DESCRIPTION OF COLLEC- REP. BASE- FY19 gress No. DESAG. INDICATORS TION FREQ. LINE OBJEC- Q1 Q2 Q3 Q4 FY19 METHOD TIVES standards and protocols report for Kolda 33% 55% 82% 82% 149% posts and health related to the baseline Matam 29% 75% 57% 57% 76% centers show that 68% management of labor 3.1-7 study Saint-Louis 38% 57% 62% 62% 109% (217/320) use the and delivery in facilities Supervisio partograph to monitor funded by the US Sédhiou 50% 75% 81% 81% 108% government n Report Tambacounda 52% 75% 58% 58% 77% labor, or 91% of the TOTAL 43% 75% 68% 68% 91% annual target. 1.1.20a Number of service Diourbel 60 89 88 99% 96% of SDPs offer the 7 delivery points Kédougou 23 32 36 113% elements of basic providing basic life- Kolda 51 60 66 110% EmONC (except for
saving maternal care 93% ventouse delivery), or Super- Every Matam 58 85 79 (basic emergency an annual performance vision 3 mos Saint-Louis 89 110 86 78% Custom obstetric and of 96%. Report Sédhiou 53 58 52 90% neonatal care) Tambacounda 61 92 99 108% supported by the US
government TOTAL 386 525 506 96% 1.1.20b Number of service Diourbel 11 47 13 28% Only 62 SDPs offer delivery points Kédougou 4 16 2 13% ventouse delivery. providing ventouse Kolda 14 33 14 42% However, 137 SDPs (or delivery supported Super- Every Matam 8 43 4 9% 51% of the annual by the US vision 3 mos Saint-Louis 15 56 15 27% target) have at least Custom government Report Sédhiou 5 26 7 27% one provider trained in Tambacounda 10 48 7 15% ventouse delivery. TOTAL 67 269 62 23% Diourbel 100% 100% 100% 100% 100% Family planning counseling and/or Kédougou 100% 100% 100% 100% 100% services are delivered Percentage of service Super- Kolda 100% 100% 100% 100% 100% in all health posts and delivery points vision 100% health centers. offering counseling Every Matam 100% 100% 100% 100% HL.7.1-2 Report and/or PF services 3 mos 100% Saint-Louis 100% 100% 100% 100% supported by the US 100% government Sédhiou 100% 100% 100% 100% 100% Tambacounda 100% 100% 100% 100% 100% 100% 100% TOTAL 100% 100% 1.1.24 Percentage of service Diourbel 0.17% 3% 3% 10.5% 5% 3.8% 3.8% 99% The stockout rate is delivery points PNA data Every Kédougou 1.06% 3% 23% 15.0% 10% 7.6% 7.6% 95% 7.2% in the assisted by USAID (Yeksi 3 mos Kolda 0.15% 3% 19% 19.0% 10% 2.6% 2.6% 100% concentration MRs. A that experienced Naa) Matam 0.28% 3% 7% 20.5% 7% 2.2% 2.2% 101%
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Neema – Integrated Service Delivery and Healthy Behaviors
