Quarterly Report No. 7

April 30, 2016

ANCRE - Quarterly Report No. 7 from January 1 to March 31, 2016 1

ANCRE Advancing Newborn, Child and Reproductive Health Program

Quarterly Report No. 7 January 1 to March 31, 2016

Distribution:

Ricardo Missihoun, USAID/Benin Agreement Officer Representative Michelle Kouletio, USAID/Benin Agreement Alternate Officer Representative

This report was prepared by the USAID/Benin Advancing Newborn, Child and Reproductive Health (ANCRE) program. ANCRE is made possible by the generous support of the American people through the United States Agency for International Development (USAID)/Benin in Cooperative Agreement No. AID-680-A-14-00001. University Research Co., LLC (URC), manages the program in collaboration with Dimagi, Inc. and the Results for Development Institute (R4D).

WARNING: The points of view expressed by the author in this publication do not necessarily reflect those of the United States Agency for International Development of the United States government.

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TABLE OF CONTENTS

ACRONYMS AND ABBREVIATIONS ...... 4 INTRODUCTION ...... 7 SUMMARY TABLE OF ACHIEVEMENTS DURING THE PERIOD ...... 8 MAJOR ACHIEVEMENTS DURING THE QUARTER ...... 12 IR 1: IMPROVED PUBLIC HEALTH SECTOR PERFORMANCE ...... 12 IR 1.1: Improved planning and management of health systems and services, especially at the decentralized level ...... 12 IR 1.2: Improved quality of service delivery in private health facilities, especially for women and young children ...... 13 IR 1.3: Essential commodities more available at service delivery and distribution points ...... 14 IR 2: IMPROVED PRIVATE HEALTH SECTOR PERFORMANCES ...... 17 IR 2.1: Improved public sector policies, oversight and supervision of private sector health care delivery ...... 17 IR 2.2: Improved quality of service delivery in private health facilities, especially for women and young children ...... 17 IR 3: IMPROVED PREVENTION AND CARE-SEEKING BEHAVIOR OF AN EMPOWERED POPULATION ...... 19 IR 3.1: Increased Appropriate Health Promoting Behaviors Made by Households and Especially Women ...... 19 IR 3.2: Informed families make appropriate choices for accessing public and private sector health services and commodities ...... 20 IR 3.3: Strengthened community-level contributions to health sector decisions and financing . 22 SUPPORT FOR MANAGING THE LASSA FEVER EPIDEMIC ...... 23 ANCRE PROJECT VISIBILITY ACTIVITIES ...... 24 PROJECT MANAGEMENT ...... 25 PARTNERSHIP AND COLLABORATION ...... 25 PERFORMANCE MONITORING...... 27 PROBLEMS/CHALLENGES ...... 31 APPENDICES ...... 32 APPENDIX 1: Progress of programmed activities from January to March 2016 ...... 32 APPENDIX 2: Visitors and consultants received ...... 42 APPENDIX 3: Changes in performance indicators ...... 43

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ACRONYMS AND ABBREVIATIONS

AGR Activité Génératrice de Revenu

AMDEC Analyse des Modes de Défaillance, de leurs Effets et de leur Criticité

ANCRE Advancing Newborn, Child and Reproductive Health Project

ANV Agence Nationale de Vaccination

AS Abomey-Calavi – Sô-Ava

AZT Allada – Zè - Toffo

CAME Centrale d’Achat des Médicaments Essentiels

CBGH Comè – Bopa – Grand-Popo – Houèyogbé

CCSC Communication pour un Changement Social et Comportemental

CHUD-BA Centre Hospitalier Universitaire Départemental du Borgou-Alibori

COZO Covè – Zagnanado – Ouinhi

CPN Consultation Pré Natale

CPN-R Consultation Pré Natale Recentrée

CRAMS Chargés de Recherche et d’Appui à la Mobilisation Sociale

CSU Couverture maladie universelle

DCO Djougou – Copargo – Ouaké

DDS Direction Départementale de la Santé

DHIS2 District Health Information System 2

DIP Direction de l’Information et du Pré-archivage

DIU Dispositif Intra Utérin

DNEHS Direction Nationale des Etablissements Hospitaliers et Soins

DNSP Direction Nationale de la Santé Publique

DPMED Direction de la Pharmacie et du Médicaments

DPP Direction de la Programmation et de la Prospective

DRFM Direction des ressources financières et du matériel

DRZ Dépôt Répartiteur de Zone

DSME Direction de la Santé de la Mère et de l’Enfant

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EAQ Equipe d’Amélioration de la Qualité

EEZS Equipe d’Encadrement de Zone Sanitaire

ERPA Evaluation Rapide de la Performance des Agents de santé

ETME Elimination de la Transmission de la Mère à l’Enfant

RBF Financement Basé sur les Résultats

FHVL Fièvre Hémorragique Virale de Lassa

FS Formation Sanitaire

FSP Formation Sanitaire Privée

GF Groupement Féminin

KGS Kandi – Gogounou – Ségbana

MCZS Médecin Coordonnateur de Zone Sanitaire

MS Ministère de la Santé

OBC Organisations à Base Communautaire

OMS Organisation Mondiale de la Santé

ONG Organisation Non Gouvernementale

PF Planning Familial/Planification Familiale

PFE Pratiques Familiales Essentielles

PIC Plan Intégré de Communication

PIHI Paquet d’Interventions à Haut Impact

PMP Plan de Monitoring du Projet

PNLP Programme National de Lutte contre le Paludisme

PNLS Programme National de Lutte contre le Sida

POS Procédures Opérationnelles Standards

PRPSS Programme de Renforcement de la Performance du Système de Santé

PSSP Plateforme du Secteur Sanitaire Privé

PTF Partenaire Technique et Financier

RAMU Régime d’Assurance Maladie Universelle

RC Relais Communautaire

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RI Résultat Intermédiaire

SABA Savalou – Bantè

S&E Suivi et évaluation

SGSI Service de la Gestion du Système d’Information

SMNNI Santé Maternelle, Néo Natale et Infantile

SNIGS Système National d’Information et de Gestion Sanitaires

SR Santé de la Reproduction

UNICEF Fonds des Nations Unies pour l’Enfance

URC University Research Co., LLC

URC-CHS University Research Co., LLC-Center for Human Services

USAID Agence des Etats-Unis pour le Développement International

VIH Rus d’Immunodéficience Humaine

ZS Health Zone

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INTRODUCTION

The Advancing Newborn, Child and Reproductive Health (ANCRE) program is financed by USAID. ANCRE supports the Ministry of Health, its partners and communities to address the direct causes of maternal and child mortality in Benin. Implemented by University Research Co. LLC (URC) with Results for Development Initiative (R4D) and Dimagi Inc. as key partners, the program operates in 10 health zones (HZ) throughout 5 departments:  Kandi – Gogounou – Ségbana (KGS) and Tchaourou in Borgou-Alibori (Northeast)  Djougou – Copargo – Ouaké (DCO) and Bassila in Atacora-Donga (Northwest)  Savalou – Bantè (SABA) and Covè – Zagnanado – Ouinhi (COZO) in Zou-Collines (Central Benin)  Cotonou 2 & 3, Abomey-Calavi – Sô-Ava (AS) and Allada – Zè – Toffo (AZT), in the Atlantic Littoral (South)  Comè – Bopa – Grand-Popo – Houèyogbé (CBGH) in Mono-Couffo (Southwest). ANCRE is in its second year of implementation. The program covers a population of 3,500,000 inhabitants representing one third (33%) of the total estimated population of Benin in 2014. The activities conducted by the program in collaboration with the Ministry of Health take place in the public and private health sectors as well as at the community level. The anticipated results are:

1. Improved public health sector performance in delivering integrated family health services;

2. Improved private health sector performance in delivering integrated family health services;

3. Improved prevention and care-seeking behavior of an empowered population.

This activity report presents the major achievements of the project from January 1 to March 31, 2016.

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SUMMARY TABLE OF ACHIEVEMENTS DURING THE PERIOD

Intermediate Results Deliverables Results from January to March 2016

INTERMEDIATE RESULT 1: IMPROVED PUBLIC HEALTH SECTOR PERFORMANCE IN DELIVERING INTEGRATED FAMILY HEALTH SERVICES

Intermediate sub-result 1.1: Improved  1. Each zone uses an improvement plan with The Quality Improvement (QI) Plans developed previously planning and management of health performance indicators were revised for 9 of the 10 zones during the orientation systems and services, especially at the sessions on the collaboratives 2. Gender considerations are integrated in decentralized level:  Orientation of 58 persons (including 16 health workers and 42 planning and services provided women’s’ group (WG) members) on gender in two health

3. CommCare pilot phase introduced in two zones: AS and CBGH health zones incorporating lessons learned  Dissemination of the Ministry of Health’s “gender” and application updates institutionalization strategy to 93 persons, including 62 women  Updated the CommCare application with the introduction of two different modules (monitoring of pregnant women and newborns and management of inputs at the community level). The application is now operational in the Tchaourou and Bassila zones and used by 77/185 (42%) and 50/105 (48%) community health workers in the two zones respectively. Intermediate sub-result 1.2: Improved 1. Conformity of PIHI services with national  Compliance of PIHI services in 2 HZ (AS and CBGH) with the quality of service delivery in public standards is improved progressive use of national standards especially for the health facilities, especially for women 2. Quality improvement teams regularly collaborative package being implemented (PNCr, FP, and young children monitor improvement plans in the 10 health childbirth, immediate postnatal care and healthy infant zones checkups) during the coaching visits conducted by midwives and zone nurses trained in coaching techniques by the project. 3. A patient/user referral and support system  Monthly monitoring of the performance of Quality between public and private health facilities Improvement (QI) teams by a team from the Ministry of and the CHWs is functional. Health with the support of ANCRE project personnel in three zones (Cotonou 2&3, COZO and AS)

