ANNUAL REPORT 1 October 2016 – 30 September 2017 USAID/NEEMA: Integrated Services Delivery and Healthy Behaviors (ISD–HB)
USAID Health Program 2016–2021
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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 79
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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BASIC INFORMATION
Project name: Integrated Service Delivery and Healthy Behaviors (ISD-HB)
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: Alliance Nationale de Lutte Contre le Sida (National Alliance Against AIDS; ANCS) ChildFund Helen Keller International (HKI) ideas 42 Johns Hopkins University - Center for Communication Programs (JHU/CCP) Marie Stopes International (MSI) Réseau Siggil Jigéen (RSJ) Coverage: Health Program Concentration Regions • Diourbel • Matam • Kédougou • Kolda • Saint Louis • Sédhiou • Tambacounda HIV/AIDS hot spots: Ziguinchor, Kolda, and Sédhiou
Reporting period: October 1, 2016–September 30, 2017
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Table of Contents BASIC INFORMATION ...... 3 ABBREVIATIONS AND ACRONYMS ...... 6 1.1 PROJECT DESCRIPTION ...... 8 1.2 Introduction ...... 8 1.3 Overall objectives and sub-objectives ...... 8 1.4 Technical strategy ...... 9 Report summary ...... 10 Main achievements by objective ...... 12 Objective 1: Increased access to and utilization of quality health services and products 12 Sub-Objective 1.1: Increased coverage and utilization of evidence-based, sustainable, high-impact interventions at the household, community, and health facility level ...... 12 Sub-Objective 1.2: Linkage between community and facility platforms is strengthened and sustained ...... 30 Sub-Objective 1.3: Quality services at household, community, and facility levels are improved and sustained ...... 40 Sub-Objective 1.4: Key populations in target areas are tested, enrolled on antiretroviral treatment, and provided quality care in alignment with the 90-90-90 goals ...... 49 Objective 2: Increased adoption of healthy behaviors ...... 55 Sub-Objective 2.1: High-quality, targeted social and behavior change communication interventions to promote high-impact services and healthy behaviors delivered at scale ...... 55 Sub-Objective 2.2: Public sector capacity to coordinate, design, and advocate for improved SBCC at the national and regional levels ...... 61 Sub-Objective 2.3: Technical and operational capacity of local SBCC organizations to design, implement, and evaluate SBCC programs improved ...... 64 Monitoring, supervision, evaluation, and learning ...... 64 Collaboration and coordination ...... 69 CROSS-CUTTING ISSUES ...... 72 1.5 Gender equality ...... 72 1.6 Environmental compliance ...... 72 1.7 Compliance with US government requirements for FP ...... 77 ADMINISTRATIVE MANAGEMENT ...... 81 1.8 The project’s quick launch ...... 81 1.9 Establishment of Regional Coordination Bureaus ...... 82 ANNEXES ...... 83 1.10 Annex 1: Performance Monitoring Plan ...... 84 1.11 Annex 2: Content of Tutorat 3.0 packages ...... 90 1.12 Annex 3: Summary of results of FP integration into vaccination services ...... 92
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1.13 Annex 4: Success Stories ...... 94
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ABBREVIATIONS AND ACRONYMS
ACPP CHANGE, PROMOTION, AND ASSESSMENT AGENT AKL ACCEPTABLE KNOWLEDGE LEVEL ARV ANTIRETROVIRALS AWP ANNUAL WORK PLAN AYRH ADOLESCENT AND YOUTH REPRODUCTIVE HEALTH BMW BIOMEDICAL WASTE MANAGEMENT BPTV OFFICE OF VIOLENCE AND TRAUMA PREVENTION BREIPS REGIONAL BUREAU OF HEALTH EDUCATION AND INFORMATION SERVICE CAC COMMUNITY ACTION CYCLE CCA ADOLESCENT COUNSELING CENTER CCW COMMUNITY CARE WORKER CHW COMMUNITY HEALTH WORKER CLM MALNUTRITION CONTROL UNIT CMV+ HEALTH COVERAGE FOR PLHIV (COUVERTURE MALADIE DES PVVIH) CNLS NATIONAL AIDS CONTROL COUNCIL COP CHIEF OF PARTY CSC COMMUNITY HEALTH UNIT CVAC COMMUNITY WATCH COMMITTEE CYP COUPLE-YEARS OF PROTECTION DCMS DIVISION OF SCHOOL HEALTH INSPECTION DGS DIRECTORATE GENERAL OF HEALTH SERVICES DHIS2 DISTRICT HEALTH INFORMATION SYSTEM-2 DLSI DIVISION OF AIDS/STI CONTROL DRH DEPARTMENT OF HUMAN RESOURCES DSISS DIVISION OF THE HEALTH AND SOCIAL INFORMATION SYSTEM DSR/SE DEPARTMENT OF REPRODUCTIVE HEALTH AND CHILD SURVIVAL ECD DISTRICT MEDICAL TEAM ECR REGIONAL MEDICAL TEAM EHA ESSENTIAL HYGIENE ACTIONS EmONC EMERGENCY OBSTETRIC AND NEONATAL CARE ENA ESSENTIAL NUTRITION ACTIONS FP FAMILY PLANNING GBV GENDER-BASED VIOLENCE HSS+ HEALTH SYSTEMS STRENGTHENING PLUS ICP HEAD NURSE IPT INTERMITTENT PREVENTIVE THERAPY FOR PREGNANT WOMEN ISD-HB INTEGRATED SERVICE DELIVERY AND HEALTHY BEHAVIORS LTPM LONG-TERM AND PERMANENT METHOD
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MNCH MATERNAL, NEWBORN, AND CHILD HEALTH MSAS MINISTRY OF HEALTH AND SOCIAL ACTION MSI MARIE STOPES INTERNATIONAL NGO NON-GOVERNMENTAL ORGANIZATION PECADOM HOME-BASED CARE PHF PUBLIC HEALTH FACILITY PLHIV PEOPLE LIVING WITH HIV PNA NATIONAL PROCUREMENT PHARMACY PNC POSTNATAL CARE PNLP NATIONAL MALARIA CONTROL PROGRAM PNQ NATIONAL QUALITY PROGRAM PP/IUD POST-PARTUM INTRA UTERINE DEVICE PPJ YOUTH PROMOTION PROJECT RB REGIONAL BUREAU RH REPRODUCTIVE HEALTH REPRODUCTIVE, MATERNAL, NEWBORN, CHILD, AND ADOLESCENT/YOUTH RMNCAH HEALTH RNP+ NETWORK OF PEOPLE LIVING WITH HIV RSAM REFERRAL SYSTEMS ASSESMENT AND MONITORING SAFI ITINERANT MIDWIFE STRATEGY SBCC SOCIAL AND BEHAVIOR CHANGE COMMUNICATION SDP SERVICE DELIVERY POINT SNEIPS NATIONAL EDUCATION AND HEALTH INFORMATION SERVICE SPEC STRATEGY TO CONTINUE SUPERVISION OF HUTS SPECS STRATEGY TO CONTINUE SUPERVISION OF HUTS AND SITES TATARSEN TEST, TREAT, AND RETAIN IN SENEGAL TFP TECHNICAL AND FINANCIAL PARTNERS TWG TECHNICAL WORKING GROUP UNICEF UNITED NATIONS CHILDREN'S FUND VADI INTEGRATED HOME VISIT VCT VOLUNTARY HIV COUNSELING AND TESTING
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1.1 PROJECT DESCRIPTION
1.2 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 (newborn mortality rate is 29.6 per 1000 live births in the concentration regions compared to 22.1 for 1000 in the consolidation regions; under-five mortality is 91.9 per 1000 compared to 64.7 per 1000). Use of family planning is nearly double in the consolidation regions. 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.
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 hamper their adoption of healthy behaviors; these norms also negatively affect women and girls.
The Integrated Service Delivery and Healthy Behaviors (ISD-HB) project supports 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.
The project is implemented in the USAID Health Program 2016–2021 regions of concentration: Diourbel, Kédougou, Kolda, Matam, Saint Louis, Sédhiou, and Tambacounda. In the first year, the project will support implementation of “Test, Treat, and Retain in Senegal” (TATARSEN) in HIV hot spots in Ziguinchor, Kolda, and Sédhiou.
The ISD-HB project is implemented by IntraHealth in partnership with the National Alliance Against AIDS (Alliance Nationale Contre le Sida; ANCS), Réseau Siggil Jigéen, ChildFund, Helen Keller International (HKI), Marie Stopes International (MSI), Johns Hopkins University/Center for Communication Programs (JHU/CCP), and ideas42.
1.3 Overall objectives and sub-objectives
The project’s objectives and sub-objectives are outlined in the figure below.
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Figure 1: Project objectives framework
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 Objective 2: Increased adoption of quality health services and products healthy behaviors
Sub-Objective Sub-Objective Sub-Objective 2.1: High- 1.1: Increased Sub-Objective 1.4: Key quality, Sub- coverage and 2.3: Technical Sub-Objective populations in targeted social Objective 2.2: utilization of Sub-Objective and 1.3: Quality target areas and behavior Public sector evidence- 1.2: Linkage operational services at are tested, change capacity to based, between capacity of household, enrolled on communicatio coordinate, sustainable, community local SBCC community, antiretroviral n interventions design, and high-impact and facility organizations and facility treatment, and to promote advocate for interventions platforms is to design, levels are provided high-impact improved at the strengthened implement, improved and quality care in services and SBCC at the household, and sustained and evaluate sustained alignment with healthy national and community, SBCC programs the 90-90-90 behaviors regional levels and health improved goals delivered at facility level scale
1.4 Technical strategy
The project intends 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 plans to collaborate with local municipalities 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. ISD-HB will use 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 2: ISD-HB project technical strategy
REPORT SUMMARY This report presents activities for the first year of USAID/Neema project implementation, which will last for five years.
With the first months of implementation devoted to hiring project staff, setting up three regional coordination bureaus, and planning in collaboration with stakeholders, activities actually started in the second quarter of the year.
The project enrolled all medical regions and health districts into Tutorat 3.0 and was thus able to instill ownership of the approach at the operational level. TutoratPlus implementation tools were reviewed and adapted for Tutorat 3.0 with the participation of stakeholders from the MSAS.
While waiting for the on-site supervisions, providers received conventional training in family planning, maternal and newborn health, malaria, and nutrition.
Adolescent and youth reproductive health was a key intervention with support for the MSAS to strengthen providers’ capacities, support for the Division of School Inspection (DCMS) to increase inclusion of adolescent and youth reproductive health (AYRH) in school health, support for adolescent
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counseling centers (CCAs) to include out-of-school youths in programming, and delivery of AYRH services in Richard Toll through a youth space set up by the project.
At the community level, the services package was expanded to the intervention areas, making injectables available in 320 health huts and incorporating the delivery of newborn-specific care in 425 health huts. The health infrastructure network was expanded with the enrollment of 61 new health huts and 360 new community sites.
Support for the Gender Unit and the MSAS Office of Violence and Trauma Prevention (BPTV) gave providers training tools and information on gender mainstreaming in programs and services and the management of gender-based violence (GBV). For the community level, tools for the integrated home visit (VADI) and community watch committees (CVACs) were revised to include factors related to gender and youth.
Once mapping of community health workers (CHWs) was updated, the Neema project allowed for an 11% increase in the CHW system especially through training for new CHWs. The process to introduce the Referral Systems Assessment and Monitoring (RSAM) tool began to improve referrals between health facilities and infrastructure at the community level. Support for logistics supervision of health huts conducted by head nurses (ICPs) and district medical teams (ECDs) helped identify gaps in the availability of commodities and medicines at the community level and taking corrective measures.
In addition to support in equipment and coordination at the Division of AIDS/STI Control (DLSI) to implement the TATARSEN strategy, the project enabled 3174 individuals (or 88%) from key populations (men who have sex with men (MSM), sex workers, and injection drug users (IDUs)) to be tested and know their HIV status and for the 61 who were HIV positive to have access to treatment.
Collection of evidence to develop local and adapted SBCC strategies began with the quantitative and qualitative baseline survey of health-promoting behaviors related to reproductive, maternal, newborn, child, and adolescent/youth health (RMNCAH). Support provided to the National Malaria Control Program (PNLP) for its communication campaign focused on malaria in the rainy season resulted in key messages on using long-lasting insecticide-treated bednets, seeking early care, and malaria prevention during pregnancy, reaching communities via 33 local radio stations. The National Education and Health Information Service (SNEIPS) used a participatory approach to conduct both its institutional diagnosis and that of the Regional Offices of Education and Health Information (BREIPSs) intervention areas of the product and, with project support, developed a plan to strengthen institutional capacities.
Integrated supervision carried out in 86% of service delivery points (SDPs) and 60% of huts identified gaps in services delivery and in compliance with environmental and family planning regulations, leading to appropriate corrective measures. The supervision also helped document some indicators in the Project Performance Monitoring Plan.
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MAIN ACHIEVEMENTS BY OBJECTIVE Objective 1: Increased access to and utilization of quality health services and products
Sub-Objective 1.1: Increased coverage and utilization of evidence-based, sustainable, high-impact interventions at the household, community, and health facility level
Expected outcomes over 18 months Achievements over 12 months 1. At least 30% of SDPs are covered by on-site All 7 of the targeted medical regions and the 29 coaching through Tutorat 3.0 health districts are enrolled in Tutorat 3.0 29 tutor trainers are trained in the various Tutorat 3.0 packages
2. 50% of SDPs offer an integrated package of 273 SDPs underwent training in RMNCAH, or high-impact services 47% of SDPs in the intervention areas
3. An intermittent preventive therapy-3 (IPT-3) 15 of the 29 districts that make up the project’s improvement approach is implemented in the 7 intervention regions have an action plan to 7 concentration regions strengthen IPT coverage for pregnant women
4. An integrated approach to systematically DIPEC.Com is implemented in 926 health huts identify client needs is implemented in 460 and home-based care (PECADOM) sites health huts
5. The revised VADI and CVAC strategies are 1407 huts and sites have included the revised implemented in approximately 700 health huts VADI in their services and community sites 265 CVACs have been set up
6. Innovative approaches in GBV are taken into A multisectoral coordination manager was account in MSAS policies and programs created within the MSAS to promote synergies with a view to implementing innovative approaches to fight GBV
Through this sub-objective, the project planned to increase the use of a complete package of essential interventions in RMNCAH in hospitals, health centers, health posts, health huts, and households in the intervention areas. During the year, the project promoted high-impact practices based on the life cycle, especially by strengthening providers’ capacities at all levels, expanding the SDP network, and equipping SDPs. The figure below shows the continuum of care established through interventions implemented during the first year. (See figure below.)
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Figure 3: Continuum of care through project interventions
We also noted significant increased use of services in intervention areas for maternal, newborn, and child health/family planning (MNCH/FP) between 2016 and 2017.
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Figure 1: Changes in the use of services in consolidation areas between 2016 and 2017
2000000 1800000 1600000 1400000 1200000 1000000 800000 600000 400000 200000 0 Accouchements assistes Nombre de femmes Accouchements assistes Femmes enceintes ayant par un personnel qualifie utilisatrice d'une avec partogramme effectue 4 CPN sous GATPA methode PF (actives) 2016 88995 99799 109810 1559253 2017 99474 111002 116752 1781625
Family planning services reported 1,781,685 new users in 2017 (over 9 months) compared to 1,559,253 in 2016. Intervention 1.1.1: Scale up a package of high-impact maternal, newborn, and child health practices in service delivery points based on lessons learned Support for care providers at the facility level to integrate high-impact practices: The project planned to use the Tutorat 3.0 approach to ensure rapid, integrated coverage of high-impact practices in all health facilities in the 29 districts of the 7 concentration regions. For the first year, in addition to Tutorat 3.0, the project planned to strengthen providers’ capacities through conventional training on the integrated package of services.
The main achievements are:
Tutorat 3.0 implementation: Tutorat 3.0 is an adaptation of TutoratPlus, aimed at institutionalizing and continuing the approach.
In the first year of implementation, the project was able to:
• Secure stakeholder engagement at the operational level: Orientation sessions were held for 109 individuals, including ECR and ECD members, local officials, and health committee members on Tutorat 3.0 in the 7 intervention regions. The workshops presented: an overview of the Neema project; the approach’s implementation steps and process; actors’ roles and responsibilities; the sub-grant process; and identification of deliverables, by level. Also, the implementation process was transferred to the district medical teams (ECRs) and ECDs by setting up a sub-grant for the preliminary steps: introducing local municipalities to the approach, conducting a situational analysis of SDPs, and selecting tutors and training them. Concerns about institutionalizing the approach within the MSAS resulted in two meetings with the Directorate General of Health Services (DGS) to set up a technical working group on Tutorat 3.0 management.
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• Include the latest updates in Box 1: Description of Tutorat 3.0 RMNCAH and malaria in the training modules: In the project’s Tutorat 3.0 first year, the project technical team Description: An approach to improve services delivery in terms of quality and availability using a capacity building approach at has begun to update the training the job site. Tutorat 3.0 follows TutoratPlus and is the third type and orientation tools on the services of tutoring program implemented in the country. package and for some key Difference between TutoratPlus and Tutorat 3.0 approaches. An internal review was ‒ An implementation approach: ownership and conducted on the updating of institutionalization within the MSAS at all levels Tutorat 3.0 tools. Hence, TutoratPlus ‒ Content of packages: covering community health tools could be adapted; content for management, gender, and AYRH tutor booklets, manuals, and reports ‒ Implementation: All steps are implemented by the could be developed; the Tutorat 3.0 ECRs and ECDs except for orientation and updating implementation process could be content developed; and the various noted Tutorat 3.0 implementation steps: packages could be defined. (See ‒ Updating and revising tools Annex 1.) ‒ Providing orientation for ECRs and ECDs (presentation, • Add a component covering sharing, and validation of district grant deliverables) management of community health ‒ Setting up a working group at the central and regional activities: A specific package on level managing community health ‒ Signing of sub-grants activities was developed. The ‒ Pre-selecting tutors and validating selection package is structured into 3 ‒ Strengthening Task Force units’ capacities in Tutorat modules: (1) Using programming 3.0 and coordination documentation ‒ Training and/or updating tutors resources to manage community ‒ Rapid assessment (situational analysis) of district SDPs health activities; (2) Integrated supervision of priority health ‒ Coaching and monitoring tutors on site programs; and (3) Supervision ‒ Evaluating sub-grants specifically for the CVAC and VADI strategies, getting a health hut or site up and running, and introducing a new service. The initially targeted Strategy to Continue Supervision of Huts and Sites (SPECS) has now been included in the module on documentation resources. Introduction of the Community Action Cycle applied to gender-based violence (CAC/GBV) and the community scorecard into Tutorat 3.0 were postponed to take time to identify lessons learned from the strategy’s implementation.
• Include gender and management of GBV in the revised modules: Gender was first included in tutoring while implementation tools were being revised. It was decided to develop a separate module presenting an overview on gender and specific content for each tutoring aspect that will be included into the booklets. Integration efforts are still underway and should be complete at the end of October. Also, with support from the MSAS gender unit and the BPTV, the 66 tutor trainers (35 men
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and 31 women) had an orientation on how to take gender and GBV into account when delivering care.
• Simplify the situational analysis process: Tools for the situational analysis were revised and shortened by saving “observation of provider performance” for on-site coaching. The data collection and processing system was automated for immediate use of collected data and to develop an action plan to resolve observed gaps. This allowed health districts to hold the restitution workshop once data had been collected.
• Set up a pool of tutor trainers in each region: The Neema project team, with support from IntraHealth headquarters, trained 66 tutor trainers (35 men and 31 women) in six days on implementation tools, facilitation techniques, and coaching adults. Tutor trainers are distributed as follows: 29 ECR and ECD members from the 7 intervention regions (including 1 regional medical officer (MCR) and 1 district medical officer (MCD)); 8 regional hospital staff (heads of nursing services); 4 staff from regional training centers; 12 staff from MSAS services, programs, and directorates at the central level; and 13 Neema project staff. Participants did simulations and demonstrations in class and completed a practical workshop on site.
The on-site supervisions could not be started as planned this year because they are included in the sub- contract deliverables for health districts and regions, which were signed late, particularly due to the boycott of the G50 per diem policy.
Strengthening providers’ capacities on high-impact interventions: In anticipation of the on-site supervisions, in Year 1 the project led activities to improve the availability of high-impact practices in public SDPs. The main activities are strengthening providers’ capacities and the implementation of high- impact approaches in malaria, FP, maternal and newborn health, and nutrition.
Strengthening providers’ capacities: The project supported provider training on high-impact interventions, as shown in the table below.
Table 1: Summary of provider training on high-impact practices Type of training Medical Regions Number of qualified providers Number of trained SDPs covered Men Women Total
Contraceptive Diourbel, Matam, 59 93 152 123 technology, focusing on Saint Louis, and long-term and Tambacounda permanent methods Sayana Press Diourbel, Kolda, 93 244 337 241 Matam, Tambacounda EmONC Matam, 0 60 60 49 Tambacounda Training for ECRs/ECDs 7 concentration 113 41 154 31 in ENA/EHA regions
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ENA/EHA Diourbel, Saint 130 161 291 204 Louis, Sédhiou, and Tambacounda Routine vitamin-A Matam, Kédougou 84 52 136 69 supplementation New guidelines for the Sédhiou, 29 54 83 49 management of malaria Tambacounda
During training sessions on contraceptive technology focusing on long-term and permanent methods (MLDAs), performance levels for counseling and Jadelle and IUD insertion and removal ranged between 50% and 98%.
Tests were administered to assess participants’ knowledge about FP and to evaluate their progress by the end to analyze the acceptable knowledge level (AKL) after the lessons.
The baseline analysis of the participants’ knowledge level for MNCH training showed a low level on the pre-test. Of the 60 participants, none achieved an AKL of 85% on the pre-test, while 51 participants (85%) had an AKL below 50%. Overall, 8 participants (13%) achieved a final AKL greater than or equal to 85% on the post-test. Generally, there was a high progress rate for participant performance, even though many did not achieve the required AKL on the post-test: the average AKL was 37% on the pre- test compared to 70% on the post-test.
The training session outcomes pushed us to adapt to the specificities of our intervention regions where providers are often new hires with little experience. Given the package’s density, it was decided to split the emergency obstetric and neonatal care (EmONC) into four modules for the second year: Active management of the third stage of labor (AMTSL)/Essential Newborn Care (ENC)/Partograph, eclampsia/pre-eclampsia, post-abortion care/FP, and ventouse delivery to give trainers an opportunity to further strengthen providers’ knowledge and skills. In addition, recommendations were made for regions and districts so that participants whose final AKL was below 85% could be the first to benefit from the first round of on-site supervision visits by tutors. This would build on achievements and close remaining gaps.
Malaria control: The main implemented activities are support for regional acceleration plans for malaria control and the IPT-3 improvement approach in health districts.
As part of support to implement the Southern Malaria Control Project, Neema supported the development and consolidation of malaria control plans for districts in the regions of Kolda, Sédhiou, Tambacounda, and Kédougou.
Working in synergy with the PNLP, the Neema project jointly supported the malaria control acceleration plans of Touba and Diourbel districts in Diourbel region since the beginning of development, implementation, monitoring, and financing of the plans’ activities in the districts and public health facilities (PHFs) of Diourbel. The goal is to provide technical and financial support to strengthen the capacities of local human resources on the new guidelines for the management of malaria and to increase communication about malaria. This support helped the districts to implement a services package consisting of radio broadcasts of spots, shows, messages, and news reports and media coverage by signing one-year service delivery contracts with community radio stations that are
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partnering with districts for wide broadcast of malaria messages. The support also enabled the medical region to introduce 20 journalists to malaria messages to strengthen communication on malaria. The acceleration plan for the Diourbel area underwent joint monitoring by the project and the PNLP to assess the implementation level of planned activities.
