Quarterly Report January 1–March 31, 2018

Home , Allada, Copargo, Tchaourou, Toffo

ANCRE ADVANCING NEWBORN, CHILD AND REPRODUCTIVE HEALTH PROGRAM

QUARTERLY REPORT JANUARY 1–MARCH 31, 2018

APRIL 2018 ANCRE

Advancing Newborn, Child and Reproductive Health Program

Quarterly Report No. 15: January 1 to March 31, 2018

Distribution: Athanase Hounnankan, USAID/Benin Agreement Officer Representative Michelle Kouletio, USAID/Benin Agreement Alternate Officer Representative File

Cover photo: Good storage conditions_Covè HZ_COZO HZ

This report was prepared for the United States Agency for International Development by University Research Co., LLC (URC) in partnership with Dimagi, Inc. and Results for Development (R4D). 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. The program is implemented by University Research Co., LLC (URC), with its sub-recipients Dimagi, Inc. and Results for Development Institute (R4D).

DISCLAIMER: 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.

ANCRE - Quarterly Report No. 15 from January 1 to March 31, 2018

TABLE OF CONTENTS

TABLE OF CONTENTS ...... ii ACRONYMS AND ABBREVIATIONS ...... iii INTRODUCTION ...... 5 Principal approaches used during the quarter ...... 7 CHALLENGES ...... 8 MAJOR ACCOMPLISHMENTS IN THE QUARTER - ANCRE ...... 9 INTERMEDIATE RESULT 1: IMPROVED PUBLIC HEALTH SECTOR PERFORMANCE ...... 9 Sub-intermediate result 1.1: Improved planning and management of health systems and services, especially at the decentralized level ...... 9 Sub-intermediate result 1.2: Improved quality of service delivery in public health facilities, especially for women and young children ...... 9 Sub-intermediate result 1.3: Essential commodities more available at service delivery and distribution points ...... 10 INTERMEDIATE RESULT 2: IMPROVED PRIVATE HEALTH SECTOR PERFORMANCE ...... 11 Sub-intermediate result 2.1: Improved private sector policies, oversight and supervision of private sector health care delivery...... 12 Sub-intermediate result 2.2: Improved quality of service delivery in private health facilities, especially for women and young children ...... 14 INTERMEDIATE RESULT 3: IMPROVED PREVENTION AND CARE-SEEKING BEHAVIOR OF AN EMPOWERED POPULATION ...... 14 Intermediate sub-result 3.1: Increased appropriate health promoting behaviors made by households and especially women ...... 14 Sub-intermediate result 3.2: Informed families make appropriate choices for accessing public and private sector health services and commodities ...... 16 Intermediate sub-result 3.3: Strengthened community-level contributions to health sector decisions and financing ...... 18 GENDER ...... 19 PROJECT MANAGEMENT ...... 20 PERFORMANCE MONITORING ...... 22 APPENDICES ...... 24

ACRONYMS AND ABBREVIATIONS

ABMS/PSI : Association Béninoise de Marketing Social/ Population Service International

ANCRE : Advancing Newborn, Child and Reproductive Health Project

AS : Abomey-Calavi – Sô-Ava

AT : Assistant Technique

ATZ : Allada– Toffo– Zè

CBGH : Comé – Bopa – Grand-Popo – Houéyogbé

CoZO : Covè – Zagnanado – Ouinhi

CRAMS : Chargé de la Recherche et de l’Appui à la Mobilisation Sociale

DCO : Djougou – Copargo – Ouaké

DDS : Direction Départementale de la Santé

DIHS2 : District Health Information Software version 2

DNSP : Direction Nationale de la Santé Publique

DPMED : Direction de la Pharmacie, du Médicament et des Explorations Diagnostiques

DPP : Direction de la Programmation et de la Prospective

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

EAQ : Equipe d’Amélioration de la Qualité

EEZS : Equipe d’Encadrement de Zone Sanitaire

FSP : Formation Sanitaire Privée

FSS : Faculté des sciences de la Santé

GDRZ : Gestionnaires de Dépôt Répartiteur de Zone

INMeS : Institut National Médico-Social

KGS : Kandi – Gogounou – Ségbana

MS : Ministère de la Santé

MVE : Maladie à Virus Ebola

OBC : Organisations à Base Communautaire

iii

ONG : Organisation Non Gouvernementale

PF : Planification Familiale

PIHI : Paquet d’Interventions à Haut Impact

PITA : Plan Intégré de Travail Annuel

POS : Procédures Opérationnelles Standards

PSSP : Plateforme du Secteur Sanitaire Privé

R4D : Results for Development

RC : Relais Communautaires

SABA : Savalou – Bantè

SMG : Suivi mensuel groupé

SMNI : Santé Maternelle, Néo Natale et Infantile

SNIGS : Système National d’Information et de Gestion Sanitaires

SR : Santé de la Reproduction

UNFPA : Fonds des Nations Unies pour la Population

UNICEF, : Fonds des Nations Unies pour l’Enfance et la Femme

URC : University Research Co., LLC

USAID : United States Agency for International Development /Agence des Etats Unis pour le Développement International

VBG : Violences basées sur le Genre

ZS : Zone Sanitaire

INTRODUCTION

The Advancing Newborn, Child and Reproductive Health Program (ANCRE), financed by the United States Agency for International Development (USAID,) supports Benin’s Ministry of Health (MOH) to address the causes of maternal and child mortality in Benin. This program is implemented by University Research Co. LLC (URC) in collaboration with Results for Development Institute (R4D) and Dimagi in 10 health zones (HZs): Kandi – Gogounou–Ségbana (KGS), Djougou – Copargo – Ouaké (DCO), Tchaourou, Bassila, Savalou – Bantè (SABA), Covè – Zagnanado – Ouinhi (CoZO), Allada – Toffo – Zè (ATZ), Abomey-Calavi – Sô-Ava (AS), Cotonou 2 & 3 and Comè – Bopa – Grand-Popo – Houéyogbé (CBGH) (see map).

The expected results of the program are improved public and private sector performance in delivering integrated family health services and improved community behaviors for the prevention and use of quality care.

