RISE-FP INITIATIVE: Zinder, Niger
BUILDING RESILIENCE THROUGH CAPACITY BUILDING AND INTEGRATION OF
REPRODUCTIVE HEALTH AND FAMILY PLANNING
FINAL REPORT Period: January 2017 to September 2020
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ABREVIATIONS
- CBD: Community Based Distributor - ARV: Anti-retroviral - CCG: CoManagement Committee - CF: Conservation Farming - COIA: Analysis of the Context of Implementation and Adaptation - ANC: antenatal care - PNC: postnatal care - CRS: Catholic Relief Service - CSI: Centre de Sante Integré (Health centre) - DMPA-SC: Medroxyprogesterone acetate- subcutaneous - DRSP: Regional Directorate of Public Health / Direction Regionale de la Sante Publique - DS: Health District - E2A: Evidence to Action - CLC: Community Leadership for Change - ULC: University Leadership for Change - LARC: Long-acting reversible contraceptive - FP: Family Planning - PPFP: Post-Partum Family Planning - RISE: Resilience in the Sahel Enhanced - AYH: Adolescent and Youth Health - MCH: Maternal and Child Health - SONGES: Support to NGOs in the East and South - BEmONC: Basic Emergency Obstetric-Neonatal Care - RH: Reproductive Health - CT: Contraceptive Technology - PtC: Pathways to Change - HIV: Human Immunodeficiency Virus
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Contents Background ...... 4 Project Approach and Partnership ...... 7 Key accomplishments ...... 9 Objective 1: Increase demand for MCH/FP services among women, men, adolescents and young people of childbearing age in the Magaria, Mirriah and Matamèye districts of Zinder...... 9 Objective 2: Increase access to FP services at the community level in the Mirriah and Magaria health districts and at the level of health structures and the community in the Matamèye health district. ... 21 Objective 3: Strengthen community resilience through integrated MCH/FP and resilience programs in selected communities ...... 29 Objective 4: Contribute to existing efforts to strengthen the health system in the three health districts (Magaria, Mirriah, and Matamèye) of Zinder ...... 33 Evolution of project performance indicators from 2017 to 2020 ...... 35 Evolution of performance indicators during the extension phase ...... 36 Evolution of project performance indicators, by health district...... 37 Matameye District ...... 37 Mirriah District (2 CSI): extension phase ...... 40 Magaria District (3 CSI): extension phase ...... 43 Major challenges and proposed solutions ...... 45 Lessons Learned ...... 47 Recommendations for sustainability ...... 49 ANNEX: BENEFICIARIES’ TESTIMONIES ...... 50
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Background The Resilience in the Sahel Enhanced (RISE) Initiative is an extensive USAID-funded program aimed at building resilience in the Sahel, particularly in Niger and Burkina Faso. In Niger, the program was implemented by the NGOs National Cooperative Business Association (CLUSA), Catholic Relief Services (CRS), and the SAWKI project in the Zinder region, in the districts of Mirriah, Magaria, and Matamèye. During its implementation, the RISE program created a significant demand for family planning services that the existing health system was unable to meet.
The USAID-funded RISE-FP Project was therefore developed to not only meet this demand, but also to strengthen community resilience by integrating family planning and reproductive health (FP/RH) services and the nutrition, conservation farming activities of the RISE initative.
The project's lifespan was marked by four periods: - An initial implementation period: from January 2017 to September 2018, i.e. 21 months. - An initial extension period without cost: from October 2018 to June 2019, i.e. 9 months. - A second extension period with cost: from July 2019 to June 2020, i.e. 12 months. - A final extension period without cost: from July to September 2020, i.e. 3 months.
After the first two periods (30 months total) in 5 integrated health centers (CSI), 20 health posts (CS), and 80 villages, and in light of the satisfactory results obtained, USAID granted a one-year extension with cost (July 2019 to June 2020) with an extension to an additional 3 CSI, 4 CS and 20 villages, then a three-month extension without cost from July to September 2020. Overall, the project's 100 community intervention villages covered a population of 133,759 in 2020. During this extension phase, in addition to family planning, the project also broadened its interventions to cover maternal and neonatal health care, including: antenatal care (ANC) and postnatal care (PNC), assisted delivery, and post-partum family planning.
Villages were selected on the basis of the following criteria:
- Village with no health facilities - Located within at least 5 kilometers of a health facility. - Population of at least 300 inhabitants.
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Evidence to Action (E2A), through Pathfinder, worked with key partners in the USAID RISE initiative to increase access to a wide range of FP methods, focusing on injectables (including DMPA-SC) and long- acting reversible contraceptives, while targeting adolescents and youth. This project reflected the Evidence to Action (E2A) Project's framework for strengthening service delivery that addresses supply, demand, and an enabling environment for MCH/FP, with a focus on the challenges that constrain the delivery of essential services to women and youth. The project sought to increase demand for and access to reproductive health (RH) and family planning (FP) services in communities in the three districts of Zinder (Matamèye, Magaria and Mirriah) by integrating resilience efforts into FP/RH programs synergistically.
More specifically, the project's objectives were to: 1. Increase demand for FP services among women, men, adolescents and youth of reproductive age in the Magaria, Mirriah and Matamèye districts of Zinder. 2. Improve access to FP services at community level in the Mirriah and Magaria health districts, and at the health facility and community level in the Matamèye health district. 3. Strengthen community resilience through integrated FP/RH and resilience programs in selected communities. 4. Contribute to existing efforts to strengthen the health system in the three health districts (Magaria, Mirriah and Matamèye) of Zinder.
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RISE-FP Project , Village of N’goual gao, photo: Adama Ali Zourkaleini
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Project Approach and Partnership
The RISE project was designed to support the implementation of the Government of the Niger’s National Family Planning Action Plan (2013-2010) and to help it reach its ambitious goal of increasing contraceptive prevalence rate (CPR) from 12% in 2012 to 50% by 2020. The project specifically aimed to increase demand and access to family planning services in three health districts (Matamèye, Magaria and Mirriah) in the Zinder region and integrate with existing resilience programming in order to synergistically ensure that both family planning and resilience interventions achieve the desired outcomes at the community and facility level. The overall strategy of the project was an expression of E2A’s service delivery strengthening framework, which addresses supply, demand, and enabling environment, in particular those challenges that constrain delivery of essential services to women and youth. In addition, the project’s strategy was designed to complement the Government of Niger’s overarching strategic areas of improving the availability of family planning services at all levels of the care continuum (community as well as public and private health facilities), increasing demand for family planning services at all levels, and promoting a conducive environment for family planning. Furthermore, the project was integrated within and leveraged existing resources in the overall USAID/SRO’s Resilience in the Sahel Enhanced (RISE) initiative to improve the health and nutrition status of women and children under 5 years old, in order to reduce chronic vulnerability of populations to recurrent crises. The project also emphasized capacity building, integration, system strengthening, documentation and scale-up of the successful elements within the Pathfinder International led Initiative de Mobilisation pour l’Accès à la Contraception pour Tous (IMPACT)/Gates Foundation and First-Time Parents (FTP)/Cargill Foundation projects in the Zinder region. The project partnered with core RISE partners and host government to strengthen access to broad range of family planning methods, with a focus on injectables (including Sayana Press) and long-acting reversible contraceptives (LARCs) while targeting adolescents and youth.
The RISE-FP Project signed a memorandum of understanding with CLUSA, responsible for the REGIS-ER Project, which is implementing the integration of conservation farming (CF) and FP/RH in order to improve community resilience in 13 project-supported villages. Another implementing partner is the national NGO SONGEs, which provided training to community-based distributors (CBDs) in the various project- supported villages.
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RISE-FP and REGIS-ER Workshop, ZINDER, Photo: Adama Ali Zourkaleini
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Key accomplishments Objective 1: Increase demand for MCH/FP services among women, men, adolescents and young people of childbearing age in the Magaria, Mirriah and Matamèye districts of Zinder.
To increase the demand for maternal and child health (MCH) and FP services, the project set up a vast network of community actors composed of 4 CBDs (2 men and 2 women), 2 young community leaders (1 boy and 1 girl), and a religious leader in each village. Overall, the project trained 400 CBDs, 100 religious leaders, and 160 youth leaders on specific themes related to their area of responsibility.