As part of the IPT improvement approach for malaria among pregnant women, 15 districts have an action plan to strengthen IPT coverage for women. These plans were developed in synergy with the PNLP at all stages of the process to validate tools for the situational analysis, identify priority actions to close gaps, and finance activities.
High impact approaches for FP: The main activities are the incorporation of FP into high-volume SDPs, IUD delivery in the post-partum stage (PP/IUD), and capacity building in the FP Division of the Department of Reproductive Health and Child Survival (DSR/SE).
Including FP in vaccination services is an opportunity to inform breastfeeding mothers about FP and offer FP services to those who need them. This should significantly reduce unmet need if it is sustained and scaled up. Tools were developed to improve this activity’s implementation process, namely, an orientation guide on incorporating FP into vaccination services and the supervision grid. Overall, 1016 information sessions were held (or a performance rate of 38% compared to the 18-month target) with the enrollment of 6866 new users of an FP method (see Annex 3). The average enrollment rate among the women who were affected by sensitization exercises is 21%. However, this rate varies significantly from one region to another, as shown in the Figure below.
Figure 2: Enrollment rate for new users of FP methods, by region
45% 40% 40% 35% 29% 30% 24% 24% 25% 21% 20% 13% 15% 10% 10% Taux moyen de recrutement de 5% nouvelles clientes 0%
Sédhiou region had the highest enrollment rate at 40%, while the regions of Kédougou and Kolda had an enrollment rate below 20%. This activity was not done in Matam. As part of extending delivery of PP/IUD counseling, the Diourbel medical region held a training session for 34 providers from 26 SDPs in Touba district. The training helped providers share information on FP, and specifically on the IUD, which can be inserted right after delivery before leaving the maternity ward. This intervention consisted of offering women the IUD in the post-partum stage in the two hospitals in
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Touba district after enrolling them during prenatal consultations in health posts. The intervention was started in the previous program in 2015. The project made a supervision visit and collected data in Touba district, involving 55 providers from 23 health posts, 1 health center, and 2 hospitals. Data were compiled since the start of the intervention in 2015 until March 2017 to formally share them at the national and regional level with the goal of scaling up the intervention based on lessons learned.
The collected data show women’s support of this method.
Table 2: Results of the PP/IUD introduction in Touba district
April–Sept Oct 2015 – Sept Oct 2016 – Total 2015 2016 Mar 2017
Clients who received PP/IUD counseling 55 5322 1556 6933
Clients who agreed to the PP/IUD after 7 606 265 878 counseling Number of women who received the PP/IUD 119 370 245 734
Thus, of the 6933 women who received counseling on the PP/IUD in health posts, 11% (734) were able to receive the PP/IUD. This low utilization rate is explained by the main reason women give for not using the method: its unavailability in the health posts and health centers where they usually choose to deliver. This could justify making the method available in all SDPs (health posts, health centers, and hospitals).
The outcomes for the PP/IUD intervention could not be shared due to scheduling conflicts, which has delayed extension into SDPs and the Diourbel regional hospital.
Support for the FP Division focused on disseminating the National Strategic Framework for Family Planning (CNSPF) and improving management procedures for health information on FP. Thus, the project provided technical and financial support to the FP Division to disseminate the CNSPF nationally and in the regions of Diourbel, Kédougou, Sédhiou, Tambacounda, and Saint Louis. Workshops involved 195 participants, including 87 women, who developed regional action plans based on domains defined in the strategic framework. The regions of Kolda and Matam plan to conduct this activity in the first quarter of Year 2.
As part of improving the health information management process, the project supported two workshops to revise the procedure manual for statistics on FP services. This initiative is in response to the identified weaknesses in the management of job-aids, the FP file, data collection procedures, comprehension of concepts, and procedures for filling out FP activity reports. The workshops reached 22 women and 8 men, and consensus was reached at the central level regarding concepts and management procedures for the FP file.
High-impact approaches in maternal and newborn health: The main intervention is continued delivery of home-based post-natal care (PNC-1) in Sédhiou region. Tools were revised and a situational analysis of new SDPs and sites selected to deliver home-based PNC-1 was conducted in Goudomp district, covering 10 SDPs and 20 sites enrolled to implement this strategy. Thus, 71 women received a PNC-1 visit and 68 newborns received home care in villages/sites delivered by ICPs and midwives from six health posts and three districts in Sédhiou region. Three of the newborns who received care were
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referred to the health center for complications. Also, 13 new SDPs covering 36 villages were enrolled to implement the approach in the districts of Bounkiling and Goudomp in Sédhiou region.
High-impact approaches in nutrition, hygiene, and sanitation: The routine vitamin-A supplementation strategy is a high-impact intervention that aims to improve child survival by combatting vitamin-A deficiency. It is an alternative to costly mass campaigns. After consultation with the DSR/SE, the project decided to conduct the intervention in Matam and Kédougou, where there are funding gaps. Thus, 131 providers from the districts of Thilogne, Matam, Ranérou, and Kanel and 31 providers from Saraya district were trained in the process to administer routine vitamin-A supplementation. Routine vitamin- A supplementation has been rolled out through project support in 101 SDPs, including 86 SDPs in Matam medical region and 15 SDPs in Saraya district in Kédougou region.
Establishments with youth-friendly services: The project is essentially aligning itself with the DSR/SE’s strategic plan for AYRH and the implementation of youth-friendly services. Thus, for the first year, the key achievements primarily focus on support to roll out the AYRH strategic plan, support for the DCMS of the Ministry of National Education to give students greater access to AYRH information and services, support for CCAs of the Youth Promotion Project (PPJ) and setting up a Youth Space in Richard Toll.
Support for the implementation of the AYRH Strategic Plan focuses on: (i) strengthening providers’ capacities; (ii) training for peer educators; and (iii) strengthening coordination of AYRH interventions.
Next, in collaboration with the AYRH Division of the DSR/SE, the project strengthened providers’ capacities in the regions of Sédhiou, Kolda, Diourbel, and Tambacounda to improve care for adolescents and youth in public SDPs (health centers and health posts) through training on the “Build Your Future” guide. Overall, 11 training sessions were organized. The table below summarizes provider training on AYRH.
Table 3: Summary of provider training sessions in AYRH
Regions Districts Number of Individuals trained sessions Male Female TOTAL SEDHIOU Goudomp 1 4 19 23 Sédhiou 1 0 21 21 KOLDA Kolda 1 8 11 19 Médina Yoro Foulah 1 4 15 19 DIOURBEL Diourbel 2 11 36 47 Bambey 2 7 40 47 Mbacké 2 14 34 48 TAMBACOUNDA Dianké Makhan 1 11 6 17
TOTAL 9 11 59 182 241
Thus, 241 providers (including 182 women) from 113 SDPs were trained on the “Build Your Future” guide.
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After provider training, Bounkiling and Goudomp districts in Sédhiou region each held a training session for peer educators on AYRH. These sessions sought to build the network of community actors who promote AYRH in SDPs. In Bounkiling, 20 peer educators (12 men and 8 women) were trained; in Goudomp, 25 peer educators (21 men and 4 women) were trained.
Lastly, the project provided support to the Division of Adolescent and Youth Reproductive Health (DSRAJ) to develop a national AYRH communication plan and to hold the first quarterly meeting of the national consultation framework on AYRH. Regarding communication, a diagnosis and behavioral analysis of the various identified targets was conducted. The various activities carried out by partners and AYRH Division throughout 2016 were shared during the coordination meeting.
Support for the DCMS aimed to respond to the lack of knowledge about sexuality education among adolescents and youths who are in school. Discussion meetings resulted in adopting an educational strategy for students delivered by trained teachers on various topics related to adolescent and youth reproductive health with the Training Manual for Trainers in AYRH and GBV in School Settings.1 The strategy will initially be implemented in middle schools (CEMs). After the trainings, the most motivated and best suited teachers will be chosen to become “school mediators.” Their role will be to teach students using various tools specifically for this strategy, namely the School Mediator Guide and the Middle Schooler Notebook.
The revision of the Training Manual for Trainers in AYRH and GBV in School Settings is complete. The content in the School Mediator Guide and the Middle Schooler Notebook still needs to be harmonized with the trainer’s manual.
Support for the PPJ CCAs: Also in keeping with the goal of participating in sexuality and reproductive health education for adolescents and youths, special efforts must be made to reach out-of-school youth, who are often the most vulnerable to misinformation and exploitation. The USAID/Neema project had planned to support the PPJ to identify and implement an activity package for CCAs. Thus, the two PPJ adolescent counseling centers in Kolda and Vélingara districts were supported by the Neema project to roll out AYRH activities targeting out-of-school youth. In Kolda district, the CCA organized a forum and 10 discussions, and in Vélingara, a panel and 10 discussions were held. The Tambacounda CCA held 30 discussions and 2 social mobilizations mainly targeting out-of-school youths. These activities reached 1709 people, including 697 boys and 1012 girls.
Table 4: Summary of information activities led by CCAs in Kolda, Vélingara, and Tambacounda
Individuals reached, by sex and by age group Female Male 10– 15– 20– 25– 10– 15– 20– 25– TOTA ACTIVITIES ≥ 35 ≥ 35 15 19 24 34 Tota 15 19 24 34 Tota L year year year year year year l year year year year l s s s s s s s s s s
1 Manual developed as part of the USAID Health Program for Senegal, 2006–2011.
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Discussions 58 170 205 21 16 470 49 199 156 12 9 425 895
Social mobilizatio 26 202 187 48 79 542 7 98 121 17 29 272 814 ns 101 TOTAL 84 372 392 69 95 56 297 277 29 38 697 1709 2
The 15–19-year-old age group benefited the most from these informational activities, while the activities had little effect on the 10–14-year-olds.
These activities resulted in referring or directing 7% of the 122 individuals (including 67 girls) who were informed to health facilities, as shown in the table below.
Table 5: Distribution of referred individuals, by reason and by age group
Referred individuals, by sex and by age group
Female Male TOT Reasons for 10– 15– 20– 25– ≥ 10– 15– 20– 25– ≥ AL referral 14 19 24 34 35 Tot 14 19 24 34 35 Tot yea yea yea yea yea al yea yea yea yea yea al rs rs rs rs rs rs rs rs rs rs Counseling/infor 0 22 31 2 0 55 3 33 12 4 0 52 107 mation
FP 0 0 7 1 0 8 0 0 0 0 0 0 8
IST screening and 0 1 3 0 0 4 0 0 2 1 0 3 7 care
TOTAL 0 23 41 3 0 67 3 33 14 5 0 55 122
This table shows that the majority of referred cases (88%) were for counseling, and only 8% were for family planning. It also indicates that the 15–19-year-old age group for both sexes had the greatest need for information. Demand for FP services was primarily expressed by young women 20–24 years.
Analysis of these data should help in restructuring CCA activities for Year 2 to have a greater impact on adolescents and youths.
Youth-friendly services: The project launched a new youth space in Richard Toll district to reach youths (15–24 years) who are educated or who do not live in urban or rural areas. The space will meet youths’ needs and expectations by providing quality information and a range of services that emphasize confidentiality and comfort. The project also set up an MS Ladies network (mobile midwives) focused on youths in Kolda region that incorporates the already existing strategy of mobile teams working in rural areas of the same region.
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Activities in the Richard Toll youth space were launched in the final quarter of the year in partnership with the health district. This involved launching several collaborative activities since the second quarter to facilitate installation of the new space, including:
- Coordination meetings with the Richard Toll district medical team (ECD) and the Saint Louis medical region to share and gather their ideas for refining the MSI youth approach and then to identify locations where youth spaces can be set up - Meetings with local officials (the prefect of Dagana, the mayor of Richard Toll, etc.) to facilitate their involvement in the project - Days devoted to RH/FP orientation and training for sports and cultural association and youth association leaders, peer educator networks, and community relais as well as members of the municipal youth council in Richard Toll - A day for consultation with the health committee and representatives of communities living in the area around the former youth center of Gallo Malick to share objectives and assign roles for each stakeholder to ensure the success of the youth space - Awareness-raising days for religious leaders organized in partnership with the Islam and Population Network (RIP), which uses an argument based on Islam to promote birth spacing among youths - And lastly, mass social mobilization sessions in the city’s neighborhoods and nearby villages, held during the last quarter in partnership with CHWs and the youth associations to publicize available services and raise youth awareness
The information, awareness-raising, and social mobilization activities associated with the Youth Space started and reached 4817 youths (1742 men, 3075 women); of these, 1227 received RH/FP services, including:
- 172 FP clients enrolled, including 58% for long-term and permanent methods - 441 Couple-Years of Protection (CYP) produced - 74 STI cases treated - 6 HIV tests performed, all negative
Information, awareness-raising, and social mobilization activities were rolled out in collaboration with the city’s youth associations, as part of the “Gindima2-Summer Tour” campaign. The campaign’s strategy revolved around fun activities with cultural competitions organized in neighborhoods. Topics presented to youths centered on AYRH and sought to increase knowledge through a theater competition and to encourage youths to share information with each other. The key strategy continues to be bringing services to youths and combining this with fun activities that cut across the targets’ (youths’) interests. We found that when activities are brought directly to youths by their peers, they are more receptive to the messages presented. In order to help peer educators and community relais to better communicate about RH/FP issues, the MSI youth team, with support from the youth space coordinator, trained 35 youths on the MSAS “Growing up in Harmony (Grandir en harmonie)” curriculum.
2 Wolof word meaning “Clarify-Guide”
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Lastly, the behavioral economics approach was used to provide youth-friendly care and to promote youth access to reproductive health services. To do this, the project conducted a study in SDPs and in the community. The preliminary data were analyzed following an initial collection phase of exploratory data, which aimed to identify potential problems needing solutions. The study mainly focused on Kédougou and Tambacounda regions as pilot sites, given their high pregnancy rates among 15–19- year-olds and low rates of modern contraceptive use compared to the national average. Based on a review of existing literature on the subject and data collected from primary targets, youth, and health providers, the study will focus on unintended pregnancies among youth. For this, a protocol was developed and submitted to the National Ethics Committee for Research in Health in Senegal (CNERS).
Support improvements in health huts to upgrade them to health posts: This support targets the central level and focuses on getting orders signed to upgrade health huts into health posts, monitoring implementation, and evaluating and documenting the process. At the regional level, it supports the signing of Memoranda of Understanding (MoUs) to hire staff and to roll out support from various stakeholders (Neema and other actors). During Year 1, the project had working sessions with the medical regions of Tambacounda and Kolda, the health card unit, and departments involved in this process (Community Health Unit, Department of Infrastructure and Equipment, and the Department of Human Resources) on the terms for implementing this support.
The selection of health huts to be upgraded to posts was validated. The mission to reassess these huts’ needs and programming with all regional actors was postponed due to changes made by the MSAS in the fourth quarter.
Intervention 1.1.2: Ensure that CHWs offer an integrated package of high-impact services covering both prevention and care Expansion of the integrated package of high-impact services delivered by community health workers: Expansion of the integrated package of high-impact services delivered by CHWs implements the following components: (1) the integrated care approach; (2) increased coverage of initial offers of injectable contraceptives and postpartum hemorrhage (PPH) care; (3) expanded delivery of newborn care; (4) expansion of the package of services in community nutrition sites and PECADOM sites; (5) delivery of a community-based services package adapted to adolescents/youth; and (6) delivery of the essential nutrition actions (ENA) and essential hygiene actions (EHA).
The table below summarizes the training for CHWs on the package of high-impact services.
Training content Number of CHWs trained Number of sites/health huts M W Total covered
DIPEC.Com 634 641 1275 926
Delivery of injectable contraceptives 192 283 475 320
Newborn-specific care 184 420 604 425
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Delivery of PPH prevention services 11 131 142 112
Delivery of community-based services adapted to 1347 1826 3173 384 adolescents/youths
The community-based integrated care approach aims to streamline resources, improve the quality of services, and take advantage of all opportunities for contact with clients at health huts or PECADOM sites. DIPEC.Com considers the direct and indirect needs of priority targets (children 0–5 years, pregnant women, women of reproductive age, and adolescents/youths) who come for a consultation in health huts and PECADOM sites. Direct needs are client health needs that are imperceptible to the client and are not the reason for the consultation in the hut or site (FP, prenatal follow-up, postnatal follow-up, delivery plan, nutritional follow-up, vaccination, vitamin-A supplementation, etc.). Indirect needs are potential or known health problems of children 0–5 years and pregnant women in the client’s family or immediate social circle.
The achievements are: the development of implementation tools (implementation guide, trainer manual, participant aide-mémoire, and the DIPEC.Com technical sheet); testing and validation of tools with the MSAS; orientation for ECRs/ECDs; provider training; and the training of 1275 community care workers (CCWs) (W: 641; M: 634) in 926 huts and sites PECADOM sites (76% of set target).
The main challenge in rolling out the DIPEC.Com is the regularity of supervision of CCWs by providers.
Strengthening coverage of community-based access to injectable contraceptives improved coverage of community-based injectable contraceptives. Overall, 475 CCWs (M: 192; W: 283) were trained in the delivery of at least one injectable method. The OICIM is available in 60 new huts and OICU in 260 newly enrolled huts. Overall, 320 of the planned 315 (102%) new health huts deliver at least one injectable method. Other activities are: support for the DSR/SE to update and validate community-based FP procedures (management of the community FP file); revision of CHW training tools on delivering modern FP methods (trainer guide and CCW aide-mémoire on OIP, OICIM, and OICU); orientation for 71 ICPs and midwives (M: 47; W: 24) on using the revised tools.
The main challenge is continuous availability of FP commodities and supervision of service delivery by ICPs.
As part of expanding the community-based package of newborn services, plans were made to systematize essential newborn care (early initiation of breastfeeding, umbilical cord care, maintaining temperature, eye care, and oral vitamin-K therapy) and incorporation of specific newborn care (management of asphyxia and management of low birth weight) in health huts. The administration of oral vitamin-K therapy at the community level was not included in the PSP of the DSR/SE. The systemization of eye care at the community level remains problematic due to the unavailability of adapted single-dose collyrium drops.
Training tools on specific newborn care (trainer guide, CCW manual) were developed and validated with the DSR/SE; 1500 trainer guides and 2000 aide-mémoires were printed and are ready for delivery. Newborn resuscitation equipment was obtained and delivered to the medical regions (922 penguin
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mucous-suction devices and 922 manual inflatable ventilation bags). Also, 604 CCWs (W: 420; M: 184) from 425 huts were trained on newborn-specific care, or an achievement rate of 107%.
To ensure that CCWs retain skills in using resuscitation equipment, it was decided to systematically retrain trained CCWs during supervisions and advanced strategies.
As part of implementing delivery of post-partum hemorrhage (PPH) prevention services, the project planned to enroll 92 new huts in the regions of Saint Louis (73 huts) and Tambacounda (19 huts) to bring PPH coverage to all seven regions.
By the end of Year 1, PPH training tools were revised to include newborn resuscitation and the management of low birth weight. Overall, 142 CCWs (M: 11; W: 131) were trained. Of the planned 92 huts, 112 were enrolled: Saint Louis (83) and Tambacounda (29). Transitory provisions were taken through the purchase of 1000 doses of misoprostol in the ChildFund cost-share budget to organize practical training for matrones while waiting for the product’s availability at the National Procurement Pharmacy (PNA).
As part of the implementation of a community-based package of services adapted to adolescents and youth in health huts and sites, the project sought to include a “youth CHW” in the system for each hut and site; identify a community-based AYRH package with the DSR/SE; and adapt CHW training tools to include adolescents’ and youths’ specific needs in order to make AYRH services available in 1689 huts and sites.
Training tools for CHWs were revised, tested, and validated (trainers guide and CHW aide-mémoire), and ECR/ECD members and 268 providers (ICPs/midwives) were introduced to them. Also, 3173 CHWs (M: 1347; W: 1826) were trained. In addition, 384 out of 1689 (23%) huts and sites have at least one adolescent/youth CHW trained in the basic package including community AYRH. Also, 1549 out of 1689 (92%) huts and sites deliver AYRH services. Kédougou (0%) and Sédhiou (44%) regions did not reach their targets. Reasons mentioned are related to the impact of the boycott of the G50 per diem policy in Kédougou and cumulative delays in Sédhiou despite concerted efforts last quarter.
As part of expanding the services package to nutrition sites and PECADOM sites, the project targeted 220 community nutrition sites and 479 existing and functional PECADOM sites for the first year. Service packages were expanded in 381 PECADOM sites, or 80% of forecasted sites, in Diourbel, Saint Louis, Matam, Tambacounda, Kolda, and Sédhiou. In addition, 195 nutrition sites expanded the services package, amounting to 89% of forecasted sites: 26 in Saint Louis, Matam, Tambacounda, and Kolda.
The project also supported giving community sites and PECADOM sites supplies and equipment (cooking demonstration supplies and management tools) to provide an expanded package. Training modules for CHWs were also updated and expanded with new content.
The PNLP, the DSR/SE, the Malnutrition Control Unit (CLM), and implementing agencies of the Nutrition Enhancement Program partnered with the project to advocate for an expanded services packages in community sites and PECADOM sites. This is in accordance with the strategic priorities of the National Community Health Strategic Plan. Proposed measures for managing nutrition sites are: having health districts take on the expansion strategy; joint supervision of activities with implementing agencies of the PRN; and including PRN staff in training sessions for trainers. A number of areas for collaboration
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with the PNLP and DSR/SE were selected to harmonize positions and the approach for PECADOM expansion. Whether home-based care providers will deliver FP methods has been left to the health districts’ discretion. Joint implementation and supervision of interventions was also recommended.
As part of delivery of the ENA and EHA package, various activities are underway with the CLM to increase synergy around the strategy to expand services: participation in the regional nutrition monitoring committee to identify and monitor joint actions to carry out with the CLM (harmonization of enrollment criteria for new sites, procedures for expanding the services package, joint monitoring of the implementation of expanded services, mapping of nutrition interventions and actors involved in nutrition, incentives for CHWs, etc.).
Activities to deliver the package of essential nutrition actions (ENA) and essential hygiene actions (EHA) at community level began with CHW training: 199 community actors (including 161 women) were trained in Diourbel region, including 102 in Mbacké district and 103 in Bambey district. Community actors are trained to facilitate debates/discussions for support groups for pregnant women and women breastfeeding children under 24 months on priority topics in nutrition and hygiene to support the adoption of healthy behaviors that promote good nutrition.
Expand the network of community health facilities to improve coverage of high-impact services: As part of enrolling new community infrastructure (health huts, community sites), forecasts for the first year are focused on getting 61 huts up and running and setting up 360 new community sites. The enrollment process started in all intervention facilities (identification of villages to accommodate new sites and health huts, community advocacy, identification and renovation of hut locations, and selection of actors, etc.). Equipment is being installed (equipment and supplies for care, management tools, cooking demonstration supplies, and furniture). The CHWs for 37 new health huts (61%) and 173 new community sites (48%) were selected and trained.
The main challenges are input availability, regular supervision of CHWs, and securing consensus between the various actors involved in expanding the services package to home-based care providers.
Intervention 1.1.3: Ensure that an integrated package of high-impact services is available at the household level
Including household-level services in supervision of ICPs: The project planned to incorporate specific supervision tools into the VADI and CVAC strategies to strengthen supervision of services delivered in households by health care staff. The revised grids for supportive supervision are currently available. CVAC and VADI supervision is included in tools for the Tutorat 3.0 package.