To achieve these results, the ANCRE program works in partnership with several central technical directorates of the MOH: the Directorate of Maternal and Child Health (DSME), the National Direction of Public Health (DNSP), the Directorate of Planning and Policy (DPP), the Directorate for Pharmacy, Medicines and Diagnostics (DPMED) as well as eight (8) departmental health directorates covering the ten HZs of the program.

The program also works with the Private Health Sector Platform (PSSP) as well as a network of community actors in the 10 HZs, composed of community-based organizations (CBO) to promote behavior change in populations.

Given the closure of the program on July 10, 2018, this report represents the last quarter of implementation of field activities. Starting in April 2018, the support of the ANCRE program will focus on transferring assets to the MOH as well as activities related to the closing of the program, especiallyThe ANCRE the organization of an open house day to share the results of the program with the various stakeholders at the central and decentralized level. project in numbers

Jan – Mars 2018

119 health workers in 71 private health facilities (PHF) trained in counseling and the provision of family 5 planning services so that 75% of PHFs report that they provide FP counseling

The ANCRE program in numbers

January – March 2018

119 health workers in 71 private health facilities (PHF) trained in counseling and the provision of family planning services so that 75% of PHFs report that they provide FP counseling

188 applications for authorization to practice medicine and/or open and operate a health facility for private clients approved by the technical commission in charge

57 private health facilities in the CBGH HZ sensitized on the process of authorization to practice medicine and open a private practice

42 mass awareness-raising campaigns on essential family practices (EFP) and gender organized in seven HZs, reaching 6,375 persons

79 new promotion and collection agents at DCO and CoZO trained on social marketing and management control techniques of health mutuelles

281 households registered for 963 beneficiaries and 2,106,500 CFA francs collected on behalf of 13 of 15 supported mutuelles

Principal approaches used during the quarter

1. Continuum of care, integrated throughout the life cycle

• Strengthening the community system for promoting behavior change in the population through advocacy by community leaders and the use of traditional popular media.

2. Continuous and shared learning

• Capacity building of the health zones’ coaching teams (HZMT) for using field data for planning and decision-making. • Consolidation, institutionalization and sustainability of program achievements

3. Improvement of equitable access to health care

• Capacity building of the HZMT, community PIHI non-governmental organizations (NGOs) and women’s organizations to take gender into account in the planning and implementation of activities.

CHALLENGES

Challenges encountered during the reporting period are summarized below.

Table No. 1: Challenges and resolution strategies

Challenges Strategies for resolving challenges Human resources for health The numerous strike movements by health The proximity of the program’s polyvalent teams that personnel have affected the implementation were posted in the DDS made it possible to work more of planned activities as well as the provision closely with the HZMT and negotiate the performance of services at the public health center level of certain key activities Coordination of interventions The beginning of the calendar year Implementation of the accelerated approach coupled characterized by the festive season has with personalized communication made it possible to somewhat affected the performance of catch up with conducting certain activities planned activities during the quarter due to the absence of some head nurses and other service providers at various levels resulting in a delay in execution

Provision of service and care Maintaining the operationality of the QI The program began a series of technical meetings with teams requires special monitoring of the the 10 HZMT to discuss and agree on measures to take HZMT to avoid lapses that may lead to their for ensuring the continuity of the QI teams after the loss at the end of the program. program and to consolidate achievements Other challenges during the quarter The announced end of the program is a The organization of working sessions at various levels of challenge for the need to accelerate and the health pyramid to anticipate the establishment of reinforce the implementation of strategies actions and decisions to enable the consolidation of for ownership of interventions by achievements and sustainability of certain activities stakeholders and also to consolidate and sustain gains

MAJOR ACCOMPLISHMENTS IN THE QUARTER - ANCRE

INTERMEDIATE RESULT 1: IMPROVED PUBLIC HEALTH SECTOR PERFORMANCE Sub-intermediate result 1.1: Improved planning and management of health systems and services, especially at the decentralized level Monthly reporting on maternal and child mobility and mortality indicators

3,506 reports on maternal and child morbidity and mortality from health facilities have been received out of 3,868 expected from the 10 HZs or 91% completeness.

Active support to the HZMT to generate and use health data in the development of Annual Integrated Work Plans (PITA)

ANCRE provided technical support to all ten zones for developing their integrated work plans. These plans were developed on the basis of routine SNIGS data drawn from DHIS2. The results of this analysis were presented and discussed to identify actions to consider in the PITA.

Activities for the next quarter

Monitor the use of the data from DHIS2 and supervision with HZMT

Sub-intermediate result 1.2: Improved quality of service delivery in public health facilities, especially for women and young children QI teams are in place and functional in health facilities

The program continued the coaching of quality improvement (QI) teams that began during the previous quarter. These visits involved 58 of 58 QI teams expected (100%) in the AS and DCO HZs. Nine QI teams received more in-depth coaching as new staff had been recently assigned, especially to DCO.

Coverage and quality of maternal, newborn and child (MNCH) health services

ANCRE provided technical assistance to DSME for the updating of the national protocols relating to the women's health component and to the components common to all aspects of women, men, adolescents / young people and children. Some new initiatives underway have been integrated in the documents, especially the provision of Sayana Press by the CHWs, Implanon’s launch on the market, the new WHO recommendations on PNC, etc.

Activities for the next quarter

• Assist DSME to organize the validation workshops of the two national reproductive health services protocol documents and their finalization; • Assist the 10 HZMT to develop plans for consolidating achievements of the ANCRE program.

Sub-intermediate result 1.3: Essential commodities more available at service delivery and distribution points Strengthen the logistical management system in support of the PIHI expansion

In collaboration with four DDS (Alibori, Atlantique, Donga and Zou), ANCRE continued coaching visits of six HZMT (KGS, ATZ, Bassila, DCO, CoZO, and CBGH), on inventory management and quality control of logistics data. These visits led to an improvement in the correct estimates of needs, storage/warehousing as well as logistical reporting of the six zone distribution warehouse managers (GDRZ) and care providers. The results obtained during these visits are presented in the table below.