SOURCE/ ACHIEVEMENT Pro- Comments DESCRIPTION OF COLLEC- REP. BASE- FY19 gress No. DESAG. INDICATORS TION FREQ. LINE OBJEC- Q1 Q2 Q3 Q4 FY19 METHOD TIVES stockouts of Saint-Louis 0.21% 3% 6% 6.5% 4% 2.9% 2.9% 100% 98% performance rate contraceptive Super- Sédhiou 0% 3% 13% 10.0% 9% 14.7% 14.7% 88% was reported. HL.7.1-3 products during the vision Tambacounda 1.06% 3% 3% 25.0% 5% 5.3% 5.3% 98% reporting period Report TOTAL 1% 3% 11% 15.5% 7% 4.9% 4.9% 98%
HL7.2-1 Percentage of Behavior Yearly Diourbel 77% 90% 66% 73% Data from the mid- individuals who Sur- Kédougou 51% 70% 97% 139% term behavioral survey remember hearing or veillance Kolda 65% 83% 89% 107% show that 85% seeing a specific Study/ Matam 65% 82% 74% 90% (3613/4264) of people message on FP/RH, Special Saint-Louis 86% 90% 93% 103% heard or saw a with support from collection/ Sédhiou 59% 74% 94% 127% message on FP/RH. the US government National Tambacounda 59% 76% 87% 114% survey TOTAL 67% 81% 85% 105% HL7.2-2 Number of Yearly Diourbel 794 1356 1252 92% 10,095 community community health Kédougou 539 692 663 96% actors, including 7768 workers supported Kolda 1655 1837 1821 99% women, offer or Mapping by the US provide information on of huts Matam 639 1402 1233 88% government who FP. and sites; Saint-Louis 1153 1503 1462 97% provide information Project Sédhiou 1229 1014 927 91% about FP, FP archives Tambacounda 1976 2738 2737 100% referrals, and/or FP services during the TOTAL 7985 10,542 10,095 96% year 1.1.28 Number of women Diourbel 39,062 39,062 9519 10,868 8711 11,135 40,233 103% 109,073 deliveries were receiving AMTSL Kédougou 3781 3781 1299 1157 1260 1126 4842 128% performed under through a program Kolda 12,377 12,377 2179 4066 3611 3628 13,484 109% AMTSL, achieving a DHIS-2 supported by the US Every Matam 10,236 10,236 576 2482 2919 3191 9168 90% 96% increase for the database Custom government 3 mos Saint-Louis 21,902 21,902 2228 3845 4956 5864 16,893 77% annual target. extraction Sédhiou 7186 12,345 1827 2736 2047 1692 8302 67% Tambacounda 13,469 13,469 2884 4107 4574 4586 16,151 120% TOTAL 108,013 113,172 20,512 29,261 28,078 31,222 109,073 96% 1.1.34 Number of children Diourbel 65,779 91,785 23,594 32,044 19,492 18,408 93,538 102% This year 30,7485 under 5 years who Kédougou 8037 11,808 3985 5575 3021 2821 15,402 130% children under 5 years received a nutrition Kolda 16,353 34,814 9692 11,027 6708 13,613 41,040 118% received growth Every intervention in a DHIS-2 Matam 25,137 13,694 3903 6031 4617 5073 19,624 143% monitoring and 3 mos program supported Saint-Louis 47,579 66,092 13,780 19,929 15,842 13,499 63,050 95% promotion, for an by the US Sédhiou 9574 42,154 8302 9517 8007 9159 34,985 83% annual performance of HL.9-1 government Tambacounda 22,927 42,690 6604 16,032 10,223 6987 39,846 93% 101%.