Including aspects related to gender and youth: The project planned to revise the VADI and CVAC strategies based on lessons learned in the previous program. For the CVACs, the tools revised with the DSR/SE and the Community Health Unit (CSC) include: surveillance of maternal and newborn death and organization of a community-level response; community-based monitoring of women with fistula; follow-up of birth registration at the Civil Registrar. For the revised CVAC strategy, 1104 members of the new CVACs were trained. Also, 265 out of 1464 (18% of the set target) CVACs were set up in the regions of Matam (42), Tambacounda (129), and Sédhiou (24). Performance for coverage is generally low due to the high volume of activities in the first year.
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The VADI strategy involves: the introduction of a new cross-cutting task on all VADI sheets entitled “Promoting Dialogue between Parents/Adolescents & Youth”; and the formulation of a new objective entitled “Negotiating with Parents to Solve Identified Problems.” For the VADI, 3166 CHWs (M: 1253; W: 1913), including 2077 new CHWs (M: 988; W: 1089) were trained in 1407 huts and sites, including 1117 new facilities, or an achievement rate of 96%.
The revised tools (CVAC implementation guide, CVAC aide-mémoire, VADI implementation guide, and sets of VADI sheets/outlines) are being printed.
The major challenge is the existing operational ambiguity relative to the CVACs/maternal health and CVACs/epidemiological surveillance. A consultation meeting between the CSC, the DSR/SE, and the Health Emergencies Operations Center (COUS), the Department of Medical Prevention, and partners (USAID-Neema, Centers for Disease Control, MEASURE Evaluation) has been scheduled to clarify positions and discuss opportunities for synergy.
Expanding access to FP methods at the household level: This component involves the use of a self- insertion method, the progesterone vaginal ring (PVA), at household level. Implementation has been postponed because the Marketing Authorization (MA) for the PVA has not been issued yet and the PVA feasibility study protocol has not been validated. Several discussion meetings on the implementation process were held between USAID-Neema and the Population Council.
Intervention 1.1.4: Implement a cross-cutting, multi-sector, gender-based-violence prevention strategy
This intervention supports the MSAS to improve inclusion of GBV in policies, guidelines, and programs. It is implemented in partnership with the Office of Violence and Trauma Prevention (BPTV), based in the DGS of the MSAS and the Directorate of Family, attached to Ministry of Women and Gender. Emphasis is on the National Plan to Combat GBV 2017–2021. Expected results for Year 1 focus on: - Coordination to combat GBV through: (i) setting up a multi-sector working group to incorporate GBV into policies, standards, and procedures related to health; (ii) support for existing coordination mechanisms to manage GBV by promoting a holistic approach and synergies between the central level and civil society.
- Strengthening actors’ capacities in combatting GBV through: (iii) the validation and dissemination of a GBV management guide as a priority activity in the multi-sector working group roadmap; (iv) orientation on innovative GBV-prevention approaches (SASA!, etc.) for the MSAS and consortium members.
- Advocacy through: (v) the development and implementation of a strategy to celebrate 16 days of activism combating violence against women.
- Research through: (vi) a participatory diagnosis of the dominant social norms related to GBV.
The main achievements are described below: Coordinating efforts to combat GBV: The process began by setting up a sector working group to incorporate GBV into policies, standards, and procedures related to health. This body is composed of focal points from the BPTV for various MSAS directorates and bilateral and multilateral cooperation partners. Its role is to provide technical guidance and to support programming and implementation of
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relevant interventions in targeted areas. Establishing the abovementioned sector committee is a preliminary step to forming a multi-sector committee that will comprise focal points who will be appointed at the request of the DGS from other ministerial sectors.
In addition, as part of support to coordinate existing mechanisms to manage GBV, it was decided to expand the partnership with the Directorate of Family, which, under the Ministry of Women, is responsible for the national strategy to combat GBV. This approach helped identify valuable points of synergy included in the Year-2 work plan and to begin an initial joint activity between the BPTV, the Directorate of Family, UN Women, and Neema. Next, the project visited the Kullimaaro Center, set up by the Platform for Women in Casamance to promote peace, with UN Women funding, to provide women and girls who are victims of GBV a safe house and holistic care.
The process described above resulted in the following achievements through coordinating efforts to combat GBV:
• The official establishment of a technical committee to prevent gender-based violence and trauma as a prerequisite for setting up a multi-sector body
• Technical and financial support for the National Plan to Combat GBV (2017–2021) through partnership with the Directorate of Family, evidenced through the inclusion of activities in the project’s work plan for fiscal year 2018
• Strengthening of synergies between the MSAS, the Ministry of Women, and civil society in the prevention and management of GBV
Strengthening actors’ capacities in combatting GBV: The first activity was to train a pool of 11 trainers from the technical committee for GVB and trauma prevention. It was followed by the preparation of the Training Manual for Trainers on the Management of GBV. This tool completes the guide for managing victims of GBV, which was begun with support from the previous HSI program. This activity, which completes the design stage for GBV tools, should have enabled the operationalization stage to begin, with training of ECDs, ECRs, and SDP providers. The second stage could not be started this year due to scheduling conflicts with the BPTV and medical regions. The activity resulted in:
• Completion of the design stage for training tools on managing GBV
• Training of a pool of 11 trainers
• Identification of lessons learned from the Kullimaaro center experience in Ziguinchor
The orientation on innovative GBV-prevention approaches (SASA!, etc.) for the MSAS and consortium members could not take place. The first sessions were planned to take place right after the joint BPTV/DF/UN Women/Neema visit to Ziguinchor. This visit could not happen until the end of September; thus, the orientation on innovative GBV-prevention approaches had to be postponed to the first quarter of Year 2.
Advocacy through the “16 days of activism” strategy: The “16 days of activism” celebration takes place from 25 November to 10 December 2017. Preparations began with internal discussions on the key objectives, targets, and themes and activities identified for the celebration of “16 days of activism.” This was followed by a consultation meeting with UN Women, which had also planned to roll out
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activities in partnership with the Directorate of Family. The meeting defined what next steps were needed to organize the event in synergy. It also helped Neema staff clarify the component’s contribution in terms of objectives and activities to conduct in the field.
Research: Participatory diagnosis of the dominant social norms related to GBV: The participatory diagnosis on social norms regarding GBV is included in the formative research on barriers and facilitators of “health-promoting behaviors” and obstacles related to gender norms. It collected key messages deemed relevant to the campaign to end the various forms of GBV. The collection stage is complete in all program intervention areas, and results are being analyzed.
In the context of capacity building, the Ministry of Family involvement in the partnership is a good opportunity because it will facilitate establishing an important link between the districts and the Regional Community Development Services and thus, ensure that new knowledge is quickly put to use.
The greatest challenge is coordinating the various stakeholders to set up a single schedule unifying MSAS and Ministry of Women partners around synergistic interventions scheduled in the Neema work plan. Sub-Objective 1.2: Linkage between community and facility platforms is strengthened and sustained
Expected outcomes over 18 months Achievements over 12 months Mapping of CHWs is updated and available The configured iHRIS software for CHWs is through iHRIS software available and will be tested in Diourbel region
A local emergency transportation system is The system is available in 23 health huts set up in at least 100 health huts
Women receive quality FP services through 4 4 mobile clinics (include 2 new ones) are up and mobile clinics in the regions of Diourbel, running and provide RH/FP services to women in Kolda, Saint Louis, and Sédhiou the 4 intervention regions
At least 65 ECR/ECD members from Training for ECRs/ECDs on gender and GBV has intervention regions received training on not started gender
The community scorecard is implemented in Implementation has not begun in huts and sites 100 health huts
At least 29 mayors have pledged to improve 23 mayors have pledged to allocating funds from MNCH at the community level their budgets, totaling 21,000,000 FCFA for MNCH
Intervention 1.2.1: Improve overall coverage of community health workers
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The Neema project planned to expand CHW coverage through training for new recruited CHWs along with the enrollment of new facilities and improving capacities of existing CHWs in the new subject areas. The project should also support the MSAS Department of Human Resources (DRH) to set up a community-based iHRIS software for mapping of CHWs. Figure 3: Distribution of CHWs, by sex
During Year 1, project support resulted in expanding the system of CHWs by 11%, with H F training for 1047 new CHWs (407 CCWs and 640 487 change, promotion, and assessment agents 414 (ACPPs), including 290 adolescents/youths) from 418 facilities that are enrolled or operating. (See 203 56 211 20 120 153 Figure 1: Distribution by sex and category of existing and new CHWs train in Year 1). anciens ACs ASC Mat DSDOM ACPP
The USAID/Neema project also supported additional training for 617 of the 2278 existing CCWs (or 27%) on PPH prevention (203) and injectables (414). Overall, expanding the network of CHWs involved 1664 CHWs who were primarily women (M: 587; W: 1077, or 65%) and adolescents and Table 6: Distribution of CHWs youths (384, or 23%).
The project also supported updating the Categories Existing New CHWs Total CHW mapping exercise conducted in CCWs trained in 2016. At the end of this first year, 9186 Year 1 CHWs are working (2685 CCWs; 6501 CCW 2278 407 2685 ACPPs) in the seven concentration ACPP 5861 640 6501 regions. (See Table 6: Distribution of CHWs Total 8139 1047 9186 who are working in Year 1)
The project supported the DRH to configure the iHRIS software to incorporate CHWs. It was decided to use data provided by the Community Health Unit as a basis for working with IT specialists to complete this. Community-based staff working in health centers and PHFs will be included in completing the unit’s database, which currently has 26,800 workers. The configured iHRIS software for CHWs will be tested in Diourbel region.
Intervention 1.2.2: Integration of community health into the health system
The key planned activities are described below.
Strengthen linkages between community platforms and health facilities: In Year 1, the Neema project had planned to evaluate the referral and counter-referral system at all levels (hospital, health center, health post, health hut) using the Referral Systems Assessment And Monitoring (RSAM) tool; revise the system for the seven intervention regions using the results; strengthen the capacities of ECRs, ECDs, 250 providers, and CHWs to use the approach and the revised RSAM tools; revise the local emergency transportation system based on results of the assessment with the RSAM tool; and support
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the organization of a revised system in 100 health huts by involving local municipalities, ICPs, and community-based resource persons.
During the first year, the project supported the DGS and various MSAS services involved in developing a concept note and a situational analysis grid with the RSAM tool, incorporating aspects related to community health in huts and sites. In Saint Louis medical region, 17 ECR and ECD members (M: 10; W: 7) were introduced to using the tools and scheduled the process in districts. The introduction considered the regions’ needs in the situational analysis grid, identified which SDPs to include in the sample, and planned the implementation steps based on the identified barriers and gaps in the regional RCR system up through the development of a regional plan to strengthen the RCR.
At the community level, Neema also conducted a baseline assessment of the local emergency transportation system, suggested an approach, and began the development process for community- based tools to manage referrals. A draft of the implementation document is available, and the approach will be tested in two districts under the Saint Louis Regional Bureau (RB) before extension, based on lessons learned. An assessment of the situation concerning local emergency transportation at the hut and site level showed that 23 out of 100 health huts (23%) in the regions of Sédhiou (15) and Diourbel (8) have a local emergency transportation system.
Improving commodity security at hut and site level and from health posts: For the first year, the project set out to: (i) organize advocacy activities to effectively activate the process to reimburse the cost of care services for children age 0–5 years in huts and sites; (ii) advocate to set up back-up inventory in 520 huts; and (iii) support ECDs in logistics supervision of health huts and PECADOM sites.
Support for advocacy for effective reimbursement of services costs at health huts: Effective reimbursement for the cost of services in health huts and sites was discussed with the MSAS at several levels: the second session of the National Steering Committee for Community Health, chaired by the Minister of Health (December 2016); inclusion in the project’s joint action plan with the CSC; and joint monitoring meetings with the CSC. The project also supported the CSC and DSR/SE to develop a concept document on applying the initiative to provide care to newborns and children under 5 free of charge at the community level. The document defines the rationale for three key points: identification of providers to reimburse at huts, community sites, and PECADOM sites for children 0–5 years; estimation of costs to reimburse based on the average cost per case for the hut, community site, and PECADOM site; and definition of methods to reimburse costs for services for children 0–5 years in huts and sites. Reported reimbursement cases involve 50 huts, with 41 in Saint Louis and 9 in Sédhiou. The proposed amount per case is 500 FCFA at huts, 400 FCFA at PECADOM sites, and 300 FCFA at community sites.
Support for advocacy to set up back-up inventory at the health post to ensure continuous supply of essential commodities and medicines in huts: The project also supported the process to set up back-up inventory. Activities began with an assessment of the availability of essential tracer medicines for priority programs through a logistics supervision visit in huts and PECADOM sites and a situational analysis in the SDPs in three districts in Sédhiou medical region. The results of these activities showed that significant stockouts were noted in huts in contrast to good availability in SDPs. The reasons mentioned were related to a lack of monitoring of huts by health post heads and ECDs, the non-
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enrollment of huts in the new PNA distribution system (YEKSINA), and especially not taking the huts needs into account in the SDP orders. To overcome these shortcomings, the project suggests testing setting up a stock of medicines at the health post level to regularly supply the huts in Touba health district. To do this, after sharing logistics supervision results for huts in Touba, the project suggested a roadmap, consisting of: (i) advocating at the MCD to raise awareness among heads of health posts to improve guidance for health huts; (ii) providing all health huts and PECADOM sites with a management tool (stock sheets); (iii) strengthening CCWs’ capacities in stock management (conducting inventories, filling out stock sheets, estimating available stock, calculating stock resupply); (iv) resupplying huts from health post inventory; (v) pre-positioning stock dedicated to huts in each health post; (vi) providing health post heads with an IT tool to monitor inventory provided to huts; (vii) strengthening the capacities of health post heads in logistics supervision of huts through Tutorat 3.0 implementation at the community level.
To deal with recurrent stockouts of essential commodities reported throughout the year in huts and sites (misoprostol, amoxicillin, oral rehydration salts, and zinc), the project took transitional measures to support securing stocks at the community level: one-time provision of ORS, zinc, and amoxicillin through the DSR/SE/MSAS at the community level (July 2017); and purchase of 1000 doses of misoprostol (ChildFund cost share) to hold practical workshops for CCWs trained in PPH prevention.
Support for ECDs in logistics supervision of health huts and PECADOM sites: The project supported ECDs/ICPs from six districts (Saint Louis, Koumpentoum, Touba, Saraya, Goudiry, and Dianké Makha) in logistics supervision. Supervision was conducted in 105 huts and sites for an annual target of 100, distributed as follows: 20 huts and 2 PECADOM sites for Saint Louis, 16 health huts and 3 PECADOM sites for Koumpentoum, 11 huts and 14 PECADOM sites for Touba, 9 huts and 9 PECADOM sites for Saraya, 13 huts for Goudiry, and 8 huts for Dianké Makha. It also found shortcomings in following medicine storage guidelines, stock management (availability and filling-out of management tools, regularity of inventories, regularity of orders, training, supervisions, reporting logistics activities), and in medicine availability. Recommendations were made (see table below) in addition to action plans for each health hut.
Table 7: Key recommendations for logistics supervision of huts and PECADOM sites
Level Recommendations
District • Check that ICPs regularly perform hut supervision • Check that stock sheets are available and filled out accurately • Check that health posts have reserved inventory to resupply huts • Share inventory data for huts and PECADOM sites during district coordination meetings
ICP • Provide regular logistics supervision of huts • Ensure stock sheets are available and filled out accurately • Forecast huts in funding for medicines • Set up inventory dedicated to resupplying health huts • Share inventory data for huts and PECADOM sites during health post meetings
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CCW • Check stock sheet availability • Check that stock sheets are filled out daily • Send medicine orders to health post • Check availability of all tracer medicines and commodities • Check that expired drugs are destroyed
Health • Check closures of health huts committee • Check for rodent control • Check availability of medicines
Partners • Support capacity building for ICPs in logistics supervision through Tutorat 3.0 • Support on-site training of CCWs in medicine stock management • Support huts with management tools (stock sheets and IT tool for data collection) • Support setting up a medicine stock at health post level to regularly supply the huts
Support to implement a consumption data-collection and early-warning system: The project launched the implementation of a consumption data-collection and stockout early-warning system in the south (Sédhiou and Kolda). The process began with orientation workshops for ECDs/ICPs on stock management procedures and the logistics information system. The workshops, followed by situational analyses in three districts of Sédhiou medical district, enabled each ECD to choose which essential tracer medicines and commodities to monitor by level with the IT tool, which is being created.
Support for the CSC to implement the National Community Health Strategic Plan The project had intended to support the Community Health Unit to implement and monitor the National Community Health Strategic Plan, particularly for coordination and monitoring as well as the continuation of community activities.
Support for the CSC to coordinate and monitor the National Community Health Strategic Plan at the national, regional, and district level: The project had intended to support the implementation of priority activities for the CSC, the recruitment of the senior position responsible for overseeing the overlap of the USAID-Neema project with the DGS and monitoring of priority National Community Health Strategic Plan (PSNSC) activities.
Throughout the year, the project supported the CSC in recruiting the senior position; the process is complete, and the position is scheduled to begin in the first quarter of Year 2.
At the central level, the CSC also received support for: development of a support guide for local officials on community health management; an evaluation of the itinerant midwife strategy (SAFI) and applying lessons learned before reviewing the test strategy; the development of a community module for monitoring community health services; and the development of a methodology for the community scorecard and revision of SPEC methodology and tools. The project also participated in the workshop to select priority community-level indicators (September 2017) and in joint CSC/USAID-Neema monitoring. In addition, support was provided for administrative and technical functioning of the 2nd session of the National Steering Committee for Community Health (December 2016) and preparation of the 3rd session of the National Steering Committee. Continuous support was also provided for technical functioning of three thematic groups set up by the DGS (multi-sector coordination,
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community health promotion, and monitoring and evaluation of reforms and community health initiatives).
At the regional and local level, the project supported an evaluation of the establishment and functioning of community health coordination bodies. All regional committees have been set up in the seven regions. At the departmental level, 10 out 22 (45%) of departmental committees have been set up; at the neighborhood (arrondissement) level, 14 out of 56 local committees were created through decrees issued by sub-prefects (73%); distribution by region is shown in the table below.
Table 8: Regional distribution of coordination bodies for community health
Level Diourbel Tamba Kédougou Kolda Sédhiou Saint Matam Total Louis
Departmental Planned 3 4 3 3 3 3 3 22 committees Completed 2 2 1 2 3 0 0 10
Neighborhood Planned 8 12 6 9 9 7 7 58 (arrondissement) committees Completed 1 1 0 3 9 0 0 14
Generally, functioning of community health coordination bodies continues to be challenging in all regions: only two departmental committees (Tamba and Kolda) and 9 local committees (Tamba: 1, Kolda: 3, and Sédhiou: 5) held a meeting during the third or fourth quarter. Some health posts held monthly coordination meetings with CHWs.
The project also participated in discussions on how to motivate CHWs during the meeting to share the PNLP study on incentives at the community level (June 2017) and the reflection workshop on CHW motivation, organized by the CSC (July 2017).
Revision of the methodology and tools for the Strategy to Ensure Sustainable Management of Huts (SPEC) and support for ECDs to implement it: The project had planned to revise the SPEC methodology and tools based on lessons learned from the SPEC review. The revised SPEC was scheduled for implementation in 309 health huts, including 94 new huts transferred to the seven concentration regions through the Tutorat 3.0 approach.
At the end of Year 1, the “Transferring Hut Supervision” strategy was revised into the “Strategy to Ensure Sustainable Management of Huts and Sites - SPECS.” The new strategy expanded the approach to include the supervision of huts and sites and significantly empowers the health post ICP and midwife. The tool that is being finalized will serve as a basis for strengthening ICPs’ and midwives’ capacities on key aspects: assessing health hut and site functionality; analysis and identification of huts’ and sites’ additional needs; planning to bring huts and sites up to standards; empowering local municipalities, communities, and partners to monitor hut and site functionality; and organizing ongoing monitoring of huts and sites.
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With Neema support, 207 out of 922 (23%) health huts were supervised by health workers (ICPs, midwives, ECDs); 838 huts (97%) received regular monitoring visits from the project’s community facilitators through support for ICPs/midwives.
Intervention 1.2.3: Expand the services package offered at the community level Two key strategies have been planned for this initial stage to bring professional RH/FP services closer to communities: mobile RH/FP teams and support for the SAFI strategy. The project had planned to launch two mobile teams to support services delivery in Sédhiou and Kolda, continue services delivery by the two operating mobile teams in Diourbel and Saint Louis, regularly evaluate the services delivered by mobile teams and client satisfaction in the intervention regions, and support the recruitment and appointment of 23 SAFIs in 5 concentration regions: Diourbel (3), Saint Louis (3), Kolda (5), Tamba (7), and Kédougou (2).
Two mobile teams launched to support delivery of RH/FP services: By the end of the project’s first year, two mobile teams were launched at the end of May in the regions of Sédhiou and Kolda. Activities focused first on hiring team members and ensuring they fully ascribe to the theoretical and practical standards so that high quality FP/RH services are provided, followed by training/retraining on the full range of FP methods, infection prevention, management of clinical events, management of medical emergencies, etc.
Delays in launching activities and heavy rains reported in the southern part of the country had a significant impact on the overall performance of these mobile teams, which nevertheless was favorable. Contributing factors to the teams’ positive results included the solid involvement of district RH coordinators, who actively participated in identifying sites with high unmet need for FP and supported the Neema regional team to rapidly integrate mobile teams and programming and conducting outings.
During four months of activities, the two mobile teams conducted 176 outings (87 in Kolda and 89 in Sédhiou). The outings reached 4920 people through demand creation activities and 3457 clients who received FP services, including 2088 (60%) for the first time in their lives. Thus, an estimated 11,065 CYP was generated, compared to the goal of 16,000 CYP, or a performance rate of 43%.
Adolescents were also targeted for FP services delivery, with respectively 26% (471) and 12% (235) of youths age 19 years and under who had access to FP services in Sédhiou and Kolda, through support from peer educators from the various visited health facilities.
In Kolda, demand creation activities targeted men due to women’s weak decision-making power there.
Since identified constraints are related to persistent socio-cultural and religious barriers, advocacy activities were carried out for religious leaders (114 in Kolda and 31 in Sédhiou), led by religious leaders trained in FP who were involved in Bounkiling district.
Continuation of FP/RH services delivery through two functioning mobile teams: The Neema project supported the medical regions and health districts to continue mobile team activities in Diourbel (starting in the first quarter) and Saint Louis and Tambacounda (starting in the second quarter). Informational and awareness-raising activities for CHWs who support services delivery were carried out in partnership with the midwives’ associations, women’s groups, youth associations, religious leaders, etc.
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Thus, these demand creation activities reached 29,714 individuals. Overall, 15,860 women attended voluntary FP services, including 5592 new women, in the FP program, or 32% of the target reached. These teams’ very strong performance produced an estimated 47,599 CYP.
Quality assessment of RH/FP services delivery: With the goal of improving RH/FP services quality, two types of clinical assessments were also conducted: internal clinical audits in the third quarter and the external QTA (Quality Technical Assistance) audit conducted in the fourth quarter in Diourbel and Saint Louis. The results were used to determine what areas needed improvement and to apply corrective measures.
