MAURITANIA RURAL MEDICAL ASSISTANCE PROJECT

QUARTERLY REPORT

JANUARY - APRIL. 1982

PREPARED UNDER

CONTRACT NO. AFR/AID-0202-C-00-1DI4-oo PROJECT NO. 682-0202

OlMPEX ASSOCIATES INC. TABLE OF CONTENTS

I.. INTRODUCT ION

I I. PROJECT'S BASIC DATA

I I I. CURRENT ACTIVITY AND RESULTS ACHIEVED TO DATE

IV. PROJECT1S MID-TERM EVALUATION ACTIVITY

V. ATTACHMENT "A": ACTI VIT I ES PLANNED FOR SECOND QUARTER OF 1982

ATTACHMENT "B": SUMMARY OF ACT IVIT IES

D1MPEX ASSOCIAYES INC. I.INTRODUCTI ON

The Rural Medical Assistance project for the , under the overall direction of the Ministry of Health, in cooperation, with the USAID Mission Health Special ist, and DIMPEX ASSOCIATES consultant in the capacity of Publ ic Health Adviser, and field operations coordinator, is currently in operation.

This quarterly report represents an update of project activities covering the period January 1 through April 30, 1982.

I I. PROJECT'S BASIC DATA & OBJECTIVES

The project's operational activity started in January 1981, and is scheduled to be completed by December 1983. Funding for this project, however, has been earmarked until March 1984.

The goal of the GIRM is to create a community supported health care system to be del ivered by trained community health care workers. At project's completion it is expected that primary health care services and a medical suppl ies dispensary will be available to 192 villages and rural encampments in the Trarza Region.

II I. CURRENT ACTIVITY & RESULTS ACHIEVED TO DATE

In the month of January 1982 the data collection ~ystem and statistical elaboration system to be used for the project's mid-term evaluation, sched­ uled for the month of April 1982 have been developed and organized.

Activity was also directed toward the organization of the third training session of Village Health Workers, scheduled to take place in March 1982. During this session, thirty-six new CHWs (Community Health Workers) will be trained. This activity included:

- Tentative selection of new villages for which community health workers will be trained.

- Preparation of the re-training course for the health workers grad­ uated during the first training session completed in March 1981.

- Revision and standardization of tests administered to candidates for the CHW Training courses prior to admission to the courses, and revision of tests required to graduate from the training course.

- Development of the checkl ists, forms and questionaires to be used by the nurses supervisors responsible for ihe control and evaluation of the field and performance of the CHWs graduated during the December 1981 training session.

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-A village inhabitants census-taking operation was carried out by the nurses supervisors in the course of their CHWs field performance evaluation activity. In order to save time and contain costs, the nurses supervisory teams also organized Community Health Committees in new villages located in the same geographical areas where the eval­ uation was taking place. This will el iminate the cost of performing this operation at a different time.

- In the course of the period covering February and March 1982, 48 villages were animated, and 36 Community Health Workers were recruited. During the March 1982 training session, 32 CHWs were graduated, and 36 Community Health Committees were formed. Steps were also taken to reinforce the animation process in those villages that did not respond to the first animation operation.

TRAINING ACTIVITY

A new training center was opened at Keur Macene and the first training pro­ gram was given in the Wolof language.

The results of this center have proven disappointing since only four of an anticipated larger number of Wolof villages were found to exist in real ity, and only 2 villages out of 4 were will ing to participate. The number of community health workers to be trained was increased by 2 Wolof-speaking Maures from the region.

After several supervisory visits to this center it was concluded that it was inadvisable from both the technical and financial point of view to oper­ ate this center, and it was closed during the last week of training.

The Community Health Workers from this center were moved to the training site of .

The third training session of Community Health Workers began on the 21st of February 1982. Thirty-two CHWs were graduated during this session.

At the close of this session a total of 98 CHWs were trained, out of a total of 192 projected.

LOCAL ACCOUNT AND LOCAL PERSONNEL

During the month of March the project fired one chauffeur and hired two others. At the same time a bil ingual secretary was engaged. The problem of hiring of local personnel by Dimpex Associates contractors has still not been resolved. The final responsibil ity for the local personnel is still under review both by USAID in Mauritania and AID/Washington. Dimpex Assoc. has submitted a proposition and budget which is currently under review.