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Intermediate Results Deliverables Results from January to March 2016 Intermediate sub-result 1.3: Essential 1. The health facilities comply with the  Finalization of the Failure Mode and Effects Analysis (FMECA) commodities more available at service standards and management parameters of tables, tools test monitoring and the FMECA tables with actors delivery and product distribution LMIS-PIHI inputs from the project’s health zones points 2. The health facilities regularly submit  Finalization of the Standard Operating Procedures (SOP) management reports on PIHI inputs document and the pocket guide on health products

management is underway  Training 6 zone distribution warehouse managers on drugs and essential commodities logistics  Data collection in 230 of 243 health facilities (95%) in 9/10 HZ  63% of the health facilities have made contraceptive tracer commodities available and 70% could make reproductive health tracer commodities available INTERMEDIATE RESULT 2: IMPROVED PRIVATE HEALTH SECTOR PERFORMANCE IN DELIVERING INTEGRATED FAMILY HEALTH SERVICES Intermediate sub-result 2.1: Improved 1. At least 75% of the activities planned in the  20/47 (43%) of the health clinics in 6 HZ were approved for an public sector policies, oversight and roadmap during the course of the year authorization to open and to operate a health facility engaging supervision of private sector health have been carried out in the practice of medicine with a private clientele. care delivery  Advocacy and consultations with the platform led to the recruitment of an assistant and the establishment of the platform’s secretariat that will coordinate the sector’s activities and be a partner for the project’s implementation in the private sector.

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Intermediate Results Deliverables Results from January to March 2016 Intermediate sub-result 2.2: Improved 1. 100% of the private health facilities (PHF)  Training of 22 staff members from 16 member organizations of quality of service delivery in private selected to receive ANCRE oversight have the private health sector platform (PHSP) via the Association health facilities, especially for women been assessed on the basis of quality of of Private Clinics of Benin on “client focus” and young children services (technical and user perception)  Information and orientation of 54/68 selected private health 2. 100% of the PHF selected are implementing facilities (79%) in the project’s zones on the process of PIHI introducing PIHI and the accreditation program 3. Functional QI teams in 100% of the PHF  Development of the rapid assessment protocol and tools on have been selected quantity and quality of PIHI services in reference to national 4. Incentives for motivating providers to standards and procedures improve the quantity and quality of PIHI  The study on setting up contracts between the PHF and services have been implemented in 50% of insurance schemes is underway the PHF selected 5. The obstacles to collaboration between private establishments and health insurance schemes are known

INTERMEDIATE RESULT 3: IMPROVED PREVENTION AND CARE-SEEKING BEHAVIOR OF AN EMPOWERED POPULATION Intermediate sub-result 3.1: Increased 1. The tools are ready for the implementation  Validation of the KGS Health Zone’s Integrated Communication appropriate health promoting of social and behavior change Plan (ICP) behaviors made by households and communication activities (SBCC)  Training 42 members of 14 community-based organizations 2. Health care providers, NGOs, CHW, and especially women (CBO) (including 40 women) in health promotion in the CBGH women’s groups selected use standardized and AS HZ on Essential Family Practices (EFP) and presentation tools to lead SBCC activities techniques for educational talks.  83 educational sessions conducted on essential family practices (EFP) by the members of twenty (20) women’s groups in three health zones (COZO, CBGH, and AS) reaching 3,312 persons, including 374 men. The number of prenatal consultations (PNC) rose from 43 to 71 between December 2015 and February 2016 in the Naogon (Cove commune) health zone after the educational sessions

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Intermediate Results Deliverables Results from January to March 2016 Intermediate sub-result 3.2: 1. The HZ community health workers conduct  Training and equipping of 161 of 191 CHW (84.3%) from the Informed families make appropriate promotion and case management (PEC) Tchaourou HZ on the Lassa Hemorrhagic Fever (LHF) epidemic. choices for accessing public and activities in their communities The CHW use these skills for community outreach 2. The CommCare mobile application private sector health services and  13 head nurses were trained to coach the community health functions for the case management of the commodities workers and monitor community activities using CommCare in three childhood illnesses, FP counseling, the two zones the monitoring of pregnant women, and  Verification of the quality of case management carried out by the management of PIHI inputs the community health workers during the monthly monitoring 3. Actors in the health pyramid, including the group of 161 CHW out of 191 (84.3%) in the Tchaourou HZ central level, are proficient in the use of the  73% of CHW are using the CommCare application effectively mobile application and ensure that the CHW are coached and the application’s use maintained

Intermediate sub-result 3.3: 1. The community QI teams are in place in the  In the Bassila HZ, a total of 29/31 (94%) community QI teams Strengthened community-level zones and have established priorities on have been put in place with a total of 323 members, including contributions to health sector the basis of the results of the analysis 72 women. The improvement plans will be developed during decisions and financing conducted; community action plans the next quarter  Definition of a consensual approach to collaboration with the initiated actors of the social mutuelles  Briefing of 14 print and broadcast journalists, including 6 women, on the concept of universal health insurance SUPPORT THE MANAGEMENT OF VIRAL HEMORRAGHIC FEVER (VHF) 1. Contribute to the resolution of the viral  Training of 31 providers from the Tchaourou HZ on preventive hemorrhagic fever epidemic, including measures against LHF and the care of infected persons Lassa Fever  Training of 10 CHW and 6 Papané village chiefs on tracking case contacts  Provision of equipment and medical consumables to the Papané zone hospital, the Borgou-Allibori departmental hospital and health centers in Tchaourou districts.

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MAJOR ACHIEVEMENTS DURING THE QUARTER

IR 1: IMPROVED PUBLIC HEALTH SECTOR PERFORMANCE

IR 1.1: Improved planning and management of health systems and services, especially at the decentralized level

Support the development and implementation of improvement plans at the zonal level: The quality improvement teams of 5 HZ (Tchaourou, COZO, SABA, and Cotonou 2&3) participated in various collaborative sessions organized in their respective zones. At the end of these sessions, each team developed a quality improvement plan based on interventions such as the refocused prenatal consultation (PNCr), childbirth and immediate postpartum care, family planning (FP), and healthy child checkups.

In addition, the sessions on the collaboratives provided information to participants and strengthened their skills on the national standards now in force. The quality improvement plans of nine out of ten health zones were finalized during these collaborative sessions.

Orientation of members of women’s groups on “gender”: In the AS and CBGH health zones, participants were oriented on gender using two tools: the “activities profile” and the “intergenerational perspective.” In total, 2 members of the health zone management team (HZMT) (including 1 woman), 14 head nurses (including 6 women) and 42 members of community/women’s groups (CBO) (including 40 women) became aware of the concept of gender. They discussed the division of household tasks between men and women, the importance of adopting a modern contraceptive method — everything that will contribute to giving women the opportunity to conduct income-generating activities for their own empowerment and the well-being of their families.

Orientation of health workers and NGOs on the Ministry of Health’s “gender” institutionalization strategy: Three orientation sessions were conducted with public sector providers and NGO partner officials. In total, 10 Health Zone Physician Coordinators and 7 DSME officials (including 4 women), 8 monitoring and evaluation officials from NGO partners (including 3 women), and 68 providers (including 55 women) from Cotonou 2 & 3 and AS health zones. This orientation informed the participants about the Ministry of Health’s “gender” institutionalization strategy.

The mobile (CommCare) application in the health zones: During this quarter, the project continued the integration of the CommCare application in Tchaourou and Bassila to improve real-time reporting of community activity data. This made it possible for actors at different levels to have real-time, useable data on the care of the three priority childhood illnesses at

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the community level — malaria, diarrhea, and acute respiratory infections. The management module on the inputs stock at the community level and the monitoring of pregnant women and newborns has been developed, taking into consideration the procurement process for inputs by community health workers. They have been validated by the Ministry of Health (MOH) and will be deployed in the field during the next quarter.

Principal activities planned for the next quarter  Organize the collaborative session in the Bassila health zone  Train the remaining Tchaourou and Bassila CHW on the use of CommCare and provide them with cellphones equipped with the CommCare application  Strengthen the capacity of the NGO actors (SIAN’SON and DEDRAS) and the Tchaourou and Bassila zone statisticians on the collection and analysis of CommCare data and monitor the CHW using CommCare

IR 1.2: Improved quality of service delivery in private health facilities, especially for women and young children

Train providers in PIHI clinical skills: Following the identification of needs during the situational analysis, trainings were organized on contraceptive technology and counseling in the AS health zone The trainings strengthened the capacities of 23 maternity service providers (nurses and nationally-trained midwives) and the availability of family planning services in this zone.