Support for organizing SAFI in services delivery and supervision: In an effort to support the MSAS to hire new midwives with partner support during the first year, the project decided to redirect resources to help the MSAS to review the strategy and strengthen health post providers’ capacities in community health management. The project supported the documentation and capitalization of lessons learned from the SAFI strategy in the pilot regions of Matam and Sédhiou to improve the strategy. Feedback from stakeholders (communities, local municipalities, ECDs and ERCs) is very positive. Results showed that midwives deployed through the SAFI strategy generally improved indicators for maternal, newborn, and child health. Shortcomings were noted in some areas: midwives’ inadequate capacities in community health due to the lack of standardized training tools; difficulties in managing itinerancy; non-systematization of packages and tools for services delivered by itinerant providers; weaknesses in coordination and sharing results in a way that supports continuous learning.
The workshop on extension and sustainability mechanisms recommended constructing an institutional model for strengthening districts capacities in community health management based on lessons learned from the SAFI strategy. The model capitalizes on the hiring mechanism for new midwives in health posts to increase services delivery at community level. Planned activities include: adaptation of implementation tools for institutional sustainability; capacity building in community health for newly hired midwives through an on-site coaching approach (Tutorat); organization of ongoing itinerancy of midwives in collaboration with local municipalities and partners; support for itinerancy through deliverables included in district grants; establishment of a coordination mechanism to support reviews and continuous learning.
Intervention 1.2.4: Integrate gender considerations into a package of services and linkage activities between the community and health facilities The project had planned the following for the first year: (i) training for consortium members on the gender approach and incorporating it into specific health domains; (ii) support for the MSAS Gender Unit to provide training tools and communication materials on gender for regional and district medical staff; (iii) training of ECRs/ECDs on the gender approach as it relates to health; (iv) collaboration with the MSAS Gender Unit to provide medical staff with monitoring tools to include gender in planning, implementation, and monitoring; and (vi) support for the celebration of International Women’s Day.
Key achievements are mainly in capacity building. Specifically, 135 people active in the consortium saw improved capacities. The project also supported the design of two training tools for healthcare and district staff and provided technical support to develop the communication plan for the MSAS Gender Unit.
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Capacity building for consortium members and MSAS partners on the gender approach and its inclusion in specific aspects of health: The training process for Neema staff on gender mainstreaming was wrapped up. It started at the Regional Bureau level, with the training of 58 Neema staff members based in Saint Louis, Kolda, and Tambacounda Regional Bureaus and the Diourbel regional unit. Next a training session was held in Dakar for the national level (17 people, including 10 M and 7 W). These activities followed an orientation conducted during the women’s day celebration on 8 March, which strengthened the capacities of 60 IntraHealth staff and partners of the Neema project on the gender approach in the health domain.
Providing training tools and communications materials on gender to regional and district health staff: The component supported development of a draft of a gender mainstreaming guide and a draft training manual for trainers for conventional training of health providers to be prepared by the MSAS Gender Unit. These two tools incorporate gender in the following domains: general and cross-cutting areas, disease control, RMNCAH, WASH, and GBV.
It was also planned to develop both tools and training at the ECR, ECD, and SDP levels, but this second step could not be started yet. The main challenge lies in mobilizing efforts around joint development of training documents, especially concerning the issue of content ownership.
Intervention 1.2.5: Reinforce community and local municipality participation in community health, especially for youth For the first year, Neema intended to: introduce rubrics at the community level using the community scorecard methodology and to support implementation in 116 huts and sites in collaboration with the Health Systems Strengthening Plus (HSS+) and GOLD projects; develop a methodology and tools adapted to AYRH and GBV, based on the community action cycle and to support implementation in districts in 518 communities: and advocate among 29 municipal mayors with a view to increasing community resources for RMNCAH. Project achievements for the end of its first year are summarized as follows:
Development and implementation of community scorecards: The project supported the CSC to develop a methodology for a community scorecard based on the national RMNCAH scorecard. The community scorecard aims to increase community contributions to managing performance in RMNCAH through: measuring and analyzing performance by communities; and the development, implementation, and monitoring of plans to correct gaps and improve community performance. It targets 12 indicators, divided into 6 categories. The 12 indicators were selected from the 25 indicators and from 8 categories, listed in the national scorecard: monitoring-evaluation (2); family planning (1); maternal and newborn health (4); child health (2); nutrition (2); and AYRH (1). The tools emphasize community contributions in achieving the national indicators selected from the national RMNCAH scorecard. They are also geared toward continuous monitoring by community actors using various mechanisms: monthly documents and displays at hut level; and analysis by CHWs and hut committees during monthly planning and self-assessment meetings. An initial draft of the implementation document, developed in partnership with the CSC, DSR/SE, and other partners, is available. Testing of the methodology and tools is planned in Diourbel region.
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Implementation of community action cycles applied to AYRH and GBV: The project supported the DSR/SE in partnership with the CSC to identify the CAC-GBV methodology and to develop implementation tools. The approach is based on the community action cycle (CAC), which was already successfully applied to various issues involving sensitive subjects (post-abortion care, FP, child protection, etc.) and has been streamlined with simplified self-diagnostic tools, a reduction in the time to implement the cycle, and elimination of capacity building for the core leaders during training for groups. In the CAC-GBV approach, five methodological principles that underlie the CAC approach were maintained (group autonomy, community leadership, partnership, democracy, and facilitator neutrality). Five types of community groups were identified to implement the strategy in each site (young mothers, male heads of household, grandmothers, girls aged 10–14 years, and coed adolescents age 10–19 years). Five forms of GBV will be addressed through implementation (physical violence, sexual violence, psychological and emotional violence, economic violence, violence resulting from harmful traditional practices), and five steps of the CAC have been maintained to start implementation (organizing communities, self-diagnosis, developing action plans, implementation and monitoring of action plans, and participatory self-evaluation). A draft implementation guide has been completed, project operations teams were introduced to it, and an implementation plan was developed for 690 huts and sites in 29 districts in the seven regions. The Year-2 enrollment plan calls for activities implemented by 2175 groups, distributed in 435 huts and sites.
Community advocacy and dialogue: The project had planned meetings at the regional and department level with ECRs and ECDs to identify the 29 intervention municipalities as part of building the implementing partners’ ownership of the intervention. Advocacy efforts in municipalities are targeting district representatives, community spokespersons, the municipal council, and the mayor’s cabinet. The goal is to obtain commitments from 29 mayors to improve MNCH/FP at the community level.
During this year, 9 training sessions on advocacy introduced 181 implementation actors: intervention- region coordinators (7), Réseau Siggil Jigéen regional focal points (7), district representatives (23), and spokespersons from municipal councils (144). A plan to monitor progress indicators is being developed at the local level for each municipality based on the local advocacy objective for effective and transparent management of resources allocated by mayors.
Since the first contacts with mayors, 23 of the anticipated 29 have made pledges, or a 79% achievement rate. The total amount of pledged resources allocated to MNCH is 21,000,000 FCFA. Regarding Also, 10 of the 58 (17%) community dialogue sessions on services quality were held between providers, community leaders, and local municipalities. Results were used to develop plans to resolve problems in relevant health posts and to reach consensus on the use of funds allocated by local municipalities.
In Year 2, advocacy sessions will be able to share the mayors’ arguments and pledges in support of MNCH with the communities.
Inclusion of adolescents and youths in interventions and in the community system to improve services delivery; applying the policy granting free-access to medicines for children age 0–5 years in health huts and sites and the availability of essential medicines at community level; strengthening capacities and leadership role of medical regions/health districts and local municipalities in monitoring, coordinating,
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and sustaining local interventions involving SDPs and huts/sites (managing emergencies, monitoring inventory, delivery of mobile services, functionality of PNSSC coordination bodies); and mobilization of efforts around the joint development of training documents.
Support for HSS/Abt will be used to assist in effective implementation of the free-access initiative in huts and sites. Sub-Objective 1.3: Quality services at household, community, and facility levels are improved and sustained
Expected outcomes over 18 months Achievements over 12 months
The RMNCAH PSP are distributed to at least 30% of The PSP dissemination guide was developed providers in concentration regions and is being finalized.
Support is given to the MSAS to increase availability of The National Strategic Plan for Quality is human resources and equipment to provide quality available. services
The key expected achievements in improving and sustaining quality services at household, community, and SDP level are: • Distribution of Policies, Standards, and Protocols • Capacity building for health workers at health centers, health posts, and health huts to implement processes that improve services quality • Capacity building for public health and local governance systems to support and monitor health system performance and quality • Improved monitoring of vital events (civil status): births, deaths, etc.
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Intervention 1.3.1: Dissemination of Box 2: Content of PSP Dissemination Guide Policies, Standards, and Protocols
Several outcomes were noted following the Overview of Dissemination Guide dissemination of Policies, Standards, and Overall Goal: Improve practices for disseminating PSP Protocols in the following areas. Specific objectives: Support for dissemination of directorate and program PSP and guidelines to providers 1. Explain the PSP dissemination process through conventional training: The Neema 2. Explain how PSP are structured for RMNCAH project supported the DSR/SE to implement 3. Identify the methodology and techniques used to PSP by completing the final versions with disseminate PSP included feedback and by printing the documents. This also helped the DSR/SE to 4. Define the assessment and dissemination print and distribute 1500 copies of RMNCAH methodology PSP in the 14 regions. Basic structure of the guide: Moreover, the project supported the DSR/SE to 1. Chapter 1: Who is the guide intended for? make a draft, updated in 2016, of the 2. Chapter 2: How is the guide used? dissemination guide for RMNCAH PSP 3. Chapter 3: Analysis of PSP content • Sub-Chapter 3.1: How are PSP documents available. This guide, currently undergoing organized? validation at the DSR/SE, will standardize • Sub-Chapter 3.2: What is the content of PSP distribution and measure providers’ knowledge documents? acquisition levels on the changes made in the PSPs. Uploading PSP and guidelines for directorates and programs via the online Learning Portal: The project supported the DSR/SE to upload RMNCAH courses based on the PSP. The PSP and dissemination guide will also be online so providers can download them. By supporting the finalization of PSP, the project helped the DSR/SE make these documents available in the 14 regions. However, the PSP implementation process took longer than planned due to difficulties in finalizing the documents, which delayed PSP dissemination to providers. Going forward, the project will support printing and distribution of an additional batch of PSP and will also support introducing providers to the PSP using the dissemination guide. Intervention 1.3.2: Strengthen health workers’ capacities at health centers, health posts, and health huts to implement processes to improve services quality Implementation of this intervention mainly involved support for medical regions and health districts to conduct audits of maternal and newborn deaths in districts.
During this exercise the project supported 11 maternal death audit sessions in districts and hospitals in Tambacounda and Kolda regions (4 sessions in Tambacounda and 7 in Kolda) in collaboration with members of the regional audit committees.
Committee members who participate in these audits are the ECR, ECD, administrative and technical staff from PHFs, providers’ representatives, and technical and financial partners (TPF).
As noted, the maternal death audit sessions sought to:
• Review all cases of maternal deaths
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• Identify factors that led to maternal deaths
• Identify cases of maternal death that were definitely avoidable
• Formulate recommendations to eliminate avoidable deaths
• Monitor recommendations (See table below presenting the example of Médina Yoro Foulah health district)
Box 3: Recommendations from a death audit session
Recommendations from a maternal death audit session in Médina Yoro Foulah health district:
The review of maternal deaths reported these findings: - The causes of death are varied - Hemorrhage and anemia are the most frequent causes - Nearly all causes except one were avoidable - Only one death was deemed inevitable by the audit committee Recommendations made during this session are:
• For relevant health posts: - Strictly observe the magnesium sulfate protocol - Routinely perform a Dextro and a rapid diagnostic test for malaria in the event of coma - Follow conditions for evacuation - Provide more detailed information on the patient referral form - Routinely create a file with detailed information for all patients seen at an SDP - Establish a patient circuit for emergency cases - Apply RH/child survival PSP - Strengthen matrones’ capacities in urgent care - Post a list of numbers to call in case of emergency • For the district: - Implement referral tools - Improve content in the obstetric referral sheet for completeness of information - Try to reach the on-duty teams by phone at the PHF maternity ward before any evacuation - Provide post-training follow-up for trained providers on RH/child survival PSP • For the region: - Advocate to train all State registered midwives from the region’s health posts in EmONC through Tutorat - Ensure obstetric referral/counter-referral forms are standardized
The main challenges for the audits primarily involve:
• Holding these sessions regularly
• Applying recommendations made in these sessions
• No regional reviews of maternal death surveillance and response (MDSR)
Intervention 1.3.3: Strengthen capacities of the public health and local governance systems to support and monitor health system performance and quality
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As part of strengthening the capacities of public health and local governance systems to support and monitor health system performance and quality, the following activities were carried out:
Support for the PNQ to develop its Strategic Plan 2018–2022: During Year 1, the project supported the National Quality Program (PNQ) for the development and technical validation of the Strategic Plan 2018–2022. The political validation process is underway. The strategic objectives of this plan are: (i) standardize the health and social action system at all levels; (ii) improve the hygiene and safety of care and services at all levels; (iii) make sustainable improvements in service quality in health and social services facilities at all levels; and (iv) improve the Program’s institutional and operational capacities.
The new Strategic Plan 2018–2022 marks a desire for streamlining and efficiency by integrating two programs (the National Quality Program and the National Nosocomial Infections Control Program) into a single National Integrated Quality Program for Health. It consolidates achievements already attained, while applying a pragmatic and realistic approach to address gaps that still affect the quality and safety of care and services to guarantee people have full confidence in their national health system.
Support for the PNQ to have quality norms and standards: This activity depends on the availability of a strategic plan that defines the MSAS strategic guidelines for standardization. Implementation of the interventions included in this plan, such as developing a document of quality norms and standards, cannot be rolled out until the integrated strategic plan 2018–2022 has received political validation.
Therefore, this activity will be renewed for Year 2.
A fundamental result of this intervention was achieved with the availability of the integrated strategic plan 2018–2022 for the PNQ, which include nosocomial infections control and the quality and safety of care and services. The next steps will be to share and distribute the strategic plan 2018–2022 and to implement interventions. The challenge will be implementing the various interventions given this program’s weak institutional capacity.
the project supported the Community Health Unit to develop implementation tools for community monitoring. The approach aims to integrate community health structures into the overall performance evaluation system for health districts. Thus, the monitoring of community interventions becomes an integral part of monitoring primary activities and extending health post monitoring. Targeted interventions in community monitoring are: nutrition, primary care consultation; family planning; community monitoring of pregnancy and postpartum; and financial management.
Planned activities for Year 2 are: finalizing implementation tools; testing tools and methodology; including the community module in monitoring tools for health posts; introducing ECRs/ECDs and ICPs to monitoring tools; and supporting implementation of community monitoring in all regions.
Support regional hygiene brigades and medical regions to implement regional BMW management plans: The Neema project supported the Diourbel medical region to develop its regional biomedical waste (BMW) management plan, covering four health districts and three PHFs.
The plan was developed in synergy with the National Hygiene Service and the National Nosocomial Infections Control Program and later with the E2A-Global Health Security Agenda project. The main
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challenges are related to implementing interventions due to the medical region’s weak capacity and to capitalizing on interventions implemented as part of the E2A-Global Health Security Agenda project.
Revise and implement the contract signing process with ECRs and ECDs: To support Tutorat 3.0 implementation and thus to help achieve the objectives, the Neema project envisages providing sub- grants to medical regions and health districts in both the concentration regions and regions considered as HIV/AIDS hot spots. This sub-grant is a direct financing mechanism that uses the Fixed Obligation Grant model, which pays the beneficiaries after deliverables are completed.
The following key achievements were noted as part of implementing the contract signing process with the ECRs and ECDs:
- Revision of the management procedure manual for sub-grants was completed with the main modifications being separating the management manual for districts and medical regions from that of sub-recipient non-governmental organizations (NGOs), on the one hand, and capacity building for sub-grant recipients, with the goal of continuing activities over the long term by overcoming gaps identified during the Situational Analysis of the medical regions and health districts. - ECRs, ECDs, and other Tutorat 3.0 actors in the project’s seven concentration regions (Diourbel, Kédougou, Kolda, Matam, Saint Louis, Sédhiou, and Tambacounda) and in three regions considered HIV/AIDS hot spots (Dakar, Thiès (Mbour), and Ziguinchor) were introduced to budgeting for deliverables and management procedures for fixed obligation sub-grants in orientation workshops. After the workshops, the ECRs, ECDs, local officials, and health committee presidents fully understood Tutorat 3.0 and the management procedures for fixed obligation sub-grants and have bought into the Tutorat 3.0 approach.
Awarding sub-grants to medical regions and districts to ensure availability of high-impact quality services: Following the orientation for Tutorat 3.0 actors in medical regions and health districts, the contract signing process continued with these achievements:
- The pre-award assessment grids were administered to chief regional and district medical officers in all concentration regions, except for Matam, and in the three regions considered as HIV/AIDS hot spots.
- The deliverables were validated, and budgets were prepared for the districts and medical regions. All regions and districts, except Matam, had to validate deliverables and create a budget for them.
- The MCRs and MCDs were introduced to and supported in the process to enroll their facility into the identification platform to obtain a Data Universal Numbering System (DUNS) number, which allows each USAID sub-grant recipient to register in the US Government database, to ensure traceability of US assistance to developing countries;
- A meeting to discuss and sign sub-grants with medical regions and health districts was held. Overall, 25 health districts and 8 medical regions signed their sub-grant contracts. The total amount for this sub-grant is 391,221,310 FCFA, including 347,516,772 FCFA in the
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concentration regions and 43,704,538 FCFA to support TATARSEN plans in the regions of Thiès (Mbour) and Ziguinchor. Distribution by region is as follows:
Table 9: Sub-grant amount, by region
Diourbel Kédougou Kolda Saint Louis Sédhiou Tamba Thiès Ziguinchor
70,832,709 29,420,551 39,067,324 87,085,040 41,412,159 79,698,989 17,768,028 25,936,510
Deliverables for the first contract have been set to ensure actual roll-out of Tutorat 3.0 activities by ECRs and ECDs. The table below provides an overview.
Table 10: Sub-grant deliverables to medical regions and health districts
Subcontractor Deliverables
Medical regions (concentration areas) 1) Signing of sub-contract
2) Retraining existing tutors
3) Selecting and training new tutors
4) Post-training follow-up of tutors
5) Biannual reviews to monitor implementation
6) Purchasing worksite equipment
Health districts (concentration areas) 1) Signing of sub-contracts
2) Introducing SDP heads, health committee presidents, and local officials to Tutorat 3.0
3) Completing the situational analysis
4) Purchasing additional equipment for services delivery and communication
5) On-site coaching of providers by tutors
6) Supervising tutors during on-site coaching by ECDs
7) Quarterly reviews organized by ECDs
Each deliverable is costed and the total budgeted amounts for deliverables is the annual amount of the grant sub-contract signed with each medical region and/or health district.
All of the intervention regions were introduced to the implementation procedures for sub-grants. Participation of other actors, especially local municipalities and health committee members, in these meetings was greatly appreciated.
For the signing of sub-contracts, all regions and districts in the concentration areas signed their sub- grant contracts, except for Matam region, which continues its boycott of project activities because of the G50 policy. The medical regions of Ziguinchor and Thiès also signed sub-contracts regarding support to implement TATARSEN plans.
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The major challenge is still scheduling and meeting deadlines for achieving deliverables in work plan implementation.
Intervention 1.3.4: Improve monitoring of vital events (civil status): births, deaths, etc. During this exercise, the results below were noted as part of improving the monitoring of vital events (civil status, births, deaths, etc.). The Neema project participated in a harmonization workshop between health and civil status on reporting births. This workshop brought together staff from various MSAS services (DSR/SE, Division of the Health and Social Information System (DSISS), Department of Medical Prevention, CSC, SNEIPS, and the Agency for Universal Health Coverage); the Directorate of Civil Status; the Ministry of Planning and Local Government; the Support Unit for Local Officials; the Ministry of Women, Family, and Children; the Ministry of Justice: (Directorate of Civil Affairs and Seals (DACS); and TFP. The aim of this workshop was to review and take stock of: (i) the process to modernize the civil status registration system through computerization and the integrated civil-status-health approach; and (ii) decentralization of the birth registration process at the local level through health centers and primary and secondary civil-status centers to bring services closer to users.
The main findings presented by the various stakeholders dealt with: • Shortcomings in the birth registration reporting system (the management tools and platforms) • Inadequate interoperability between the two systems (civil status and health sector)
The following recommendations were made: 1) Conduct an assessment of civil status locations in Kédougou, Kolda, Sédhiou, and Tambacounda regions with a view to extending them (in pilot regions) and national scale-up
2) Strengthen government civil servants’ and health workers’ capacities on civil registration software and the District Health Information System 2 (DHIS2)
3) Check the availability of collection tools (health and civil status) and the health card in all SDPs
4) Test and scale up a collaborative module on RapidPro for birth registration between civil status bodies and health facilities
5) Implement an electronic reporting system for births and deaths (universal registration)
In addition, the Neema project supported the CNEC and Unicef as part of deploying the RapidPro application in Kolda region to improve notification of vital events. Implementing this application is important for these reasons:
• Establishing a link between health facilities and civil status centers • Interoperability of civil status/health to monitor births and deaths • Notification of vital events occurring at health facility level • Transmission of data on births and deaths occurring at health facility level sent to centralized civil status centers
Nevertheless, problems were noted in the coordination between TFP working in this sector, making it hard to implement interventions.
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Intervention 1.3.5: Institutional support for the MSAS for quality services availability During Year 1, the project supported the MSAS to improve services functioning at the central and SDP level in human resources, equipment, logistics, and organization of special events.
Support in human resources: In terms of strengthening human resources, the project recruited a portion of the senior technical staff at the Division of AIDS/STI Control (DLSI) and DSR/SE. Alongside the senior position at the DLSI, the project supported the recruitment of a physician and social worker to work with key populations. Recruitment of a senior position at the SNEIPS is also being completed. However, recruitment of some staff, especially senior positions at the CSC, DSR/SE (complementary), and additional staff for health posts (SAFIs) has been put on hold, at the request of the donor.
Support in equipment: The project supported: • The DLSI: with IT and office equipment. This included 3 laptop computers, 4 desktop computers, 4 multi-functional printers, 7 Wi-Fi hotspots, 4 external disc drives, 1 meeting table, 15 visitor chairs, 2 storage cabinets, and 1 video projector. This support will significantly help to improve functioning of DLSI services.
• The MSAS Community Health Unit (CSC): acquisition of equipment for newborn resuscitation in health huts (922 penguin mucous-suction devices and 922 manual inflatable ventilation bags). Acquiring this equipment will significantly help reduce newborn mortality.
• Community-based structures: acquisition of cooking demonstration equipment (for 37 new health huts, 173 community sites, and 712 home-based care providers); health care supplies (for 37 new health huts); supplies for infection prevention (for 37 new health huts); office furniture (37 health huts and 173 community sites); and community trashcans/incinerators (37 new health huts).
Support in logistics management of essential commodities and medicines: The component provided support to the MSAS for: preparation of the Contraceptive Procurement Tables; logistics supervision of huts; setting up back-up inventory in health posts to regularly resupply huts; and installation of a logistics data collection system.
The project supported the DSR/SE to organize two mid-year review workshops to prepare Contraceptive Procurement Tables. The reviews re-adjusted the country’s contraceptive needs for 2017, 2018, and 2019 and scheduled orders sent to three suppliers (USAID, UNFPA, and the State). The country’s needs in FP commodities for 2017, 2018, and 2019 amount to approximately $6,792,850, including $5,419,156 from USAID (79.8%), $1,354,806 (19.9%) from UNFPA, and $18,888 (0.3%) from the PNA.