These community actors were selected by villagers on the basis of the following criteria: - Residence in the village - Not a potential outgoing/seasonal migration candidate - Ability to read and write. Prior to the project’s intervention, the FP/RH situation in this area had the following characteristics: • Insufficient supply of and access to reproductive health and family planning services despite the information campaigns organized by health services and projects. • Questions about contraception and family planning are often taboo in the community; and even when they are discussed, men and religious leaders are rarely involved. • Despite their needs, adolescents and youths are rarely involved in RH/FP activities. • Stigmatization of youth and adolescents who use contraceptive services.
To enable them to conduct their role effectively, all the community, actors were provided with materials, work tools, and data collection tools.
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CBD work kits
1. Contribution of CBDs to demand creation CBDs carried out sensitization activities in their respective villages on the various themes for which they were trained. These sensitization activities were done through home visits and group talks.
The following topics are included in the CBDs’ activities:
- Benefirs of FP and the different modern contraceptive methods - General hygeine and water treatment - Case referrals - Community outreach/counseling - Healthy timing and spacing of pregnancies - Gender and reproductive health - Exclusive breastfeeding - Sexually transmitted infections (STI), Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) - Vaccination
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- Antenatal consultatation - Child illnesses (coughing or breathing difficulties, diarrhea, and fever) - FP/RH commodity management - Data collection
Every month, the CBDs of each area met at the CSI to exchange among themselves and with the nurse, submit their data, and receive their supplies of products and data collection tools, if needed.
Community actors meeting in a health center
Throughout the project period, CBDs conducted a total of 115,556 home visits, reaching 84,605 individuals, 49% of whom were men and 51% of whom were women, as is shown in Table 1 below.
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Table N° 1: Number of people visited per year, gender and age group through home visits during project implementation.
Indicators 2017 2018 2019 2020 Total # Home visits undertaken 26444 36616 15554 32475 111049 Women visited -24 years 6967 10742 4980 9561 32350 +25 years 7099 7924 3011 6742 24776 Men visited - 24 years 5503 8487 4261 8562 26813 +25 years 6875 9463 3262 7610 27210
Table N° 2: Number of group talks held and people reached per year
Indicators 2017 2018 2019 2020 TOTAL # Talks given 1835 4458 2812 5056 9105 # People covered women 25663 39980 24630 25360 115633 # People covered men 25963 49178 35286 21104 131531
CBDs also conducted a total of 9,105 group talks, reaching a total of 115,633 women and 131,531 men. With regard to home visits and group talks, the relatively low number of people covered in 2020 is due to the suspension and adaptation of these activities (reduced number of participants) in compliance with the COVID-19 prevention measures.
Data on Clients' Referrals for FP Services by CBDs 2017 to 2020 From 2017 to 2020, CBDs referred 7,953 women for contraceptive methods. Below is the number of referrals by year. Clients are primarily referred for their first dose of FP, for a change of FP method, for a method that the CBD agent cannot provide, or for the management of side effects caused by FP products.
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Table N° 3: Users referred for FP services by CBDs, by year Year Number of clients referred by CBDs 2017 (Data not available) 2018 2266 2019 2212 2020 3475 Total 7953
The RISE-FP project through the CBDs has enabled 7,953 clients to be referred to health centers for family planning services out of a total project target of 4,760, or 167% completion rate. The high number of referrals in 2020 is due to the consequences of COVID-19 and the capacity of community agents to offer their services
2. Contribution of religious leaders to demand creation Religious leaders provided sensitization on FP and responsible parenthood during collective prayers, baptism and marriage ceremonies. They also organized preaching caravans in the project intervention villages under the supervision of their Departmental Trainers. The religious leaders use these events to convey clear messages on the favorable and well-accepted position of FP by Islam through the verses of the Qur'an and the hadiths as follows: {Mothers shall breastfeed their children for two whole years, for those who wish to complete the term}. (Sura 2: Verse 233) or {And his gestation and weaning last thirty months} (Sura 46: Verse 15).
Sermons led by religious leaders
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Table No 4: Number of people reached, by District and by gender, during sermons organized by religious leaders during project implementation. District # Sermons # Men reached # Women reached Total Matameye 575 5881 5473 11354 Magaria 448 6839 6163 13002 Mirriah 378 3398 2556 5954 Total 1401 16118 14192 30310
During the project period, religious leaders conducted 1,401 sermons on FP/RH/MCH, reaching 30,310 people, 53% of whom were men.
Table No 5: Number of people reached, by District and by gender, during the preaching caravans organized by religious leaders during project implementation.
District # Preaching Caravans # Men reached # Women reached Total Matameye 1 771 1039 1810 Magaria 1 521 447 968 Mirriah 1 596 581 1177 Total 3 1888 2067 3955
Three preaching caravans have been completed out of the two planned (150% of completion). These preaching caravans have reached 3,955 people, almost equally men/women. However, in almost all the health districts, we note a very good attendance of men at the preaching sessions, contrary to other community activities.
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Village of N’goual Gao, meeting with religious leaders, Photo: Adama Ali Zourkaleini
3. Contribution of young community leaders to demand creation To increase the demand for MCH/FP services among rural youths and adolescents, the project developed an approach that adapts the University Leadership for Change (ULC)1 to the community level - known as the Community Leadership for Change (CLC) initiative. By bringing this approach into rural communities, the CLC initiative2 enabled young people, ages 15 to 24, to discuss FP/RH-related issues with peers of the same age and gender in the 80 RISE-supported villages. To do this, 160 young leaders (2 girls and 2 boys per village) were identified and trained on MCH/FP, the elaboration of AYH action plans, and how to lead behavior change activities through Pathfinder's Pathways to Change (PtC)—a behavior change tool in the form of a simple game—to (1) promote healthy behaviors and gender equality; (2) identify and collect data on barriers and facilitators to change in gender dynamics,
1 Katie Chau, Regina Benevides, and Ousseini Abdoulaye, University Leadership for Change in Sexual and Reproductive Health in Niger: Project Report (Washington, DC: Evidence to Action Project/Pathfinder International, March 2017). 2 https://www.e2aproject.org/wp-content/uploads/Utilizing-a-Three-Step-Process-to-Remove-Barriers-to-Youth- Behavior-Change.pdf
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To facilitate the process of adapting the ULC intervention to community contexts, E2A and Syntegral3 produced and used two tools: the Analysis of the Context of Implementation and Adaptation (COIA) and the Frontline Aggregate Monitoring and Evaluation Tool (FrAME).
Analysis of the Context of Implementation and Adaptation (COIA)
The COIA is a structured approach for data collection from key stakeholders and analyzing the context of an activity or practice in order to adapt it. In essence, the COIA systematizes adaptation - a COIA exercise should identify elements of the original context that influenced the effectiveness of a practice or activity. When considering adaptation for scaling up, the COIA analysis systematically compares the original context with the target context and adjusts the program in line with the results.
Front-line aggregate monitoring and evaluation (FrAME) The Frontline Aggregate Monitoring and Evaluation Tool (FrAME) sends automated calls to frontline workers on a regular basis to assess their perceptions of the project. These front-line workers can be community health workers, primary level service providers, or, as in this intervention, youth leaders. The automated voice calls ask front-line workers to report whether they strongly agree, agree, disagree, or strongly disagree with statements such as “I think that I and other youth leaders are getting the supervision we need”. This tool enables project staff to obtain feedback from front-line workers to assess the quality of a program activity and adapt to changes in context over time. In doing so, FrAME simultaneously harnesses the most sensitive source of adaptation data in any project - its front-line implementers - and uses the information provided by these workers to make informed decisions that will lead to more effective programming.
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Young Women Community Leaders
The youth of the Zinder ULC accompanied the young community leaders in all stages of the process of this approach through: - Context analysis (COIA) - Young community leader training on leadership, MCH/FP and PtC games - Facilitation of 1,554 PtC games, with 9,229 participants, to identify barriers and facilitators to the use of health services. - Organization of village assemblies to inform the village population of the barriers identified and prioritize them. At the end of these general assemblies, 3 main barriers were identified: 1) Insufficient knowledge of services offered by health centers, 2) Inability to pay for the services, 3) Lack of means of transportation to convey patients to health centers. - Training of young community leaders on the development of community action plans to address the priority barriers identified during the PtC games - Development of 57 community action plans to address the barriers identified.