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Neema – Integrated Service Delivery and Healthy Behaviors
SOURCE/ ACHIEVEMENT Pro- Comments DESCRIPTION OF COLLEC- REP. BASE- FY19 gress No. DESAG. INDICATORS TION FREQ. LINE OBJEC- Q1 Q2 Q3 Q4 FY19 METHOD TIVES TOTAL 195,386 303,037 69,860 100,155 67,910 69,560 307,485 101% Number of children Diourbel 48,135 69,359 16,548 26,301 15,687 14,885 73,421 106% 231,961 children 0–23 1.1.35 0–23 months old Kédougou 6075 9235 2631 4138 2466 2003 11,238 122% months old received who received a Kolda 16,525 24,211 7543 9338 5217 10,900 32,998 136% growth monitoring and nutrition intervention Every Matam 15,831 8968 2131 4308 3137 3363 12,939 144% promotion services, or DHIS-2 in a program 3 mos Saint-Louis 36,600 52,230 8850 15,535 12,160 10,680 47,225 90% a performance rate of supported by the US Sédhiou 23,497 29,604 5072 6823 5553 5977 23,425 79% 100%. HL.9-2 government Tambacounda 20,318 39,249 4526 12,757 7978 5454 30,715 78% TOTAL 144,466 232,855 47,301 79,200 52,198 53,262 231,961 100% 1.2.1 Percentage of SDPs Diourbel 48.0% 79% 89% 89% 113% Of the 320 facilities that have a Kédougou 54.0% 82% 85% 85% 104% (health posts, health functioning Kolda 54.0% 82% 83% 83% 101% centers, and health Super- referral/counter- Every Matam 43.0% 77% 86% 86% 112% huts) supervised this vision Custom referral system from 3 mos Saint-Louis 45.0% 78% 89% 89% 114% year, 86% have a Report the community to Sédhiou 83.0% 93% 87% 87% 94% functioning referral/ the health post Tambacounda 67.0% 87% 81% 81% 93% counter-referral TOTAL 54.5% 82% 86% 86% 105% system. 1.4.1 Number of Dakar IHS 827 1343 281 305 152 256 994 74.0% Of the 2719 individuals individuals of key Pikine 150 896 117 172 117 177 583 65.1% from key populations
populations tested Every Mbour 124 1294 75 27 158 238 498 38.5% who were tested District who receive their 3 mos (including 1456 MSM), reports Ziguinchor 295 1443 160 46 189 249 644 44.6% HTS_TS results 224 are positives, or an TOTAL 1396 4975 633 550 616 920 2719 54.7% T 8% yield. 1.4.2 Number of persons Dakar IHS 65 90 21 27 14 35 97 108% Of the 224 from key (adults and children) Pikine 8 46 21 10 8 16 55 120% populations who tested District Every newly enrolled on Mbour 8 66 8 5 8 12 33 50% positive, 211 were put reports 3 mos TX_NEW ARVs Ziguinchor 9 74 9 3 9 5 26 35% on ARVs, or a 94% TOTAL 90 275 59 45 39 68 211 77% linkage rate. 1.4.3 Percentage of District Dakar IHS 0% 90% 9% 69% 69% 69% 77% 60% of PLHIV have a patients on ARVs reports Every Pikine 15% 90% 15% 45% 45% 45% 50% suppressed viral load, with an undetectable 3 mos Mbour 24% 90% 28% 71% 68% 68% 79% or a performance rate viral load reported in Ziguinchor 0% 90% 0% 21% 21% 21% 23% of 67%.
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Neema – Integrated Service Delivery and Healthy Behaviors
SOURCE/ ACHIEVEMENT Pro- Comments DESCRIPTION OF COLLEC- REP. BASE- FY19 gress No. DESAG. INDICATORS TION FREQ. LINE OBJEC- Q1 Q2 Q3 Q4 FY19 METHOD TIVES registers in a TX_PVLS treatment center or laboratory information system TOTAL 3% 90% 11% 60% 60% 60% 67% in the last 12 months