Figure 4: Partners’ contributory shares for purchased contraceptives for 2017, 2018, and 2019
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0.30%
19.90%
USAID UNFPA PNA
79.80%
The State budget allocated to contraceptives, which is $600,00 annually, cannot cover DSR/SE needs for 2017, 2018, and 2019 ($5,156,832). • The project supported ECDs/ICPs in Saint Louis, Koumpentoum, Touba, Saraya, Goudiry, and Dianké Makha in logistics supervision of 77 health huts and 28 PECADOM sites for an annual target of 100.
• The project also provided support to districts to set up a consumption data collection system and a stockout early-warning system through orientation sessions for ECDs/ICPs from Kolda and Sédhiou on stock management procedures and through the situational analysis on stock management in health posts and health huts in three districts in Sédhiou.
• Lastly, the project supported the districts to set up back-up inventory in health posts to regularly supply health huts. An advocacy meeting was held with the Touba MCD, and a roadmap was proposed that would allow for setting up back-up inventory in health posts.
Support for partners’ events: The project supported various services, directorates, programs, and decentralized MSAS services, notably:
• The DSR/SE to launch of the CNSPF and the strategic plan 2016–2021 for nutrition and on the Day to Combat Maternal Mortality, organized by the Bajenu Gox association of Senegal
• The Center for Training and Research in Reproductive Health (CEFOREP) to organize the International Symposium on Emergency Obstetric and Neonatal Care
• The DLSI to organize a review of TATARSEN 2016 plans for Sédhiou region. This review assessed performance of the strategy’s implementation at the regional level and developed new TATARSEN operational plans for districts following the revision of the care cascade.
• The PNLP to organize World Malaria Day 2017
• The SNEIPS to update the national strategic health promotion plan 2018–2022 and to hold the biannual coordination meeting for SBCC activities
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• The Division of School Inspection (DCMS) to organize a workshop to develop management tools for school health. Gender and aspects related to AYRH were considered when developing these tools
• The Community Health Unit to organize a workshop to discuss implementation of the RMNCAH scorecard
• The Diourbel medical region to organize a Regional Development Committee on maternal mortality in order to conduct a diagnosis of maternal mortality in the region and to propose appropriate strategies to combat it
• The National Network of Associations for PLHIV (RNP+) to organize the Candlelight Day commemoration and the general assembly to renew RNP+ bodies
• The National Midwives Association of Senegal (ANSFS) to organize the International Day of the Midwife commemoration Sub-Objective 1.4: Key populations in target areas are tested, enrolled on antiretroviral treatment, and provided quality care in alignment with the 90-90-90 goals
Expected outcomes over 18 months Achievements over 12 months
90% of key populations identified in mapping of Overall, 88% of people in key populations, Kolda, Sédhiou, and Ziguinchor regions are tested or 3174 (MSM, sex workers, and IDUs) out of and receive their results 3575 surveyed in 2016, were tested and received their results 90% of key populations in the intervention regions 61 out 65 PLHIV who tested positive were of Kolda, Sédhiou, and Ziguinchor who test put on ARV therapy, or 94% positive are put on antiretrovirals (ARVs)
Individuals from key populations who tested 90% of those in key populations in Kolda, positive and were put on treatment no Sédhiou, and Ziguinchor regions who were put longer wait 6 months for their viral load on ARVs and who saw a suppression in their viral assays load
Intervention 1.4.1: Support for the DLSI for the coordination and monitoring- evaluation of the TATARSEN approach During Year 1, the Neema project supported the DLSI to monitor and implement the TATARSEN strategy. Thus, the DLSI action plan was validated with identification of priority actions. Also, the Division’s operational capacities were strengthened through support for human resources and IT equipment and office supplies.
The project supported the division to review, update, and develop TATARSEN operations plans in the regions of Kolda, Sédhiou, Ziguinchor, Thiès, and Dakar. This support helped the Division have an implementation plan for the strategy at the regional level.
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The project initiated a meeting with the National Aids Control Council (CNLS) to discuss the coordination and synergy of interventions as part of support for the DLSI for TATARSEN implementation. Thus, an integrated action plan for the DLSI was developed with accurate mapping of resources and partners’ interventions.
A meeting was held with the Ambulatory Treatment Center (CTA) to establish contact and discuss the issue of Neema support for the DLSI for updating the nutrition component of the TATARSEN program.
The various interventions resulted in giving implementation actors a better understanding of the TATARSEN strategy and in including topics that support the strategy, such as nutrition and universal health coverage. Moreover, this led to harmonization of the TATARSEN implementation approach, monitoring of the strategy at the central level, and coordination between the various stakeholders. The project also opened discussions with UNAIDS to instill synergy around interventions.
Intervention 1.4.2: Strengthening target regions’ capacity to implement TATARSEN regional plans For the first year, the Neema project focused on supporting the regions of Kolda, Sédhiou, and Ziguinchor as priority regions for TATARSEN implementation. Thus, plans for the three regions were revised and updated after implementing the strategy for one year. The regional laboratories that measure viral load in Ziguinchor, Kolda, and Sédhiou were given IT equipment and supplies to improve transmission of results. In five districts in Ziguinchor region, 129 providers, including 66 men, were trained on ARV treatment and its beneficial effects.
These various activities contribute to the decentralization of HIV care to health posts, thus promoting treatment access and improvements in performing viral load assays.
Also as part of support for regions and districts to coordinate, plan, and implement interventions aimed at achieving the 90-90-90 targets, the project supported the regions of Thiès and Dakar to organize sessions to develop operational work plans for their districts. Session participants assessed performance of the strategy’s implementation at the regional level and developed new operational work plans for districts following the revision of the care cascade.
The medical regions of Ziguinchor and Thiès received support to monitor coordination of TATARSEN activities through the signing of a sub-grant with the project.
Intervention 1.4.3: Strengthen capacities for focused counselling and testing services for key populations During the fiscal year, the Neema project recruited 20 mediators from key populations (4 MSM, 10 sex workers, and 6 IDUs), who are available at treatment sites to facilitate access to prevention, care, and treatment services for their peers. There are four mediators in Kolda (1 MSM, 2 sex workers, and 1 IDU), one mediator in Dakar (1 IDU), five in Sédhiou (2 MSM and 3 sex workers), seven in Ziguinchor (1 MSM, 3 IDUs, and 3 sex workers), one in Kédougou (1 sex worker), one in Tambacounda (1 sex worker), and one in Thiès (1 IDU). The mediators were able to mobilize their peers to participate in advanced strategies offering voluntary counseling and testing (VCT).
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The Neema project strengthened the capacities of 25 health staff (social workers, laboratory technicians, and mediators) from the regions of Kolda (5), Sédhiou (7), and Ziguinchor (13), including 20 men, in VCT for key populations with new counseling tools from the DLSI.
Mediators partnered with screening teams from health districts and sensitized and screened 3174 individuals from key populations (760 MSM, 1873 sex workers, and 541 IDUs) in the regions of Kolda (980), Sédhiou (900), and Ziguinchor (1294), for an annual target of testing 3000 people from key populations. Photo 1: Screening injection drug users in Kolda
Figure 5: Ratio between the set target for individuals from key populations to test and the number of these individuals who were tested
Key populations tested during advanced strategies 3300 3174 3200 3100 3000 2900 2800 2700 2700 2600 2500 2400
Nombre de populations clé à dépister Nombre de populations clé dépistées
A performance rate of 117% was achieved for the goal for testing individuals from key populations through a combination of factors.
The estimated data for the number of MSM calculated by Enda Santé in 2016 found an MSM population of 1513 (1032 for Ziguinchor, 358 for Kolda, and 123 for Sédhiou) and a sex worker population of 2082 (1086 for Ziguinchor, 670 for Kolda, and 326 for Sédhiou). This estimation does not include the IDU target. Given the presence of other actors in these three regions that offer the same services, the project had planned to test 2700 individuals from key populations, i.e., sex workers, MSM, and IDUs. Moreover, the “mediator” approach helped enroll more people than planned for the screening sessions.
However, frequent stockouts of inputs for VCT significantly delayed activity roll-out and confirmation of positive results by BiSpot™, which was not being manufactured.
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Figure 6: Distribution of key populations who were screened, by category
MSM PS CDI
17% 24%
59%
During the VCT advanced strategies, 65 individuals from key populations tested positive (including 47 sex workers, 11 MSM, and 7 IDUs) for a set target of 150. Among them, 61 received support for transportation and were referred for ARV therapy.
Data analysis shows an HIV prevalence for key populations in the three southern regions that is higher than the national average for the general population (0.5% Spectrum 2016), but lower than the national prevalence rates reported for key populations (17.8% ELHIOS 2014; sex workers: 6.6% ENSC 2015; IDUs: 5.5% UDSEN 2011). Prevalence rates following VCT advanced strategies carried out by the Neema project at the end of September report rates of 1.4% for MSM, 2.5% for sex workers, and 1.29% for IDUs. This figure confirms the marked decline in prevalence rates for key populations due to significant efforts by various actors in HIV prevention for key populations. Results of studies to estimate the size of key populations conducted in 2016 by Enda Santé in the regions of Kolda, Sédhiou, and Ziguinchor reported prevalence rates of 5.22% for MSM and 3.81% for sex workers.
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Figure7: Distribution of key populations testing positive during advanced strategies
2500
2000 47
1500
1000 1873 11 500 7 760 541 0 MSM PS CDI
Dépistées Cas positifs
However, some treatment sites required that PLHIV complete a pre-inclusion check-up as a condition for starting treatment, despite DLSI recommendations. Since this project does not cover this medical check-up, it is important to advocate with the DLSI to ensure better standardization of practices around the TATARSEN strategy and raise providers’ awareness.
Intervention 1.4.4: Strengthen MSAS capacity to provide quality treatment services to key populations identified as HIV-positive During the year, three workshops trained 82 PLHIV mediators, leaders, and individuals from key populations, including 56 women, on the continuum of ARV treatment and care from Kolda (29), Sédhiou (24), and Ziguinchor (29) regions. The training gave mediators a stronger grasp of the package of treatment, care, and support services for PLHIV offered at all levels and helped them focus their interventions on the needs of key populations and PLHIV.
To improve the environment for treating key populations and delivery of client-friendly services in public health facilities, the capacities of 70 ECR and ECD members from Kolda (18), Sédhiou (17), and Ziguinchor (35) regions were strengthened using the LILO (Link In, Link Out) approach to deepen their understanding on issues surrounding key populations—particularly LGBTI, sex workers, and drug users.
Similarly, 15 community dialogue sessions were organized in treatment sites by social workers and mediators. These sessions sensitized 375 health care providers (50 in Kolda and 325 in Ziguinchor), including 197 women, on quality of care for key populations and PLHIV.
Moreover, the project supported capacity building for providers through supervision of quality of STI care and follow-up for sex workers in Dakar and Thiès regions. The supervision identified needs for strengthening provider skills on syndromic management of STIs. In addition, support was provided to supervise laboratory technicians who perform viral load assays in the regions of Kolda, Sédhiou, and Ziguinchor. This supervision raised the number of viral load assays performed in the three southern regions.
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Intervention 1.4.5: Identify and support the implementation of innovative strategies to improve adherence and retention of newly diagnosed patients Two training workshops were organized on ARV therapy and its beneficial effects. These sessions strengthened the capacities of 55 community actors from Ziguinchor (30), Kolda (12), and Sédhiou (13). These community actors, mostly PLHIV mediators and leaders who dispense ARVs had a better understanding of the treatment regimens and how to strengthen patients’ ARV treatment adherence.
In order to reduce financial barriers to access to care, technical support was provided to the Agency for Universal Health Coverage (ACMU) to reduce the costs of treating opportunistic infections and co- morbidities related to HIV. For this, two technical meetings were held, attended by consortium members, including the ANCS and key actors in the response, such as the CNLS, the DLSI, the RNP+, and in partnership with the HSS+ project. This support continued with a national workshop bringing together actors involved in mutuelle schemes, representatives of PLHIV associations and local officials, and the Social Protection Delegation to discuss the implementation of a sustainable model to provide care and treatment for PLHIV through universal health coverage.
The workshop did a thorough investigation to take stock of the care subsidy mechanisms for PLHIV in Senegal, identify opportunities and challenges related to their care, and define priorities for the care of PLHIV in the context of universal health coverage.
The workshop issued strong recommendations focusing on sustainability of social protection and progress in the universal health coverage system, which must be made more attractive through the care packages that are offered. A roadmap was developed to operationalize the general recommendations from the workshop and to support implementation of the operational action plan.
In Kolda, Sédhiou, and Ziguinchor regions, 51 PLHIV of the 65 who tested positive, along with 3 family members, were enrolled in health mutuelles for their medical care through Health Coverage for PLHIV (Couverture Maladie des PVVIH; CMV+).
Concurrent support activities provided psychosocial care to 292 PLHIV (including 226 women) from the regions of Kolda (146), Sédhiou (85), and Ziguinchor (61); services reached 212 PLHIV through discussion groups and 57 through home visits; 23 PLHIV lost-to-follow-up were found.
Awareness-raising campaigns on stigmatization and discrimination of key populations were organized in the departments of Kolda, Vélingara, Médina Yoro Foulah, Bounkiling, Sédhiou, Bignona, Ziguinchor, and Oussouye, in the form of panel discussions on respecting human rights. These panels featured administrative, local, and health officials, security forces, various sectors, religious leaders, media outlets, and community leaders. They were facilitated by coordinators from law shops (set up to provide legal advice) in Ziguinchor and Kolda, with support from key population mediators. The panels reached 267 individuals, including 208 men and 59 women (62 for Ziguinchor, 67 for Kolda, and 67 for Sédhiou). The human rights approach used during the awareness-raising campaigns on stigmatization and discrimination were successful and raised interest among officials and leaders.
Also, 29 leaders and mediators from key populations in the regions of Dakar, Thiès, Tambacounda, Kédougou, Kolda, Sédhiou, and Ziguinchor were trained in the LILO (Link In, Link Out) approach to build their self-esteem.
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Objective 2: Increased adoption of healthy behaviors Sub-Objective 2.1: High-quality, targeted social and behavior change communication interventions to promote high-impact services and healthy behaviors delivered at scale
Expected results for 18 months Achievements over 12 months A literature review for all the The documentary review of “social and behavior change project’s intervention domains, communication (SBCC) interventions” to promote the use including an in-depth analysis of of high-impact health services and the adoption of gender norms and decision-making healthy behaviors in Senegal was completed, and the processes report is available.
A longitudinal baseline survey of Data collection is done, and the databases of women of behaviors to examine barriers and reproductive age, men, and households and analysis plan facilitators to health-promoting is validated. For the initial stage of the longitudinal behaviors and obstacles related to quantitative study, called the baseline study, emphasis is gender norms on documenting regional and socio-demographic variations in services use, “health-promoting behaviors,” and other behavioral indicators relevant to changes in each of the project’s thematic areas.
A qualitative formative study to 112 focus groups were conducted in the 7 intervention explore gender norms and to better regions on the themes: AYRH, MNCH, GBV, and essential identify communications messages family health practices. Focus groups specifically brought and strategies together close to 1120 people, including men, women, adolescents, and elders from both rural and urban areas. We received the AYRH thematic report on 30 September. Other thematic reports are expected in October.
A national campaign covering all Development of the concept for the national campaign is aspects of maternal, newborn, child, scheduled for the fifth and sixth quarters in the 18-month and adolescent health is developed work plan but is subject to the availability of research and implemented in each data. intervention region Support for the malaria control acceleration plans in intervention regions resulted in broadcasting 4044 spots on local radio stations on malaria prevention and seeking early care.
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A national awareness-raising Design and implementation of a national awareness- campaign on the effects of GBV on raising campaign on the effects of GBV on families and families and youth youth depend on the availability of formative research data.
A strategy to motivate and recognize 14 dialogue sessions were organized in the 7 regions, welcoming providers is implemented which mobilized 422 participants. The concept document was developed and is being validated by the MCDs and MCRs for the intervention area.
Mini-surveys, conducted in the form This activity depends on activity implementation; since of qualitative feedback loops to the latter did not start during this first year, this activity understand messages and could not be started. communications strategies
Intervention 2.1.1: Using data to define approaches and messages For the first year, USAID/Neema conducted several studies to better situate project interventions in the current context of the seven concentration regions. This comprises a series of studies: a literature review, a qualitative formative study, and a longitudinal quantitative baseline survey.
The literature review included an analysis of MNCH project documents and communications aspects implemented in the last five years to identify outcomes that were not published but that are relevant to USAID/Neema project implementation in rural areas of the concentration regions. The review was completed and its findings were shared.
The qualitative formative research was conducted to understand social and gender norms related to decision-making for couples and in extended families and to identify regional specificities. It was an opportunity to divide up the population relative to the various existing communication channels and to identify the key determining factors and influencers for each theme that could be genuine levers for change.
The focus groups were led using interactive exercises. In the first photo below, adolescents indicated their preferred communication channels. According to them, for the behavior “Receive and have access to contraceptive methods,” the best channels are billboards, especially if they are placed on the roadside; radio stations, particularly “Tim-Timol FM”; the local cable television channel Sogui TV; and discussions held in public places, such as the youth center, named “Diaka.” They also believe that in order for identified influencers to fully assume their roles, discussions within the family must be promoted, with support from Bajenu Gox. They also support audio messages sent via social networks, especially on WhatsApp groups. The second photo illustrates the GBV theme. Women from an urban area in Sédhiou identified facilitators and influencers related to “Physical violence, assault, and battery,” by prioritizing factors as either most influential, less influential, or no influence.
A baseline behavioral study on ideational factors focused on health-promoting behaviors, such as MNCH, safe motherhood (ANC, PNC, delivery in a health facility), and family planning, was conducted.
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This study will provide specific information to identify the audience segmentation needed to implement SBCC interventions.
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Box 4: Summary of quantitative research
DESCRIPTION OF QUANTITATIVE RESEARCH The quantitative study used a longitudinal methodology, with an initial survey, a midterm survey, and a final survey, with the same households and the same people at each data collection period. Due to the specificity of the project’s objectives, only households with a child under 5 years were eligible. Given the sociodemographic differences in the intervention regions, all the project regions were included in the sample. For each region, a specific number of clusters were selected for surveys proportional to the size of the region’s population. The study population comprised women aged 15–45 years and men aged 18–45 years. Overall, 4935 households, 6774 women aged 15–45 years, and 2496 men aged 18–45-years, or a total population of 9270 individuals, were surveyed during this study. Study participants were selected randomly and sequentially based on the selection of municipalities, clusters, households, and individuals. Target individuals gave their free and informed consent. Data was collected onto a tablet. Each household and each individual answers questionnaires three times for the length of the project: at the start, midterm, and final phase. Phase 1: Exploratory baseline study 1. Document regional and socio-demographic variations in services use, “health-promoting behaviors,” and other behavioral indicators relevant to changes in each of the project’s thematic areas 2. Assess the ideational variables that underlie key indicators that could play major roles in the change process 3. Examine potential social, cultural, and economic barriers to change 4. Document the exposure and response to existing communication strategies 5. Synthesize these data to guide services delivery and improve communications strategies (in terms of regional targeting and audience segmentation, etc.) Phase 2: Midterm 1. Document the USAID/Neema exposure, responses, and initiatives taking into account behavior change, stratified according to level of exposure 2. Note changes at midterm in services use, “health-promoting behaviors,” and other selected behavior indicators 3. Specify changes obtained in services delivery from the community perspective relative to services satisfaction 4. Understand the ideational, social, cultural, and economic factors that motivate behavioral changes Phase 3: Final evaluation 1. Assess the USAID/Neema exposure, responses, and initiatives taking into account behavior change, stratified according to level of exposure 2. Assess changes reported at midterm in services use, “health-promoting behaviors,” and other selected behavior indicators 3. Assess services quality from the community perspective (reception, services, follow-up, etc.) 4. Understand the ideational, social, cultural, and economic factors that motivate behavioral changes
The USAID/Neema project planned to implement the “Nurturing Connection” approach in two selected regions that it will evaluate, if needed, before its scale-up. For Year 1, implementation of the approach was postponed to avoid influencing the baseline behavioral study. However, orientation for ECRs/ECDs took place in Saint Louis region, and districts are being selected for enrollment.
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Regarding the use of mHealth to document SBCC activities, USAID/Neema intends to support districts in supportive supervision for community-based staff on the ISM. For the first year, several meetings with the DSISS were held to identify roles and responsibilities. It was decided to conduct an analysis in Saint Louis next quarter.
Intervention 2.1.2: Local promotion of essential household health behaviors In anticipation of the study findings for the development of the integrated communication strategy, it was planned to organize song competitions on AYRH targeting youth in the seven regions. The song competition will provide a compilation of songs that will reinforce the tools and communication media for young people. Next, a series of meetings organized by the technical committee (SNEIPS, DSR/SE, USAID/Neema) completed the terms of reference. The design and process for the contest was firmed up by the organizing committee (including the Ministries of Youth, of Education, and of Culture, etc.).
Through collaboration with the PNLP, the USAID/Neema project supported malaria control acceleration plans in the seven regions. Contracts signed with 33 radio stations in the seven regions resulted in broadcasting 4044 spots, 28 radio shows, and 28 messages inserted during shows with a wide audience.
Table 11: Summary of broadcasted media on malaria prevention and seeking early care Regions Number of Activities implemented Media radio stations coverage signing Spots Radio Inserted contracts shows messages
Saint Louis 6 672 0 0 2 Matam 2 0 0 0 0 Kolda 5 686 7 8 3 Sédhiou 1 366 0 0 0 Tamba 7 0 0 0 0 Kédougou 3 294 5 0 0 Diourbel 9 1996 16 20 4 Total 33 4044 28 28 9
Also in support of the malaria control acceleration plan 2016–2020, USAID/Neema helped with holding orientation sessions for 12 journalists and 3 traditional communicators. It also supported organizing an advocacy visit to 17 community leaders from the SAFINATOUL AMANE association to prohibit the use of long-lasting insecticide-treated bednets for other purposes. Organization of 20 advocacy days with community leaders reached 156 men and 163 women.
Intervention 2.1.3: Implement gender-focused SBCC strategies This intervention includes a component to combat GBV combined with the development of an approach to transform norms of gender inequality. The GBV dimension is taken into account through mass communication efforts (a campaign, televised series, and radio shows). Aspects related to transforming gender relations in communities are addressed through capacity building sessions and community- based activities.
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Mass communication activities have not begun yet since starting them depends on the results of the formative research to examine barriers and facilitators to health-promoting behaviors and obstacles related to gender norms.
The component related to an approach to transform gender relations includes developing activities for community members (men, women, youths). It deals with capacity building, on the one hand, and social mobilization, on the other hand.
The capacity building involves training a core group of national and regional trainers in gender analysis and gender mainstreaming, who will then set up a training plan over several years. This will involve training on gender for community actors who will serve as liaisons between health districts and communities to promote gender-sensitive services and an adapted community response.
Social mobilization consists of communities conducting activities dealing with gender. It encompasses the implementation of primary preventions based on a social and ecological model (for example, women-centered advocacy, community mobilization, group training for women and men, and combined livelihood and training interventions for women).
Training a core group of national and regional trainers in gender analysis and gender mainstreaming has not started yet. It was decided for the first year to focus efforts on training providers on gender mainstreaming and the management of GBV separately. This decision is based on the fact that the two training processes require the involvement of the same partners at the MSAS level, and because of this, there are significant scheduling conflicts.
Intervention 2.1.4. Improve service providers’ attitudes and behaviors The formative research and dialogue sessions held in the seven concentration regions collected data on barriers to service use and criteria for services quality from the community perspective.