Table No. I: Performance of the DRZ during the period in health commodity management and family planning

Health Data compliance commodity Correct estimation of between different storage Availability of Availability of FP Health Zones health commodity needs health product requirements in PIHI tracker commodities according to standards management complying zone products supports distribution warehouses ATZ 80% 100% 100% 56% 75% CBGH 100% 100% 100% 100% 91% CoZO 100% 100% 100% 100% 90% KGS 80% 100% 94% 93% 90% DCO 80% 100% 100% 89% 84% Bassila 60% 67% 94% 71% 83% Average 83% 94% 98% 85% 86%

Overall, four of the six GDRZ (ATZ, CBGH, CoZO and DCO) comply 100% with good storage conditions and five of the six GDRZ (ATZ, CBGH, CoZO, DCO and KGS) produce compliant data on management supports of health commodities.

Photo 2: Good storage conditions observed in the Covè _HZ CoZO zone hospital store (ANCRE, January 30, 2018)

Refresher session for the statisticians and GDRZ of the 10 HZs: ANCRE provided support to the MOH for training on filling out the A7 logistics materials and the capture and extraction of data on management of PIHI inputs from the 10 GDRZ and 10 HZ statisticians. Moreover, ANCRE supported the MOH to reproduce and provide 300 copies of the A7 register to the health facilities.

Quantification of MNCH and reproductive health (RH)/ family planning (FP) input needs

Standing Operating Procedures (SOP): ANCRE has continued the revision of the SOP manual for PIHI inputs with a team composed of DPMED, Centralized Purchasing of Medicines and Medical Consumables (Centrale d’Achat des Médicaments et Consommables Médicaux and the GHSC-TA Francophone project implemented by Chemonics International. After approval by the MOH, the SOP manual will be distributed to care providers and CHWs by the MOH, in order to increase the use of the A7 registers.

Principal activities planned for the next quarter

• Organize coaching visits to the GDRZ and health providers on inventory management and quality control of PIHI input logistical data in the Tchaourou HZ.

INTERMEDIATE RESULT 2: IMPROVED PRIVATE HEALTH SECTOR PERFORMANCE

Sub-intermediate result 2.1: Improved private sector policies, oversight and supervision of private sector health care delivery Private sector PIHI-based accreditation system

Capacity building of private facility providers and professionals on quality of services and care: Jointly with PSSP, ANCRE trained 19 providers, including 15 women, on client focus. This training made it possible to provide skills on reception and management of clients to staff trained to improve the welcoming of clients, especially by reception staff.

Infection control training was held for 19 providers, including 10 women from 13/13 PHF (100%) involved in the accreditation process. At the end of the training, the participants committed to establish Infection Control Committees in their respective centers. At the end of the ANCRE program, the implementation and functioning of these committees will be monitored by PSSP in collaboration with the MOH.

Photo 3: Training of private sector care proviers on infection control and prevention (ANCRE, February 1, 2018).

Coaching PHF quality focal points involved in the accreditation process: Seven PHFs have completed their self-evaluations. ANCRE organized coaching sessions specifically for the quality focal points of these seven PHFs to advise on the implementation of corrective actions selected after the self- evaluation. To assess the level of progress, these seven PHFs will carry out a second self-evaluation during the next quarter.

Registration of PHFs and granting operating licenses

Of the 227 applications received (174 requests for authorization to practice medicine with private clients and 53 requests for authorization to open and operate private facilities in eight HZs), the technical commission in charge approved 188 applications (83%), including 29 authorizations to open and operate private facilities.

ANCRE provided assistance for organizing inspection visits of infrastructures of 91/91 (100%) sites belonging to nurses and state-licensed nurses who requested authorizations to open and operate with private clients. These applications will be examined by the commission during the next quarter.

Moreover, an awareness-raising campaign was organized by the CBGH HZMT for managers of 57 of 72 PHFs (79%) in the HZ.

Support to PSSP and collaboration with the MOH to strengthen the health system

Support to PSSP and the MOH to organize the workshop “Strengthening the private health sector in Benin: experience of the ANCRE Program:” PSSP and the MOH, with the support of ANCRE, organized a workshop that brought together 51 participants: executives of MOH technical directorates, technical and financial partners (PSSP, UNICEF, UNFPA, USAID, ABMS/PSI, etc.), NGO leaders working in the health field, institutes and health training schools (INMeS, FSS) and private facilities in the Benin health sector. This workshop served to inform health actors about the progress made in organizational strengthening and strategic positioning of the private sector in Benin's health system through the PSSP, which is its basic structure. The principal recommendation focused on the improvement of both internal and external communication by PSSP for greater visibility that will lead to better access to funding for its consolidation and sustainability of actions in the sector.

Photo 4: Opening of the workshop on strengthening the private sector in Benin (ANCRE, February 15, 2018)

Support to the functioning of PSSP bodies: PSSP, with the technical support of the ANCRE program, held two important meetings which made it possible to discuss and confirm the need to document actions in the private sector and then develop and implement a communication plan to enable, among other things, the strengthening of relations between private sector actors and PSSP as well as with certain strategic partners.

Activities planned for the next quarter

• Support holding the session of the technical commission charged with examining the applications for authorization to practice medicine, open and operate as a private practice for the MOH; • Provide technical support to PSSP to develop the internal and external communication plan and promote coordination and mobilization of resources; • Support the seven PHFs participating in the implementation of their improvement plan to complete their second self-evaluation of the accreditation benchmarks.

Sub-intermediate result 2.2: Improved quality of service delivery in private health facilities, especially for women and young children Key MNCH services, including counseling and the provision of FP services

The ATZ, CBGH, DCO, KGS and Tchaourou HZs trained 119/130 (92%) health workers (including 77 women) in FP counseling and contraceptive technology from 71 of 78 PHFs expected (91%). The various workers trained are midwives (9), nurses (57), physicians (5) and nurses’ aides (48).

Cooperative framework between the PHF and HZMT managers of the ATZ HZ

A consultation meeting of PHF and HZMT managers from ATZ was organized, bringing together 15 managers from the PHFs. A four-member office was set up by the participants present. This office will be the contact point of PHF managers with the ATZ HZMT, serving as an interface for improving the coordination of health actions at the zone level with the contribution of the private sector.

Activities planned for the next quarter

• Monitoring the implementation of the quality improvement plans by the units and quality focal points by PSSP with the remote technical support of the ANCRE program; • Capitalization of the partnership with PSSP for improving the quality of care in the private sector in the final reporting process of the program.