Photos 1 and 2: Practicing the TCU-380-A IUD pose on the anatomical model of the pelvis (left) and insertion of Jadelle into a client by a FP training participant (right)

Coaching and Supportive Supervision: Coaching visits for the QI teams were conducted by the zonal coaching teams with the support of the project in 3 health zones: Cotonou 2&3, COZO, and AS. The coaching visits occurred 2 months after the orientation sessions on the collaboratives, demonstrating that health facilities that have been coached have greater

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respect for the norms and standards of providers as defined at the national level, especially with regard to PNCr, childbirth, and immediate postpartum care, as well as healthy child checkups. During this visit, monitoring sheets were completed to estimate the proportion of criteria sought, illustrating the quality services provided to clients in accordance with national standards. The results from all zones will be better illustrated when the coaching has been carried out in the remaining 7 health zones during the next quarter.

Principal activities for the next quarter  Update the knowledge of providers in clinical FP and counseling in the COZO, AZT, and KGS health zones  Introduce the trainers and midwives in charge of the health zones to online training on the policy of the United States Government with regard to FP  Organize coaching visits in the project’s other HZ (CBGH, Tchaourou, KGS, SABA, AZT, DCO and Bassila)  Organize a joint coaching visit (Public and Community clusters) in the Tchaourou health zone

IR 1.3: Essential commodities more available at service delivery and distribution points

Harmonization of Standard Operating Procedures (SOP): A consultant has been recruited to develop a standard operating procedures manual and a pocket guide for the management of PIHI inputs. These documents take the community, public, and private health facilities into account. The data collected from the actors involved in the product supply chain have been analyzed by the Failure Mode, Effects, and Criticality Analysis (FMECA) method to develop the POS document being finalized.

Monitoring the logistics of drugs and essential commodities (Public Sector): ANCRE contributed to the training of distribution depot managers in 6 health zones, including Tchaourou, Cotonou 2&3, AS, AZT, Bassila, and CBGH. This training made it possible for 5 health zones to correctly quantify their needs for RH/FP commodities based on the distribution data and the norms and standards in regards to supplies.

Subsequently, ANCRE provided technical and financial support to the health zones to conduct active logistical data collection at the health facility level to induce the health facilities to submit monthly reports on PIHI inputs to the distribution warehouses. Five reports out of an expected 6 were produced by health facilities for the period October 2015 to February 2016. The collection was conducted by health zone management teams under the supervision of the zone Physician Coordinator or from CAR/HZ.

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The data collection took place in 9 out of 10 health zones, with the exception of the Tchaourou HZ, and included 230 out of 243 health facilities (95%). This active data collection made available timely and quality data on the consumption of RH/FP tracer commodities at the health zone level, thus providing good visibility of the situation of real time inputs at the zonal level. This exercise improved the completeness of the data as shown in Chart 1 below.

Chart 1: Percentage of health facilities submitting a report on PIHI commodity tracers, by health zone, to March 31, 2016.

In all 9 HZ, 95% of health facilities were able to make available monthly reports on contraceptive commodities and 91% of health facilities produced reports on RH for October 2015 to February 2016.

Chart 2: Percentage of health facilities that did not have a stockout in contraceptive methods that they had implemented from January to March 2016 in 9 HZ by commodity

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On average, more than 60% of health facilities in 9 HZ were able to make contraceptive tracer commodities available during the first 2 months of this quarter. Most of the health facilities carry short duration methods while several health facilities have had stockouts of other methods.

Chart 3: Percentage of health facilities in nine HZ by commodity that did not have a stockout of reproductive health commodities from January to March 2016

On average, more than 70% of health facilities were able to make contraceptive tracer commodites available during the first 2 months of this quarter. Most health facilities have products for intermittent preventive treatment, the active management of the third stage of labor, and the treatment of infections, anemia, malaria, and diarrhea/nutrition. Several health facilities have had stockouts of other commodities for the management of pre- eclampsia/eclampsia and Prevention of Mother to Child Transmission (PMTCT).

Principal activities planned for the next quarter  Validate the Standard Operating Procedures manual  Distribute the Standard Operating Procedures manual  Support the semi-annual organization of the End Users Verification (EUV) in the 10 HZ.  Support the implementation of a national LMIS for PIHI inputs

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IR 2: IMPROVED PRIVATE HEALTH SECTOR PERFORMANCES

IR 2.1: Improved public sector policies, oversight and supervision of private sector health care delivery

Authorization to practice medical and paramedical professions with private clients and for the opening and operating of private health establishments: With the support of the project, during the past quarter, 47 private health facilities that did not have legal authorization for the private practice of medicine were inspected to regularize their situation. Of 47 files examined by the national commission, 20 have obtained their authorization including 8 doctors’ offices and 12 medical offices in 6 HZ (AS, Cotonou, AZT, KGS, Tchaourou, DCO). ANCRE continued to strengthen its support to the private health sector through its platform so that technical preparation work is done prior to the filing of applications in order to significantly improve the quality of submissions and the rate of obtaining authorizations. Establishment of a PSSP secretariat: The platform of Benin’s private health sector, a key organization of the private health sector’s actors, did not have a physical headquarters or personnel. ANCRE facilitated an exchange process between private actors on the one hand and the Ministry of Health on the other, which helped to establish a technical secretariat for the private sector platform. To this end, the MINAH Company, a specialist in the distribution and installation of medical devices, provided an office on its premises that will serve as the headquarters for the PSSP secretariat. A technical secretary has been recruited for PSSP management and will be in place at the beginning of the next quarter.

Principal activities planned for the next quarter  Finalize and technically validate the accreditation manual  Conduct the Rapid Assessment of the performance of private sector health workers  Support the technical commission session responsible for processing authorization to open requests and operation of private health establishments

IR 2.2: Improved quality of service delivery in private health facilities, especially for women and young children

Training of PSSP clinical staff members on “client focus”: At the request of Benin’s private clinics association, a member of Benin’s private health sector platform, ANCRE organized a training on “client focus” in February and March 2016 for 22 participants (including 17 women) from 16 clinics. This training generated awareness about the importance of paying attention to the quality of care provided. It will be scaled up in the training and coaching package for sustainable quality improvement in the private sector.

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Private facility information on the introduction of PIHI and accreditation: In the perspective of introducing PIHI at the private health facility level, 68 of these establishments were selected for a start-up phase. To ensure full compliance of the private sector actors, ANCRE, in collaboration with the Ministry of Health through the zone physician coordinator, held a work session with the officials from these health facilities from February 29 to March 5, 2016. Officials from 54 out of 68 health facilities (79%) participated in this information session and agreed on principle to participate in this baseline study.

Private sector contracts for health insurance schemes: ANCRE has recruited a consultant to conduct an in-depth study on establishing private sector contracts for health insurance schemes. The protocol of these studies is being finalized with the technical support of R4D and the study will be carried out during the next quarter so that results are available.

Development of the protocol and design of the Rapid Assessment of Health Worker Performance (ERPA) in private facilities: Conducting ERPA was noted regarding making the database available for the introduction of PIHI in the private sector. To this end, the study protocol and investigative tools were designed in order to conduct the assessment during the next quarter.

Principal activities planned for the next quarter

 Conduct the Rapid Assessment of the performance of private sector health workers  Monitor the conduct of the in-depth study on establishing private sector contracts for health insurance schemes.  With actors from health insurance and the private sector, organize a workshop to develop a roadmap to improve collaboration between health insurance schemes and private health facilities  Start the accreditation program process for private health facilities by enrollment  Start the process of building capacity to integrate the provision of PIHI services (FP) in the private sector

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IR 3: IMPROVED PREVENTION AND CARE-SEEKING BEHAVIOR OF AN EMPOWERED POPULATION

IR 3.1: Increased Appropriate Health Promoting Behaviors Made by Households and Especially Women

Validation of the KGS Integrated Communication Plan: This validation marks the end of the health zone’s ICP development process. It has included the active participation of 24 people (including 2 women) representing various stakeholders in the health zone (mayoral representatives, Kandi central Iman, representative of the Bishop of Kandi, official from the center of social promotion (CPS), King of Kandi, community health workers, CBO and HZMT from KGS) and Technical and Financial Partners (TFP) such as UNICEF and the DEDRAS ONG.

Training and monitoring of CBO in health promotion: During this quarter a total of 42 members of 14 CBOs (including 40 women) were trained in the CBGH and AS health zones on Essential Family Practices (EFP) and presentation techniques for educational talks. Head nurses were trained on EFP, the “gender” concept and tools, and also on community coaching for monitoring women’s groups in the field. The CBOs which have undergone training will be actively engaged in health promotion activates, especially PIHI, beginning in the next quarter. Moreover, they will benefit from material and inputs support for revenue- generating activities for which ANCRE will partner with other actors.

In the COZO, CBGH, and AS HZ, members of 6 trained groups have already each led at least 2 educational sessions per month (83 total), under the supervision of coaches during the reporting period. The management tools have also been well-stocked. In the COZO, CBGH, and AS HZ, 3,312 persons have attended awareness-raising and health education sessions, including 374 men. The remaining participants (2,938) were pregnant women, mothers and caregivers of children under 5, and women of reproductive age. For example, following the training received, women’s groups (Alowanou from the Ouinhi-Central neighborhood) conducted an awareness-raising session on Lassa fever onsite for the teachers and students of the Ouinhi-Central public elementary school and provided this school with 2 hand washing appliances.

Communication activities for social and behavioral change led by women’s groups and the CBO made an impact on the use of services. As shown in Chart 4, the number of prenatal consultations (PNC) rose from 43 to 71 between December 2015 and February 2016 in the Naogon (Cove Commune) health zone. Field monitoring results indicate that this trend should continue in the future.