These data served as a basis for developing a strategy to recognize and motivate model providers. The initiative consists of supporting a process to identify (based on consensus-based criteria) providers who are seen as models. These providers will then be honored during a public ceremony and their photos will be featured through the most relevant channels and methods for the district and/or region. The concept document is being validated by the medical regions, especially to gather their recommendations on the process to identify model providers. Two sequences have been provided for the concept.
Identification of providers based on technical criteria: Collected information on technical performance is included in routine activities. Following analysis of routine data, a number of providers will be targeted in SDPs with the best results.
Selection of providers based on criteria set by the community: A system will be set up to include community participation in the selection process. This participation will occur in two ways:
• First, by asking women’s, men’s, and youth groups to evaluate the providers selected by the district for their performance based on the indicators for the different selected areas.
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• Then, by evaluating interactions between these providers and the health facility users. The mystery client approach and/or interviews with clients after a consultation will be used to do this. After scoring, the best providers will be selected. Sub-Objective 2.2: Public sector capacity to coordinate, design, and advocate for improved SBCC at the national and regional levels The project is committed to the SNEIPS’ drive to strengthen their capacities so it can better assume the strategic dimension of its mission. This support also covers the BREIPSs and Education and Health Information Branches to strengthen linkages between levels and improve coordination of SBCC interventions.
During the first year, the project supported the SNEIPS and BREIPSs to better identify aspects that are most likely to drive these structures’ performance. Thus, the interventions were geared toward an institutional diagnosis and data collection and analysis in order to set up a knowledge management mechanism for SBCC.
Expected results for 18 months Achievements over 12 months
A capacity building plan for SNEIPS Following an institutional diagnosis of SNEIPS, a capacity building and BREIPS staff is available. plan was developed
An electronic portal for SBCC In the run-up to launching the online portal, a needs assessment for knowledge management is developed the implementation of a knowledge management mechanism was and uploaded. conducted The hiring process for the resource person is done
The technical working group (TWG) Utilization of questionnaires sent to members of the technical for communication is functioning and working group (TWG) so that TORs for the technical group could be decentralized at the regional level. revised
Intervention 2.2.1: Provide institutional support to SNEIPS and BREIPSs The first year was devoted to assessing the institutional capacities of the SNEIPS and BREIPSs and conducting an analysis of the effectiveness of SBCC interventions, messages, and materials in the project’s seven intervention regions.
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An assessment was performed using the Figure 4: Advancement in the PROGRES tool PROGRES tool (Program for Organizational development Growth, Resilience and Sustainability). This tool assesses an organization’s institutional sustainability, financial viability, and programmatic sustainability. It covers seven core and seven optional domains. Each domain is divided into sub-domains that each include an ideal practice, a key question for each ideal practice, five levels of development for each key question, and one column for the means of verification used to guide which level to choose.
The diagnosis highlighted the need for capacity building both in the SNEIPS and BREIPSs. This is more apparent for core domains for the SNEIPS, particularly SBCC, human resources management, and monitoring-evaluation/knowledge management. A capacity building plan spread over five years that suggests corrective measures was developed. The USAID/Neema project will support its implementation.
Intervention 2.2.2: Support SBCC knowledge management Supporting the SNEIPS to set up an SBCC portal is one of the project’s key interventions. Once available, the portal will give professionals access to a virtual center with SBCC materials that can be adapted to each region and local context. The platform will host MSAS-approved SBCC materials and messages (aide-mémoires, posters, radio spots, training guides, etc.) and will be managed by the SNEIPS with the support of a resource person hired by USAID/Neema.
In order to better adapt the design of this platform with the realities of the environment, a needs assessment of knowledge management was conducted with key stakeholders (SNEIPS, BREIPS, district Health Sector Policy Initiatives Teams (EIPS), and international and local NGOs.) The report is available. In addition, the hiring process for the resource person who will be based at the SNEIPS to support this intervention has started.
Analysis of the effectiveness of SBCC interventions, messages, and materials had a dual objective. On the one hand, ensuring the availability of a database on the SBCC job-aids and tools, and on the other hand, identifying interventions and tools for each region for which their current status in terms of protocols and sociocultural acceptability for the region authorizes their inclusion in SBCC plans for each region.
Thus, the project supported a process with the following steps:
• Development of a guidance document between SNEIPS, BREIPS, and USAID/Neema
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• Hold a workshop to finalize the overall approach and tools • Introducing Health Sector Policy Initiatives Teams to data collection and synthesis • Collect data on SBCC interventions, job-aids, and tools in the districts • Hold an inter-regional workshop to analyze data
This review resulted in recommendations on SBCC interventions and tools for consolidation in the intervention areas.
Intervention 2.2.3: Ensure coordination and consistency of messaging The communication TWG is one of the major bodies involved in coordinating SBCC interventions at the national level. Set up by the Director General of Health in February 2013, this framework has not been very functional since its creation. Observations and recommendations gathered from stakeholders and discussions during a SNEIPS/USAID/Neema meeting made it possible to review this group’s terms of reference. However, the meeting to relaunch the TWG has not taken place yet, despite being scheduled multiple times. Regarding the BREIPSs, contacts are being established at the regional level to set up the SBCC coordination framework involving the education, youth, family, and culture sectors.
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Sub-Objective 2.3: Technical and operational capacity of local SBCC organizations to design, implement, and evaluate SBCC programs improved
Expected results for 18 months Achievements over 12 months ● A local NGO is selected using ● Following a call for candidates, ten local NGOs transparent criteria to implement expressed their interest and submitted their SBCC activities applications. A consultant was hired to conduct a pre-assessment of each NGO’s capacities. ● A capacity building plan for a ● This activity is subject to the completion of the selected NGO is available NGO selection process.
Intervention 2.3.1: Select a local NGO using transparent criteria Transferring SBCC skills to a local NGO is one of the key intervention priorities in Objective 2 of the project. Through gradual support, this NGO will capitalize on best practices in SBCC and will eventually help other local organizations strengthen their capacities.
The selection of a local NGO based on a competitive process was launched. Following a call for candidates, 10 local NGOs submitted their applications.
A consultant was hired to provide factual information on certain key aspects listed in the selection criteria. The consultant initiated a “pre-assessment of the 10 bidding organizations in the following key areas: (i) governance; (ii) financial management and sustainability; (iii) human resources; (iv) program management and monitoring-evaluation; and (v) skills transfer.
Intervention 2.3.2: Develop a tailored capacity building plan for the selected NGO This activity is subject to the completion of the NGO selection process.
The major identified challenge is the vacancy of the SNEIPS Director position, which poses a real leadership problem for the revitalization of the TWG.
To address this challenge, the project initiated the process to set up a TWG in all intervention regions, bringing together the education, youth, family, etc. sectors around the BREIPS. Monitoring, supervision, evaluation, and learning
The main missions of the Monitoring & Evaluation, Research, and Learning (MER&L) component are monitoring implementation of program activities, support for integrated supervision, support for the information system, and documentation of interventions. The expected results and achievements for Year 1 are summarized in the table below.
Expected results for 18 months Achievements over 12 months A detailed monitoring and evaluation plan that A monitoring and evaluation plan was developed defines the key indicators required by USAID and validated by USAID. for program performance monitoring.
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Program implementation monitoring tools • Data collection tools (situational analysis (data collection tool; IT software for data tools, program management tools) were entry, compilation, and transmission) and an finalized electronic filing system for reports. Program • Development of the automation platform for staff will be trained to use the program manual project operations management is being and its various tools. completed • Completion of a quality audit of data produced by the program in the Saint Louis Regional Bureau
In the 7 concentration regions, at least 80% of • 504 out of 582 SDPs (hospitals, health centers, health posts and 80% of health huts will be and health posts) were supervised at least regularly supervised based on the guidelines once during Year 1, or an 86% coverage rate defined by the Ministry of Health. • 515 out of 861 huts, or 60%, were supervised at least once in Year 1
A data quality audit is conducted by the The project supported the DSISS to conduct a Division of the Health and Social Information data quality audit in all districts in the regions of System (DSISS) at the national level and Saint Louis and Diourbel. follow-up missions for recommendations are organized. A plan to document and share high-impact A plan to document and share high-impact interventions is developed with stakeholders interventions is developed with stakeholders. The and validated. documentation process for the partograph is underway.
The key achievements are described below, by intervention:
Monitoring program implementation:
The following achievements were made as part of monitoring program implementation during the first year:
Development and validation of the monitoring-evaluation plan on schedule: This plan was developed with the support of the USAID/Neema consortium members. It was submitted with the PMP on schedule and validated by USAID.
Finalization of data collection tools for the program: This involved program management tools and tools for the situational analysis of SDPs to be conducted through Tutorat 3.0.
• Program management tools: all program tools have been revised and validated by all consortium members. Next, they were shared with all staff at the central and Regional Bureau level.
• Revision of the situational analysis tools for 29 health districts: The project finalized the data collection tools, the data-entry template, the analysis plan, and the training guides for trainers and for investigators. The templates for these tools were changed in the tablets. Staff from the central level were introduced to the tools and procedures, as were the ECRs/ECDs of Kolda.
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Development of an automation platform for project operations: The project developed an automation platform to manage operations. A beta version is available, and the user manual is being prepared. Staff at the central level and the Tambacounda Regional Bureau were introduced to their use. In addition to reporting, the platform intends to incorporate management of reconciliations. This module has already been developed and is awaiting Box 5: Summary of the data audit results validation by the project’s financial officers.
Installing a Geoportal for project data: For the SUMMARY OF THE DATA AUDIT RESULTS installation of the ISM Geoportal, the geographic • Strength: Reports are properly archived at the layers have been developed and presented to central Regional Bureau • Challenge: Archive attendance sheets in reports level staff. The deployment phase was postponed to • Recommendations: work in synergy with USAID GOLD on o Archive reports with signed timesheets implementation. Meetings were held to identify key o Incorporate the data-quality audit areas for collaboration. component into supervision of program Quality audit of data produced by the program: interventions o Monitor implementation of audit The Regional Bureaus of Saint Louis and recommendations Tambacounda conducted the audit. This audit assessed the quality of data used for reporting by comparing the available data with primary sources, identifying factors that have an impact on their quality, and suggesting necessary corrections.
Strengthening supervision systems at the district, SDP, and community levels: During Year 1, the Neema project supported integrated supervision of 504 of the 582 SDPs (health centers and health posts), or 86%, and 515 of the 861 huts, or 60%. The main findings and recommendations are summarized in the table below.
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Table 12: Summary of supervision results
Community level (N=515) Health post and health center level (N= 504) Maternal and child health The key findings are: ✓ 32% of CHWs do not promote the 4 required ANC ✓ Only 53% of SDPs monitor all women in delivery with visits the partograph ✓ 33% of CHWs do not know the danger signs of ✓ 55% of files are not filled out in compliance with norms pregnancy and protocols ✓ 50% of visited huts perform unexpected deliveries ✓ 39% of SDPs experienced a partograph stockout in the ✓ Only 11% of huts administer misoprostol for PPH last 3 months prevention ✓ 20% of SDPs do not have the most recent version of ✓ However, 95% of huts do not have misoprostol the WHO partograph ✓ 10% of SDPs do not perform basic newborn resuscitation The following recommendations were made: ‒ Train CHWs on the basic and specific services ‒ Train providers (nurses and midwives) on the package Partograph ‒ Advocate among MSAS entities to provide ‒ Train providers in EmONC misoprostol ‒ Provide SDPs with the most recent version of the WHO partograph Family planning The key findings are: ✓ Only 20% of huts do not provide FP services (short ✓ Also, there were insufficient FP communication tools, term method) such as posters on the methods (32% gap), aide- ✓ 37% of CHWs do not fill out FP registers according mémoires (27% gap), and displays of contraceptive to standards methods (17% gap) ✓ Contraceptives stockouts were noted in 70% of ✓ Gaps were noted in terms of equipment: 25% for IUD huts on the day of data collection, including: 55% and Jadelle insertion and removal kits, 8% for of huts for the pill, 62% for Depo IM, and 80% for gynecological examination tables, 28% for footstools, Sayana 52% for portable lamps, and 13% for FP files ✓ The following recommendations were made: ‒ Train CHWs on short-term FP methods (OICIM and ‒ Provide SDPs and huts with FP communication tools OICU) (Tiahrt poster, aide-mémoires, FP methods display) ‒ Train CHWs to use FP management tools ‒ Provide SDPs with IUD and Jadelle insertion kits, ‒ Make contraceptives available gynecological examination table, footstool, portable ‒ Provide huts with communication materials lamp, and FP file (posters on FP and Tiahrt poster) Referral and counter-referral system The key findings are: ✓ 80% and 53% of huts do not have, respectively, ✓ Unavailability of registers and sheets was noted in 44% registers and referral sheets and 38% of SDPs, respectively ✓ 39% of huts do not receive feedback from ✓ 52% of SDPs do not receive feedback from reference reference facilities facilities ✓ 90% of huts do not have a vehicle to transport ✓ Availability of functioning ambulances is not effective emergencies in 74% of SDPs ✓ However, 38% say they are able to find a vehicle ✓ However, 77% of SDPs state they are able to find a elsewhere (health posts or health huts) vehicle from elsewhere to transport emergency cases ✓ 66% of CHWs are unaware of which cases to refer ✓ 20% of SDPs have no means of communication
The following recommendations were made:
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‒ Provide huts with referral tools, such as referral ‒ Provide SDPs with referral tools, such as referral registers and referral sheets registers and referral sheets ‒ Train CHWs on the basic services package ‒ Provide SDPs with functioning medically-equipped ‒ Organize communities to set up transport systems ambulances for emergencies/referral cases ‒ Urge providers from reference facilities to officially complete counter-referrals through formal channels ‒ Urge health committees to provide SDPs with means of communication These results will be shared during annual reviews with medical regions and health districts in order to monitor recommendations drawn up during supervision at the operational level. Increased availability and use of health data for decision-making purposes at district, SDP, and community level The key HSI achievements are summarized below: • The Neema project supported the DSISS to revise tools for the information and management system for the child survival/nutrition/Expanded Program on Immunization (EPI) module. Following this activity, the revised management tools were incorporated into the various monthly reports (health hut report, overall report for area, health center report), routine data was updated in the DHIS2, and an analysis module was developed on the platform. • Lastly, the DSISS received support to audit DHIS2 services data for 2016 and the first half of 2017 in the regions of Saint Louis and Diourbel. This intervention identified 1793 errors and corrected 1715 of them, or 96%.
Documenting and sharing high-impact approaches During the first year of implementation, the project developed a learning and documentation plan. Documentation of the selected topic for learning, particularly use of the partograph by providers, began last quarter. Data are available, and analyses are underway.
For the study, the following study protocols were submitted to the National Ethics Committee for Research in Health (CNERS) in August, and are awaiting approval before rolling out these activities:
- The “mystery client” study, used to assess the concrete application of service quality principles for which providers received training and to develop corrective actions per channel to improve services quality and increase client attendance - The study including surveys on KPC (Knowledge, Practices and Coverage) for new MSI intervention regions as well as the situational analysis on delivering FP/RH services in gold- mining areas in Kédougou
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Collaboration and coordination
For the first year of implementation, the project planned the following:
At the central level: develop the integrated action plan for the USAID Health Program, participate in Chief of Party (COP) meetings, organize inter-agency meetings, and implement synergistic interventions around technical assistance and cross-cutting issues.
At the consortium level: establish and hold bi-monthly advisory committee meetings, hold bi-annual review and planning meetings, implement a project marketing and branding strategy, regularly organize consortium advisory committee meetings, and develop the annual action plan and monitor performance (quarterly and annual reviews).
At the Regional Bureau level: train RB staff on the USAID Health Program; support the organization of Regional Development Committees to launch the USAID Health Program; organize workshops to discuss Neema project implementation at the district level, including local municipalities, hold a quarterly coordination meeting and review of USAID Health Program implementation at each RB; participate in project review and programming meetings; support programming meetings (Operational Plans, Local Government Operational Plans, Annual Work Plans (AWPs), Review) in partnership with HSS+; and participate in district and regional coordination meetings.
During Year 1, the project completed the following activities:
At the central level:
• Hold the national planning meeting for project activities with the MSAS directorates and programs, consortium members, and representatives from other projects in the Health Program. Also, work sessions specifically with the DCMS, the DGS, the Quality Program, the Gender Unit, the BPTV, the Division of Adolescent and Youth Reproductive Health, the PNLP, the PNA, and the IPM project were able to complete the project work plan before submitting it to USAID. This allowed for developing the annual work plan and performance monitoring plan. • Participation in workshops to launch USAID programs at the national level and in all concentration regions. To do this, the project partnered with other Program projects to organize regional development committees to launch the Program in each concentration region, by overseeing the funding, production, and provision of communication materials (posters, personalized notepads, and information sheets for each project). These workshops have continued at the health district level for administrative, customary, and health officials during departmental development committees, and health district coordination meetings. The workshops brought the ECRs, ECDs, and local officials up to date on the health program and priority interventions for each of its projects. • Holding seven regional planning workshops with the participation of 29 health districts resulted in the development of 36 action plans for health districts and medical regions. • The COP’s participation in the inter-agency coordination meetings organized by the GoTAP project, which resulted in identifying synergistic areas, and writing the RB procedure manuals.
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• Organization of Steering Committee meetings to allow consortium partners to discuss problems related to implementation and to propose avenues for solutions • Participation by the COP and project staff in numerous coordination meetings between CA and/or USAID. These meetings covered topics such as a review of quarter reports, development of an integrated action plan, building synergy with the SHOPS+ and HRH 2030 projects, etc. • Organize 3 meetings to review performance, prepare quarter reports, and conduct project planning
Efforts to promote synergy with other projects and programs resulted in two meetings held with the Malnutrition Control Unit to discuss support for the CLM strategic plan, mapping nutrition in the intervention areas to avoid duplication between Neema and CLM implementing agencies, and joint institutional support for the Division of Food and Nutrition (DAN). It was decided that the CLM implementing agencies will work with the Regional Bureaus to complete mapping of intervention areas.
The GOLD, Neema, and HRH 2030 technical teams also met with each other to share their interventions and identify synergies. For effective synergism, working groups were set up to work on: (1) the use of new information technologies; (2) training for health committees/management committee; (3) community advocacy and engagement; (4) monitoring and evaluation; (5) gender and inclusion of vulnerable groups; and (6) the community scorecard and incorporating governance issues.
At the operational level, the project supported: organization of a training workshop on the USAID Health Program in the Kolda and Tamba RBs; launch of the USAID/Neema program for administrative, policy, health, and customary officials in each concentration region; and division of the USAID Health Program during departmental development committees and health district coordination meetings.
Working in synergy with the HSS+ component, the project supported 20 workshops to develop Local Government Operational Plans for health and 23 AWPs, all for 2018, covering 6 medical regions and 17 health districts.
Also, to improve activity coordination at the medical region and health district level, RB staff regularly participated in quarterly regional coordination meetings (Number), monthly coordination meetings (Number) at the health district level with providers and local municipalities, and internal meetings of centers of responsibility. These meeting and discussion frameworks were an opportunity to determine the completion rate for quarterly work plans and to conduct quarterly monitoring of the AWPs for 2017 of the centers of responsibility, to negotiate the inclusion of project activities in their programming, and to facilitate decision making between partners involved in implementing interventions.
Weekly coordination meetings were held with all USAID/Neema, USAID/HSS+, and USAID/GOLD components at the RB level. They are sometimes open to senior staff. These meetings provide a framework for sharing information, joint planning, and analysis of constraints related to intervention implementation and rationalized use of logistics and identification of potential synergistic areas in the field.
Quarterly program coordination and monitoring meetings were held at each RB to review performance as well as to develop a quarterly work plan that is consolidated and incorporated into the various centers of responsibility.
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Regarding collaboration with administrative officials, the RB coordinators regularly participated in Regional Development Committees and other regional meetings to which they were invited. BR participation in the various coordination frameworks (weekly planning meeting for medical regions, Regional Development Committees, Departmental Development Committees, Community Action Networks, program reviews, etc.) gave interventions greater visibility and identified key areas for collaboration with other partners.
Visits were made to establish contact with government, local, and health officials to share the status of project implementation and to advocate to secure commitments from mayors to mobilize additional resources for MNCH.
Synergy at the RB level between the project and program: Several activities to identify and develop joint plans were conducted:
- Meetings to build synergy with the CLM Regional Executive Offices to conduct mapping of intervention areas in order to rationalize resources and avoid duplication and saturation areas. The mapping results of the intervention areas were shared with CLM implementing agencies during these meetings. - Support to develop Local Government Operational Plans and AWPs for 2018, enabling the inclusion of other specific Neema interventions in the regional and district AWPs. - Meetings of a working group for USAID-funded projects (USAID/Neema, GOLD, HSS+, ACCESS, and Naatal MBay) around the focal point were held to prepare the synergy plan.
Project management: An automated operations management platform was set up, and staff have already been trained on its use. The same is true for the RB management procedure manual. All administrative and technical staff have been hired as well.
Also, the COP conducted a quarterly supervision of the Regional Bureaus, and the deputy COP conducted a joint supervision mission with USAID in Saint Louis and Diourbel.
The coordinator conducted a supervision of the regional program managers and district coordinators.
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CROSS-CUTTING ISSUES
1.5 Gender equality
Gender issues are addressed through a cross-cutting approach through various objectives. Achievements are described in Intervention 1.4.1 of Sub-Objective 1.1, in Intervention 1.2.4 of Sub-Objective 1.2, and in Sub- Objective 2.1 in the qualitative survey.
1.6 Environmental compliance
The main achievements are:
Development of an Environmental Mitigation and Monitoring Plan (EMMP): Implementation of project interventions could have negative impacts resulting from the generation, storage, and disposal of BMW, especially related to services delivery. These mainly include: (i) accidental blood and biological fluid exposure; and (ii) environmental contamination to SDPs, neighboring populations, and the water table due to BMW.
Also, a large part of the developed plan covers BMW management and includes the prescribed mitigation measures for it. It includes training activities for project staff and service providers, advocacy in local municipalities, supervision, and implementation of regional BMW management plans.
Strengthening the capacities of project staff: The technical advisor for strengthening and improving health system performance participated in five days of training on compliance with environmental regulations. The regional environmental training is sponsored by USAID/West Africa and implemented by Sun Mountain International (SMTN) and the CADMUS Group, Inc., through the Global Environmental Management Support II (GEMS II) project. It covered how to include environmental issues in project design and management and complying with USAID Environmental Regulation 216.
The third-quarter review served as a framework for introducing Neema central-level staff and staff from three Regional Bureaus who were at this meeting on the environmental regulations applied to USAID-supported projects and partners. This orientation was led by the team from the USAID-Senegal Environment Bureau, and it helped staff understand how to design activities that respect the environment and how to ensure these activities’ environmental procedures. Overall, 56 people (30 men and 26 women) received orientation.
Regular supervision of compliance with environmental protection regulations: It enabled monitoring of infection prevention and BMW management in 504 SDPs and 515 health huts. Findings on infection prevention in public SDPs (hospitals, health posts, and health centers) are presented in the table below.