To ensure consolidation and continuity between the community-based efforts, the project set up four communal committees and 22 sub-committees around health posts. These various committees have joined the implementation chain and have taken part in these exchange meetings in order to fully play their role, which is to consolidate and sustain the project's accomplishments by supporting and monitoring the implementation of community action plans developed during the village general
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For the sustainability of the approach, the implementation of community action plans under the leadership of young community leaders and the supervision of the Zinder ULC youth, 5 follow-up visits were undertaken to monitor the implementation of these community action plans.
Young University Leaders, Niamey, Photo: Adama Ali Zourkaleini
During these follow-up visits, the following observations were made:
3.1. Evaluation of the functionality of the co-management committees (CMC) Communal CMC
In the 4 communes, the main activities in which the CMC took part were the monthly meetings of CBDs as well as the introduction and certification of CBDs for the administration of DMPA-SC. During these events, members of the communal committees expressed their commitment to ensure the conservation and sustainability of the accomplishments achieved by the project in their communities. They thus urged
FINAL REPORT 2017 _ 2020 RISE-FP Zinder-Niger 18 all stakeholders (CBDs, religious leaders, young community leaders) to pursue the activities even after the project’s completion, for the good of the entire community as well as the populations of neighboring villages. At this point, the CMC have not yet started monitoring activities in the villages because of farming in the fields. However, the ULC supervisors helped them develop a monitoring plan that they intend to implement as soon as the work in the fields is completed.
CMC sub-committee at the health post level
At this level, the sub-committees hold meetings and follow-up on the activities of project actors at the village level. The sub-committees are therefore very active and all the activities carried out have been documented. The number of activities undertaken varies from 1 to 4, depending on the sub-committee.
The themes covered during the meetings include the following:
Reminder of the responsibilities and tasks assigned to each member according to his or her position Involvement of village chiefs in the implementation of activities Continuation of activities at village level Problems related to non-use of refocused ANC and PNC Raising awareness of the barriers imposed by COVID-19 Raising awareness of the risk of home delivery The importance of referring women to the health center ANC, PNC, childbirth, and FP Informing the population about free-of-charge deliveries in health posts.
3.2. Monitoring the implementation of Action Plans In the action plans developed for each participating village, the villages chose to focus on one or more of the three barriers listed below. Concerning the barrier related to inadequate knowledge about the services offered by health centres, the activities implemented are home visits and small group discussions.
In the 26 villages that chose to focus on this barrier, awareness-raising sessions were conducted by volunteers with the support of CBDs and young community leaders on the importance of family planning, ANC, and PNC; the consequences of early marriage; and the availability of free-of-charge deliveries at the health center. This was an extra activity in the costed extension period. During the 9 months of implementation of integration activities (October 2018-June 2019), CBDs made 3,977 home visits involving 3,977 people and 567 group talks that reached 12,447 people.
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Djan kalgo Village, CBD Awareness-raising Session, Photo: Adama Ali Zourkaleini
Concerning the barrier related to insufficient money, community funds have been set up in the villages that have opted for this barrier.
These community funds are available in 17 villages in three forms:
1. Weekly, bi-weekly and monthly contributions for loans 2. Weekly, bi-weekly and monthly contributions for donations 3. Special contributions in case of emergency to assist the sick
The number of cash deposits in the community coffers ranged from 17 deposits per village to 34 deposits per village during the nine months of implementation of this approach and the amounts available range from F CFA 24,050 to F CFA 69,650. In total, 36 women and 6 men received loans while 9 women and 3 men were given grants for health assistance.
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These funds operate in all the villages concerned with the involvement of everyone especially the village leaders who are responsible for their regular monitoring, according to Moutakka, Chief of Angoual Gao Village (CSI Daratchama):
« We always keep track of the fund to avoid mistakes made in the past by other projects, because some people act in bad faith and through negligence refuse to pay or sometimes take a long time to reimburse (…..) while these funds constitute a " passkey " for our women and children to use health centers ».
Concerning the barrier related to lack of means of transport, local means of transport have been identified in villages for evacuation to the health center.
In all the villages with this action plan, new strategies have been adopted by volunteers to improve the availability of means of transport for patients. For example, village carts and oxen are scheduled to take turns transporting women and children to the health center. In these villages, 47 carts and 29 oxen were identified to transport patients to health centers.
Objective 2: Increase access to FP services at the community level in the Mirriah and Magaria health districts and at the level of health structures and the community in the Matamèye health district.
To increase access to services, the project assisted health districts in the organization of field trips, mobile clinics, the introduction of community-based distribution of modern contraceptive methods, the administration of DMPA-SC by CBDs, and the implementation of community action plans by young community leaders. In the Matameye Health District, the mobile health fairs and clinics cover all the villages with no access to health centers. In Mirriah and Magaria, the villages within the project intervention area are covered by the IMPACT Project, implemented by Pathfinder International.
These different approaches serve as a response to the low health coverage in the region, in general, and more specifically in the project intervention area. Health coverage, similar to that of the Region, was less than 50% in the 3 Districts. Therefore, less than half of the population had access to health services. In fact, the 100 villages covered by the project were chosen among those without access to health services—their populations totaling about 133,759 inhabitants in 2020 did not live within 5 km of a health structure. This situation is characterized by the limited use of health services, in general, and
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MCH/FP in particular. It takes approximately 3 to 5 hours for the population to reach a health structure. Thus, even if they need to go to the health center, some people often give up because of the long distance they have to travel to get there.
1. Health fairs and mobile outreach The project conducted health fairs and mobile outreach aimed at increasing access to health services for populations that do not have access. The outreach teams visit the targeted sites and villages on a regular basis (once every two months or once every three months).
Mobile clinic site Matamey, Zinder, Photo: Adama Ali Zourkaleini
Table N° 6: Situation of health fairs and mobile outreach from 2017 to 2020 Strategies Indicators 2017 2018 2019 2020 Total Health fairs # visits 4 60 45 60 169 villages covered 40 195 195 195 195 Mobile outreach # visits 2 12 9 12 35 villages covered 40 97 97 97 97
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In 2017, these actiities were confined to the two project-supported CSI (Daratchama and Daouche) of the Matameye health district and did not start until July, hence the low number of outreach visits and villages covered. Beginning in 2018, these visits were extended to the entire Matameye District, which explains the larger number of outreach visits and villages covered.
From 2017 to 2020, through health fairs and mobile outreach, the project provided FP services to 5,060 FP new users in the Matamey District.
Table N°7: Number of new FP acceptors through health fairs and mobile outreach in the Matamey district from 2017 to 2020
Strategies 2017 2018 2019 2020 Total
Health fairs 488 752 377 620 1749
Mobile outreach 263 1128 837 1083 3311
2. Community-based distribution of contraceptives Trained CBD agents are in charge of the replenishment of oral contraceptives and condoms to clients after the first dose/supply is administered by health care workers. All clients who need condoms (male or female) are supplied directly by CBDs.
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Ngouana zinder Village, CBD, Photo: Adama Ali Zourkaleini
Table N°8: Distribution of contraceptives by CBDs 2017 to 2020 Methods 2017 2018 2019 2020 Total Microgynon Pills 8930 14866 9686 5507 38989 Microlut Pills 6293 6886 4990 2644 20813 Female condoms 514 809 1427 474 3224 Male condoms 12836 4188 4343 151 21518 Sayana Press - - - 729 729 Total 28573 26749 20446 9505 85273
During the project period from 2017 through 2020, 85,273 contraceptives were distributed by CBDs, including 729 doses of Sayana Press.
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3. Administration of DMPA-SC by CBDs The administration of DMPA-SC by CBDs was introduced in February 2020 in villages where the project operates within the framework of the delegation of tasks approved by the Government. The strategy was implemented in several phases:
Training of trainers on DMPA-SC
To train approximately 400 CBD agents on DMPA-SC, a significant number of trainers is needed. Thus, a training of trainers session was held in Bande and Daouche. The training site at Bande included trainers from Droum, Gogo, Gabi, Angoil Manda and Bande. The Daouche site included trainers from the CSI of Daratchama, Ichirnawa Ta Gabass and Daouche. Overall, 36 trainers were trained during these sessions.