Objective 2: Increased adoption of healthy behaviors Percentage of DHS Diourbel 43.8% 69% 83.5% 121% Data from the mid- 2.7 households that reports Kédougou 52.8% 63% 65.2% 103% term behavioral survey have a designated c-DHS Kolda 46.5% 61% 47.8% 78% indicate that 75.9% space for hand Behavior Matam 93.2% 90% 91.9% 102% (1030/1347) of Yearly HL.8.2-5 washing with soap Sur- Saint-Louis 94.9% 90% 76.9% 85% households have a and water that family veillance Sédhiou 47.0% 73% 88.4% 121% designated space for members use washing hands with Study Tambacounda 17.2% 57% 95.5% 168% frequently soap and water. TOTAL 53.9% 72% 75.9% 105%
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Neema – Integrated Service Delivery and Healthy Behaviors
2. Summary of results of FP integration into vaccination services
No. of individuals New users of FP methods reached No. of No. of PNC No. of No. of Enrollment DISTRICTS children consultations Standard SDPs sessions rate M W T vaccinated conducted PILL INJECTABLE IMPLANT IUD Days TOTAL Method DIOURBEL MEDICAL REGION Bambey 12 60 81 1212 1293 1751 416 97 293 68 21 0 479 40% Diourbel 3 9 2 216 218 542 35 13 33 8 4 0 58 27% Touba 2 10 0 381 381 379 60 8 19 11 1 0 39 10% MR Total 17 79 83 1809 1892 2672 511 118 345 87 26 0 576 32% KEDOUGOU MEDICAL REGION SALÉMATA 3 18 14 498 512 371 35 0 10 29 1 0 40 8% MR Total 3 18 14 498 512 371 35 0 10 29 1 0 40 8% KOLDA MEDICAL REGION Kolda 33 86 486 3541 4027 3797 515 24 349 342 26 0 741 47% Médina Yoro Foulah 11 26 97 1078 1175 1018 99 6 58 30 2 0 96 9% MR Total 44 112 583 4619 5202 4815 614 30 407 372 28 0 837 18% SAINT-LOUIS MEDICAL REGION DAGANA 13 25 35 570 605 570 53 34 68 24 22 0 148 26% SAINT-LOUIS 13 49 45 2132 2177 2546 280 187 266 172 37 1 663 31% MR Total 26 74 80 2702 2782 3116 333 221 334 196 59 1 811 30% SEDHIOU MEDICAL REGION Bounkiling 9 13 58 325 383 364 102 2 30 41 1 0 74 23% Goudomp 16 36 226 1115 1341 1907 514 5 131 256 29 0 421 38% Sédhiou 23 25 129 513 642 740 0 7 54 55 1 0 117 23% MR Total 48 74 413 1953 2366 3011 616 14 215 352 31 0 612 31% TAMBACOUNDA MEDICAL REGION Bakel 6 3 11 57 68 136 3 3 4 0 0 0 7 12% Kidira 5 9 13 160 173 245 98 5 30 30 1 0 66 41% Tambacounda 15 2 1 40 41 94 8 1 11 18 1 0 31 78% Diankémakha 6 3 16 57 73 73 4 0 0 0 0 0 0 0% Koumpentoum 10 3 7 58 65 79 11 0 8 11 2 0 21 36% MR Total 42 20 48 372 420 627 124 9 53 59 4 0 125 34% GRAND TOTAL 180 377 1221 11,953 13,174 14,612 2233 392 1364 1095 149 1 3001 25%
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Neema – Integrated Service Delivery and Healthy Behaviors
3. Summary of results for integrated mobile units (IMUs)
# of # of # of # of # of # of # of children 6– # of # of # of persons Total # of children 6– # of persons # of # of # new FP adolescents/youths children 59 months who children Cervical Breast children # of users of reached adolescents/youths 59 months persons reached DISTRICT visits LLITNs PNC users in 10–24 years who 0–23 received vitamin 12–59 cancer cancer seen in a visits FP by an 10–24 years who screened screened through planned distributed visits the received FP months A months screening screening pediatric
methods IEC received services for for HIV another Performance