72
Table 13: Supervision results of infection prevention in SDPs
-
TOTAL
KOLDA
MATAM
TAMBA
SEDHIOU COUNDA
DIOURBEL
KEDOUGOU SAINT LOUISSAINT Number of SDPs involved 68 26 43 56 99 115 97 504 Total number of SDPs 101 36 59 58 120 98 582
INFECTION PREVENTION Is there a provider in the SDP who received 72% 96% 81% 67% 71% 62% 52% 67% training in the last three years on infection prevention and environmental protection or biomedical waste management? Availability of a guide on infection prevention 19% 58% 54% 42% 28% 38% 16% 34% and environmental protection
Existence of decontamination equipment (3 49% 58% 77% 71% 48% 59% 50% 59% plastic basins, including 1 with a lid)
Availability of decontamination and cleaning 99% 100% 99% 98% 95% 99% 93% 97% products ‒ Chlorine 99% 100% 91% 93% 97% 100% 98% 97%
‒ Liquid soap 99% 100% 91% 93% 97% 100% 98% 97%
‒ Hydro-alcoholic solution 81% 92% 79% 71% 80% 70% 52% 72%
Availability of sterilization equipment 72% 38% 70% 62% 55% 59% 39% 57%
‒ Autoclave 39% 40% 23% 44% 59% 18% 38% 36%
‒ Poupinel 80% 60% 75% 73% 54% 84% 64% 72%
Thus, regarding infection prevention at the hospital, health center, and health post level, there is good availability (97%) of decontamination and cleaning products, namely chlorine, soap, and hydro-alcoholic solution. Staff trained in infection prevention and environmental protection remains low, with only 67% of supervised SDPs that have staff trained in the last three years. Areas needing immediate improvement are the availability of the infection prevention and environmental protection guide (only 34% availability), autoclave availability (in only 36% of SDPs), and existence of decontamination supplies (only in 59% of SDPs).
Supervision also assessed biomedical waste management in these same SDPs.
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Table 14: Supervision results of biomedical waste management in SDPs
-
TOTAL
KOLDA
MATAM
TAMBA
SEDHIOU COUNDA
DIOURBEL
KEDOUGOU SAINT LOUISSAINT Number of SDPs involved 68 26 43 56 99 115 97 504 Total number of SDPs 101 36 59 58 120 98 582
BIOMEDICAL WASTE MANAGEMENT Availability of staff in charge of biomedical 93% 77% 87% 77% 90% 81% 84% 84% waste management Training for staff in charge of BMW 60% 50% 75% 50% 45% 47% 33% 50% management on the risks
Is there staff responsible for supervising 76% 58% 80% 72% 73% 74% 78% 74% BMW management?
Staff responsible for the supervision of BMW 81% 93% 95% 81% 89% 76% 57% 79% management is trained Staff in charge of BMW management is equipped with protective equipment
‒ Glasses 10% 19% 28% 12% 7% 12% 46% 19% ‒ Gloves 69% 42% 70% 49% 71% 69% 83% 67% ‒ Boots 24% 15% 26% 18% 12% 20% 60% 26% ‒ Masks 50% 27% 52% 37% 38% 62% 78% 52% ‒ Aprons 24% 12% 20% 16% 12% 20% 44% 22% Existence of functioning trash cans (step-on 19% 12% 61% 22% 8% 40% 13% 25% trash cans with liner bags and covers) in the courtyard, corridors, and entrances? Existence of functioning trash cans (step-on 41% 31% 77% 54% 46% 67% 43% 54% trash cans with liner bags and covers) in each room
Availability of a suitable container used to 96% 100% 96% 94% 95% 92% 89% 93% store sharps
Existence of small equipment for cleaning sites ‒ Wheelbarrows 34% 23% 30% 18% 18% 57% 67% 38%
‒ Rakes 60% 42% 54% 39% 45% 61% 65% 54%
‒ Shovels 51% 31% 41% 39% 41% 66% 67% 51%
‒ Brooms 24% 31% 28% 24% 12% 25% 38% 25%
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Existence of a secured interim storage area, 62% 54% 83% 76% 77% 79% 79% 75% accessible only to authorized staff
Available means of transport for biomedical 28% 50% 77% 69% 77% 61% 50% 61% waste with sufficient security
Existence of a specific location for waste 99% 85% 99% 96% 99% 90% 93% 95% disposal ‒ Incineration site 32% 0% 26% 24% 37% 27% 71% 35%
‒ Incinerator/burner 37% 50% 39% 45% 41% 30% 17% 35%
‒ Landfill pit 24% 27% 32% 27% 18% 28% 2% 21%
Location of waste disposal site?
‒ Inside the facility 70% 59% 85% 70% 76% 80% 96% 79%
‒ Outside the facility 13% 23% 6% 23% 15% 9% 1% 12%
‒ Far from the facility 13% 18% 9% 7% 9% 11% 2% 9%
Are there any traces at the disposal site? (To be checked by investigator) ‒ Syringes 33% 18% 15% 14% 15% 20% 13% 18% ‒ Sharps waste 28% 18% 10% 20% 15% 19% 13% 17%
‒ Partially treated infectious waste 31% 14% 21% 14% 22% 23% 15% 20%
There is staff dedicated to BMW management in 84% of supervised SDPs, but half of these employees have not been trained on the risks. The staff mainly have gloves (92%) and masks (72%), while boots and glasses are not widely available, with availability rates of 19% and 22%, respectively.
Collection of sharps is satisfactory, with 94% availability of containers in SDPs, while trash can availability in rooms and outside (in courtyards and hallways) in accordance with standards for waste and trash collection remains low, at 54% and 25%, respectively. Most SDPs have a designated place for waste storage (75%) and procedures for safe transport (61%) and disposal (95%) of biomedical waste.
Monitoring of environmental protection was conducted in 515 health huts, or a 60% coverage rate for huts in the intervention area.
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Table 15: Summary of environmental compliance monitoring in health huts (n=515)
Regions
NDA
SAINT SAINT LOUIS
TOTAL
KOLDA
MATAM
SEDHIOU
DIOURBEL
TAMBACOU KEDOUGOU Number of huts affected 50 25 82 84 98 124 52 515
Total number of huts 91 61 244 84 135 185 61 862 INFECTION PREVENTION Existence of staff in charge of biomedical waste 82% 88% 82% 83% 76% 60% 60% 74% management Are CHW and matrone trained in biomedical waste 44% 50% 69% 28% 50% 47% 103% 51% management? Individual in charge of biomedical waste 61% 27% 18% 29% 57% 36% 52% 39% management is equipped with protective equipment
‒ Gloves 42% 24% 12% 27% 42% 16% 25% 25% ‒ Mask 16% 0% 0% 4% 6% 4% 2% 4% Availability of small equipment for cleaning sites ‒ Brooms/Wheelbarrows 32% 12% 15% 41% 36% 42% 62% 35% ‒ Rakes 36% 20% 0% 5% 17% 8% 21% 12% ‒ Shovels 20% 8% 1% 4% 15% 13% 21% 11% ‒ Other 8% 20% 2% 6% 4% 5% 8% 6% Availability of decontamination equipment (3 plastic 66% 16% 73% 26% 31% 24% 56% 40% basins, including 1 with a lid)
Existence of functioning trash cans (step-on trash 48% 28% 38% 25% 41% 19% 48% 33% cans with liner bags and covers) in the hut
Existence of decontamination and cleaning products 98% 84% 71% 74% 67% 74% 85% 76%
‒ Chlorine 88% 81% 83% 79% 62% 89% 82% 80% ‒ Liquid soap 100% 81% 79% 81% 79% 90% 80% 85% ‒ Hydro-alcoholic solution 49% 29% 10% 23% 35% 33% 55% 32% Effective waste sorting after collection in various 56% 20% 35% 49% 42% 46% 40% 47% receptacles, according to type
Is a suitable safety box used to store sharps? 76% 72% 89% 73% 81% 75% 87% 79%
Existence of a specific location for waste disposal 98% 88% 93% 87% 80% 86% 88% 88% ‒ Incinerator/Burner, e.g., PICOM 87% 44% 73% 36% 69% 31% 81% 53% ‒ A landfill pit 26% 11% 15% 43% 15% 47% 10% 30% ‒ Other 0% 22% 0% 8% 3% 12% 4% 7% Location of waste disposal site
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‒ Inside the facility 88% 48% 68% 65% 53% 39% 67% 56% ‒ Outside the facility 8% 28% 20% 30% 17% 27% 12% 20% ‒ Far from the facility 2% 12% 5% 17% 8% 16% 4% 10% Existence of traces of waste at the elimination site 32% 24% 13% 37% 19% 18% 12% 21%
• Syringes 28% 4% 4% 15% 12% 10% 2% 10% • Sharps waste 22% 16% 1% 12% 11% 9% 2% 9% • Partially treated infectious waste 20% 16% 11% 26% 14% 10% 4% 14%
At the health hut level, supervision reported that 74% of huts have staff for medical waste management and just over half (51%) have received training in this topic. The availability of equipment to decontaminate supplies remains low (40%) as well as for trashcans with lids (33%). Also, 88% of huts have a biomedical waste disposal site.
In view of these results, the project plans to take these steps:
• Share supervision results with medical regions and districts during coordination meetings through in- depth analysis in order to develop a local action plan to resolve identified problems
• Advocate forcefully among local municipalities to assist in implementing action plans to resolve problems
• Revisit the community-level supervision grid
1.7 Compliance with US government requirements for FP
Revision of the Tutorat 3.0 training tools: Integration of USAID legal provisions and requirements for FP was effective in the Tutorat 3.0 training modules. This ensured better understanding of the main laws and policies governing United States assistance for FP activities.
Introduction on FP legislation and regulations: USAID organized on-site orientation sessions for staff in Saint Louis RB and the Diourbel coordination unit. Overall, the sessions reached 13 women and 14 men. These sessions strengthened staff skills on the relevant requirements and should enable staff to avoid violations and to monitor regulations.
Also, in terms of CHW training on the FP package, 1522 CHWs, including 946 women, participated in an orientation on Compliance with US government requirements for FP, focusing on the principle of non-coercion and free choice.
Surveillance of compliance for FP: The project assessed compliance with family planning legislation and regulations in the intervention regions. The sampling involved 504 SDPs (or 86% coverage) and 515 health huts (or 60% coverage).
Supervision at the SDP level showed these results:
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Table 16: Summary of supervision results of compliance with US government requirements for FP in public SDPs
SDP Percentage for Year 1
LOUIS
SAINT
TOTAL
KOLDA
TAMBA
MATAM
SEDHIOU
DIOURBEL KEDOUGOU Number of SDPs involved 68 26 43 56 99 115 97 504
Total number of SDPs 101 36 59 58 120 98 582
COMPLIANCE OF US REGULATIONS REGARDING FAMILY PLANNING
Existence of a “Tiahrt poster” or an equivalent poster providing full information on FP methods posted on a wall in the SDP or equivalent 76% 88% 46% 74% 58% 49% 5% 42% informational materials available in the SDP that describe the adverse side effects and health risks of the various FP methods
Use of the “Tiahrt poster” or equivalent informational materials (flip charts or displays) by providers to give clients clear and complete information on the 87% 88% 67% 85% 74% 72% 57% 64% chosen FP method (the benefits, adverse side effects, and health risks, including the conditions that would make using the method inadvisable for the client)
Training for clinical staff on the Tiahrt and other US government legislative 81% 77% 71% 80% 63% 25% 6% 42% regulations and policies regarding FP
Provision of clear and complete information to clients on the various FP methods without encouraging them to 96% 100% 96% 98% 90% 97% 88% 83% accept a particular method of FP during counseling by providers Provision of information to clients on the benefits, health risks (including the conditions that would make using the 97% 100% 93% 98% 91% 92% 89% 82% method inadvisable), and known adverse side effects of the FP method during specific counseling by providers
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Existence of a range of FP methods to ensure clients make a free choice from 99% 96% 91% 99% 96% 96% 88% 83% among approved methods
Bonus payment for staff for achieving 0% 0% 0% 0% 0% 0% 0% 0% FP targets
Existence of a set target or quota for staff for needs other than program 0% 0% 0% 0% 0% 0% 0% 0% planning
The SDP received equipment purchased 0% 0% 0% 0% 0% 0% 0% by the project for abortion services 0%
Availability of voluntary sterilization 0% 0% 0% 0% 0% 0% 0% 0% services
The analysis found: • Less than half of the visited SDPs (42%) have the Tiahrt poster: this gap is higher in Matam region where only 5% of SDPs have one. On the other hand, providers use the “Tiahrt poster” or equivalent informational materials (flip charts or displays) to provide clients with clear and complete information on the chosen FP method in 64% of SDPs. • Less than half of SDP staff (42%) are trained in the Tiahrt and other US government legislative regulations and policies regarding FP. However, these figures mask disparities in Matam and Saint Louis regions, respectively 6% and 25%. • In over 80% of visited SDPs, the principles of full information and voluntary client access are followed. • There is a range of FP methods to ensure clients make a free choice from among approved methods in over 80% of the visited SDPs. • Compliance with the principle of coercion was observed in all the visited SDPs.
Findings for health huts are summarized in the table below.
Table 17: Summary of supervision results of compliance with US government requirements for FP in health huts
Total number of huts affected in Year 1
DIOURBEL KEDOUGOU KOLDA SEDHIOU TAMBA LOUISSAINT MATAM TOTAL
Number of huts affected 50 25 82 84 98 124 52 515
Total number of huts 91 61 244 84 135 185 61 862
COMPLIANCE WITH FAMILY PLANNING LEGISLATION AND REGULATIONS
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Existence of a poster or an equivalent poster 52% 32% 57% 45% 47% 49% 69% 51% providing full information on FP methods posted on a wall in the health hut or equivalent informational materials that describe the benefits, adverse side effects, and health risks of the various FP methods Use of a poster on the various methods or 56% 40% 78% 37% 43% 61% 73% 56% equivalent informational materials (flip charts or displays) by CHWs to provide clients with clear and complete information on the chosen FP method (the benefits, adverse side effects, and health risks, including the conditions that would make using the method inadvisable for the client)
Training for CHWs who provide FP services on the 46% 48% 46% 28% 52% 46% 65% 46% Tiahrt amendment and other US government legislative regulations and policies regarding FP
CHWs provide clear and complete information to 70% 76% 80% 57% 73% 78% 87% 74% clients on the various FP methods without encouraging them to accept a particular method of FP during counseling CHWs provide information to clients on the 70% 76% 85% 59% 73% 85% 81% 76% benefits, health risks (including the conditions that would make using the method inadvisable), and known adverse side effects of the FP method during specific counseling Is there of a range of FP methods authorized at 70% 60% 74% 44% 66% 71% 79% 66% the community level to ensure clients make a free choice from among approved methods?
Bonus payment for CHWs for achieving FP targets 0% 0% 0% 0% 0% 0% 0% 0%
Setting a target or quota for CHWs for needs 0% 0% 0% 0% 0% 0% 0% 0% other than program planning
The analysis found:
• Over half the visited huts (51%) have a poster providing complete information on FP methods posted on a wall in the health hut or equivalent informational materials that describe the benefits, adverse side effects, and health risks of the various FP methods. However, these figures hide disparities between regions, with gaps reported in the regions of Kédougou, Sédhiou, Tambacounda, and Saint Louis, respectively 32%, 45%, 47%, and 49%. • In over half of the visited huts (56%) CHWs use the poster describing the various methods or equivalent informational materials (flip charts or displays) to provide clients with clear and complete information on the chosen FP method (the benefits, adverse side effects, and health risks, including the conditions that
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would make using the method inadvisable for the client). Gaps remain in the regions of Kédougou, Sédhiou, and Tamba. • Less than half of CHWs in the visited huts (46%) are trained in the Tiahrt and other US government legislative regulations and policies regarding FP. However, this gap is higher in Sédhiou region where only 28% of CHWs have been trained, while the regions of Tamba and Matam exceeded 50%. • In over 74% of visited huts, the principles of full information and voluntary client access are followed, with a gap reported in Sédhiou region. • In over half of the visited huts (66%), there is a range of FP methods authorized at the community level to ensure clients make a free choice from among approved methods. A gap was reported in Sédhiou region (44%). • Compliance with the principle of non-coercion was observed in all the visited huts.
For the next steps, the project intends to:
• Share supervision results with medical regions and districts during coordination meetings through in- depth analysis in order to develop a local action plan to resolve identified problems.
• Advocate forcefully at district level to make FP commodities available at the health hut level.
ADMINISTRATIVE MANAGEMENT
1.8 The project’s quick launch
Beginning in September 2017, the project management team focused its efforts on staff hiring and installing equipment.
For the first year of program implementation, the forecasted workforce was 204 employees, including 143 (70%) full-time and 61 (30%) part-time employees. On 30 September 2017, 192 positions were filled, or 94% compared to hiring forecasts.
The discrepancy between hiring forecasts and actual hires is not only due to vacancies, a constant factor in personnel management, but also to the decision to make adjustments and not fill all positions in Year 1.
Of the Program’s 192 employees, 106 (55%) belong to the technical unit, 14 (7%) are monitoring-evaluation specialists, and 72 (38%) belong to the administrative, financial, and human resources (support) unit.
Staff distribution is as follows: 112 (58.2%) staff members are assigned at the central level at the headquarters of partnering organizations in the consortium, 3 staff members (1.6%) are seconded at the Ministry of Health (DSR/SE, DLSI, and Community Health Unit), 77 (40.1%) staff members are based at the regional and health district level.
All acquisitions of heavy equipment and computers were completed despite delays in the process. The project obtained exemption titles, issued through a delivery process that underwent significant changes at the both the USAID and at customs services level. Technical support from USAID helped to clarify the situation at the USAID level.
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1.9 Establishment of Regional Coordination Bureaus
The project set up three Regional Bureaus, as planned in the technical proposal. Locations have been identified for all Regional Bureaus. In Kolda and Tambacounda, the Regional Bureaus are on the premises rented by the different medical regions; in Saint Louis, the project rented premises located near the medical region offices. These Regional Bureaus accommodate the GOLD project (only in Tambacounda and Kolda) and the health program’s HSS+ project. They provided coordination and monitoring of health program implementation at the operational level and served as a liaison between the various projects and local officials.
In addition to the Regional Bureaus, the project set up a regional coordination unit in Diourbel to facilitate coordination with the medical region. This unit is housed within the medical region.
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ANNEXES
USAID/NEEMA Annual Report: 1 October 2016 – 30 September 2017 Page 83
1.10 Annex 1: Performance Monitoring Plan
Data used to prepare the Performance Monitoring Plan for this quarter are from four sources: 1. DHIS-2 platform for services data. The annual data completion rates in the DHIS2, measured on 20 October 2017, are shown in the table below. Data from the first three quarters has been updated.
DSR/SE: Monthly Child nutrition and HIV (screening) HIV (treatment) Medical Region report health Dakar 78.1 47.2 Diourbel 94.4 83.3
Kédougou 95.4 86.6 69.4 63.9 Kolda 97.8 92.2 63.9 43.8 Matam 94.0 80.0 Saint Louis 94.9 90.6 Sédhiou 99.2 98.5 81.3 87.5 Tambacounda 94.1 88.0 50.95 35.5 Thiès (Mbour) 45.8 50.0 Ziguinchor 76.2 76.2 2. Informed Push Model project database for the stockout indicator. The completion rate for this indicator is 100% for all concentration regions. 3. Regional Procurement Pharmacies’ database to calculate couple years of protection, based on distribution data. 4. Supervision data: Throughout the year, the project supported supervision of 504 health posts and health centers and 515 health huts conducted by ECDs.