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80 70 67 71 60 49 50 45 40 40 30 20 10 Women’s Group Intervention 0 Sep-15 Oct-15 Dec-15 Jan-16 Mar-16

Chart 4: Evolution of the number of PNC in the Naogon health zone (Cove commune) before and after women’s group activities: effect of educational talks led by the women’s groups Photo 3: Educational talk led by a female group member

Principal activities planned for the next quarter  Develop and put in place the functional community system model in the project’s 10 zones, especially in the 6 zones without NGOs  At the zonal level, strengthen the provision for the continuum of care on the basis of norms and standards and documented best practices  Finalize and distribute communication material to the actors  Put in place and operationalize the partnerships necessary for training radio presenters, broadcasting radio emissions on local radio stations identified in the health zones, implementing integrated communication plans, and presenting community awareness-raising sessions on various themes, such as gender, family planning, and maternal and child health

IR 3.2: Informed families make appropriate choices for accessing public and private sector health services and commodities

Use of the mobile application by the community health workers: A field visit with a DIMAGI consultant in the Tchaourou health zone in February, coupled with the joint follow-up organized by the SIAN’SON NGO, monitored CHW-led activities. The purpose of this supervision was to strengthen the capacities of the CHW, head nurses (CP), Statistician, Head of Research and Support to Social Mobilization (CRAMS), and NGO actors involved in activities at the community level through the use of the CommCare application.

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Seventy-three (73%) of the community health workers use the application effectively. CRAMS, the Statistician and the SIAN’SON NGO were provided with a tool for supervising the CHW using CommCare to monitor the work that each CHW performs and to assist them if needed.

To monitor the CHW’s use of the application and to improve the monitoring of their work, the head nurses will track the percentage of CHW submitting 10 or more reporting forms per month.

Training of Community Health Workers on Lassa hemorrhagic fever: With the outbreak of the hemorrhagic fever epidemic, the ANCRE team, in collaboration with the SIAN’SON NGO and the head nurses from the Tchaourou health zone, began monthly group monitoring to train the CHW on the Lassa Fever epidemic, the mode of transmission, and prevention measures. Materials for protection (gloves, bibs, and bars of soap) were provided. 161 community health workers were equipped to raise community awareness about the epidemic and preventive measures, as well as for community-based monitoring of the disease. These community health workers were able to identify and notify the health centers regarding several suspect cases through which rapid disease management contributed to halting the epidemic in the zone.

One month after the response to the Lassa epidemic, a mission was carried out to assess the effectiveness of this response, evaluate new needs in the Tchaourou HZ and review the response plan that includes the supply of inputs. It was noted that the actions led by ANCRE together with the departmental and health zone officials slowed the progression of the epidemic in the department. The new assessed needs helped to refocus the action plan for the Ebola project. There was a general decline in Lassa Hemorrhagic Fever (LHF) in the department.

Monthly Group Monitoring of Community Health Workers’ Activities: In February 2016, ANCRE supported the SIAN’SON NGO in leading the monthly group monitoring of the CHW in the Tchaourou health zone. 161 CHW out of the 191 trained (84.3%) were supervised in the health center during which the registers as well as the monthly data summary tools were reviewed. Adjustments were made to improve data collection.

Principal activities planned for the next quarter  Develop and put in place the joint partnership and operational planning for the implementation of ICP in each of the ten zones  Provide registers to the CHW for implementing their activities in the KGS, Tchaourou, DCO, and Bassila HZ  Strengthen the capacities of the DEDRAS NGO actors in Bassila and the head nurses on monitoring CommCare activities

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 Strengthen the capacities of the community health workers and head nurses in Tchaourou and Bassila on supplementary stock management modules and monitoring pregnant women and newborns

IR 3.3: Strengthened community-level contributions to health sector decisions and financing

Put in place quality improvement teams and quality control of services: A total of 29/31 (94%) of QI teams, each composed of 7 to 10 people, have been placed in the Bassila HZ, after training the members of the Health Centers Management Committees (COGECS) from various health zones on community coaching. These community QI teams, totaling 323 members, including 72 women, will be placed in networks (collaboratives) and trained in their roles and responsibilities in the management of service quality as well as activities to carry out in the collaborative.

Monitoring 4 QI teams helped to improve their performance through effective consultation, awareness-raising, and safety campaigns. Additional effort should be made to provide these teams with technical support through coaching to further improve their performance.

Analysis of the current situation of the social mutuelles and RAMU and definition of a consensual collaborative approach with the actors of the health insurance sector in the ANCRE zones: As part of this activity, meetings were conducted from January 26 to February 29 with the officials of 13 mutual benefit societies, 6 support structures, and 2 promoters. These meetings made it possible to (i) present the summary of the results of the analysis of the current situation of the social mutuelles and RAMU in the 10 intervention zones; (ii) collect their observations of these results; (iii) update the database of mutual benefit societies, and (iv) share possibilities for collaboration with them to promote the social mutuelles.

At the end of this mission, it was noted that:  The results presented were, on the whole, approved by all the actors involved;  In terms of performance, only 23 of 56 mutuelles identified by the current situation analysis continue, as of January 2016, to participate in mutual benefit societies and offer case management services to their members in 7 ANCRE zones, namely: CBGH, AS, Cotonou 2 and 3, DCO, Tchaourou, KGS, and Bassila;  The availability of the actors involved to collaborate is clear and verbal agreements to co-finance activities have been obtained.

A joint support plan for activities having a large impact on the increase in the number of households participating in a health financing mechanism was developed for 23 functional mutuelles.

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Effective and sustainable implementation of RAMU: As part of the support for orienting the decision-makers for effective and sustainable implementation of RAMU, ANCRE provided technical and financial support to organize an information session for journalists on Universal Health Coverage (UHC) following the recommendations of the regional peer-to- peer learning seminar on universal health insurance in Ghana, in which Benin participated. Briefings of 14 print and broadcast journalists on the concept of UHC and its importance in strengthening health systems, as well as its likely role in their development were held from February 15-19, 2016. The anticipated effect of this session is that once equipped, the journalists will view UHC from the perspective of maintaining and effectively implementing the Universal Health Insurance Scheme in Benin.

Principal activities planned for the next quarter

 QI teams develop improvement plans  Implement the support plan in the 23 functioning social mutuelles  Implement an awareness-raising program for households on health insurance by the community health workers using the cellphone via CommCare

SUPPORT FOR MANAGING THE LASSA FEVER EPIDEMIC

In partnership with various Ministry of Health organizations and other TFP, ANCRE was involved in the response against the LHF epidemic in the Tchaourou commune and at the Centre Hospitalier Universitaire Départemental of Borgou-Alibori (CHUD-BA).

ANCRE trained 31 providers from the Tchaourou HZ on preventive measures against LHF and the care of infected persons, as well as 10 CHW and 6 Papané village chiefs on tracking case contacts. A supply of material and medical consumables (solutions, infusers, catheters, gloves, blouses, single-use gowns, bibs, glasses, boots, aqueous alcohol solution, 4 laser thermometers, 7 tanks including 4 in Papané etc.) has been provided to the Papané zone hospital and to the health centers in Tchaourou districts, as well as to CHUD-BA.

Photos 4, 5 and 6: Delivery of medical consumables to the providers trained on preventive measures against LHF (left) and delivery of water tanks to the Papané hospital and CHUD-BA (center, right)

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Moreover, ANCRE attended the field visit organized by the Ministry of Health, together with USAID and WHO, as part of the response to LHF.

The Ministry of Health set up thematic sub-committees that meet periodically and in which ANCRE participates in case management and communication. This participation has helped the program to contribute actively to the design of several messages and communication support including press reports, a pamphlet, comics, posters, and commercials on Lassa fever in populated areas. The pamphlets were widely distributed to communities and health workers in affected areas.

ANCRE PROJECT VISIBILITY ACTIVITIES

Additional activities conducted during the quarter are summarized below.

Development of the ANCRE project’s quarterly bulletin: Intended for health and other TFP actors, this bulletin summarizes the essential information on work carried out during the quarter and the results obtained. The first issue covers October to December 2015.

Writing a success story on ANCRE’s response to Lassa fever: This success story highlights the effectiveness of the ANCRE project’s response to the Lassa fever epidemic in the Tchaourou health zone. ANCRE provided technical support and materials which were well received by various actors in the health system, especially in the Papané zone hospital and the Borgou-Alibori DDS to which cases were referred.

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PROJECT MANAGEMENT

During the period covered by the report, the new project director took office as well as the technical advisor in child, infant, and maternal health, and the private sector technical advisor. Recruitment of Ebola personnel is still underway and it is expected that, in addition to the financial assistant already recruited, the remainder of the team will be in place before the end of April.

The signing of the URC-CHS Headquarters Agreement took place on February 12, 2016 at the Ministry of Foreign Affairs, African Integration, la Francophonie and Beninese Abroad.

Principal activities planned for the next quarter  Complete the recruitment of the Ebola team and the organization of the expanded review meeting on the response and updating of needs  Put in place and organize a session of the ANCRE Advisory Board with officials from the Ministry of Health’s technical directorate.  Conduct a field mission to monitor activities and update operational needs jointly with the Ministry.

