ARM3 FOURTH QUARTER REPORT ______
FISCAL YEAR 2012 – QUARTER 4 JULY 1 – SEPT 30, 2012
Participants in Abomey during the IMCI training .
October 30, 2012
This report was produced for the United States Agency for International Development (USAID) by Medical Care Development International (MCDI).
ARM3 Accelerating the Reduction of Malaria Morbidity and Mortality Program
Fourth Quarter Report July 1, 2012 to September 30, 2012 Fiscal Year 2012
Submitted to: Dr. Emile Bongo, USAID Agreement Officer Representative (AOR), USAID/Benin Dr. Milton Amayun, Family Health Team Leader, USAID/Benin Ms. Anne Busaka, Senior Acquisition and Assistance Specialist, USAID/Benin
ARM3, Accelerating the Reduction of Malaria Morbidity and Mortality Program (ARM3), is funded by the United States Agency for International Development (USAID), under Cooperative Agreement AID-680-A-11-00001. ARM3 is managed by Medical Care Development International (MCDI) as the prime, in collaboration with sub-grantees Africare, Johns – Hopkins University – Center for Communications Project (JHU-CCP) and Management Sciences for Health (MSH). The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or of the United States Government.
Table of Contents Table of Contents ...... 1 Table of Acronyms ...... 1 Acknowledgements ...... 3 Executive Summary ...... 4 Introduction...... 6 Start-up Activities (continued) ...... 6 Achievements ...... 6 Result 1: Implementation of malaria prevention interventions in support of the National Malaria Strategy improved...... 8 Sub-Result 1.1: IPTp Uptake Increased ...... 8 Achievements ...... 8 Results ...... 9 Sub-Result 1.2: Supply and Use of LLINs Increased ...... 9 Achievements ...... 10 Results ...... 10 Result 2: Malaria diagnosis and treatment activities in support of the National Malaria Strategy improved 11 Sub-Result 2.1: Diagnostic Capacity and Use of Testing Improved ...... 11 Achievements ...... 11 Results ...... 13 Sub-Result 2.2: Case Management of Uncomplicated and Severe Malaria Improved ...... 13 Achievements ...... 13 Results ...... 16 Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened...... 17 Sub-Result 3.1: MOH/NMCP Capacity to Deliver and Manage Quality Malaria Treatment and Control Interventions Improved .. 17 Achievements ...... 17 Results ...... 18 Sub-Result 3.2: Capacity to Collect, Manage and Use Malaria Health Information for M&E and Surveillance Improved ...... 19 Achievements ...... 19 Results ...... 22 Sub-Result 3.3: Capacity in Commodities and Supply Chain Management Improved ...... 22 Achievements ...... 23
Cross Sectional Activities ...... 26 Behavior Change Communication (BCC) ...... 26 Achievements ...... 26 Performance Improvement Approach ...... 28 Achievements ...... 28 Program Management ...... 30 Home Office Backstopping and Reporting...... 30 Achievements ...... 30 Major Challenges (per ARM3 sub-result): ...... 31 Major Activities Planned for next quarter (Oct– Dec): ...... 32 Financial Summary ...... 34 Annex 1: OTSS Data – Round 9 (Group D Baseline) vs. Round 8 (Comparison Groups A, B, and C) ..... 35 ANNEX 2: SUMMARY OF PRELIMINARY RESULTS OF THE APRIL 2012 END-USE VERIFICATION SURVEY...... 47 ANNEX 3: MINI CARAVAN QUOTES ...... 54 Annex 4: ARM3 Quarterly Financial Report (July through September 2012), Reporting from Inception (October 3, 2011) through September 30, 2012 – Cumulative ...... 56 Annex 5: ARM3 Quarterly Financial Report (July through September) Reporting from July 1 through September 30, 2012 – Non Cumulative ...... 57 Table of Acronyms
AAA/3A Akpro Misserte – Avrankou – Adjarra ABC Analysis of stock value, turnover, and volume ABD Adjohoun – Bonou -- Dangbo ABFC Association Béninoise de Femmes Chanteuses ACPB Association des Cliniques Privées du Bénin ACT Artemisinin Combination Therapy AIRS Abt’s Indoor Residual Spraying Program AL Artemether + Lumefantrin AMCES Association des Œuvres Médicales Privées Confessionnelles et Sociales ANC Antenatal Clinic AOR Agreement Officer Representative ARM3 Accelerating the Reduction of Malaria Morbidity and Mortality Program (ARM3) BASICS Basic Support for Institutionalizing Child Survival BCC Behavioral Change Communication BDHS Benin Demographic and Health Survey CAFE Stock Management Software Company CAME Centrale d’Achat des Médicaments Essentiels (Central Medical