84
SOURCE/ ACHIEVEMENTS DESCRIPTION OF COLLEC- BASE- FY17 Achiev Achiev Achiev- Achiev- Achiev- # REGIONS Prog- Comments INDICATORS TION LINE OBJEC- -ed -ed ed ed ed ress METHOD TIVES Q1 Q2 Q3 Q4 Y1 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 Diourbel 24,148 28,978 9143 11,289 10,277 1071 21,503 110% During this year, 263,887 CYP Regional Kédougou 2421 2905 - - - - - were generated throughout Procure- Couple-years of protection Kolda 21,396 25,676 17,549 15,614 22,362 7216 40,379 103% the seven concentration ment regions. This strong 1.1.4 (CYP) through a program Matam 14,071 16,885 4941 5961 7213 7293 18,195 150% Pharmacy performance is due to an HL.7.1-1 supported by the US Saint Louis 7025 8429 19,465 12,007 25,641 12,262 43,734 823% (PRA) underestimation for FY2017. government Sédhiou 29,467 35,360 - - - - - distribution The targets have been revised using Y1 data as data. Tambacounda 9685 11,622 17,928 24,982 19,290 12,383 55,293 513% TOTAL 108,213 129,855 69,026 69,853 84,783 40,224 263,887 203% baseline. Diourbel 27,633 31,502 6623 5437 4564 7253 23,877 76% Data from the DHIS-2 indicate that 112,155 (or 77% Number of children under Kédougou 5380 9249 1031 1354 1238 1147 4770 52% of the annual target) cases of Kolda 33,085 36,954 7975 8690 8618 8802 34,085 92% 5 years with pneumonia children with pneumonia receiving antibiotics Matam 7254 11,123 965 1166 1081 1122 4334 39% received the recommended 1.1.10 recommended by Saint Louis 17,148 21,017 5160 5546 4228 3124 18,058 86% antibiotics. This performance DHIS-2 3.1.9.2-3 providers and CHWs Sédhiou 12,838 16,707 2359 2201 1637 2424 8621 52% rate is due to the decrease in pneumonia cases in recent trained through a program Tambacounda 15,528 19,397 4304 4668 4360 5078 18,410 95% supported by the US years and because not all reports were received (6329 government TOTAL 118,866 145,949 28,417 29,062 25,726 28,950 112,155 77% received of the expected 7270). Number of children under Diourbel 33,325 34,225 6418 10,734 6919 11,120 35,191 103% Data from the DHIS-2 5 years with diarrhea Kédougou 5937 6097 982 2790 1996 1298 7066 116% indicate that 153,556 treated according to Kolda 27,025 27,755 3862 7498 4671 5120 21,151 76% childhood case of 1.1.12 national guidelines (oral Matam 17,116 17,578 2800 4315 2735 5134 14,984 85% DHIS-2 diarrhea were treated HL.6.6-1 rehydration salts/zinc) Saint Louis 32,754 33,638 6907 10,233 8679 9300 35,119 104% with oral rehydration through a program Sédhiou 12,665 13,007 3251 4882 4142 5478 17,753 136% salts/zinc, or an overall supported by the US Tambacounda 15,557 15,977 3435 6959 5070 6828 22,292 140% performance of 104%. government TOTAL 144,379 148,277 27,655 47,411 34,212 44,278 153,556 104% Diourbel 154 24 0 0 0 76 76 317% Number of qualified Kédougou 48 8 0 0 0 0 0 - During this year, the project community providers Kolda 44 11 0 0 0 0 0 - supported training for 291 providers, including 163 1.1.18 trained in nutrition Project Matam 0 27 0 0 0 0 0 - women, on ENA and EHA. HL.9-4 through a program archives Saint Louis 372 0 0 0 97 0 97 - Targets were reset based on supported by the US Sédhiou 91 36 0 0 25 42 67 186% activity programming for government Tambacounda 0 44 0 0 0 51 51 116% Year 2. TOTAL 709 150 0 0 122 168 291 194% Diourbel 33% 50% 33% 33% 33% 33% 66% 85
SOURCE/ ACHIEVEMENTS DESCRIPTION OF COLLEC- BASE- FY17 Achiev Achiev Achiev- Achiev- Achiev- # REGIONS Prog- Comments INDICATORS TION LINE OBJEC- -ed -ed ed ed ed ress METHOD TIVES Q1 Q2 Q3 Q4 Y1 Situational Kédougou 44% 50% 44% 50% 43% 46% 92% analysis Kolda 33% 50% 33% 68% 79% 60% 120% Percentage of providers report for Matam 29% 32% 29% 36% 32% 32% 100% The five last partograph who comply with standards the baseline Saint Louis 38% 50% 38% 37% 28% 34% 68% forms filled out by each and protocols related to study provider were evaluated. 1.1.19 Sédhiou 50% 50% 50% 72% 65% 62% 124% the management of labor Supervision Only 45% of providers have 3.1-7 Tambacounda 52% 30% 52% 33% 39% 41% 137% and delivery in facilities Report demonstrated an acceptable funded by the US performance level for partograph use. government TOTAL 43% 50% 43% 48% 45% 45% 90%
Diourbel 7 7 7 7 7 7 100% It became apparent from Number of service delivery Kédougou 2 3 2 3 3 3 100% quarterly supervisions that, points providing life-saving Kolda 2 6 2 4 4 4 100% except for type-1 and type-2 health centers and PHFs, no 1.1.20 maternal care (basic and Supervision Matam 3 6 3 4 6 6 100% health post provided EmONC Custom comprehensive EmONC) Report Saint Louis 12 10 10 10 10 10 100% without requiring a referral. supported by the US Sédhiou 4 4 4 4 4 4 100% The situational analysis will government Tambacounda 10 8 8 8 8 8 100% provide an accurate view of TOTAL 40 44 40 44 42 42 95% the situation in health posts. Diourbel 100% 100% 100% 100% 100% 100% 100% Kédougou 85% 88% 100% 100% 100% 100% 114% These data are from the Percentage of service Supervision Kolda 79% 83.20% 100% 100% 100% 100% 120% supervision of 504 health delivery points offering posts and health centers Report Matam 100% 100% 100% 95% 100% 100% 100% HL.7.1-2 counseling and/or PF conducted this fiscal year. Saint Louis 95% 96% 100% 100% 100% 100% 104% services supported by the Family planning counseling Sédhiou 97% 97.60% 94% 98% 100% 100% 102% US government and/or services are delivered Tambacounda 86% 88.80% 100% 100% 100% 100% 113% in all the visited SDPs. TOTAL 93% 93% 98% 98% 100% 100% 107% Diourbel 0.17% 3% 1% 2.04% 2.10% 0% 0% 100% Routine IPM Percentage of service Kédougou 1.06% 3% 0% 0.00% 0.00% 15% 15% 85% Data are from the IPM- data delivery points assisted by Kolda 0.15% 3% 1% 16.13% 0.00% 12% 12% 88% Yeksina project. Data for
1.1.24 USAID that experienced Matam 0.28% 3% 2% 7.37% 4.10% 0% 0% 100% the month of July have
HL.7.1-3 stockouts of contraceptive Saint Louis 0.21% 3% 4% 4.20% 10.20% 0% 0% 100% been reported. A 5%
products during the Sédhiou 0% 3% 0% 10.91% 0.80% 5% 5% 95% stockout rate was noted
reporting period for all seven regions. Tambacounda 1.06% 3% 7% 0.00% 3.40% 4% 4% 96% Total 1% 3% 2% 5.15% 2.90% 5% 5% 95% 1.1.28 Number of women Diourbel 39,062 39,062 11,094 9763 8053 8631 37,541 96% Overall, 10,195 deliveries DHIS-2 Custom receiving active Kédougou 3781 3781 1138 971 1119 1124 4352 115% performed in health facilities
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SOURCE/ ACHIEVEMENTS DESCRIPTION OF COLLEC- BASE- FY17 Achiev Achiev Achiev- Achiev- Achiev- # REGIONS Prog- Comments INDICATORS TION LINE OBJEC- -ed -ed ed ed ed ress METHOD TIVES Q1 Q2 Q3 Q4 Y1 management of the third Kolda 12,377 12,377 3788 3933 3474 3091 14,286 115% were under active stage of labor through a Matam 10,236 10,236 3120 2112 2636 2327 10,195 100% management of the third stage of labor, or a 100% program supported by the Saint Louis 21,902 21,902 6454 5344 4652 4273 20,723 95% performance rate relative to US government Sédhiou 7186 8906 1927 2454 1903 1521 7805 88% the annual target. Tambacounda 13,469 13,469 4239 3179 3818 3837 15,073 112% TOTAL 108,013 109,733 31,760 27,756 25,655 24,804 109,975 100% Diourbel 215,286 218,515 40,460 35,597 31,640 35,890 143,587 66% During Year 1, there were Kédougou 44,596 45,265 8729 9112 8682 7298 33,821 75% 875,936 cases of children under 5 years who received Kolda 279,851 284,049 68,680 71,459 71,758 44,766 256,663 90% growth monitoring and Number of children under Matam 53,003 53,798 8886 7466 8220 9213 33,785 63% promotion, or 89% of the 5 years who received a Saint Louis 171,109 173,676 37,088 46,974 49,184 47,582 180,828 104% annual target. The indicator 1.1.34 nutrition intervention in a DHIS-2 Sédhiou 113,585 115,289 19,909 21,571 19,913 19,739 81,132 70% requires that only the HL.9-1 number of children be program supported by the Tambacounda 88,962 90,296 33,551 33,858 39,821 38,890 146,120 162% US government reported. This is a new change for this indicator. 217,30 226,03 TOTAL 966,392 980,888 229,218 203,378 875,936 89% Targets are being reviewed 3 7 with this requirement in mind. Number of children 0–23 Diourbel 150,087 152,338 30,623 26,588 25,835 27,742 110,788 73% months old who received a Kédougou 37,132 37,689 8080 8972 9145 6791 32,988 88% DHIS2 data indicate that nutrition intervention in a Kolda 226,140 229,532 59,536 65,809 63,350 42,258 230,953 101% 748,883 of children 0–23 1.1.35 program supported by the Matam 37,232 37,790 8654 6607 7180 8045 30,486 81% months old received US government DHIS-2 Saint Louis 141,794 143,921 33,141 37,783 42,248 36,755 149,927 104% growth monitoring and HL.9-2 Sédhiou 81,469 82,691 16,340 17,291 15,878 14,202 63,711 77% promotion, or 99% of the Tambacounda 70,223 71,276 29,398 30,367 37,476 32,789 130,030 182% annual target. 185,77 193,41 TOTAL 74,4,077 755,237 2 7 201,112 168,582 748,883 99% Diourbel 48.0% 58.4% - 67% 67% 87% 74% 127% Data are from the supervision Kédougou 54.0% 63.2% - 56% 70% 95% 74% 117% of 504 health posts and Situational health centers and 515 health Percentage of SDPs that Kolda 54.0% 63.2% - 56% 64% 62% 61% 97% analysis huts. The facility has one have a functioning Matam 43.0% 54.4% - 47% 77% 80% 68% 125% report functioning ambulance or 1.2.1 referral/counter-referral Saint Louis 45.0% 56.0% - 46% 52% 74% 57% 102% another vehicle for
Custom system from the Sédhiou 83.0% 86.4% - 38% 69% 82% 63% 73% emergency transport; or the Quarterly community to the health facility has access to an supervision Tambacounda 67.0% 73.6% - 48% 83% 68% 66% 90% post ambulance or another vehicle report parked at another facility for TOTAL 54.5% 63.6% - 54% 67% 77% 66% 104% emergency transport of patients. Dakar* 29,551 35,461 19,142 20,937 23,837 19,584 83,500 235%
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SOURCE/ ACHIEVEMENTS DESCRIPTION OF COLLEC- BASE- FY17 Achiev Achiev Achiev- Achiev- Achiev- # REGIONS Prog- Comments INDICATORS TION LINE OBJEC- -ed -ed ed ed ed ress METHOD TIVES Q1 Q2 Q3 Q4 Y1 Kédougou* 1736 2083 1552 1113 2463 1125 6253 300% District Kolda 21,906 26,287 8809 6240 10,258 1183 26,490 101% These data were extracted reports for Sédhiou 15,841 19,009 8742 3434 7066 3595 22,837 120% from the DHIS-2. 201,728 annual individuals were screened Tambacounda 1.4.1 Number of persons tested monitoring 6390 7668 this year, or 152% of the * 2258 3801 9785 4016 19,860 259% HTS_TST who receive their results annual target. Targets were Thiès DHIS2 9749 11,699 reset taking into account (Mbour) 3376 5389 2817 4005 15,587 133% these results and project Ziguinchor 25,429 30,515 4479 5822 7734 9166 27,201 89% objectives for 2018.
TOTAL 110,602 132,722 48,358 46,736 63,960 42,674 201,728 152%
Dakar 519 1240 87 145 83 69 384 31% During this year, 2194 PLHIV District Kédougou 78 97 20 26 62 11 119 123% were put on ARVs, or 39% for reports for Kolda 310 233 70 120 75 5 270 116% the annual target. This low annual Number of persons (adults Sédhiou 372 700 275 77 44 41 437 62% performance is due, in part, 1.4.2 monitoring to the low completion rate and children) newly Tambacounda 339 110 47 50 46 49 192 175% TX_NEW (57%), and because the enrolled on ARVs Thiès DHIS2 98 100 15 26 19 11 71 target was not based on the (Mbour) 71% seropositivity rates. The target will be reset in Ziguinchor 574 3092 211 170 154 186 721 23% TOTAL 2290 5572 725 614 483 372 2194 39% consideration of these rates.
Dakar 82.4% 90% 12% 13% The baseline is estimated Percentage of patients on Kédougou 46.3% 90% 50% 56% using CNLS data. Data found ARVs with an undetectable District Kolda 79.6% 90% 63% 70% in the DHIS2 indicate that for viral load reported in reports for Sédhiou 16.4% 90% 1% 1% this year, only 12% of viral 1.4.3 load assays that were registers in a treatment annual Tambacounda 56.6% 90% 0% 0% TX_PVLS performed found detectable center or laboratory monitoring Thiès 20.5% 90% 0% 0% levels. A supervision of the information system in the (Mbour) CNLS, DLSI, and Neema is last 12 months. Ziguinchor 69.7% 90% 8% 9% underway to get updated data for Year 1. TOTAL 74.9% 90% 12% 14% Objective 2: Increased adoption of healthy behaviors Reports 145.9 Diourbel 43.80% 49.00% Initial results of the Percentage of households DHS, DHS-c 71.50% % behavioral survey found that have a designated ESC Kédougou 52.80% 56.20% 43.97% 78.2% 65.69% of households 12.7 space for hand washing Kolda 46.50% 51.20% 47.50% 92.8% have a designated space HL.8.2-5 with soap and water that is Matam 93.20% 88.60% 81.10% 91.5% for washing hands with used frequently by family Saint Louis 94.90% 89.90% 88.65% 98.6% soap and water, or a members 155.0 Sédhiou 47.00% 51.60% 115% performance rate, 80.00% %
USAID/NEEMA Annual Report: 1 October 2016 – 30 September 2017 Page 88
SOURCE/ ACHIEVEMENTS DESCRIPTION OF COLLEC- BASE- FY17 Achiev Achiev Achiev- Achiev- Achiev- # REGIONS Prog- Comments INDICATORS TION LINE OBJEC- -ed -ed ed ed ed ress METHOD TIVES Q1 Q2 Q3 Q4 Y1 169.6 compared to the annual Tambacounda 17.20% 27.80% 47.14% % target. 115.0 TOTAL 53.94% 57.15% 65.69% %
USAID/NEEMA Annual Report: 1 October 2016 – 30 September 2017 Page 89
1.11 Annex 2: Content of Tutorat 3.0 packages
Package Topic Proposed content Services workflow – Information System for Management (ISM) – Systematic Identification of Client Needs (ISBC) – Adolescent/Youth care – Cross-cutting Management of gender mainstreaming– Cross-cutting integration of GBV – Interpersonal Package pregnancy, delivery, communication – Referral/Counter-referral – Infection prevention – Screening 1 and post-partum for cervical and breast cancer – Focused antenatal care – Natural delivery –
Partograph – Active management of the third stage of labor – Post-abortion care – Pre-eclampsia/eclampsia – Management of post-partum hemorrhage – Postnatal consultation – Audit of maternal deaths – Birth registration
Services workflow – ISM – ISBC – FP for adolescents/youth – Cross-cutting gender mainstreaming – Cross-cutting integration of GBV – Referral/Counter-
referral – Infection prevention – Cervical and breast cancer screening – Package Family Planning Interpersonal communication/Counseling – Contraceptive technology, 2 focusing on LTPMs – Management of the FP file – Infertility support – Management of STIs – FP logistics – Nutrition
Services workflow – ISM – ISBC – Cross-cutting gender mainstreaming – Cross-cutting integration of GBV – Interpersonal communication –
Package Referral/Counter-referral – Infection prevention – Screening for cervical and Disease Management 3 breast cancer – Integrated management of childhood illnesses – Maternal and
child nutrition – Expanded Program on Immunization – STI/HIV/AIDS – Malaria
Management of drugs and commodities – Financial management – Human resources management – Procurement management – ISM (area report) – Management and Cross-cutting gender mainstreaming – Cross-cutting integration of GBV – Package organization of services Adolescent- and client-friendly services – Client reception and management 4 of client flow – Continuous improvement in services quality – Biomedical waste management – Supervision – Coordination of SDP activities Development and monitoring/evaluation of work plans and action plans
Social and behavior Situational analysis – Planning/Management of SBCC activities – Development Package change communication of health promotion plan – Monitoring of plan implementation – Cross- 5 (SBCC) cutting gender mainstreaming – Cross-cutting integration of GBV
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Package Topic Proposed content
Using programming and coordination documentation resources to manage Package Community community health activities - Integrated supervision of priority health 6 interventions programs - Supervision specifically for CVAC and VADI strategies - Getting health huts or sites up and running - Introducing a new service
USAID/NEEMA Annual Report: 1 October 2016 – 30 September 2017 Page 91
1.12 Annex 3: Summary of results of FP integration into vaccination services
No. of No. of No. of individuals reached No. of PNC New users of FP methods SDPs Enroll- No. of children consul- DISTRICTS ment sessions vaccinat tations Standard M W T PILL INJECTABLE IMPLANT IUD Days TOTAL rate ed con- Method ducted DIOURBEL MEDICAL REGION Bambey 47 152 86 3294 3380 4785 1027 224 542 61 37 7 871 26% Mbacke 14 52 1 1266 1267 1337 425 97 222 28 6 0 353 28% Touba 9 28 6 778 784 1175 305 48 127 42 7 1 225 29% Diourbel 61 124 897 2636 3064 3001 641 320 456 50 44 0 870 33% KOLDA MEDICAL REGION Kolda 21 210 1134 9615 10,749 8814 1176 80 821 436 8 0 1345 14% Médina Yoro 17 72 455 3421 3876 3442 283 18 129 109 5 0 261 8% Foulah Vélingara 7 124 358 4497 4855 5638 1256 59 393 190 5 0 647 14% MATAM MEDICAL REGION Ranérou 2 20 131 320 451 377 38 22 66 10 0 0 98 31% SAINT LOUIS MEDICAL REGION Podor 4 34 0 984 984 0 0 44 74 11 3 0 132 13% Saint Louis 1 9 0 455 455 419 66 76 103 10 10 0 199 44% Dagana 6 27 44 626 670 518 77 37 146 54 6 0 243 39% SEDHIOU MEDICAL REGION Sédhiou 5 27 55 656 711 832 170 15 118 93 4 0 230 35% Goudomp 7 29 146 1052 1198 1429 525 10 108 257 9 0 384 37% Bounkiling 8 33 72 925 997 873 371 25 173 167 16 0 381 41% TAMBACOUNDA MEDICAL REGION Kidira 3 9 0 191 191 291 40 1 20 12 0 0 33 17% Makacolibantan 3 9 0 180 180 102 43 0 20 10 1 0 31 17% 92
No. of No. of No. of individuals reached No. of PNC New users of FP methods SDPs Enroll- No. of children consul- DISTRICTS ment sessions vaccinat tations Standard M W T PILL INJECTABLE IMPLANT IUD Days TOTAL rate ed con- Method ducted Tambacounda 3 9 42 233 275 353 23 10 53 55 2 1 120 52% Bakel 4 10 0 661 661 498 135 25 45 41 14 2 125 19% Reference 1 3 2 66 68 38 0 5 2 5 2 0 14 21% Center/RH* GRAND TOTAL 223 981 3429 31,856 34,816 33,922 6601 1116 3618 1641 179 11 6562 21%
USAID/NEEMA Annual Report: 1 October 2016 – 30 September 2017 Page 93
1.13 Annex 4: Success Stories
Mediators build trust in key populations “Together, we can do it.” These are the words of “D.,” a young high-school student in Kolda. For the past three years, he has been living as an openly gay man and speaks with disarming calmness about the support he received through the USAID-funded program to test, treat, and retain people infected with HIV with support and guidance from mediators. D. is among those commonly known as key individuals, forming a key population of MSM,3 sex workers, and IDUs,4 characterized by challenges in reaching them because they often go underground. In response to these difficulties, the USAID/Neema project built a strategy around community mediators who initiate a trusting relationship with them to h empower them so that they can come out of hiding and benefit from prevention activities developed by the program. Testing session for an MSM in Kolda D. met Nourou, a mediator in Kolda, and considers him a friend. “Thanks to him, I agreed to get myself tested regularly, and when my result came back positive, he’s the one Photo 2: An MSM gets tested at the laboratory who referred me to get my ARV treatment and to sign up for the mutuelle.” D. learned that he was HIV positive four days before his baccalaureate. Instead of feeling beaten down, he readily confides that the mediator helped him see things from a positive side: “Nourou helped me understand that it’s not the end of the world, that thanks to the program, I can pursue my treatment and follow my dreams, ....” He believes that the mediators are quite understanding and offer life-saving advice. He sees his membership in the CMV+ and the medical treatment as a godsend because he is still a minor who depends on his parents and lives in an impoverished area, where the onset of infections and prescription costs would have exposed his HIV status. From his mediator’s viewpoint, Nourou believes the system set up by the USAID/Neema project lets participants avoid any form of stigmatization by providing regular follow-up of appointments and medical care. “This avoids the risk of their being exposed, reduces the spread of rumors, and promotes psychosocial and medical care. The peer approach that we use is quite simply excellent because it has the advantage of reaching ‘invisible’ individuals and wins them over by maintaining discretion, often a high concern for patients....” Overall, 20 mediators were recruited for key populations (MSM, sex workers, and IDUs) in treatment sites in the regions of Kolda, Sédhiou, Ziguinchor, Thiès (Mbour), Diourbel, Tambacounda (Kidira), Dakar, and Kaolack. In the space of three months, their interventions resulted in screening 3174 individuals from key populations in the regions of Kolda, Sédhiou, and Ziguinchor; and among these, 65 tested HIV positive and were put on treatment. They, along with three family members, were able to enroll in the health mutuelles to support their medical care through CMV+. D., a high school student and MSM, is among these beneficiaries. Speaking about his personal journey and the program support, he sums it up with, “Together we can do it... because I always dreamed of being a surgeon or an agronomist, and thanks to your interventions, I can pursue this dream. I am heartened by the discretion that the program has shown, and I have complete confidence in your support.”
3 Men who have sex with men
4 Injection drug users
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USAID Health Program addresses the challenge of involving local officials
Ely Fall is neither a patron nor a millionaire. He is simply a mayor who is committed to a “local contract to improve health.” He states, “On behalf of the residents I represent, I believe that protecting the health of our people was never more crucial. The commitment we’ve made under the guidance of Réseau Siggil Jigéen is a way for me and my peers to play a genuine role in managing health problems. The moment we take direct action on behalf of the people, we are at the heart of public action.” As part of the Neema project, the Réseau Siggil Photo 3: Advocacy session at Ngoye City Hall Jigéen, in partnership with health districts, identified municipalities affected by acute health problems where advocacy sessions were held. Using an inclusive approach including municipal councilors, who vote on budgets, community members, and providers, the sessions provided a forum to raise relevant arguments for sustainable health investments. According to the Mayor of Ngoye, “It’s true that the municipality of Ngoye has two health posts and four functioning huts. Despite this health system, I’m surprised to learn during this advocacy session, that even today in my municipality, women do not follow the ANC visits and continue to deliver at home regardless of the known consequences and risks. The providers’ testimonies opened my eyes to my responsibility in this situation....” From the people’s perspective, this advocacy is timely. “It gave us an opportunity to sit down with the mayor to tell him about the health problems we are experiencing. Here in Ngoye, pregnant women face problems related to the health post’s geographic accessibility and lack the financial means to do ultrasounds.” Mayor Eli Fall is very aware of these problems and has pledged to provide 3,000,000 FCFA to conduct prevention and promotion activities to put an end to this situation through IEC/BCC activities. Seventeen other mayors in municipalities such as Bona, Yarang, Niani Toucouleur, and Sadio have made unprecedented financial commitments for health in their communities in addition to donated funds, with the goal of helping to reduce maternal and child mortality under the guidance of Réseau Siggil Jigéen through the Neema project. If this positive example spreads and the commitments are kept by all municipalities in Senegal, hundreds of millions of FCFA will be mobilized to save the lives of women and children.
USAID/NEEMA Annual Report: 1 October 2016 – 30 September 2017 Page 95
“These conversations between us ...” Photo 4: Sédhiou session: Discussions among a Youth sub-group This story describes a bridge between communities and providers or how to reconcile needs and services. Only one step was needed between the two: bringing together a “doctor” and his community around a frank and fruitful tête-à-tête. There were all these people who felt unwelcome and sometimes received poor care and all these unsatisfied, unmotivated providers who had been suffering from emotional burnout for a long time!!! This was the situation when the Neema project arrived with the community dialogue frameworks. Initially started to improve client use of facilities, the 14 community dialogue sessions ended up being liberating, or “ndeup,” sessions allowing participants to vent their frustrations and unload long-held, repressed expectations between health actors and beneficiaries. A participant in Koumpetoum had this to say: “This is the first time anyone has sought my opinion about services delivery. I regarded health workers as demigods, who were superior to people. I’m proud to be able to freely give my opinion, and I hope that these dialogue sessions will be held more often.” The dialogue sessions gave people an opportunity to express themselves confidently without reservations about their expectations vis-à-vis workers and, more generally, the facility. The topics ranged from the cleanliness of the bathrooms to the wait-time in facilities, and included harassment experienced by workers. Moctar, head of the village of Kanel sees this as “an opportunity to be listened to and heard” and is even more committed to take measures to motivate his community, for example, behaving with greater civility when using common spaces in facilities. For the youth groups, the exercise offered intermediaries who understood them without stigmatizing them and who could grasp the singularity of their needs. As for providers, they appreciated this opportunity to express their needs vis-à-vis users. “We would like people to follow certain rules to help us take better care of them. For example, we’re criticized for not following measures to provide care for children under 5 years free of charge, but most parents do not automatically provide proof of age for their child.” This was one of the misunderstandings cleared up during the dialogue session. From both the viewpoint of providers and communities, each dialogue session was a rich and dynamic forum for addressing factors that affect the quality of services. In Kolda, the Chief District Medical Officer, convinced by the participants’ criteria, will be the first to take immediate measures. Dr. Mangane began by pledging to renovate the health center bathrooms and to institutionalize these discussion frameworks, etc. To sum up, Korka Baldé, the doorman at the health post in Kolda told us that after 30 years, he is happy to have been able to share his thoughts for the first time on how services are organized at his health post, and thanks to him, there are now information signs to help users better orient themselves. Far from a being a conversation among deaf ears, the dialogue sessions have successfully found common ground between services delivery and communities’ needs!
USAID/NEEMA Annual Report: 1 October 2016 – 30 September 2017 Page 96