Training of 392 CBDs on the administration of DMPA-SC
The training sessions for CBDs were facilitated by 36 trainers deployed in 8 sites (8 CSI). On each site, the session was conducted in 4 stages:
Theoretical stage: For two days, participants were briefed about the following themes: - Information about DMPA-SC as an effective, sustainable, reversible and discrete method of contraception. DMPA-SC comes in the form of UNIJECT, single-dose, pre-filled, easy to use, non-reusable and small in size. It is administered subcutaneously on the back of the non- dominant arm and is valid for 3 months or 13 weeks. - Women eligible for SAYANA PRESS: Any non-pregnant woman of childbearing age who needs an effective and reversible method, including women who are breastfeeding a baby at least 6 weeks old, have or have not had children, cannot or do not want to use other methods (e.g., those containing estrogen), have a sexually transmitted infection, including Human Immunodeficiency Virus (HIV), and women taking medication, including anti- retrovirals (ARVs). - Women Not Eligible for DMPA-SC: Like any contraceptive, DMPA-SC should not be used by pregnant women. Women with hypertension, cancer, severe headache, lung disease, liver disease, etc. are also ineligible. - Advice to be given to the client: Build client's confidence, explain all the side effects of DMPA-SC and how to manage them if they persist.
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- Transport and storage of DMPA-SC: It is stored and transported in the same manner as Depo Provera in a vial, at room temperature (do not refrigerate), transport away from sunlight and heat and keep out of the reach of children and pets. - Materials required for injection practice - The different steps to follow to perform the injection. Practical step on anatomical arm: For a whole day, participants practiced the injection of DMPA-SC on the anatomical arms in order to master the technique. Practical step on clients: During the two days of theory and the day of practice on the anatomical arm, some participants took advantage of their period of rest (in the evening during the recess) to enlist clients interested in DMPA-SC. The recipients were injected with DMPA-SC by the CBD under the supervision of the health worker.
At the end of this training, 388 CBDs out of the 392 initially planned, were trained. Three were absent and one delivered on the day the training began.
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CBD Training on DMPA-SC Zinder, Photo: RISE-FP
Post-training supervision stage:
The post-training supervision was not conducted in a conventional (passive) manner, i.e. the health worker went to the villages to supervise the CBDs or the CBD sat at the health center to wait for potential clients. The team of trainers opted for active post-training supervision as follows:
Within the framework of their home visits and group talks, trained CBDs identify women who intend to use DMPA-SC. They go to the health center with these women to administer the product under the supervision of the health worker. This strategy enabled CBDs to rapidly master the injection process because it made it easier to recruit more women than if the CBDs and the health workers had to sit at the health center and wait for them to come in on their own.
Before certifying the CBD for the administration of DMPA-SC, the last step is its introduction to the community. This introduction is done by a team visiting each village and comprised of representatives of the District, the CSI, the health center, the town hall and the project. The introductory meeting took place at the village chief's home in the presence of CBDs, young community leaders, the religious leader, a women's representative (leader) and a male leader who is well listened to by the population. CBD candidates for certification proceed one by one to demonstrate the administration of DMPA-SC from the preparation of the material to the administration of injection and waste management.
In all the villages visited, the populations thanked Pathfinder International and the RISE-FP Project for implementing this strategy. Locally-elected representatives (mayors or their representatives), village chiefs, CBDs, and beneficiaries all expressed their satisfaction, as evidenced by the following comments by the Mayor of Daouché commune:
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Mayor of Daouché Commune, Mr Abdoul Aziz Hayo:
« I would like to express my sincere congratulations for this initiative of delegating tasks to CBDs trained on the practice of Sayana Press and especially for the fruitful and permanent collaboration with Pathfinder, which has allowed the town hall to have a clear overview of the activities carried out in its commune. The advantage for these beneficiary villages is that women have access to contraception with less hesitation about health services and are relieved from the burden of traveling under the blazing sun often with children on their backs unlike in previous years. I hope that with time other villages will be included with a view to spreading this practice throughout the commune. Many thanks to the Pathfinder organization for making women and children its priority ».
Table N°9: Data on the administration of DMPA-SC by CBDs:
Year Number of DMPA-SC doses administered by CBDs 2020 729 Total 729
The CBDs administered 729 doses of DMPA-SC through the delegation of tasks. After only a few months of activity, CBDs made it possible for many women to receive DMPA-SC without having to travel to the health center. Without this option in the village, many of these women would not have been able to travel to the health center to obtain the services even though they needed them.
The project also increased access to health care by supporting the Ministry of Public Health in scaling up the delegation of tasks. In this regard, CBDs have been trained in the administration of DMPA-SC, while agents serving in health posts have been trained to insert and remove implants. Thus, CBDs provide DMPA-SC at the village level while health post workers provide implants at the health post level.
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4. Implementation and monitoring of community action plans (Adapting ULC to community settings) The implementation of community action plans has contributed to improved access to health services through community funds and the identification of transportation means for evacuations. To this end, a few months after the implementation of action plans started, 95 women and 50 men received loans or grants for health assistance from the community funds while 148 women and 90 children were transported to health centers with the means of transport identified within the community. This strategy has enabled many women, men and children to benefit from the health services they need. The villages in which these initiatives have already started have pledged to pursue them even after the project's completion.
Objective 3: Strengthen community resilience through integrated MCH/FP and resilience programs in selected communities
This integrated approach was developed in 13 villages (8 in the commune of Bande, Magaria health district and 5 in the commune of Droum, Mirriah health district) for 10 months (from September 2018 to June 2019). Within this framework, the following actions were carried out: - Training of 28 CBDs on conservation farming (CF) - Training of 28 leading producers on MCH/FP - Development of integrated communication tools for data and indicator collection - Providing integration players with materials, work tools and data collection tools - Launching integrated activities in the 2 communes - Conducting integrated awareness-raising activities on MCH/FP/CF - Joint supervision (REGIS-ER, Pathfinder International, SONGES, health agents) of integrated activities
Prior to the implementation of this integration approach, the REGIS-ER Project was implementing a resilience program in the area while Pathfinder International focused on the implementation of the RISE-FP Project. At the village level, the interventions of the two projects, taken individually, translated into the following outcomes: • REGIS-ER's resilience program alone was able to ensure that the population had a good harvest thanks to the use of modern agricultural techniques. The households therefore have enough food to feed the family. However, all these efforts were hindered by the family burden (many children), non-practice of birth spacing, and the health costs of family members (women and children who are constantly sick) who must be taken to the health center frequently. The bulk of
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the production has to be sold to cover the needs of this large family. Such a situation exposes the household to vulnerability, despite good agricultural yields. The interventions of REGIS-ER also created demand in the villages in terms of MCH/FP, that was not being met. • In the same way, when the household uses only birth spacing without using modern agricultural techniques, it has a relatively healthy household with relatively healthy family members, spending little money on health but exposed to the risk of malnutrition because the food stock is insufficient to cover their needs. In response to this situation, Pathfinder, in collaboration with REGIS-ER, implemented a strategy integrating conservation farming (CF) and MCH/FP in 13 villages to improve household resilience and meet the needs for MCH/FP created by the REGIS-ER interventions.
The integrated interventions aimed to strengthen the resilience of targeted communities by integrating MCH/FP with resilience in partnership with a RISE partner not involved in the health sector. E2A also documented4 and shared lessons learned from this approach in order to inform donors and implementing partners for eventual scale up in Niger and throughout the Sahel.
4 https://www.e2aproject.org/publication/linking-family-planning-resilience-sahel-findings-integrated-pilot- project-zinder-niger-report/
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Collaboration with RISE partners The REGIS-ER Project was selected from among the RISE partners following a process directed by a consultant. After selection, REGIS-ER's conservation farming was selected as the resilience activity to be integrated with the FP/RH activities of the RISE-FP project. The objective was to get community actors engaged in CF to encourage their members to make greater use of FP/RH and those in FP/RH to encourage their members to practice conservation farming. CF improves production and therefore increases yields, while MCH/FP helps control fertility and improves the health of the mother and children in the household.