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 Communication tools for behavioral change (BCC) related to PIHI

Integrated Communication Plans (ICP): ICP of the Bassila, KGS, CBGH and ATZ HZs have been reviewed, bringing the number of ICP updated to 9/10. New activities were added, including those related to including gender and the prevention of Ebola virus disease.

Advocacy sessions with community leaders to promote essential family practices (EFP) and gender were conducted in 9 of 10 HZs (except for the DCO HZ). They reached 180 community leaders, including 45 women. These influential people include heads of local communities or traditional leaders, local elected officials (heads of villages/city districts), religious leaders (preachers, pastors, imams), traditional healers, and opinion leaders such as teachers and chairpersons of women’s and youth associations.

These strategies were set out by leaders committed to improve the behavior of their respective communities after discussions on the level of maternal and child health indicators. These include organizing awareness-raising sessions during religious and market days, and also at meetings of Women's Groups. With the support of the CHWs, the leaders of each health area developed community actions plans based on the priority issues of their locality. These plans will be followed by the head nurses (CP) of the different health areas.

Mass awareness-raising campaigns on EFP / gender with the support of the traditional popular media (theater companies, folklore groups) were organized. A total of 42 mass awareness-raising campaigns were carried out in seven HZs (CoZO, SABA, Bassila, Tchaourou, KGS, AS and CBGH) at the rate of six villages per HZ. Overall, 6,375 people were reached, including 3,537 women and 2, 213 men. Topics discussed include FP, vaccination, prenatal consultation (PNC), post-natal consultation, hand washing, early use of care, recognition of danger signs, AME and the use of impregnated mosquito nets.

Local women’s’ groups participating in health promotion activities

A follow-up of CBOs' health promotion activities was carried out during the quarter in two HZs (CoZO and SABA). In the two HZs, a total of 35,268 persons were reached by health promotion messages including 28,218 women and 7,050 men through 403 educational sessions on EFP.

Table No. III: Distribution of targets reached by CBO educational talks by HZ

Health Zones Number of Number of women Number of men Total numbers of educational talks reached reached persons reached CoZO 105 2941 730 3671 SABA 298 25,277 6320 31,597 Total 403 28,218 7050 35,268

Activities planned for the next quarter

• Support the HZMT and the Community PIHI NGOs in updating the ICP (taking gender and Ebola Virus Disease (EVD) into account in the DCO HZ); • With the HZMT, conduct a quarterly monitoring visit of activities led by the CBO, the CHWs, community radio stations and community leaders (village headmen and religious and traditional leaders) in the health areas of the CBGH and AS HZs.

Sub-intermediate result 3.2: Informed families make appropriate choices for accessing public and private sector health services and commodities Appropriate choices of families on health care of women and children

The ANCRE program supported the CoZO and SABA HZs and the DEDRAS NGO to develop contracts with local radio stations for broadcasting spots and radio programs on EFP identified by the HZs themselves, taking into account their needs to raise the level of behavior change indicators on the basis of the LQAS results. The topics chosen are compliance with the vaccination schedule, PNC, hand washing hygiene, post-natal consultation and FP.

Strengthening the CHW support systems

Along with the Community PIHI NGOs in the HZs of the Sud and Zou-Collines (AS, CBGH, Cotonou 2 and 3, AZT, CoZO and SABA), ANCRE participated in training sessions on PIHI and monthly group monitoring (MGM) of the CHWs in the different health areas. ANCRE reviewed concepts about malaria case management, acute respiratory infections, diarrhea and filling out management tools with the CHW.

ANCRE provided technical support to the Community PIHI NGOs for developing terms of reference for nutrition technical assistants (TA) and to build their capacities for better effectiveness in their work in the communes. Indicators for the performance framework were selected as well as the adopted TA action plans that will be finalized with the respective HZs for their appropriation.

MNCH services provided by the CHWs

A monitoring mission on the use of CommCare was conducted jointly by the MOH and ANCRE in the Tchaourou HZ during this quarter. Its purpose was to assess the use of CommCare in the field, gather actors’ expectations and prepare CommCare’s transition phase at the MOH/DIP. This visit led to discussions on the sustainability of the CommCare tool and the management process of the CommCare platform at the end of the program.

Several recommendations emerged from this visit:

1. Include supervision on the use of CommCare in the Annual Work Plans (PTA) of the Community PIHI NGOs.

2. Include the use of CommCare in the performance evaluations of the CHWs and head nurses.

Moreover, the data generated by the use of the CommCare application made it possible to note that of 64 children seen for fever and tested for malaria, 63 (98%) had a positive diagnostic test and were treated by the CHWs with an artemisinin-based combination therapy.

Principal activities planned for the next quarter

• Remotely support the MGMs of the CHWs using CommCare to solve technical problems that they encounter in the Tchaourou and Bassila HZs. • Finalize and present the integration of two key CommCare indicators in DHIS2 with DPP;

• Conduct a final field visit with all the partners to learn from the implementation of CommCare in the field in order to inform policy discussions for consolidating achievements and sustainability in the framework of policies and strategies underway.

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

ANCRE continued its collaboration with four NGOs promoting health mutuelles1.

In DCO and CoZO: 40/40 (100%) new promotion and collection agents, including five women (12%), in DCO and 39/40 (97%) managers, including 8 women (20%), in CoZO, were trained on social marketing and management control techniques to properly conduct the mobilization and awareness-raising activities of populations on the one hand, and ensure good management of collected resources on the other hand. These 79 participants come from 15 health mutuelles including 13 in DCO. Photo 6: Collection of contributions by a promotion and collection agent from household members of the Wara mutuelle in Gogounou (ANCRE, March This activity was co-financed by ANCRE 17, 2018) and BØRNEfonden.

In KGS: 16 promotion and collection agents were monitored in activities to promote household membership in health mutuelles. 281 households were registered for 963 beneficiaries and 2,106,500 CFA were collected on behalf of 13 of 15 supported mutuelles in order to ensure their medical care in the event of illness.

Activities planned for the next quarter

• Monitor the awareness-raising campaigns in the Gogounou health mutuelles.