#of ANC #ofvisits ANC program services vaccinated supplementation dewormed consultation
activity malnutrition service # of IPTs under DOT # under of IPTs Diourbel 46 358 268 13 99 131 303 4539 390 88 841 1567 1592 1586 140 99 105 1655 507
Touba 25 328 186 27 130 100 328 2328 420 114 682 871 925 810 124 50 50 1106 50 144 Bambey 29 89% 226 183 11 49 90 240 2392 275 61 603 939 810 682 69 122 0 1258 60
Mbacké 28 173 139 9 49 124 260 2635 232 72 500 1039 1363 1199 53 51 107 778 129
MR TOTAL 128 1085 776 60 327 445 1131 11,894 1317 335 2626 4416 4690 4277 386 322 262 4797 746
Podor 22 144 119 13 60 33 78 1643 185 38 542 543 394 282 50 50 236 583 0
Saint-Louis 16 68 64 7 59 14 50 1020 158 17 122 228 219 176 51 50 184 665 0
Dagana 144 9 59 48 3 12 5 16 491 78 23 36 183 142 125 30 69 77 300 0 47%
Pété 13 211 189 0 37 24 46 1265 147 12 317 330 348 238 112 74 300 264 0
Richard Toll 7 23 16 6 3 8 37 501 29 16 86 200 175 141 11 55 50 142 0
MR TOTAL 67 505 436 29 171 84 227 4920 597 106 1103 1484 1278 962 254 298 847 1954 0
Kolda 27 298 243 28 48 65 150 2457 315 65 969 603 313 206 91 126 103 325 233
Médina Yoro Foulah 144 26 342 291 49 53 65 119 2575 300 44 810 720 313 176 97 124 55 309 283 55%
Vélingara 26 207 205 58 37 72 111 1947 261 41 581 361 270 196 64 112 63 218 160
MR TOTAL 79 847 739 135 138 202 380 6979 876 150 2360 1684 896 578 252 362 221 852 676
Goudomp 25 170 110 79 24 46 72 641 212 20 345 401 224 165 55 13 358 517 125
Bounkiling 144 24 176 126 94 35 25 60 645 249 11 541 327 137 81 67 43 279 574 236 50%
Sédhiou 23 159 105 92 41 53 93 562 196 29 348 509 158 105 49 36 322 580 223
MR TOTAL 72 505 341 265 100 124 225 1848 657 60 1234 1237 519 351 171 92 959 1671 584
Grand Total 576 346 60% 2942 2292 489 736 855 1963 25,641 3447 651 7323 8821 7383 6168 1063 1074 2289 9274 2006
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4. Summary of VADI implementation
No. of No. of children No. of breastfeeding No. of No. of No. of seen No. of Secondary pregnant mother- WRA parents Regions VADIs (malnourished, adolescents/youths targets women newborn reached affected conducted sick, & reached reached reached couples (FP) by UHC healthy) reached Diourbel 2475 741 422 165 1127 93 715 2223 Kédougou 3841 1360 635 1205 1457 686 847 6086 Kolda 2725 2810 2671 667 1733 2756 1486 4333 Matam 2393 1014 305 787 1485 504 484 874 Saint-Louis 1459 790 426 557 677 222 807 1735 Sédhiou 1486 646 251 424 464 103 368 940 Tambacounda 4807 1694 1600 1419 2862 1960 2802 13,217 Total 19,186 9055 6310 5224 9805 6324 7509 29,408
5. Summary of CVAC implementation
Number Number of No. of of Deliveries Home births women Home births Regions CVACs maternal performed by a performed by a referred for seen set up deaths matrone in a hut matrone delivery reported
Diourbel 55 482 0 311 0 0 Kédougou 84 296 2 474 27 24 Kolda 69 151 0 307 25 25 Matam 47 152 0 64 55 55 Saint-Louis 108 260 0 175 3 3 Sédhiou 65 181 0 114 60 60 Tambacounda 203 533 0 170 38 33 Total 631 2055 2 1615 208 200
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6. Summary of Tutorat 3.0 implementation