Stores) CCM Community Case Management CDC Centers for Disease Control and Prevention CEBAC-STP Coalition des Entreprises Béninoises et Associations Privées Contre le SIDA, la Tuberculose, et le Paludisme CHD Centre Hospitalier Départemental CHW Community Health Workers CNHU Centre National Hospitalier Universitaire CoGeS Comité de Gestion COP Chief of Party DDMS Disease Data Management System DDS Direction Départmentale de Santé DHS Demographic Health Survey DIEM Direction de l’Infrastructure de l’Equipement et de la Maintenance DPMED Direction de la Pharmacie, des Médicaments et de l’Exploration Diagnostique DPP Direction de la Programmation et de la Prospective DRZ Dépôt Répartiteurs de zone DSME Direction de la Santé de la Mère et de l’Enfant EEZS Equipe d’encadrement de zone sanitaire ETAT Emergency Triage, Assessment and Treatment EUVS End Use Verification Survey FO Field Office FSS Faculté des Sciences de la Santé GFATM Global Fund to Fight AIDS, Tuberculosis, and Malaria GHI Global Health Initiative GOB Government of Benin HMIS Health Management Information System HO Home Office HOMEL Hôpital de la Mère et de l’Enfant de Littoral HW Health Workers ICCM Integrated Community Case Management IMaD Improving Malaria Diagnostics INMES Institut National Médico-Social INSAE Institut National de la Statistique et de l’Analyse Economique IPTp Intermittent Preventive Treatment for Pregnant Women IRS Indoor Residual Spraying IRSP Institut Régional de Santé Publique
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IVCC Innovative Vector Control Consortium JHU-CCP Johns Hopkins University – Center for Communication Programs KPI Key Performance Indicator LDP Leadership Development Program LIAT Logistic Indicator Assessment Tool LLIN Long Lasting Insecticide-treated Nets LMIS Logistical Management Information System LOP Length of Project MCDI Medical Care Development International M&E Monitoring & Evaluation MEDISTOCK Commodities Management Program MIS Malaria Indicator Survey MMAC Malaria Microscopy Accreditation Course MMRT Malaria Microscopy Refresher Training MNCH Maternal, Neonatal and Child Health MOH Ministry of Health MOU Memorandum of Understanding MOP Malaria Operational Plan MSH Management Sciences for Health NGO Non-Government Organization NMCP National Malaria Control Program ORTB Office de Radio et Telévision Béninoise OTSS Outreach Training Support and Supervision PAK Pobe – Adja Ouere -- Ketou PAS Porto Novo – Aguegues – Seme-Kpodji PI Performance Improvement PISAF Project Intégré de Santé Familiale PITA Plan Intégrée de Travail Annuel PMEP Performance Monitoring and Evaluation Plan PMI President’s Malaria Initiative PNLP Programme National de Lutte contre le Paludisme QA/QC Quality Assurance/Quality Control RBM Roll Back Malaria RDT Rapid Diagnostic Test RFA Request for Applications RMIS Routine Malaria Information System ROBS Réseau des ONG Béninoises de Santé SAGE Stock Management Software SAKIF Sekete/Ifagni SAM Senior Alignment Meeting SCM Supply Chain Management SGSI Service de gestion du Système d’Information SNIGS Système National d’Information et de Gestion Sanitaire SOP Standard Operating Procedures SP Sulfadoxine-pyrimethamine STTA Short Term Technical Assistance SWOT Strengths, Weaknesses, Opportunities and Threats TWG Technical Working Group UAC University of Abomey – Calavi UAM United Against Malaria UNICEF United Nations Children’s Fund USAID United Stated Agency for International Development WHO World Health Organization WOM Warehouse Operation Management WG Working Group
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Acknowledgements
ARM3 wishes to thank everyone who helped create this document as well as various technical and financial partners for providing constant support to Benin in the fight against malaria including the National Malaria Control Program, our private sector partners (Coalition des Entreprises Béninoises et Associations Privées Contre le SIDA, la Tuberculose, et le Paludisme, CEBAC-STP, Association des Œuvres Médicales Privées Confessionnelles et Sociales, AMCES, Réseau des ONG Beninoise de Santé, ROBS, and Association des Cliniques Privées du Bénin, ACPB). In addition, we acknowledge the USAID Benin Mission for their constant guidance and financial support in the implementation of the ARM3 Project.