Group talk on CF/RH/FP integration, photo: Adama Ali Zourkaleini
The combination of the two strategies allows the household to be self-sufficient in food and have a well- fed family and fewer cases of illness and thus fewer health expenses. Therefore, the household can save money and increase its resilience capacity. This approach has been very successful in these villages, as witnessed by the account of this young leading producer below:
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Ayouba is a young 31-year-old leading producer and community-based distributor of the Regis-ER and RISE-FP projects in the village of Jan Kalgo (Commune de Bande) with two children and a perfectly healthy wife.
« I am from the first intake of leading producers in my village trained five years ago. I was lucky to have been selected to experiment conservation farming called "noman Zamani: local language". The training provided by REGIS-ER enabled me to share new farming techniques (compost preparation, Zai) with my community through a group of men and women that I lead. For several years, our granary reserves have been growing but health problems (children's illness, malnutrition, closely spaced pregnancies, etc.) and social problems are preventing us from fully appreciating the usefulness of this strategy.
This started to change after my training with the RISE-FP project in collaboration with REGIS-ER on the integration of CF/FP. We were able to learn about the importance of birth spacing, antenatal and infant consultations and the availability of different voluntary contraceptive methods etc... I shared this new knowledge I gained on FP/RH with members of my group of leading producers but also with other producers during baptism ceremonies, weddings and home visits. With this approach, we are now growing steadily with our granaries full, fewer health and social problems due to birth spacing, fewer baptisms, less health care expenses and improved health for our women and children. Today, we are convinced that health, agriculture and nutrition are all linked and must go together for greater resilience (Jimiri: local language) ».
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Objective 4: Contribute to existing efforts to strengthen the health system in the three health districts (Magaria, Mirriah, and Matamèye) of Zinder
The project supported the capacity building of the health system by providing vehicles and motorcycles, technical equipment, medicines, medical consumables and data collection tools. These capacity building activities have made quality services available, including the full range of family planning methods (within the limits authorized by the delegation of tasks) in all the health facilities supported by the Project.
To strengthen the capacities of health workers and improve the quality of services, joint monitoring/supervision visits (MSP, DRSP, USAID, Pathfinder International, DS, SONGEs) are undertaken periodically in health facilities (District Hospital, CSI and health posts).
In 2017, prior to the launching of the Project, the situation of health services was characterized by: • Insufficient qualified personnel to provide quality services and manage inputs efficiently. • Frequent shortages of medical products and consumables due either to lack of financial resources or a malfunction in the supply system or insufficient means to ensure the delivery of products up to the last kilometre • Insufficient means (logistic and financial) to organize health fairs and mobile outreach • Insufficiency and obsolescence of biomedical equipment to ensure the provision of quality services
1. Strengthening the capacity of health workers Training sessions for health workers were held in person and on site (tutoring). Thus:
104 health workers were trained on contraceptive technology (CT), stock management and compliance (FP and environmental). 69 health workers were trained on basic emergency obstetric and newborn care (BEmONC) and insertion of long-active reversible contraceptives (LARCs) through on-site tutoring sessions 30 health workers were trained on the integrated MCH/CBD module 22 health workers were trained in Quality Assurance 50 health workers were trained on adolescent and youth health (AYH) 89 health workers were trained in the upkeep of data collection media
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Tutoring session in a health facility
Joint mission for monitoring/supervision of project activities
2. Provision of vehicles and motorcycles The Project provided the Health District of Matameye with a vehicle for the organization of mobile outreach visits and 5 CSIs with motorcycles for field trips. Moreover, at the end of the Project, 7
FINAL REPORT 2017 _ 2020 RISE-FP Zinder-Niger 34 motorcycles initially intended for the project field agents and the NGO SONGES during implementation, were given to 7 other CSIs in the intervention area to pursue the field trips.
3. Provision of technical equipment, drugs, medical consumables and data collection media
Given the scarcity of medicines and the obsolescence of technical equipment, the project supported the health facilities in its intervention zone in this regard as well as in data collection media. This support has considerably improved the quality of service delivery and the quality of data in these health facilities.
The project also provided support (either in vehicles or fuel) in the supply of inputs at all levels: from the central level to the Region, from the Region to Districts, from the Districts to CSI, from the CSI to health posts and from health posts to CBDs. This has significantly reduced the number of stockouts (only 3% of health facilities reported stockouts in 2020).
Evolution of project performance indicators from 2017 to 2020
The RISE-FP project has made an important contribution to the strengthening of resilience through capacity building and the integration of reproductive health and family planning in the intervention areas. Performance indicators have been deined to monitor and demonstrate progress in increasing demand for MCH/FP services, increasing access to FP services at the community level, building community resilience, and strengthening the health system.
The tables and graphs below show the performance recorded in terms of:
- Evolution of number of new acceptors of modern contraceptive methods - Utilization of long-acting methods - Range of contraceptive methods selected - Assisted delivery and number of women receiving atleast 4 antenatal care visits (ANC4+)
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Evolution of performance indicators during the extension phase
Figure 1: New user recruits in the three districts
419 793 388 761 509 1138 920 932 637 637
3383 3088 3106 3270 2990
T3 2019 T4 2019 T1 2020 T2 2020 T3 2020
Matamey Magaria Miriah
During the project extension period (Q3 2019-Q3 2020), a total of 22,971 new users adopted a contraceptive method in the three health districts supported by the project. Figure 1, above, shows the number of new FP acceptors by health districts for each of the quarters in the extension period. Figure 2, below, shows the percentage of FP users that selected a LARC, by district, across the five quarters of the extension period. This percentage was highest in Matamey district, and substantially lower in Magaria and Miriah.
Figure 2: Percentage of new FP users that selected a LARC, by quarter and district 32%
28% 28% 27% 28%
11% 9% 7% 6%7% 6% 7% 2% 4%
T3 2019 T4 2019 T1 2020 T2 2020 T3 2020
Matamey Magaria Miriah
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Figure 3: Female PPFP users, by quarter and district
16
35 94
42 31
15 78 29 17 29 197 205 134 119 79
T3 2019 T4 2019 T1 2020 T2 2020 T3 2020
Matamey Magaria Miriah
During the extension phase of the RISE-FP project, there were a total of 1,120 new acceptors of postpartum family planning (PPFP) across the three health districts supported by the project. The number of new PPFP acceptors was highest in the first and second quarters of 2020.
Evolution of project performance indicators, by health district Matameye District
Figure 4: New FP acceptors from Q3 2017 to Q3 2020 in Matameye District
First phase RISE FP Extension Phase 3718 3300 3270 3383 3018 3088 3106 2990 2622 2776 2378 1969 1702
T3 2017 T4 2017 T1 2018 T2 2018 T3 2018 T4 2018 T1 2019 T2 2019 T3 2019 T4 2019 T1 2020 T2 2020 T3 2020
The RISE-FP project, through its interventions, has contributed to the provision of FP services to at least 37,320 new FP users, with an average of 3,100 new users per quarter during the extension phase. Among the new users, 57% were under 25 years of age.
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Figure 5: Percentage of new users that adopted a LARC in Matameye District from Q3 2017 to Q3 2020
32% 30% 28% 28% 28% 27% 25% 25% 24% 23% 24% 19%
11%
T3 T4 T1 T2 T3 T4 T1 T2 T3 T4 T1 T2 T3 2017 2017 2018 2018 2018 2018 2019 2019 2019 2019 2020 2020 2020
As is shown in Figure 5, above, the rate of FP acceptors selecting a long-acting methods in Matameye has increased from 11% at the beginning of the project interventions to about 30% in 2020, making the health district the champion in the provision of LARCs in the entire Zinder region. As shown in Figure 6, below, at the beginning of the RISE-FP project interventions, pills were the most common method used by new users and long-term methods were the least. With the support of the project, this has changed with injectables and implants being the two most common method amongst new FP users.
Figure 6: New FP users by method from Q3 2017 to Q3 2020 in Matameye District
2000 First Phase RISE FP Extension Phase 1800 1600 1400 1200 1000 800 600 400 200 0 T3 T4 T1 T2 T3 T4 T1 T2 T3 T4 T1 T2 T3 2017 2017 2018 2018 2018 2018 2019 2019 2019 2019 2020 2020 2020
Pilules Injectables Implants DIU
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Figure 7: Continuing FP users by quarter in Matameye District (extension phase)
60000 49533 50000 42449 35588 40000 29303 30000 20000
10000
0 T3 2019 T4 2019 T1 2020 T2 2020
Figure 7 (above) and Figure 8 (below) show the situation of continuing users in the Matameye Health District of Zinder. It was found that the continuing FP users in the Matameye health district during the extension phase of the RISE-FP consisted largely of implants and injectables users.