PARTNERSHIP AND COLLABORATION

The following activities have been conducted during the period covered by this report:  On February 25, 2016, ANCRE took an active part in a work session on methodological guidelines with the consultant in charge of the mid-term evaluation of the 2009-2018 National Health Development Plan and the return of the evaluation checklist.  During the period covered by the report, a work session with UNICEF on the question of installing a water supply at the Papané hospital recommended that a feasibility study be conducted to determine if drilling was successful. This was in addition to the purchase and installation of medical tents. It was agreed that ANCRE would address the feasibility study with USAID at a later date.  ANCRE also participated in the ETME-MNCH working group meeting at the UNICEF office bringing together WHO, UNAIDS, France-Expertise, and UNICEF to harmonize neonatal and child health guidelines and the integration of the Prevention of Mother to Child HIV Transmission in MNCH activities.  A meeting with DPMED provided the opportunity to discuss needs for sanitary gel in the fight against the Ebola virus and other forms of viral hemorrhagic fevers. ANCRE will explore to what extent these commodities may be acquired for the HZ that need them.

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 ANCRE participated in the consultation on the implementation of community PIHI in urban and peri-urban health zones organized by the Ministry of Health on January 27, 2016. Recommendations were made regarding the use of women’s groups. At this meeting, ANCRE was asked specifically to make available the reporting tools to the specially trained CHW in the 10 zones.

Coordination meeting between the DDS, MCZS, DSME, and ANCRE: The meeting took place on February 9 - 10, 2016 at the BEL AZUR hotel (Grand-Popo) between the DDS, MCZS, DSME, and ANCRE. It brought together some 30 managers from DSME, DNSP, DPP, DDS, and MCZS (from the 10 intervention zones) as well as a representative from USAID. This meeting was intended to serve as a framework for coordination and periodic consultations (quarterly/ biannual) with the stakeholders. The discussions that followed these presentations emphasized certain inadequacies. The proposed corrective actions for these are: training, coaching, supervision, and active data collection. Recommendations were formulated, especially the organization of exchange meetings between ANCRE, DNSP, DSME, and USAID to restore and operationalize ANCRE’s focal point role and organize coordination meetings periodically to share experiences and problems between the HZ.

Tool harmonization workshop to integrate the CHW and RBF: The purpose of this workshop was to maintain a consensual list of community indicators for purchase by the RBF, on the basis of the experience of the TFP (UNICEF, PRPSS, PNLP), then to develop evaluation grids of community health worker performance, to determine the unit purchase cost of indicators, and to define the CHW motivation mechanism by the RBF. The RBF was to pay for a total of 17 quantity and 12 quality indicators.

In addition, in its partnership with the Ministry of Health, ANCRE participated in a number of technical meetings with the Ministry and certain partners as follows:  The work group meeting on the introduction of Sayana Press  Validation workshop on the updated protocol of the national health guidelines on newborns in Benin  Consultation with the EmONC implementation actors in the Mono and Couffo departments  International Women’s Day

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PERFORMANCE MONITORING

Performance Monitoring Plan (PMP): The monitoring/evaluation reference documents, namely the PMP, PIRS, and M&E plan were submitted to USAID in October 2015. ANCRE is waiting for the conclusions of the internal review of the indicators by USAID before completing the PMP. Several work sessions were held with USAID and were conducted to complete USAID’s PPR in addition to the sectorial work review in the ANCRE project according to the guidelines and strategies detailed in the proposal. Regarding community indicators, in response to USAID’s request for ANCRE to concentrate on the 6 health zones that do not yet have NGOs, an assessment of CHW availability and performance was carried out in 2 zones (SABA and CBGH), resulting in the following observations:  In SABA: UNICEF trained 249 CHW except for in WASH and FP; they are equipped but financing is being sought to motivate them and monthly group monitoring sessions are being held to make them functional.  In CBGH: there are approximately 200 CHW; their training planned by ANCRE has been suspended by the Physician Coordinator, which established the identification of the financing source of their compensation as a precondition.

The quarterly mission to verify the completeness and the quality of the SNIGS data found the following:  the completeness of the data rose from 92% before the mission to 96% at the end of the mission;  the entry error rate on the platform is 4%;  the report preparation error rate at the health centers is 71%. This rate is very high and justifies the need for training health workers on SNIGS tools in the health zones

Other monitoring and evaluation activities conducted during the quarter are:

Orientation workshop at the national level to train health workers on filling out SNIGS tools including the tools on managing inputs: In collaboration with the Ministry of Health, ANCRE organized a harmonization workshop on information about SNIGS tools from February 16-17, 2016 with the participation of representatives from the Ministry of Health’s technical directorates, such as the Directorate of Programing and Forecasting (DPP), DNSP, and DSME.

The goal of this session is twofold: availability of the training module for health workers on filling out SNIGS tools and the support of monthly reporting on managing PIHI inputs (tracer commodities), and a collection device and increase in monthly reports of PIHI input consumption (tracer commodities) in all the health facilities.

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Following the DPP presentation on the different SNIGS tools, it was noted that the last revision of these tools was in 2007 while normally they should be revised every 5 years. Unfortunately, this revision could not be made in 2012. With financial support from the Health System Performance Strengthening Program (PRPSS) at the Ministry, the modification of some tools is underway.

The recommendations made to DPP at the conclusion of this observation with the support of ANCRE are:  harmonize the SNIGS supports being modified  validate the tools being revised in the various directorates  update the guide for filling out SNIGS tools  organize a training manual ownership session  create a timeline for health worker training

Harmonization meeting on the various SNIGS tools being modified with concerned Ministry of Health directorates: This meeting was held on the ANCRE program’s premises on Monday, February 22, 2016 with the participation of DPP, DSME, and DPMED, with the following objectives:  Harmonize the revised SNIGS tools  Validate the inputs management tool  Define the next steps leading to the training of health workers on the SNIGS tools

Discussions between representatives of the directorate facilitated harmonization of the tools. As to the directorates absent from the meeting (DRFM, DNEHS, and ANV) on the modifications related to vaccination, it was agreed that DPP would organize a meeting with these organizations to finalize the tools concerning them.

Regarding the FP commodities on the inputs management tool, DSME wanted to have only the consumption data on FP commodities distributed by CAME. A road map has been retained and supplemented with a timetable for the training of health workers in the project’s zones on SNIGS tools, to be concluded by May 2016:  validation of all SNIGS tools  development of the guidebook for filling out community data collection tools  updating of tools on the DHIS2 platform  development of the training manual  reproducing SNIGS tools  training of health workers

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Completing the harmonization of the RBF-SNIGS indicators (hospital tools) and taking into account new needs of the SNIGS actors on the collection tools: ANCRE participated in the workshop in Bohicon organized by the Ministry of Health’s DPP with the financial support of PRPSS from March 15-17, 2016. The general objective of the workshop was to strengthen the data collection system so that the health system is properly managed.

All the previously existing tools in the SNIGS guide have been reviewed and modified as needed. A7 support (monthly logistical report: Status of stocks and consumption) has been created to satisfy needs to improve the management of tracer commodities.

SNIGS’ data collection supports have been revised and validated after integration of RBF information as well as other information needs. The new tools should satisfy both the information needs of the health system as well as results-based financing needs.

ANCRE’s interest in this workshop is the consideration of 2 objectives that it had already addressed with the principal actors from the Ministry of Health during an earlier work session in the project, namely:  Complete and integrate in DHIS2 a tool for reporting data on consumption of essential FP and PIHI commodities;  Finalize all the revised SNIGS tools.

Thus, ANCRE helped with the integration of A7 support of monthly commodities consumption data in the health centers into the health information system

Finalize the guide for filling out SNIGS tools: Finalization of the guide for filling out SNIGS tools took place from March 29-31, 2016 at the Atlantic-Littoral Departmental Directorate of Health in Cotonou, with the participation of representatives of several technical directorates from the Ministry of Health (PNLS, DNSP, DPMED, DSME) and the Advancing Partners and Communities (APC) and Accelerating the Reduction of Malaria Morbidity and Mortality (ARM3) projects, and under the leadership of DPP’s Information Management Service (SGSI). The 3 categories of SNIGS tools have been finalized and the guide for filling out tools updated.

ANCRE staff training on CommCare: The ANCRE program’s m-Health specialist trained technical personnel on accessibility to the CommCare web platform with the following points:  The creation of an account on the platform including the project’s CommCare module  Consultation of case management data provided by the CHW and head nurses on the platform  Reading the various aggregate reports

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A more technically-oriented training on the indicators collected by the CommCare application will be held later.

CommCare mobile application and case management at the community level: Transfer of data produced by the CHW trained in case management using the mobile application in 2 health zones (Tchaourou and Bassila) was carried out on the CommCare website. This transfer makes these data available and accessible. The various aggregated reports of these data show the results in the following charts that illustrate some activities led by the CHW in these 2 health zones using CommCare.

Chart 5: Percentage of children treated for diarrhea with SRO/Zinc via the CommCare application

Principal activities planned for the next quarter  Train the HZMT trainers from the 10 HZ on SNIGS tools  Train the health workers from the 10 HZ on SNIGS tools  Configure and set the Android phones for the CommCare start up  Deploy phase 2 of CommCare in Tchaourou

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PROBLEMS/CHALLENGES  The principal challenge is the capacity to comply with the planning of activities by the health zone teams and to be able to execute them on time. This observation could be related to the inadequacy of a true integration of project activities in planning at the departmental and zonal levels. In addition, it can be attributed to the need for an increase in ownership of the project by governmental actors at various levels to better register the activities of the project in their priorities for action. Following recent consultations however, the establishment of quarterly coordination with the zone coordinators will help to resolve this problem.  The remaining challenge raised regarding the management of inputs is the correct quantification of needs for RH/FP commodities based on the consumption data. To this end, we will carry out (i) the integration at SNIGS-DHIS2 of the management reporting form for health commodities and (ii) the entry in DHIS2 at the HZ level, of logistical data from all health centers while providing technical support for skills transfer and generating awareness-raising and ownership by the zonal teams.