1 BØRNEfonden in CoZO and DCO; Support for Social Welfare (Appui pour la protection sociale) in KGS, and Association for the Development of the Agricultural Mutual Insurance Scheme (Association pour le développement de la mutualité agricole) and ESSENTIAL in DCO

GENDER

Awareness-raising on gender-based violence (GBV)

Supporting the SIA N’SON NGO during the MGM in the ATZ HZ, 74 CHWs were sensitized on the typology of GBV, the penalties incurred under Beninese law and the assistance needed for the victims (social welfare center, hospital for care, police station for court decisions and telephone contacts of the Community PIHI NGOs in case of emergency). The CHWs will bring the information to the communities.

The Monthly Group Monitorings (MGM), mass awareness-raising campaigns with the support of traditional popular media and advocacy sessions with 180 community leaders made it possible to conduct awareness-raising on GBV and distribute a thousand (1000) posters. They are committed to share information on the topic in their circle.

Other activities related to gender

ANCRE participated in the inter-project experience circle organized by USAID on the integration of gender in projects and programs involved in the improvement of reproductive, newborn and child health.

Following this meeting, ANCRE is going through the revision sessions of the integrated communication plans with the various HZs to insert this dimension. Moreover, with the advocacy workshops with community leaders for the promotion of behavior change, ANCRE was able to organize 42 mass awareness-raising campaigns on essential family practices (EFP) and gender in seven HZs. These different campaigns reached 6,375 persons. During these meetings, discussions focused on the integration of gender in planning, the provision of health services and the sharing of experiences about good practices for integrating gender.

PROJECT MANAGEMENT

Closing the EVD component

The ANCRE program’s EVD component was closed on January 31, 2018. On January 24, 2018, the ANCRE program presented the Readiness Assessment of its 10 HZs, conducted in collaboration with the MOH, on the basis of the World Health Organization’s consolidated checklist. The average level of superior preparation is assessed at 75% in the HZs. Preparation for closing the ANCRE program

Preparations for the closure of the program have been marked by active communication with the DDS and the HZs to prepare the withdrawal of the program’s polyvalent teams, which will be redeployed as of April 30. The polyvalent teams implemented the acceleration strategy in the execution so as to complete the planned activities in the PTA. In addition, logistically and administratively, an inventory of program equipment and materials has been completed and a plan for disposing of this equipment has been approved by USAID.

Preparations for the closing ceremony of the ANCRE program are underway in the framework of a committee put in place and chaired by the Ministry of Health and in collaboration with the ARMN3 program that is also coming to an end. As recommended by the USAID program agreement representative, the closure will be done jointly with the ARM3 project also financed by USAID, in the form of an open house on Thursday, March 31, 2018. Partnerships and Collaboration

On February 16, 2018, the ANCRE Program Advisory Board (COCOA) met to discuss strategies for sustaining program achievements. Discussions on the main strategic points concerned sustainability for consolidating the achievements in the program’s intervention areas for which the MOH is committed. These include:

1. Holding regular sessions of the technical commission responsible for granting authorizations to open and practice medicine with private clients;

2. Holding the quarterly coordination meeting of central actors bringing together the TFP participating in monitoring the implementation of the national contingency plan for Hemorrhagic Virus Diseases;

3. Long-term financing of the management of CHWs in the framework of the implementation of Community PIHI;

4. Establishment of the QI teams at the health facility level and quality teams at all levels of the health pyramid.

Activities for the next quarter

• Implement activities concerned with the closure of the program, especially preparation of the open house, the field visit of Commencer sites and managing the redeployment of teams in Cotonou

PERFORMANCE MONITORING

Performance Monitoring Plan (PMP)

The table in Appendix I provides an overview of the current level of PMP indicators compared to the targets set for the second quarter of fiscal year 2018.

Point of execution of activities

The following activities were conducted during the reporting period:

Organization of a training/retraining of trainers on completing SNIGS tools: ANCRE supported DPP to organize a training/retraining of trainers (at the departmental level) on filling out SNIGS tools, including conducting the Data Quality Assessment with other monitoring-evaluation staff members from DNSP, DSME and the National Agency for Vaccination and Primary Health Care (ANV/SSP).

This training took place simultaneously in two sites in Dassa and Abomey from February 6 to 9, 2018 and brought together 61 trainers, including 50 from the 10 HZs and 11 from DDS.

During this training the principal points addressed were the revised tools in regards to the content of the new guide for filling out tools and particularly the new A7 tool.

Print and distribute 500 guides for filling out SNIGS tools: To facilitate the training of providers on filling out SNIGS tools, 500 instruction guides were published and provided to trainers and a manager of each health facility in the 10 HZs;

Training providers on filling out new SNIGS materials: ANCRE provided support for training 772 providers on filling out new SNIGS materials (326 nurses (42%), 164 nurses’ aides (21%), 81 midwives (10%), 20 physicians (3%) and 181 administrators (23%)) in nine of 10 HZs. The CBGH HZ postponed this training for the period from April 10 to 13, 2018 following schedule conflicts in the zone.

Quality assurance and control of SNIGS data: All members who were trained are oriented on quality control of SNIGS data: During the SNIGS tool filling training, emphasis was placed on the quality of the data and the importance of the promptness of the reports according to MOH deadlines. The HZs’ statistical units in close collaboration with the decentralized polyvalent teams carry out quality control of SNIGS data. In addition, the queries conducted on DHIS2 were made available to the polyvalent teams to facilitate discussions with statistical officials. This has improved the timeliness of the January and February 2018 reports to a significant rate of 95% and 90% respectively as of March 28, 2018.

Organize quarterly meetings of the HZs on validating SNIGS data and calculating performance indicators of the ANCRE program: During the quarter, SNIGS data was validated and indicators in all the HZs reviewed with the decentralized polyvalent teams; capture and reporting error rates are less than 5%.

Drafting of 2018 LQAS and 2018 ERPA protocols: On the basis of the 2017 LQAS protocol, ANCRE updated the protocol to be implemented in 2018, taking into account the imperfections noted during the course of 2017. This internally validated protocol was shared with USAID and all MOH stakeholders (DPP, DNSP and DSME) and the 10 HZMT for the implementation in April 2018. The 2018 ERPA protocol is being developed and will include the private sector.

Activities planned for the next quarter

• Active data collection by the Magpi system; • Conduct the LQAS in all health zones; • Carry out ERPA in the private health facilities.