Figure 8: Continuing FP users by method in Matameye District (extension phase)
25000 22925
20000 1752317230 18073 15805 14269 15000 13763 11520 10000 8335 7453 5350 5000 3899 121 164 243 200 0 T3 2019 T4 2019 T1 2020 T2 2020 Pilules Injectables Implants DIU Linear (Implants)
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Figure 9: Number of assisted deliveries and ANC4+ in Matamey District, by quarter (extension phase)
4280
3733 3599 3655 3458 3116 3043 2970 2985 2677
T3 2019 T4 2019 T1 2020 T2 2020 T3 2020
II.1 Nombre d'accouchements assistés aux centres de sante
II.2 Nombre de femmes enceintes ayant reçu au moins le CPN-R4 (Fiche de consultation prénatale – au moins 4 visites )
The indicators presented in Figure 9, above, are specific to the extension phase. Due to the influence of increased FP uptake, there has been a decrease in the number of deliveries. Almost all of the women who gave birth at health facilities received at least four ANC visits prior to delivery.
Mirriah District (2 CSI): extension phase HMIS data for the Mirriah health district was only collected during the extension phase of the RISE-FP project, with the inclusion of MCH data. The data presented is from the two CSIs in which the project intervened.
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Figure 10: New FP Users, by quarter, in Mirriah District (extension phase)
900 793 761 800 700
600 509 500 419 388 400 300 200 100 0 T3 2019 T4 2019 T1 2020 T2 2020 T3 2020
As shown in Figure 10, above, the project recorded a strong increase in new FP acceptors in the second quarter of project implementation during the extension phase. This unfortunately dropped in the second and third quarters of 2020 due to the COVID-19 pandemic. After Niamey, Zinder was the region most affected by the pandemic. Figure 11, below, shows the percentage of these new FP users that selected a LARC, which was typically around 7%. Figure 11: Percentage of new FP users that selected a LARC, by quarter, in Mirriah District (extension phase)
8% 7% 7% 7% 7% 6% 6%
5% 4% 2% 3% 2%
1% 0% T3 2019 T4 2019 T1 2020 T2 2020 T3 2020
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Figure 12: New FP users, by method and quarter, in Mirriah District (extension phase)
450 408 426 400 350 366 300 280 254 250 250 223 200 184178 150 138 100
50 55 25 19 32 31 0 1 0 0 0 0 T3 2019 T4 2019 T1 2020 T2 2020 T3 2020 Pilules Injectables Implants DIU
At the beginning of the project’s extension period, pills were the most commonly accepted method of new users in Mirriah District, however, after the initiation of project interventions, injectables became the most commonly selected method for new users. The number of users selecting implants also increased. Figure 13: Number of assisted deliveries and ANC4+ in Mirriah District (extension phase)
300 249 250 218 235 178 200 192 209 178 150 157
100
50
0 T4 2019 T1 2020 T2 2020 T3 2020
II.1 Nombre d'accouchements assistés aux centres de sante
II.2 Nombre de femmes enceintes ayant reçu au moins le CPN-R4 (Fiche de consultation prénatale – au moins 4 visites )
Assisted childbirths have increased in the two CSIs in Mirriah due to sensitization conducted by the project and referrals of pregnant women by CBDs. ANC4+ also increased but dropped in Q2 2020 due to fear of COVID-19 at the health facilities.
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Magaria District (3 CSI): extension phase
Figure 14: New FP Users, by quarter, in Magaria District (extension phase)
1200 1137
1000 920 932
800 637 637 600
400
200
0 T3 2019 T4 2019 T1 2020 T2 2020 T3 2020 In Magaria District, the project observed a similar trend in new FP users as was seen in Mirriah District. The number of new FP users decreased in the first and second quarters of 2020, likely due to the COVID- 19 pandemic and the resulting reluctance of clients to go to the health facility for FP services.
Figure 15: Percentage of new FP users that selected a LARC, by quarter, in Magaria District (extension phase)
12% 11%
10% 9%
8% 6% 6% 6% 4% 4%
2%
0% T3 2019 T4 2019 T1 2020 T2 2020 T3 2020
In Magaria District, the rate of new FP users that selected a LARC progressively decreased during the project implementation period. This is likely due to the decrease in the volume of health fairs and mobile outreaches conducted due to the COVID-19 pandemic.
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Figure 16: New FP users, by method and quarter, in Magaria District (extension phase)
709
475 463 387 396 396 388 340
203 203 105 78 38 38 41 0 4 0 0 0
T3 2019 T4 2019 T1 2020 T2 2020 T3 2020
Pilules Injectables Implants DIU
At the beginning of the extension phase of the project, pills were the most commonly accepted method among new FP users in the two CSIs of Magaria District, however, by the end of the project injectables became the most commonly selected method, due to the project’s sensitization efforts and the implementation of community distribution of DMPA-SC. Figure 17: Number of assisted deliveries and ANC4+ in Magaria District (extension phase)
456 423 402 376 386 357 335
228
T3 2019 T4 2019 T1 2020 T2 2020 T3 2020 II.1 Nombre d'accouchements assistés aux centres de sante
II.2 Nombre de femmes enceintes ayant reçu au moins le CPN-R4 (Fiche de consultation prénatale – au moins 4 visites )
In the two CSIs supported by the RISE-FP project in Magaria district, the project reported an increase in the number of women that received at least four ANC visits prior to delivery, likely due to the sensitization and referrals provided by the CBDs trained and mentored by the project. The number of assisted deliveries has remained more or less stable throughout the implementation period.
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Major challenges and proposed solutions
1. Commodity stockouts
Stockouts of contraceptive commodities were a major challenge throughout the implementation period. This situation has several causes: it is due either to national shortage, poor stock monitoring (poor management) by agents, or a malfunction in the supply chain. With regard to poor stock management, the project implemented stock management training sessions for agents. This contributed to a significant reduction in stockouts (only 3% of the health facilities reported stockouts) in the last year of implementation. The dysfunction of the supply chain is primarily linked to the fact that the health facilities have a procurement plan on paper, but often lack the means to implement it. Thus, the project supported the supply system at all levels (National, Regional, District, CSI and CS) either with fuel or vehicles to supply the health facilities.
2. COVID-19 Pandemic
The COVID-19 pandemic had a negative impact on the implementation of activities. In this context, a contingency and adaptation plan was developed in order to pursue the implementation of planned activities. Thanks to this plan, the activities were identified and adapted to the new situation, which requires compliance with the measures enacted by the Government in the fight against the epidemic. To comply with these measures, a number of activities were identified and included in the contingency plan. These involve:
Providing CBDs, SONGES agents, religious leaders, young community leaders, and tutors with protective equipment against COVID-19 Orientation for SONGES supervisors and tutors on COVID-19 prevention measures Briefing community actors (CBDs, young community leaders, and religious leaders) on COVID-19 prevention measures.
Other project activities were adapted by reducing the number of participants in group talks (5-10 people), preaching (15-20 people), introduction of CBDs trained on DMPA-SC (10-15 people). For training sessions and workshops, it was mandatory to wear masks and respect social distancing measures. It was in this context that all the activities undertaken during the final quarters were implemented.
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3. Sustainability of Project accomplishments
The project has left in its area of intervention some positive achievements in the health facilities as well as in villages with or without health structures. However, the challenge lies in the need for the communities and health workers to take ownership of these accomplishments and to pursue the activities after the project’s completion. To this end, the RISE-FP project supported the establishment of CoManagement Committees (CCG) in each of the four intervention communes and at the level of health posts (21) supported by the Project. After the project’s completion, these committees will take ownership of all the assets/activities of the project through:
- The supervision of activities - Participation in the meetings for the restitution of activities at the health posts level - The organization of monthly meetings for the restitution of the outcomes of activities - Collecting and sharing reports with stakeholders (District, CSI) - The organization of weekly meetings at the village level by the 7 actors (CBDs, religious leader, and young community leaders) in order to identify the barriers constraining the implementation of activities
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Lessons Learned The implementation of this project has led to the following lessons learned:
Youth Community Leadership is a model catalyst for change at the individual, social and environmental levels:
For each of the 3 main barriers identified in PtC games, young community leaders were successful in developing and implementing action plans in collaboration with community participation. This has led to a real change in behavior, with people making better use of health services and financing their own health (men accompanying women and children to the health center, creation of community funds for health funding, and availability of local transportation for health evacuations in the villages).