Situational Analysis SDPs that received at least SDPs that received at SDPs that received at least Private two visits, regardless of the Medical region District least one package two packages Public Total package Semi- Achieved Number % Number % Number % public Diourbel YES 23 1 24 19 79% 6 25% 14 58% Touba YES 27 0 27 27 100% 13 48% 23 85% Diourbel Bambey YES 28 1 29 25 86% 1 3% 24 83% Mbacké YES 24 0 24 22 92% 9 38% 11 46% MR Total YES 102 2 104 93 89% 29 28% 72 69% Saraya YES 18 0 18 14 78% 8 44% 0 0% Kédougou YES 14 0 14 6 43% 1 7% 0 0% Kédougou Salémata YES 7 0 7 7 100% 5 71% 0 0% MR Total YES 39 0 39 27 69% 14 36% 0 0% Kolda YES 27 1 28 24 86% 2 7% 1 4% Médina Yoro YES 14 0 14 9 64% 4 29% 7 50% Kolda Foulah Vélingara YES 22 0 22 18 82% 7 32% 8 36% MR Total YES 63 1 64 51 80% 13 20% 16 25% Kanel YES 45 0 45 25 56% 4 9% 0 0% Matam YES 30 0 30 21 70% 6 20% 0 0% Matam Ranerou YES 17 0 17 9 53% 1 6% 0 0% Thilogne YES 13 0 13 9 69% 3 23% 0 0% MR Total YES 105 0 105 64 61% 14 13% 0 0% Podor YES 35 2 37 32 86% 5 14% 10 27% Saint-Louis YES 19 6 25 30 120% 2 8% 10 40% Dagana YES 13 2 15 13 87% 5 33% 7 47% Saint-Louis Pété YES 28 0 28 25 89% 0 0% 13 46% Richard Toll YES 25 0 25 9 36% 0 0% 0 0% MR Total YES 120 10 130 109 84% 12 9% 40 31% Goudomp YES 15 2 17 15 88% 9 53% 10 59% Bounkiling YES 23 0 23 21 91% 7 30% 18 78% Sédhiou Sédhiou YES 23 1 24 18 75% 10 42% 17 71% MR Total YES 61 3 64 54 84% 26 41% 45 70% Bakel YES 20 0 20 12 60% 1 5% 0 0% Diankhe Makha YES 9 0 9 6 67% 2 22% 1 11% Tambacounda Goudiry YES 17 0 17 15 88% 0 0% 11 65% Kidira YES 17 0 17 14 82% 4 24% 3 18% Koumpentoum YES 18 0 18 17 94% 3 17% 3 17% 19
Neema – Integrated Service Delivery and Healthy Behaviors
Maka Coulibantang YES 11 0 11 10 91% 5 45% 6 55% Tambacounda YES 25 0 25 16 64% 5 20% 9 36% MR Total YES 117 0 117 90 77% 20 17% 33 28% Neema total 27 607 16 623 488 78% 128 21% 206 33%
Percentage of SDPs that received at least one package
Saint-Louis
84 %
Matam
Diourbél 61% 89%
Tambacounda
77%
Kolda
Sé dhiou 80% Ké dougou
84 % 61%
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Neema – Integrated Service Delivery and Healthy Behaviors
7. Summary of CBO activities
Number of Number of males reached Number of females reached Regions Activities activities Male adolescents/youths Female adolescents/youths Adults Total Adults Total implemented (10–19 years) (10-19 years) Group discussions 983 1184 160 1344 7770 550 11,008 Diourbel Focus groups 165 167 181 348 1145 339 2180 VADI 3610 2298 1284 3582 8376 2394 17,933 Group discussions 615 684 481 1165 3311 202 5843 Kolda VADI 2560 2852 1368 4220 8526 2380 19,346 Group discussions 235 338 429 767 2307 583 4424 Sédhiou VADI 3300 2718 902 3621 4151 1802 13,194 Group discussions 324 296 81 377 7672 915 9341 Saint-Louis VADI 3939 3015 1362 4377 4786 4011 17,550 Group discussions 215 183 32 215 5849 2493 8771 Matam VADI 1899 2013 980 2993 11,053 636 17,675 Group discussions 176 939 177 1115 1673 513 4416 Kédougou VADI 1150 1906 530 2435 2618 673 8162 Group discussions 243 857 207 1064 5765 262 8155 Tambacounda VADI 1015 1074 340 1414 4190 1531 8549 Group discussions 2957 4646 1750 6396 35,490 5856 54,138 Total VADI 17,473 15,876 6766 22,642 43,699 13,427 102,410
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