APPENDICES

APPENDIX I: Table of evolution of the ANCRE program’s performance indicators (Jan-Mar 2018)

% of Q2 Results 2018 annual Performance indicator (JAN-MAR Comments Target target 2018) reached Objectives 1 and 2: Improved public health sector performance in delivering integrated family health services

The low rate is the result of a lack of adequate Modern contraceptive prevalence rate 20% 8.1% 40% documentation of FP campaigns in the national information system.

Public sector 7.5% Private sector 0.5% Couple Years of Protection (CYP) 103,290 Reported annually. Public sector Private sector

% of USG-assisted service delivery sites providing FP 97% 92% 95% counseling and/or services

Public sector 96% Private sector 75%

% of USG-assisted health facilities providing emergency 75% Reported annually. obstetrical and newborn care (BEmOC or EmONC)

Public sector Private sector Number of USG-assisted health facilities providing emergency obstetrical and newborn care (BEmOC and 89 Reported annually. EmONC) Public sector 9 Private sector 80

% of newly delivered mothers that received at least 4 The low rate of the first PNC consequently leads 90% 42% 47% prenatal consultations during pregnancy to a lower rate for the fourth.

Public sector 43% Private sector 33%

% of newborns receiving post natal health check within 75% Reported annually. two days of birth (newborn care and treatment)

Public sector Private sector

% of births attended by a doctor, nurse or midwife 94% Reported annually.

% of women giving birth who received uterotonics in the 85% 81% 95% third stage of labor (AMSTL)

Public sector 84% Private sector 50% % of children who received the DPT3 vaccine by 12 95% 89% 94% months of age Public sector Private sector

% of children who received the third dose of 95% 89% 94% pneumococcal conjugate vaccine by 12 months of age

Public sector Private sector % of children 12-23 months of age that received the 80% 94% 118% measles vaccine by 12 months of age Public sector Private sector

The average completeness of morbidity and % of health zones reporting morbidity and mortality mortality data for all 10 HZs is 91%. 10 of 10 HZs indicators to the national program on a monthly basis 100% 100% 100% submitted at least one report, with the during the previous 12 months completeness rate varying between 43% (Cotonou 2&3) and 100% (SABA).

Number of USG-assisted health zones correctly Quarterly reports from the distribution quantifying MNCH and FP/RH commodity needs 10 6 60% warehouses were not submitted by KGS, DCO, according to procurement protocols COZO, and SABA.

Average stockout rate of contraceptive commodities at This result is based on the current completeness 10% 3.1% family planning service delivery points of 59% for A7 materials.

Male condoms 3.1% Female condoms 4.0% Rhythm method (cycle beads) 0.0% Implants 2.0% Injectable contraceptives 5.3% Intrauterine devices 2.5% Oral contraceptives 3.3%

% of USG-supported health facilities that submit a Some health facilities are lagging behind in monthly PIHI tracker products report with timeliness, 100% 72% 72% submitting monthly reports for PIHI tracker exactitude and completeness of data products.

Public sector Private sector

This result represents the number of sites that % of USG-supported service delivery points that have not have not reported a stockout for the following experienced a stockout at any time during the reporting 75% 68% 90% commodities: Oxytocin, Sulfadoxine, Amoxicillin, period of any tracker products Malaria RDT, ACT (3 artemether), Iron fumarate (Iron / Folate), Magnesium Sulfate.

Public sector Private sector

The public sector target is nearing completion. Number of USG-assisted service delivery points However, for the private sector, the number of implementing quality assurance/quality improvement 572 307 54% quality improvement focal points is still low approaches because enrollment is voluntary.

Public sector 254 247 97% Private sector 318 60 19%

Number of targeted health zones that have at least 80% of their partners involved in annual planning and 10 Reported annually. budgeting on an annual basis

Number of targeted health zones using data to inform 10 Reported annually. their annual work plan

Number of targeted health zones with a communication plan that includes the promotion of men’s involvement 10 Reported annually. in family planning

Number of Sayana Press products used in USG-assisted 6,000,000 Reported annually. health facilities Public sector Private sector Objective 2: Improved private health sector performance in delivering integrated family health services

The weak performance is explained by the fact that few private health facilities submit their % of births delivered by caesarean section in the private SNIGS reports to the HZs. Providers have been 15% 3% 19% sector trained on filling out SNIGS tools this quarter, which will improve the availability of the data next quarter.

% of USG-assisted private institutions accredited for PIHI 50% Reported annually.

% of USG-assisted private sector providers that offer Source: 2018 ERPA. To be reported in the next 75% quality PIHI services report. Objective 3: Improved prevention and care-seeking behavior of an empowered population

% of newborns receiving a postnatal health check-up 75% Being collected by LQAS. within the first week of life by a CHW

ANCRE provides technical support to the training Number of USG-assisted CHWs providing FP information of CHWs by APC (Advancing Partners and 2,730 8,001 293% and/or services during the year Communities), which may have decided to increase the number of trained CHWs.

% of health zones with functional CHW systems 100% Reported annually.

This figure comes only from health facilities. The community data are reported by APC.

Number of cases of child diarrhea treated in USC-assisted 33,507 485 1% The result is consistent in regards to previous programs quarters, which indicates that perhaps diarrhea cases are not adequately referred to health facilities.

CHW 9,289 Reported by APC Public sector 371 24,218 2% Private sector 114

Number of children under 5 years of age with suspected This figure comes only from health facilities. The pneumonia receiving antibiotics from health facilities or 74,478 10,124 14% community data are reported by APC. CHWs trained in USG-assisted programs

CHW 13,934 Reported by APC Public sector 9,413 60,544 17% Private sector 711

% of households seeking care for a sick child within 24 65% Reported annually. hours of onset of symptoms

% of the public that remembers hearing or seeing a 95% Reported annually. specific message on FP/RH

% of children age 0-5 months who were exclusively 92% Being collected by LQAS. breastfed during the last 24 hours

% of households participating in health financing 45% Reported annually. schemes

% of children age 0-5 referred by a community health 80% Reported by APC worker and warranted by danger signs

% of households with a place for hand washing with soap 65% and water Reported annually. % of pregnant women at the community level with a 80% birth plan for delivering their babies

APPENDIX II: Table of progress in programmed activities for the period from January to March 2018