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APPENDICES

APPENDIX 1: Progress of programmed activities from January to March 2016 Situation at the end of Activities Comments the quarter

INTERMEDIATE RESULT 1: IMPROVED PUBLIC HEALTH SECTOR PERFORMANCE IN DELIVERING INTEGRATED FAMILY HEALTH SERVICES

Intermediate sub-result 1.1: Improved planning and management of health systems and services, especially at the decentralized level

Support the development and implementation of Improvement plans are developed in the 10 zones and collaborative improvement plans at the zonal level based on Underway sessions have been organized in 9 out of 10 zones. The collaborative session situational analysis results. will be organized in the last health zone (Bassila) during the next quarter Organize the collaborative session in the Bassila Planned for April 2016 Activity postponed for calendar conflict issues health zone Planned for the end of Planned for the end of the next quarter once coaching is completed in all Organize learning sessions in the health zones: the coming quarter health zones

Update the knowledge of providers in the COZO, Discussions are underway with the physician coordinators to plan and Planning underway AZT, and KGS health zones in clinical FP and conduct these trainings counseling Introduce the health zone trainers and nationally trained midwives to the United States Government Planning underway Activity scheduled to be completed in May (USG) online training of FP policy Coaching activities will be the priority for the next quarter before the Organize coaching visits in the other HZ of CBGH, Planning underway Tchaourou, KGS, SABA, AZT, DCO, and Bassila organization of sessions to share experiences

Organize a joint coaching visit (Public and The joint visit is expected to shed light on the collaboration between the Planning underway Community clusters) in the Tchaourou health zone clinical and community QI teams

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Situation at the end of Activities Comments the quarter CommCare application undergoes regular updating and is implemented in 2 CommCare application is updated and introduced Underway health zones (Tchaourou and Bassila) that will be covered completely. It will in 3 additional health zones not be introduced in any other health zones this year

Intermediate sub-result 1.2: Improved quality of service delivery in public health facilities, especially for women and young children

 An analysis of the current situation regarding resusscitation of the newborn is being finalized. It will be followed by a plan to strengthen Update PIHI clinical skills for health care providers the technical platform in this area in both the zone hospitals and health according to needs identified in the situational Underway centers. analysis  The capacities of providers in the KGS and AZT HZ will also be strengthened during the next quarter. This will result in all the HZ having FP coverage including counseling. Support to the quality improvement teams is taking place through the Support facilities’ quality improvement teams to coaching of the QI teams. This was carried out in 2 HZ (AS and CBGH) during generate and use health data to institutionalize Underway this quarter and will continue during the next quarter in the other HZ. The continuous improvement in service delivery. goal is to visit all the health zones. Intermediate sub-result 1.3: Essential commodities more available at service delivery and product distribution points

Support the development of a standard operating  Recruitment of a consultant to finalize the SOP manual procedures manual for the management of PIHI  Finalization of the SOP document, the pocket guide on health products inputs for each level management, and the FMECA table. Underway  Test of the FMECA tables and tools with HZ actors

 Sharing documents with the steering committee for amendments and collection of inputs for improving documents Support the implementation of a national LMIS for Underway TDRs finalized and awaiting validation PIHI inputs

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Situation at the end of Activities Comments the quarter Active collection of logistical data on PIHI inputs carried out: entirely in 7 of Support decentralized logistics management Underway 10 HZ and underway in 2 of 3 HZ remaining due to the rise in monthly monitoring teams in the health facilities reports  Medistock is used in the project’s 10 health DRZ and has expanded to 2 Support the updating and expansion of Medistock HZ (CHD Donga and Comè HZ) and incentives to harmonize logistics systems Underway  Partnership between ANCRE and VaxTrac for the pilot phase of the Medistock expansion to the health centers through the use of tablets put in place by VaxTracs Support the organization of quarterly inventories The inventory took place during the active data collection in 9 of 10 health of PIHI tracer commodities in the DRZ and Completed zones with the exception of Tchaourou, which has not yet conducted the healthcare facilities activity  CommCare Supply is developed and should be introduced in 2 pilot Introduce CommCare Supply for monitoring the zones (Bassila & Tchaourou) management of products stocked in “last mile” Underway  The test of the CommCare stock management module with the supply points. Tchaourou HZ CHW is completed for future deployment Support DSME for the timely submission of the follow-up report on procurement planning for Underway DSME submits the RSPA report for March 2016 to DELIVER/USAID contraceptive commodities (RSPA) at USAID.

Support DSME in organizing workshops for the annual revision of contraceptive acquisition tables Not implemented ANCRE will be the support in the next quarter (CAT)

Progressively support DIP in the implementation of the Extra-Hospital Information System in the Underway Identification of needs underway health centers of the 10 HZ

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Situation at the end of Activities Comments the quarter

INTERMEDIATE RESULT 2: IMPROVED PRIVATE HEALTH SECTOR PERFORMANCE IN DELIVERING INTEGRATED FAMILY HEALTH SERVICES

Intermediate sub-result 2.1: Improved public sector policies, oversight and supervision of private sector health care delivery The quarterly visit to private health facilities that have requested an Provide technical and financial support for authorization to open and to practice medicine with private patients was implementing the roadmap activities developed Underway conducted in collaboration with the Ministry of Health and the support of during the workshop on private sector regulation various organizations and professional health associations. Provide support to the stakeholders so that the Technical and financial assistance was provided to the actors for the visit of health facilities selected can receive the support of Underway 21 applicants for the authorization to open with a private clientele the project to obtain their authorization to open Put in place a work group of private providers to The platform of Benin’s private health sector has been identified to house inform and monitor high-quality service delivery Underway the accreditation program’s technical secretariat. To this end, two work activities, accreditation, and incentives for private sessions were organized with PSSP officials. providers Develop and validate an accreditation procedures The manual has been developed. The validation workshop is planned for manual for PHF integrating stakeholders’ Underway April 8, 2016. suggestions

Intermediate sub-result 2.2: Improved quality of service delivery in private health facilities, especially for women and young children

The rapid assessment study protocol of PIHI service quality and quantity in Carry out rapid assessment of PIHI service quality Underway selected private facilities is written and the assessment tools are being and quantity in selected private health facilities validated.

Conduct a more comprehensive analysis of the obstacles to and incentives for collaboration The contract with the consultant has been signed. The protocol and data Underway between private establishments and health collection tools have been developed. insurance schemes

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Situation at the end of Activities Comments the quarter

Train the PHF to introduce new PIHI services and Not implemented This activity is consecutive to the previous one strengthen existing services in the PHF

Put quality improvement (QI) teams in place in Not implemented This activity is consecutive to the previous one selected private health facilities

Implement the incentives mechanism at selected Not implemented This activity is consecutive to the previous one private health facilities and follow-up

Facilitate quarterly workshops with private and public providers, including PSSP, to share Not implemented This activity is consecutive to the three previous ones experiences, results, and lessons learned from the QI teams

Support the development of a roadmap to introduce and monitor innovative approaches to Will be carried out after the completion of the in-depth study on increase the number of approvals between the Not implemented establishing private sector contracts in the implementation of health private establishments and an insurance scheme in insurance schemes now underway the selected zones

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Situation at the end of Activities Comments the quarter

Provide technical and financial support to establishments and schemes for the Not implemented This activity is consecutive to the previous one implementation of the road map

INTERMEDIATE RESULT 3: IMPROVED PREVENTION AND CARE-SEEKING BEHAVIOR OF AN EMPOWERED POPULATION

Intermediate sub-result 3.1: Increased appropriate health promoting behaviors made by households and especially women Revision of the SBCC tools for essential family practices is in the final phase. Update and reproduce the SBCC tools Underway Finalization awaits the integration of amendments from URC headquarters

Train the heath care providers, NGOs, CHW, and women’s groups selected on SBCC activities and Underway Implement in 3 out of 6 HZ (women’s groups) the use of standardized SBCC tools and equip them with SBCC tools Finalize and disseminate the harmonized catalog ANCRE is waiting for the harmonization of the advice cards with the Ministry of updated communication materials, adapted to Underway of Health and UNICEF PIHI needs

Monitor and support supportive supervision on Activity conducted in the four HZ in which the women’s groups and CHW Underway the use of communication media adapted to PIHI have been trained

Intermediate sub-result 3.2: Informed families make appropriate choices on accessing public and private sector health services and commodities

Provide technical and financial support to the  Training the CHW on Lassa fever in the Tchaourou HZ health zones for training in ICMI, FP, and WASH  UNICEF trained the CHW in ICMI in 4 HZ. There are no local NGOs and equipment for the trained CHW in the zones Underway not yet covered (CBGH, Cotonou 2&3, CoZO, AZT, financed by USAID in these zones to complete the FP and WASH Abomey-Calavi /So-Ava, SABA, KGS) packages

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Situation at the end of Activities Comments the quarter Update the CommCare mobile application to The CommCare application has been updated with the integration of the integrate the monitoring of pregnant women and Completed modules for monitoring pregnant women and management of PIHI inputs, management of PIHI inputs and has been tested