The involvement of traditional chiefs and religious leaders promotes community ownership of the project's activities:
For the enhanced ownership of the project's actions, CoManagement Committees (CMC) have been set up at the communal and health post levels involving the administrative and customary authorities, health workers, and project stakeholders at community level.
These committees are entrusted with:
- Supervizing the activities of the sub-committees at the health post level - Representing the committee at meetings for the restitution of activities at the health facility level - Supporting the health post committees in carrying out their activities, as needed - Organizing monthly meetings to evaluate the activities - Collecting and sharing reports with stakeholders (District, PATHFINDER, etc.) - Voluntarily pursuing the activities at community level (PtC games, home visits, preaching, group talks, distribution of contraceptive products, referrals and village assemblies) - Organizing weekly meetings at the village level by the 7 actors (CBDs, religious leader, and young community leaders) in order to identify the barriers constraining the implementation of the activities - Organizing monthly meetings at the health post level with members of the co-management sub- committee to collect data, discuss and plan future activities - Preparing and transmitting monthly reports to the communal committee
Traditional chiefs and religious leaders play a crucial role in these committees because they are the guarantors of the implementation of activities by community stakeholders. They constitute a social stratum that is well listened to by the population.
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CF/RH/FP integration significantly improves household resilience:
This approach combines conservation farming (which is a set of modern farming techniques that increase production) and the use of FP/RH services. This has shown that households increase their agricultural production through CF, on the one hand, and on the other hand, that their children are well fed and healthy thanks to the use of FP and other RH services. This allows the household to save more money because there are fewer or no sick children in the household, which means less or no health expenditure and enough food in stock, resulting in greater resilience. In the villages concerned, prior to the implementation of this approach, households that engaged in CF alone had their efforts hindered by the family burden and the colossal health expenses due to the permanent illness of household members. Similarly, households that used FP without CF, while they had a relatively healthy family and children, did not have sufficient food stocks to cover their family's needs. As a result, their household (family members) was at risk of being undernourished, and thus vulnerable. Hence, the need to combine the two (CF and FP/RH) for enhanced resilience.
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Recommendations for sustainability To the Ministry of Public Health:
• Ensure the popularization and scaling-up of the community leadership for change (CLC) approach. Adapting university leadership to the rural environment will respond to the needs of youth in rural areas by strengthening their ability to speak out and make community participation effective through community action plans to address the needs identified by the community itself. This approach gives credibility to youth leadership and elicits adherence not only from other youth, but also from the entire community with a view to perpetuating the interventions. • Establish a program to integrate family planning into agricultural services. By integrating FP/RH and farming, women and men can be committed in new and interesting ways. Discussions around agriculture represent a significant opportunity to provide advice on reproductive health, child nutrition and information on contraceptive methods for men and women who are also learning conservation farming techniques. • Continue to support interventions (fairs, outreach, supervision of community activities) in the project area • Support the organization of monthly meetings around the CSIs and health posts • Continue to strengthen the supply system to minimize stockouts
To partners (Pathfinder and Save The Children):
• Cover the entire RISE-FP intervention area with the support of the KULAWA Project and extend the intervention to other communities • Continue to support health facilities with technical equipment and supplies to guarantee free FP services
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ANNEX: BENEFICIARIES’ TESTIMONIES
A young woman beneficiary of the program: “My name is Salaha. I am familiar with this project and its activities. The CBDs raise our awareness about the methods and present them to us. If the woman wants injections or implants, they refer her to the health center, but if she wants the pill, they provide them themselves on the spot. Because before the arrival of this project, we didn't have information about FP. We were just giving birth any way we could and in the end we suffer, our husbands suffer and so do the babies. Personally, I use the methods. You see my child in front of me is three years old, and I don't even think about having another one. This little girl [she is pointing at a little girl next to her] is not mine, she is my little brother’s who didn't use the methods and had another child before the first child was weaned, he brought her to my house in a state of malnutrition and I've been taking care of her ever since. I take her to the Dratchama [health center] to get milk every week to give to her. That's how the child is recovering. You also have the Young Community Leaders who play the game and invite us to their work sessions and Malam Hamza (the religious leader) who preaches. You know, before the project started, people used to say that spacing births is like preventing oneself from having children, but with the preaching we finally understood that this is not the case. We understood that if you don't plan, the woman doesn't rest. That's why there are always problems and we are always on our way to the health center to seek treatment for our children who are constantly sick.
CBDs, young community leaders and Malam Hamza, usually invite us to their activities, and I am using FP now. But before, I gave birth once and within less than a year I got pregnant again. My child that I did not wean suffered, he had diarrhea, vomiting and I did not have peace of mind in this situation. The child was malnourished, I had to go back and forth to get milk and medicine. He was the first malnourished child I had. As soon as he recovered, I immediately chose a method. I told myself that this is the first and last time I will have closely spaced pregnancies. Currently I am on the pill and my last child is three years old.
The project’s intervention has brought a big change in our daily and family lives. For example: the mother's rest and the baby's well-being, stability in the home because when the woman gives birth every year the husband doesn't want to come near her (she's in a state of uncleanliness with everything the malnourished
FINAL REPORT 2017 _ 2020 RISE-FP Zinder-Niger 50 baby demands of her). For example if he has two wives and the other one takes care of herself , he will always leave you to go to the other one's house and it's a problem in the home.
Before the project started, very few women used FP in secret (unbeknown to their husbands and family members). You have to go to the health center to get it. With the project, which raises our awareness, in addition to the methods, it has become much easier and we have the courage to inform even our husbands that we are going to the center for injections, for example. And the other methods (pill) are available in the village itself.
Prior to the project, many people did not accept or take FP into account. For example, when you attend a wedding or an activity that requires the regrouping of people, the small children will bother you so much because they were so many, but at the moment they are reduced in number. I remember we had a visit recently in the village, these are people who used to come, they made the observation, and said that now the number of children has reduced, it is not like before when you found small children under two years old in large numbers and in poor health. But now the project has brought some order with its intervention, the women are planning births and the village has fewer and fewer sick and malnourished children!
My husband knows that I am on the pill. In fact, every night when I don't take it, he reminds me to do so.
We have a serious problem with early marriages here. For example, imagine I am poor and I have a 13- year-old daughter who is in school. A wealthy man will come wanting this girl in marriage and because of this I will give in and marry her to this man for the money he will give me. Or even if it's a young man who wants her I will remove her from school to marry her. She is not mature enough to put up with a man, so she will suffer even during childbirth and her whole family will suffer. We have examples like this in this village, if the project can assist us more to curtail this tragedy, our community will be much better off.”
Head of a health post Rachida is a mother of three children and is in charge of the Beikori Health Post in the CSI Bande area in the Magaria Health District, which is an intervention area of the RISE-FP project. She has already served in two health posts before joining the Beikori health posts where she participated in the implementation of the PtC approach in villages within her health district. She found it so interesting because it provides the health worker with an understanding of the reality of the target populations’ lives. To gain more insight into the real problems of the people in her health district, she took the initiative to work with the young community leaders to implement the approach in five villages that are not among the targets of
FINAL REPORT 2017 _ 2020 RISE-FP Zinder-Niger 51 the RISE-FP project. To ensure that the approach was firmly rooted in the community, she chose to involve community leaders. Here is her testimony: "I was very interested in the tools of the PtC game and I took the initiative to put them into practice in 5 villages that are not within the project's intervention zone, in collaboration with the project's young community leaders and the local leaders of these villages who chose 4 volunteer leaders in each village. I borrowed the PtC tools of the young leaders of Beikori, with the exception of the collection forms that I photocopied in order to redistribute them to the other volunteers of the 5 villages. The information collected using the PtC games made me understand how the populations in the intervention villages perceive the use of my services and the improvement of my FP/RH indicators. I would like to thank the RISE-FP Project for training us to help communities adopt the best behaviors for their well-being. (…..)”.