Situation at the Activities end of the quarter Comments - DASHBOARD

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

Sub-intermediate result 1.1: Improved planning and management of health systems and services, especially at the decentralized level Organize workshops with the 10 HZs and TFP to develop the Completed 2018 evidence-based PITA. Organize a quarterly active data collection and data quality Underway Only quality control was conducted in the different HZs and control in DCO, Bassila, Tchaourou, CBGH, Cotonou 2 et 3, promptness is 90%. AS and AZT. Organize a meeting of COCOA under the leadership of the Completed MOH Organize a joint mission with the central level of the MOH Completed and the DDS for strategic monitoring of the program implementation Organize a semi-annual program coordination meeting with Not completed Due to the postponement of some scheduled activities as a the Ministry of Health, including the DDS and health zones, result of the delay in execution related to the strikes, it was to review progress and share best practices including the decided to postpone this coordination meeting to focus on management of FP inputs. activities with potential impact on the indicators and to explore the possibility of holding it during the next quarter

Support the health zones to organize quarterly coordination Completed meetings with partners and stakeholders to assess progress towards achieving the PIHI objectives and specifically ANCRE’s PMP.

Situation at the Activities end of the quarter Comments - DASHBOARD

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

Develop quality improvement plans at the HZ level under Completed the leadership of the HZMT In collaboration with the HZMT of the 10 HZs, organize Completed quarterly coaching visits of the QI teams to strengthen the functionality of the teams and the quality of services provided. In collaboration with the other TFP, organize two campaigns Not completed This activity was cancelled because there are problems in to provide FP services with free contraceptives in the HZs mobilizing the other actors around the subject in a context where contraceptive prevalence is low (Cotonou 2 et 3, AS, where health services are affected by the repeated strike DCO, ATZ and CBGH) including the provision of strategic FP actions. services Hold discussions with DDS and the zone teams on ways to Not completed ANCRE advocated and provided support for this activity to motivate and reward successful health facilities be included in the Community PIHI NGO work plan to be carried out.

In collaboration with the HZs, organize advanced strategies Not completed Following DSME's request, this activity was canceled. It was to provide ANC and other services in the health areas with a replaced by the revision of family health services protocols low ANC 4 rate. including common components.

Support the Ministry of Health to organize high-level Completed advocacy in order to mobilize more government funding for

MNCH and FP including FP inputs.

Work with DSME to organize a workshop on family health Completed to update the national maternal health protocols as well as common components

Situation at the Activities end of the quarter Comments - DASHBOARD

Sub-intermediate result 1.3: Essential commodities more available at service delivery and product distribution points

Present commodity data during the CODIR meetings in each Completed commune and HZ meetings for monthly decision-making.

The activity is postponed for April 2018. Discussions are Evaluate the pilot phase on the use of the A7 logistics underway to analyze the type of evaluation needed and reporting tool in DHIS2 under the direction of DPMED and Not completed how to mobilize supplemental funding when needed for the advocate for its institutionalization during a restitution evaluation and dissemination if the final proposed meeting methodology is more costly than expected.

Strengthen the capacity of the HZMT to take into account This activity was conducted in three HZs during the inventory management and quality control of PIHI input preceding quarter (Oct-Nov-Dec 2017), then in six HZs Underway logistical data in the supervisions/coaching of GDRZ and during this quarter (Jan-Feb-Mar 2018) bringing the total to health service providers. 9/10 HZs.

Coach the GDRZ to ensure the monthly monitoring of Completed logistics reports in DHIS2 by verifying promptness, completeness and quality of reports submitted by health facilities to the health zone.

Provide 300 A7 logistics report registers for 2018 to health Completed institutions in the 10 HZs.

INTERMEDIATE RESULT 2: IMPROVED PRIVATE HEALTH SECTOR PERFORMANCE IN DELIVERING INTEGRATED FAMILY HEALTH SERVICES Sub-intermediate result 2.1: Improved public sector policies, oversight and supervision of private sector health care delivery Organize a session of the technical commission Completed responsible for examining the requests for granting authorization to open and practice medicine with private clients, by the MOH.

Provide logistical and financial support to the HZs (CBGH, Completed CoZO, ATZ, SABA, DCO, KGS, Bassila and Tchaourou) to identify and raise the awareness of 369 health facilities that operate illegally on the legal provisions in regards to authorizations to open and practice medicine with private clients;

Provide financial and logistical support to the MOH and Completed PSSP for organizing a sharing workshop on the private health sector.

Support PSSP and the Ministry of Health to develop and Completed reproduce six promotional products (brochure, posters, etc.) to inform private health facilities on how to open and operate a private practice.

Work with the Ministry of Health to organize a session of Not completed The session was postponed until the next quarter due to a the technical commission responsible for examining delay in the organization of the field inspection mission, application packages for authorization to open and which is prerequisite for holding the commission session practice medicine with private clients

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

With PSSP and the MOH, coach the 60 PHFs and five Underway The 7 PHFs who have finished their improvement plan are

pharmacies involved in the accreditation process currently being coached for the implementation of activities to improve the quality of their health care delivery. In partnership with the HZs (CBGH, CoZO, ATZ and SABA), Completed train staff of 109 PHFs in FP contraceptive technologies/counseling, including supervision of community-based services and data management

Support PSSP and health zones to strength/expand the Completed quality improvement teams and plans in private health facilities

Work with the health zones to support and coach workers Completed in private health facilities

Facilitate the holding of coordination sessions between Underway Conducted only at ATZ, it will no longer be carried out in the the PHF and HZMT for planning, implementing activities, other HZs due to the unavailability of funding. monitoring/supervision as well as collecting HZMT data in each HZ (CBGH, CoZO, ATZ and SABA)

Support the health zones to hold learning sessions with Completed the quality improvement teams

Provide financial and technical support for coordination Partially completed This activity was organized in ATZ during the reporting period between the private health facilities and the zone and will continue in the coming months management teams in all ten zones

Organize two learning sessions between the quality Not completed Learning sessions involving the public and private sectors improvement teams in the public and private sectors, were not conducted during the quarter due to interruptions especially in the Abomey Calavi zones, Sô-Ava and in public sector activities related to staff strikes. Cotonou 2&3

Provide technical support to the AS and Cotonou 2 & 3 Completed HZs for integrating the private health facilities in their supervision plan.