Train the statisticians and other actors in the The statistician and 13 head nurses from Tchaourou have been trained in health pyramid on the use of CommCare and Underway the use of CommCare and the monitoring of community activities with the technical support use of CommCare’s monitoring tools

Extend CommCare coverage to 3 other zones:  ANCRE will focus on the 100% coverage of the CHW for the use of the Training, equipping and monitoring of the CHW on application in the 2 initial health zones (Tchaourou and Bassila) in the the CommCare mobile application containing the Not completed second year. PEC module of childhood illnesses, FP counseling, monitoring of pregnant women and newborns,  There will be no further expansion of this activity in the other zones this plus the tracking of drug stock-outs. year

Support the MOH to organize and carry out synthesis workshops to resolve problems, share Not completed Will depend on the success of the preceding activity best practices, and scale-up

Technically and financially support the supervision system of the community health workers and Support to the CHW’s monthly monitoring group has been put in place in Underway the Tchaourou HZ NGOs

Implement the financial incentives protocol (pilot phase in two health zones) in collaboration with Not completed It is conditional on the implementation of the accreditation the PSSP

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Situation at the end of Activities Comments the quarter

Intermediate sub-result 3.3: Strengthened community-level contributions to health sector decisions and financing

Establish coalitions between different organized Underway The 24 coalitions established in the DCO HZ during the past quarter are social-community groups waiting to be trained on presentation and advocacy techniques Train the QI teams in quality management at the Underway 29 community QI teams are installed in the Bassila HZ and are waiting to be community level trained in quality management and networking to lead activities

Capacity-building of solidarity organizations The 23 mutuelles now functioning have been selected out of 56 initially chosen for FP inclusion in their package of Underway identified during the analysis of the current situation and an action plan has services, improvement of governance and/or been developed to support them communication MONITORING AND EVALUATION

Obtain a space allocated to ANCRE from MOH with The process is underway with the management service of DPP’s information an access code on the DHIS2 platform showing Underway system at the Ministry of Health ANCRE activities and results The workshop on this activity was held on March 29-31, 2016 at the Support the development of the guidebook for Completed Atlantic-Littoral DDS in Cotonou. The information system management filling out community data collection tools service conducts its review. Support the publishing of the guidebook on filling The guide to filing out forms is being finalized by the Ministry of Health’s out forms and community tools (Registers and Not completed SGSI synthesis support) Train the head nurses, the Heads of Research and Social Mobilization Support (Chargés de Recherche Two tools are essential for this training: the guide to filling out the tools, et d'Appui à la Mobilisation Sociale), (C/RAMS) and Not completed which is in process of finalization, and the training manual that has not yet the heads of health zones’ cellular statistics on the been developed guidebook for filling out community data tools (Training of CHW trainers)

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Situation at the end of Activities Comments the quarter Train community health workers to complete Not completed SNIGS tools correctly Activity postponed to the next quarter.

Integrate the community database in the DHIS2 for This integration is a SNIGS strengthening activity carried out by the ANCRE Completed use in the health zones program. The integration process based on these data on the DHIS2 platform is being completed by the Ministry of Health’s SGSI The quality control of these data was carried out so far in the 4 zones with NGOs that help at the monthly group supervision of the community health workers. USAID however, instructed the ANCRE program to fill in the Organize a quarterly community data quality Not completed community data soon in the 6 zones that are not yet covered by NGOs and control in which the recruitment process is underway at USAID. To achieve this, a feasibility study is being prepared to conduct the analysis of the current situation in these 6 health zones so as to develop a strategy to put into place. Build the capacities of the statisticians on the monitoring and use of community data on the Not completed Activity postponed to the next quarter. CommCare platform

Collect routine private sector data on a monthly Not completed basis Activity to start after the ERPA investigation in the private sector

There are SNIGS tools for the public sector. For the private sector, currently 45 private health facilities out of 68 pre-selected are already integrated with Develop periodic collection tools of PMP data for SNIGS. Advocacy should be undertaken for the remaining 23 private Not completed the three sectors facilities to be integrated with SNIGS so that they can use the same tools. Pending their integration, data will be collected using SNIGS tools. As such, the creation of parallel tools will be limited to the collection of data not collected by SNIGS. Periodically conduct the collection and quality Underway Activity organized at the end of each quarter in the 10 health zones before control of data to inform PMP calculating the indicators with a SNIGS data source

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Situation at the end of Activities Comments the quarter Participate in activity planning sessions in the The participation of the ANCRE program in this activity is by invitation of the health zones to integrate ANCRE activities in their Underway zone physician coordinators. The activity has already been conducted in 7 plan health zones: COZO, AZT, Cotonou 2&3, SABA, Tchaourou, Bassila and DCO

Create a database for the ANCRE program Not completed The relevance of this activity is to be reviewed in light of the possibilities available on the DHIS2 platform. Create an ANCRE website for key M&E elements with a link to the MOH website and ensure its Underway The website is in process and will be launched next quarter maintenance

Train ANCRE M&E office personnel on the use and analysis of community data on the CommCare Completed ANCRE technical staff have been trained platform.

Carry out the preparation, collection and analysis Underway The draft protocol draft has been developed and is being amended by of ERPA data in private health care facilities headquarters in collaboration with R4D. Progressively support DIP to set in place the Extra- The relevance of this activity is to be reviewed with the possibility of access Hospital Information System in the health centers Underway to the DHIS2 platform by the IT department and the Ministry of Health’s of the 10 HZ pre-archiving. Currently, all the health zones already have access to the DHIS2. In addition, needs are being identified Edit the 2015 ERPA report on the pubic and Underway community sectors The draft of this report is developed and being amended.

This activity is part of the SNIGS strengthening to which the project contributed. A7 support: monthly logistical report that provides the status Integrate the monthly commodities consumption of stocks and consumption was created during the workshop organized in Completed data in the health centers with SNIGS Bohicon, March 15-17, 2016 to satisfy needs to improve the management of tracer commodities. The integration of this tool with SNIGS also marks its integration with DHIS2.

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APPENDIX 2: Visitors and consultants received

No. of Structure/ organiz First and last names Reason for visit/consultation Persons involved Period Function ation 1 Zakari Saley URC/Niger Technical support to the ANCRE program for the Technical staff January 17-30, 2016 launching of the first phase of the ANCRE program’s health zones PIHI collaboratives

2 Jean N’GUESSAN URC ANCRE Project Interim Director All staff January 10- Headquarters February 12, 2016

3 Cheryl Combest URC Technical support All staff January 30- Headquarters February 12, 2016

4 Ismaïla DIENE Dimagi  Field visit Technical Staff & February 22-  CommCare application usability test Community Health March 10, 2016)  Strengthening of users’ capacities Workers  Partner meeting  Development of indicators

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APPENDIX 3: Changes in performance indicators

Result Anticipated Source and obtained T1 Anticipated target Data sources / period of the Value of AF2015 FY2016 T2 FY2016 Project Performance Collection target (Oct (October USAID Code Type Disaggregation collection base base (Oct (Oct- (Jan-Mars Code indicator frequency 2014 - Sept 2015 - method reference reference 2014 - Dec 2016) 2015) September (year/month) Sept 2015) 2016 2015) Objectives 1 and 2: Improved public and private health sector performance in delivering integrated family health services Modern SNIGS Health contraceptive Center Reports: SNIGS OCT prevalence rate 1.a 3.1.7-38 Outcome Health Zone Maternal Quarterly 2013- SEPT 7% 10% 8% NA 6% 13% in USG- health monthly 2014 supported report programs¹ Couple Years of SNIGS Health Protection SNIGS OCT Center Reports: 3.1.7.1-1 (CYP) in USG- Output Health Zone Annual 2013- SEPT 47,869 58,646 77,603 NA NA 89,243 Monthly supported 2014 Reports programs 1.b 3.1.7.1-1 Public Sector NA NA NA NA 2.a 3.1.7.1-1 Private Sector NA NA NA NA % of USG- assisted service SNIGS Health SNIGS OCT delivery sites Center Reports: 3.1.7.1-3 Output Health Zone Quarterly 2013- SEPT 83% 65% 88% NA 75% 92% providing FP Monthly 2014 counseling Reports (C6) and/or services 87% 1.c 3.1.7.1-3 Public Sector NA NA NA (221/254) 29% 2.b 3.1.7.1-3 Private Sector NA NA NA (20/68)

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Number of USG-supported facilities that provide appropriate ERPA: PUBLIC AND life-saving observation Function of PRIVATE USAID maternity care and forms of EmONC, ERPA DATA 1.d Recommended (This will be Output management Annual 46.5% 50% ND NA NA 60% Health Zone, IN 2014; Custom defined as and Sector INVESTIGATE seven signal questionnaire IN FEB 2015 functions for inputs BEmONC and nine signal functions for CEmONC)² Number of USG-supported facilities that provide appropriate ERPA: PUBLIC AND life-saving observation PRIVATE maternity care and forms of ERPA DATA 1.e N/A (This will be Output Health Zone management Annual 4 4 ND NA NA 6 IN 2014; defined as and INVESTIGATE seven signal questionnaire IN FEB 2015 functions for inputs BEmONC and nine signal functions for CEmONC)² % of births receiving at SNIGS Health least 4 SNIGS OCT Center Reports: 1.f 3.1.6.1-2 antenatal care Output Health Zone Quarterly 2013- SEPT 43% 50% 50% 41% 40% 70% SNIGS Monthly (ANC) visits 2014 Reports (C6) during pregnancy