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Dur~ng the period January through April 1982 the money spent in the local account totaled U.S. $49.847. The bulk of the money went to the payments of trainee scholarships and "per diems" to the field personnel. as well as vehicle maintenance:

Local Vehicle Opp. Date Personnel Support Commodities Support Training Total

Jan. 82 213.232 103.359 -0- 243.693 19.200 579.484 Feb. 82 188.361 41 .329 -0- 55.017 66. 100 350.807 Mar. 82 371. 520 61 .541 -0- 54.582 I 71 .00I 658.644 Apr. 82 283.639 58.686 -0- 147.145 164.691 654.161

1.056.752 264.915 -0- 500.437 420.992 2.243.096 45 UM = $1.00 U.S.

MEDICAL/PHARMACEUTICAL SUPPLIES PROCUREMENT AND DISTRIBUTION

The community health workers have begun buying medical suppl ies at the wholesale bulk rate. as well as obtain a special 10% discount requested for them by the Director of Health. This reduces substantially the costs of medical suppl ies for the villagers and should serve as an incentive towards continued buying.

Approximately 80% of the project villages seem to have re-stocked the supply originally furnished them by the project. Some ~f the suppl ies were fur­ nished as a gift by the governor or by wealthy relatives 1iving outside the vi Ilage.

The minority of the suppl ies were purchased at Pharmarin. the wholesale dis­ tributor. at Rosso or .

IV. PROJECT'S MID-TERM EVALUATION ACTIVITY

The project's mid-term evaluation was originally scheduled to coincide with the last week of the training programs in March 1982. The evaluation started the first week of April 1982.

The evaluation teams consisted of the following members:

- TEAM LEADER: Dr. Ramiro Delgado, Professor of Publ ic Health at the Touro Research Dept. and Dimpex Associates Consultant.

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- TEAM MEMBERS: GIRM Ministry of Publ ic Health:

- Dr. Mohamed Mahmoud Ould Hacen, Director of the Ministry of Health, and Director of the Rural Medical Assistance Project of Trarza.

- Dr. Moskar, Chief of Medicine of The Trarza Regional department.

- Mr. Diouf Ibrahima, Nurse Supervisor and the Trarza health pro­ administrator.

- Mr. Moctor Ould Memah, Nurse Supervisor and Education Adviser for the Trarza health project.

- Ms. Mamadou Sy, Nurse Supervisor of The Traditional Midwife department of the Ministry of Health.

- DIMPEX ASSOCIATES, INC.

- Ms. Mona Grieser, U.S. Publ ic Health Adviser, and Trarza Health Project Chief of Party.

- U.S. PEACE CORP VOLUNTEERS

- Ms. Rebecca Brooks, Director.

- U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT {USAID)

- Linda Neuhauser, USAID Health Officer and Manager of the Trarza Hea Ith Project.

- George Jones, USAID Health Regional Officer, Abidjan, Ivory Coast.

- Alan Reed, USAID Program Director. - David Carr, USAID Economist.

- GIRM MINISTRY OF RURAL DEVELOPMENT

- Diall0 Amadou Yero, Administrative Dept. Supervisor.

- GIRM MINISTRY OF ECONOMIC AFFAIRS

- Ba Cumar Pusala, Economist.

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- WORLD HEALTH ORGANIZATION (WHO)

- Andre Kitoko, Sanitation Engineer.

Dr. Ramiro Delgado arrived at post March 29 and Dr. George Jones the fol low­ ing day. The program of the evaluation was such that the evaluators spent the first few days planning the evaluation, preparing the tools and famil­ iarizing themselves with the project. Three field teams were organized each visiting three villages in the departments of /R'kiz, Boutil imit and Rosso, after which a general assembly of the evaluators drew their conclusions for the final draft.

Some recommendations made by the evaluators are already being put into action (revision of forms; standardizat·ion of procedures, amendents to the medical kits, etc...). Others await government discussion and approval of particular importance has been the problem of integrating the project in such a manner as to ensure continuation of project activities by the government. The GIRM (represented by Dr. Hacen, project director as well as Director of Health for Mauritania has categorically stated that it will be impossible for the govern­ ment to finance any future activities of this project. It simply does not have the means. This depressing but real istic summation of the situation forced the project's principals to look for alternative solutions. To examine this problem more data is needed than can be generated through the project itself and it was decided to request additional funds through PRICOR. These additional funds will be used to examine the condition of the villages, their socio-economic situation to determine whether or not their structure can support the financing necessary to maintain proje~t activities.