A CBD in a project-supported village
“I was recruited by the community 2 years ago in connection with the implementation of the RISE-FP project led by Pathfinder. We undertake the following activities: group talks; home visits as part of the FP/RH activities and community-based distribution of contraceptives. In addition, we have recently been trained on the administration of DMPA-SC but now we are undergoing a practical internship that will enable us, once we receive a new user, to go with her to the health post and administer DMPA-SC under the health worker’s supervision.
Prior to the project’s intervention in our community, women did not use the health services for FP/RH, there were many closely spaced pregnancies and many maternal and infant deaths.
However, after only 2 years of the RISE-FP project intervention, we see a great change at the community level including, among other things:
- Replenishment of contraceptives by women themselves at our level - The use of reproductive health and family planning services. Now, women come with their husbands to us to seek further knowledge on FP/RH - Decrease in health problems and maternal and infant deaths due to closely spaced pregnancies, etc.
Our work is well appreciated in the village because we are seen as leaders for change, we are widely listened to by the community and the population takes our advice into account with respect to health in general and FP/RH in particular. Knowing the importance of the project interventions, they fully adhere to the project activities and support us 100%. The community would like the project interventions to continue and reiterates its gratitude to the donors.
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As CBDs, we are proud of the role we play in serving as an intermediary between the community and health services to improve the health of our population”.
Village Chief on the administration of DMPA-SC by CBDs
“We would like to express our gratitude for all the work done with the 4 people we had selected. Thank God, they are now able to administer the Sayana Press product, it is a success. I'm very happy about that and I will continue to be happy because they can do it all with a little help. And besides, we thank them for their commitment and their willingness to go and ask for details about issues when necessary in order to perform their tasks better... It's a big change for us and especially for our women, no need now to go to the nearby health center (5 to 6 km) to choose a method, thank God and thanks to the RISE-FP project”.
An uncertified CBD during the first DMPA-SC certification passage
“As our peers have received their certificates, by the will of God we will work to earn ours, in turn, by focusing more on our activities despite the rainy season that is setting in. To achieve this goal we need the support of health workers especially their availability to assist us and help us remedy our shortcomings in order to keep the promise we made to our community”. He was certified during the second passage.
Beneficiary of a village
“This project is in its third year of implementation in our village. It works with CBDs, the religious leader and young community leaders. The young community leaders sensitize their youth peers, the religious leader preaches in favor of FP according to the Sunnah and the Qur’an and the CBDs conduct home visits, group talks and give out contraceptive products. My brother is a CBD. Sometimes I even help him during health fairs and mobile outreach visits to mobilize women. I also attend the religious leader’s sermons.
With the support of this Project, close pregnancies are rare in our village, children are no longer malnourished, and women no longer have to struggle for access to contraceptives. We have access to condoms confidentially. Recently we have had injectables (referring to the DMPA-SC administered by the CBD) in our village. I really wish that the activities of this project would be pursued in our village”.
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A young beneficiary of the program
“(.....) I was a young returnee to my village when one evening I was invited by one of the young people there to play with him a game that he thought would help him understand the difficulties of using the health centers. (……). Very attentive during the game, on returning home, I approached my wife to discuss it with her. (I told her...... ) to avoid getting pregnant before I leave, I would like to accompany you to the health center to choose a contraceptive method. I am interested in your health today and after I leave so that I can better stabilize my small business. After my departure, (.....) during my 8 months of absence I was able, for the first time, to save more money than in previous years. The first two of our 3 years of marriage were difficult to manage. This third year was a great relief. My two children are doing well and we are not thinking of having any so far because apparently my wife doesn't even want to talk about having her implant removed. (.....) I am taking full advantage of it because thanks to our discussions with the young leaders of my village, I was able to leave behind a healthy and happy family for 8 months. Thank you RISE-FP for assisting the young people of our village !!!”
A 26-year-old project beneficiary
“I am married with a 4-year-old child. CBDs, young community leaders, and religious leaders raise awareness about maternal and child health, especially FP. The youth leaders of my village invite me to all their activities. I have also received several home visits from CBDs, and I have participated in several preaching sessions held by religious leaders. Because of my participation in the activities held by CBDs, young community leaders, and the religious leader, I am presently considered as a guiding light among the newlyweds of our village. Indeed, after 4 years of marriage we have only one child thanks to FP. We are a happy couple in good health and with fewer expenses. There is no barrier between our couple and FP. Thanks to the preaching of the religious leader, I have now memorized several Qur'anic verses related to FP.”
Head of a CSI supported by the project
“Look, for several years we have been working with partners, but no partner has thought of leaving a replacement who will ensure the perpetuation of the activities at the end of the program. But with this project it's very different because in addition to the quality and expertise they have demonstrated in the implementation of activities, they differ from the other partners through their intense and regular monitoring. It is very important to acknowledge the good will and determination of this project which strives to sustain and preserve its accomplishments. This can be seen especially in the targeting of stakeholders who constitute the members of the co-management committees. They have given serious thought to having the representatives of the mayor's office, the traditional chieftaincy, religious leaders, CSI and stakeholders trained by this same program within these committees. In other words, they have
FINAL REPORT 2017 _ 2020 RISE-FP Zinder-Niger 54 included all the competent authorities to ensure the sustainability of the activities even after the project's completion, all for the good of the commune in terms of maternal and child health (FP, ANC, assisted childbirth etc.). It is therefore our duty to be fully involved.”
A young female CBD from her village
“My feelings very honestly is to thank the RISE-FP project with this significant step forward in my life as a woman who never went to school, not even adult classes (laughs). In the past, Sayana Press was injected only by health workers, but now we administer the injection ourselves within the community. In the beginning, it was done at the head of the health center’s office and the health worker came to the village where we did the injection in his presence, Here I am with my certificate in my hands which will allow me to inject Sayana Press myself when the need arises. I hope that the project can move forward.”
A beneficiary of the program
“I don't participate in the activities of the youth in my village because I am not interested. With the influence of my wife's friends, my wife often asks my permission to participate. The first time she approached me, I was categorically against health services, especially FP, although my wife believes she has found a solution to her closely spaced pregnancies. Never tired, she takes advantage of a few opportunities to bring up the issue so that I can allow her to use FP services. One day, out of curiosity, I approached the young leader of my village with whom I explained my wife's concern about spacing her births and I am scared, especially with the rumors about side effects. With frankness I was convinced of his words and back home with enthusiasm I asked my wife to prepare herself tomorrow we will go to the health center to choose a contraceptive method. The idea for me was to try it and today I am supporting my peers so that others can follow me. My wife is happy and that was my wish. Thank you to the actors of the RISE-FP project.”
A father testifies about the community fund
“I brought my child to the health center but due to insufficient means I had to return home where I met the managers of the community fund set up by the young leaders of my village from the RISE-FP project who lent me 7,000 CFA. Afterwards I returned to Marekou health post, where my child received treatment, thanks to which he is now cured. Back home, after a few days, I repaid what I owed the fund, and I was very happy about that. Now I am committed to mobilizing my peers to make the fund much stronger and available to everyone. I was really satisfied and the amount was commensurate with my needs.” .
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A young woman beneficiary of the intervention “My name is Salbia, I am 26 years old, married and mother of 4 children. I know the CBD, religious leader and young community leader of the RISE-FP project, they involve us in the implementation of their activities in different ways. They invite us during group discussions or inform us about the availability of products. We come to choose our method, each is free and voluntary. For example, the first time we brought the injectables, the CBDs went door to door to inform people that anyone who wants the method can come and see them and that it is not mandatory, as there are many methods, we give the woman the one that suits her but we must go to the health center for the first dose. I chose the Implanon, I've had it since last year.
I started contraception after the birth of my third child with the arrival of the project because before the different methods were not available, we only heard about the pill. There is a 5-year gap between my 3rd and 4th child. And now he has a 3-year-old kid sister and I don't intend to have another child at the moment! With the first two children, I had difficult births, a situation that I do not wish for any woman, very close pregnancies with sick children. At that time we had no information about contraception, no awareness, we were left to ourselves until I learned that there were ways to space births. (.....) My husband knows that I use contraception, he himself motivated me to use a method of my choice. (…..). We want the project to continue to assist us (...).”
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