Participate in sharing sessions between ANAM, ARCH, Completed PSSP and CONSAMUS on methods for developing partnerships

Organize a workshop on developing partnerships Completed

Validation workshop on partnership models Completed

Training actors on the management of public and private Partially completed The process of capacity-building was initiated, especially in partnerships ATZ and AS and will continue during the next quarter in consultation with potential beneficiaries

Support PSSP to organize information sharing and Not completed This activity was postponed in order to gain the support of capacity building sessions on partnerships, especially with R4D during the next quarter banks and insurance companies.

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

Support the HZMT and Community PIHI NGOs to update Underway The activity was conducted in all the HZs except DCO where it the ICP of the 10 HZs (taking gender and EVD into will be carried out during the next quarter. account), through participating in two work sessions in each HZ (all 10 HZs)

In 35 health areas (at the rate of 5 low performing health Completed areas per HZ), organize two advocacy sessions for community leaders on Essential Family Practices/Gender (AS, Tchaourou, Bassila, Cotonou 2&3, ATZ, CoZO and SABA)

In 36 villages (at the rate of 6 low performing villages per Completed HZ), organize a mass awareness-raising campaign on Essential Family Practices/Gender with the support of the popular media in 6 HZs (Cotonou 2&3, ATZ, CBGH, CoZO, AS and SABA)

With the HZMTs and PIHI NGOs in each health area, Underway The activity was conducted in all the HZs except AS and CBGH conduct a quarterly visit to monitor the activities led by where it will be carried out during the next quarter. the CBO, CHW, community radio stations and community leaders (village headmen and religious and traditional leaders) in the KGS, Cotonou 2&3, ATZ, and CBGH HZs, in order to improve the collaboration and avoid DCO, CoZO and AS duplications

Conduct a working session in each HZ to advocate for Completed strengthening the collaboration with the community radio stations and PIHI NGOs to build local synergies for the broadcasting of radio programs on EFP in the ten zones, including after the end of the ANCRE program. Sub-intermediate result 3.2: Informed families make appropriate choices for accessing public and private sector health services and commodities

With APC, co-facilitate three sessions to build the Completed technical capacities of managers, facilitators and M&E officers from Community PIHI NGOs.

Co-facilitate two sessions to build the capacity of the Completed CHWs by HZ in the six HZs newly provided with Community PIHI NGOs (integrated planning, training, monthly group supervisions, on-site supervision and data quality control) (CBGH, AZT, AS, Cotonou 2&3, CoZO and SABA)

Co-facilitate a session to build the capacities of Completed community health workers by zone in the four HZs

previously provided with Community PIHI NGOs (monthly group supervision, data quality control and joint supervision) in the KGS, Tchaourou, Bassila and DCO HZs

Organize a session to document and share good practices Not completed The community QI teams were not adequately coached by with quality improvement teams at the community level health center managers to identify changes. These managers in the Tchaourou and Bassila HZs; were perpetually on strike

Build the capacity of intermediate level actors (DDS focal Completed points and CRAMS, Statistical Officers) on the use and monitoring of the CommCare mobile application through training and equipping with needed tools Together with the HZMT, train the facilitators and M&E Completed officers of the DEDRAS and SIA N’SON NGOs on the CommCare supervision and maintenance tools. Work with PIHI NGOs to strengthen their skills in coaching, especially on the use of FP and troubleshooting community workers’ mobile telephones Collaborate with the DPP to finalize the integration of two Underway The configuration of the two key indicators (relating to key CommCare indicators in DHIS2 malaria and diarrhea) is done on the CommCare platform, while at the level of DHIS2, it is in progress because its security certificate is expected for the finalization of the process.

Support the Community PIHI NGOs to organize high level Not completed ANCRE also advocated and provided support for this activity advocacy events at the national level in collaboration with to be integrated in the Community PIHI NGO work plan to be other stakeholders to put in place a national budget line carried out for community health and particularly for the community worker system.

Support the Ministry of Health in ongoing discussions on Completed

urban community health and work with DNSP to organize a national workshop to validate the model.

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

Financially support the organization, by 32 health Completed mutuelles, of a quarterly campaign to raise awareness and collect contributions from member households in 6 HZs (CBGH, AS, CoZO, DCO, Tchaourou and KGS)

Coach 150 mutuelle leaders on the management control Not completed Activity cancelled in favor of other programmatic priorities of supported mutuelles that occurred during the implementation of the plan.

Organize an advisory-support mission by quarter to 65 Not completed Activity cancelled in favor of other programmatic priorities women's groups for access to micro-loans, and to that arose during the implementation of the plan. establish and manage health solidarity funds (AS, CBGH, CoZO, SABA and DCO)

Equip 100% of the CBO according to their performance Not completed The CBO will receive materials for their motivation in the with material to enhance their revenue-generating framework of the plan for disposing of the program’s material activities (65 women’s’ groups in 5 HZs) and equipment.

Reproduce and distribute 250 copies of the national Underway The document is finalized. It is being copied for release in the health insurance education model for members of ColoSS coming quarter in the ten zones. Organize an advocacy workshop with the authorities and Not completed During the quarter, it wasn’t possible to mobilize the various local elected officials as well as the associations of three stakeholders due to an agenda conflict If possible, discussions KGS communes to mobilize financing for health mutuelles will continue in order to organize it in the next quarter.

Participate in strategic events and technical meetings Completed related to the operationalization of ARCH and support the process under way to reform the health sector Initiate strategic partnerships with other TFP to increase Completed

access of populations to health mutuelles

GENDER Organize an inter-project experience circle on integrating Not completed The same type of activity was conducted directly by USAID gender in projects and programs involved in the and ANCRE participated in it. Therefore, it appears useless to improvement of reproductive, newborn and child health us to repeat what was planned in ANCRE’s PTA and document best practices

Develop a national module on gender for use by actors in Not completed This activity could not be carried out due to the emergence of the health pyramid. new needs considered to be higher priority during implementation to the detriment of other activities like this one. Organize a workshop to revise the Strategic Plan for Not completed Supplementary budget not mobilized by the MOH Institutionalizing Gender at the MOH;