A detailed proposal has been sent to PRICORlWashington outl ining a program of research. That would provide community financial data. At the moment of writing no word has been heard from Washington as to whether or not this project has been accepted. A compromise has been arrived at between the pro­ ject and PRICOR enabl ing PRICOR to use project staff and vehicles during the period of their field work. Moctar Ould Memah, the Health Educator of the project, will serve as the principal investigator and DIMPEX Associates will provide the services of Dr. Ramiro Delgado as the overall supervisor. Addi­ tional assistance will be provided to the project through the offices of USAID and their nutrition/health adviser Dr. Heather Goldman. Dr. Ramiro Delgado, Dimpex Assoc. consultant is preparing a full project evaluation report which will be available in the near future.

FUTURE ACTIVITIES

Future activities of the project will revolve around the results and recom­ mendations of the evaluation team. Attachment IIA" describes the activities of the project of the following quarter.

DIMPEX ASSOCIATES INC. ATTACHMENT ItA" ACTIVITIES PLANNED FOR THE SECOND CHARTER OF 1982

MAY JUNE JULY AUGUST

1. Seminar in Statistics 5. Seminar in Statistics for Volunteers for Nurses

2. Revision of Project Activities according to 9. PRICOR activities Evaluation Report begin

3. Evaluation Report 10. 4 Nurses return from completed Lome training Centre

~. Supervision of ASC all departments

8. Volunteers-vacation 13. I'Recyc 1agell a 11 proj ect staff in revised project activities

6. Nurses-vacation

7. Chauffeurs-vacation 14. Publ ic Health Adviser vacation

11. 4 New nurses join the project

12. 1 New Project Government 15. Project Manager Administrator to replace leaves Project Diouf Ibrahima joins the project 7

ATTACHMENT "B"

SUMMARY OF ACTIVITY

TRAINING

31 health agents trained in February/March 1982.

- Bou til imit (Hassan iya) 7 - R'Kiz (Hassan iya) 4 - Mederdra (Hassan iya) 10 - Rosso (Hassan iya) 6 - Keur Macene (Ha s san iya) 4 Total 31

RECYCLI NG

24 health agents out of 35 from the first group of health agents were re-trained.

- Rosso (Pulaar) 8 - Rosso (Wo I of) 9 - R'Kiz (Hassan iya) ...l Total 24

Of the 7 health agents trained in R'Kiz one is from Mederdra.

Thus at the end of the 3rd Training session 98 health agents have been trained out of 192 making goal achieval of 51% at mid-term.

CENSUS AND HOUSEHOLD SURVEY 27 villages of the 31 from which health agents were trained, have been sur­ veyed. 4 villages in the Keur Macene region were also surveyed but proved to be incomplete and are being re-surveyed.

SUPERVISION

All the health agents in the Dept. of R'Kiz. Mederdra and Boutil imit were supervised between April and May 1982. In Rosso the Hassanophones have been supervised but the Pulaar and Wolof-speaking ASC have not been. This is due to a shortage of nurses. (2 nurses speaking these languages are currently receiving further training at the OMS health centre in Lome the 3rd Supervisor nurse, Mr. Diouf Ibrahima is on loan to the Union Travailleurs Mauritanian and not available for work.)

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At the end of the supervisory trip 7 kits were removed from health agents who had either abandoned their post or their task. Thus the current situ­ at ion i s as f 011 ow. - R'Kiz 26 rema in of 32 trained = 6 lost - Mederdra 16 remain of 22 trained = 6 lost 12 rema in of 12 trained = 0 lost - Rosso 26 remain of 28 t ra ined = 2 lost - Keur Macene - 4 remain of - 4 trained = - 0 lost Total 84 98 14

PERSONNEL

Currently the Ministry of Health has provided to the project

- 4 nurses (in training at Lome) - 1 nurse/trainer (Rosso) Hassaniya - 1 nurse/trainer (Boutil imit) Hassaniya - 1 nurse/trainer (Mederdra) Hassaniya - 2 supervisor/nurses (Nouakchott)

The status of one of this latter category is in question since a formal request has been made by the Worker's Union to detach him from the Ministry of Health and attach him to the Union. This request has unofficially been approved and the project has since requested an additional number of nurses. 5 new nurses have been requested:

1 nurse midwife (Hassan iya) 1 nurse midwife (Pulaar/Wolof) 3 nurse/trainers

This is to ease the burden of lending 4 nurses and four volunteers to the PRICOR project as well as to increase the number of trained personnel who can expand Primary Health Care to other regions of the Trarza.

Additionally the project has requested the Ministry to provide:

nurse/supervisor (Wolof/Pulaar) statistician

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