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% of newborns receiving PUBLIC AND postnatal ERPA: To be PRIVATE health check collected in the ERPA DATA 1.g 3.1.6.3-1 Output Health Zone Quarterly 40% 40% ND ND 55% within 2 days future by the IN 2014; of birth coaches INVESTIGATE (newborn care IN FEB 2015 and treatment) LQAS: % of births interview with attended by a women who LQAS JUN- 1.h 3.1.6.1-1 skilled doctor, Output Health Zone Annual 54% 54% ND ND 75% have a child JUL 2015 nurse, or less than 1 year midwife old Number of women giving birth who received SNIGS Health SNIGS OCT USAID Recommended uterotonics in Health Zone, Center Reports Output Quarterly 2013- SEPT 54% 58% 58.6% 69% 72% 70% Custom the third stage Sector SNIGS Monthly 2014 of labor Reports (C6) through USG- supported programs 1.i Public Sector NA NA NA NA 74 2.c Private Sector NA NA NA NA 44 Number of children who SNIGS Health received DPT3 Center Reports: SNIGS OCT Health Zone, 1.j 3.1.6.4-1 by 12 months Output monthly Annual 2013- SEPT 58.8% 65% 60.2% 55% 50% 75% Sector of age in USG- vaccination 2014 assisted reports programs % of children who received SNIGS Health the third dose Center Reports: SNIGS OCT 1.k 3.1.6.4-3 of Outcome Health Zone monthly Annual 2013- SEPT 58% 65% 59% 54% 50% 75% pneumococcal vaccination 2014 conjugate reports vaccine by 12

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months of age in USG-assisted programs

% of health zones reporting morbidity and mortality SNIGS Health indicators to SNIGS OCT Center Reports: 1.l N/A the national Process N/A Quarterly 2013- SEPT 0% 30% 10% NA 30% 70% Epidemiological program on a 2014 report monthly basis during the previous 12 months Number of USG-assisted health zones correctly ANCRE quantifying Supervision of PROJECT MNCH and 1.m N/A Process N/A Health Zones’ Quarterly REPORTS 4 5 ND 1 5 8 FP/RH distribution 2014 commodity warehouses needs according to procurement protocols3 Number of newborn infants PUBLIC AND ERPA: Maternal receiving PRIVATE and child antibiotic ERPA DATA 1.n 3.1.6-63 Output Gender health records Quarterly 6,358 6,358 ND NA NA 7,312 treatment for IN 2014; To be collected infection INVESTIGATE by coaches through USG- IN FEB 2015 supported programs

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% of USG- assisted service delivery points (SDPs) that ANCRE experience a Distribution PUBLIC AND stock out at warehouse PRIVATE any time supervision Health Zone, ERPA DATA 1.o 3.1.7.1-2 during the Output reports on the Quarterly 91% 80% ND 24% 23% 50% Sector IN 2014; reporting reports INVESTIGATE period of a submitted by IN FEB 2015 contraceptive the health method that centers the SDP is expected to provide % of USG- supported institutions ANCRE (health Distribution centers) that warehouse submit a supervision monthly PIHI 1.p N/A Output Health Zone reports on the Quarterly NA ND 85% ND 91% 91% 30% essential reports products submitted by report with the health promptitude, centers exactitude and completeness of data

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% of USG- supported service delivery points (PPS) that have not experienced a stock-out at any time during the period of any of the following main products: ANCRE Amoxicillin , Distribution SRO / ZINC, warehouse sulfadoxine - supervision pyrimethamine 1.q N/A Output Health Zone reports on the Quarterly NA ND 0% ND 54% 56% 35% (SP), reports Therapeutic submitted by Artemisinin- the health based centers combination (ACT), Oxytocin, Zidovudine (AZT), Nevirapine, Lamivudine (3TC ), Effavirenz ( EFV), HIV rapid tests, and malaria rapid tests

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Objective 2: Improved public and private health sector performance in delivering integrated family health services % of births delivered by PUBLIC AND SNIGS caesarean PRIVATE Summary section when ERPA DATA 2.d 3.1.6.2-1 Output Health Zone Reports of Quarterly 2% 2% 1% 0.2% 0.1% 5% clinically IN 2014; private sector indicated, in INVESTIGATE health centers the private IN FEB 2015 sector % of private PUBLIC AND sector PRIVATE providers ERPA DATA 2.e N/A supported by Output ERPA Biannual 85% 86% ND NA NA 87% IN 2014; ANCRE INVESTIGATE implementing IN FEB 2015 PIHI % of selected facilities in the private sector ANCRE Project 2.f N/A involved in the Process Health Zone Biannual NA 0% 5% 0% NA NA 30% reports accreditation process for PIHI4 Objective 3: Improved prevention and care-seeking behavior of an empowered population. % of newborns receiving postnatal SMG: CHW SMG OCT health check Monthly Group 3.a N/A Output Health Zone Quarterly 2014-SEPT 2% 3% 2% 8% 8% 60% within two Supervision 2015 days of birth Reports (newborn care and treatment) % of women of LQAS: reproductive interview with age in the LQAS JUN- 3.b 3.1.7-38 Outcome Health Zone women of Annual 15% 15% 15% NA NA 16% community JUL 2015 reproductive using modern age contraception

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% of pregnant LQAS: women at the interview with community women who LQAS JUN- 3.c N/A level with a Output Health Zone Annual 14% 14% 14% NA NA 60% have a child JUL 2015 birth plan for less than 1 year delivering their old babies Number of additional USG- assisted community health workers SMG: CHW PROJECT (CHWs) Monthly Group 3.d 3.1.7.1-4 Output Health Zone Quarterly REPORTS 0 874 874 874 874 1365 providing Supervision 2015 family planning Reports (FP) information and/or services during the year % of health SMG: CHW PROJECT zones with Monthly Group 3.e N/A Output N/A Quarterly REPORTS 0% 40% 40% 40% 40% 50% functional CHW Supervision 2015 systems Reports

Number of SMG and cases of child SNIGS: CHW SMG and Health Zone, diarrhea and SNIGS SNIGS OCT Output Treatment Quarterly 96% 56% 96% 97% 97% 98% treated in USG- Monthly Group 2014-SEPT Source assisted Supervision 2015 programs6 Reports 3.f 3.1.6-6

CHW 12% 12.0% 9.9% 96.0% 24.8%

Public Sector NA 71.1% 100.0% 84% 84% 73.2% Private Sector 16.0% 100.0%

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Number of children under five years of age with SMG and suspected SNIGS: CHW SMG and pneumonia Health Zone, and SNIGS SNIGS OCT receiving Output Treatment Quarterly 38% 38% 38% 28% 37% 55% Monthly Group 2014-SEPT antibiotics by Source Supervision 2015 trained facility Reports or community 3.g 3.1.6-63 health workers in USG-assisted programs6

CHW 5709 3.5% 1.0% 36.9% 9.3%

Public Sector NA 24.0% 5.2% 56,142 34.5% 45.7% Private Sector 3.0% 0.5%

% of women who recall LQAS: hearing or interview with seeing a Health Zone, LQAS JUN- 3.h 3.1.7.2-1 Output women of Annual 0% 65% 0% NA 75% specific USG- Gender JUL 2015 reproductive supported age: FP/RH message7 % of men who participated in LQAS: Additional 3.i N/A family planning Output Health Zone interview with Annual ND NA ND ND 30% 2016 counseling cleaning men sessions % of CHWs trained on community ANCRE Project Additional 3.j N/A Process Health Zone Biannual 48% NA 48% 48% 48% 60% level package reports 2016 of high-impact interventions

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% of children age 0-5 months LQAS: who were interview with SMG OCT 3.k N/A exclusively Output Health Zone women with a Annual 2014-SEPT 73% 85% 73% 76% 87% breastfed child less than 2015 during the last 6 months old 24 hours6 % of LQAS: households interview with participating in LQAS JUN- 3.l N/A Output Health Zone women of Annual 8% 8% 8% NA 15% health JUL 2015 reproductive financing age: schemes % of completed referrals by the SMG: CHW community SMG OCT Monthly Group 3.n N/A health worker Output Health Zone Quarterly 2014-SEPT 63% 69% 63% 66% 61% 73% Supervision for children 2015 Reports with danger signs6 1 Value of base reference, including implants, injectables. IUDs, and birth control pills. 2 The base reference value was measured with the total number of health centers that have essential personnel trained in EmONC. 3 This information was collected by ERPA in 2015 but will be informed regularly by the supervision reports in the project’s zones 4 The registration of private health facilities in the accreditation process begins on May 2, 2016. 5 These values were calculated from data from two health zones that currently collect this information (Kandi Gogounou Ségbana et Bassila). The reference value refers to the period from Oct - Dec 2014 and from Oct 2014 - September 2015 as a result of the 2015 AF The data will be collected in all the health zones once the CHW reporting forms are available in all the health zones 6 The base reference value was calculated from data from 4 health zones that currently collect this information (Tchaourou, Bassila, Djougou-Ouaké-Copargo and Kandi). The reference value refers to the period Oct-Dec 2014 and from Oct 2014-September 2015 as a result of the 2015 AF. The data will be collected in all the health zones once the CHW reporting forms are available in all the health zones

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