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Executive Summary
ARM 3 Results Sub-Results Key Achievements
Submitted a proposal to USAID/Benin to incorporate integrated community case management (ICCM) activities in ARM3 activities in the five former Management Sciences for Health (MSH) health zones John Hopkins University - Center for Communications Program (JHU- CCP) recruited a Behavior Change Communication (BCC) Officer Start-up Activities Africare recruited and posted a Field Supply Chain Officer for the Abomey Field Office Rented office space in Parakou and took possession of the Basic Support for Institutionalizing Child Survival (BASICS) Project‘s inventory of office supplies and other equipment Continued discussions with teaching institutions 1.2.1 IPTp uptake Reviewed integrated supervision guidelines taking into account IPTp as increased part of the strategic and operational plans of the Atlantique-littoral and Oueme-Plateau health departments
1. Implementation of ARM3, Coalition des Entreprises Béninoises et Associations Privées malaria prevention Contre le SIDA, la Tuberculose, et le Paludisme (CEBAC-STP) and the programs in support of National Malaria Control Program (NMCP) signed a memorandum of the National Malaria understanding (MOU) that outlines the roles and responsibilities of each Strategy improved 1.2.2 Supply and use of of the three partners. LLINs increased USAID and DELIVER confirmed ARM3’s order for 100,000 nets with anticipated delivery in Benin the second week of December 2012 A training was organized by the JHU-CCP’s NETMARK Project and partially funded by ARM3 on three new planning tools for routine distribution of LLINs Conducted Round 10 Outreach Training and Support Supervision 2.1 Diagnostic capacity (OTSS) in 118 facilities (102 public and 16 private) and use of diagnostic Collaborated with the National Malaria Control Program (NMCP) in the testing improved elaboration of a plan for the introduction of the use of rapid diagnostics tests (RDTs) at the community level 2. Malaria diagnosis and 24 health care providers from Ouidah-Kpomasse-Tori Bossito health treatment activities in zones trained in 11-day Integrated Management of Childhood Illness support of the national (IMCI) training malaria strategy improved 2.2 Case management of Organized first Leadership Development Program (LDP) workshop uncomplicated and severe attended by 40 participants malaria improved Trained 13 practitioners in Emergency Triage, Assessment, and Treatment (ETAT) from 5 hospitals in the Oueme-Plateau Health Department Organized, supported and held the second malaria BCC technical working group (TWG) meeting 3.1 NMCP’s technical Organized, supported and held the first Case Management (CM) capacity to plan, design, Technical Working Group (TWG) meeting manage, and coordinate a Supported the NMCP to organize a quarterly review of the Plan Integre comprehensive malaria de Travail Annuel (PITA) and gave a presentation on the achievements control program enhanced of ARM3 to date 3. National health Supported NMCP in coordinating with other Roll Back Malaria (RBM) system’s capacity to implementing partners deliver and manage Carried out supportive supervision visits of health information staff in quality malaria treatment the health zones constituting the Donga-Atacora and Borgou-Alibori and control interventions Health Departments 3.2 MOH capacity to strengthened Organized a workshop and trained statisticians (from the six health collect, manage and use departments, NMCP and SGSI) on LOGISNIGS malaria health information Facilitated the preparation of two Routine Malaria Information System for monitoring, evaluation Newsletters (Number 5, July edition and Number 6, August edition) and surveillance improved Conducted an annual review of the health zone Routine Malaria Information System (RMIS) data by organizing three separate regional workshops 3.3 MOH capacity in Trained the Board of Directors of the Central Medical Stores (CAME) in 4 | P a g e
commodities and supply good governance and strategic monitoring and evaluation chain management Led ad hoc committee established by the NMCP to develop strategies improved for mitigating risk of expiration of Artimether – Lumfather (AL 1 X6) Developed and validated Logistics Management information System (LMIS) supportive supervision tools and terms of reference (TOR) for supportive supervision at the intermediate level Forecasted one month RDT needs for the five health zones in northern Benin formerly supported by BASICS/MSH Redesigned and harmonized the malaria LMIS to track malaria drug consumption Based on comments received from MCDI, MSH is in the process of finalizing the French and English versions of the End Use Verification Survey (EUVS) report Shared findings of the JHU-CCP BCC research literature review at an ARM3 strategic communication workshop Finalized 2 TV commercials and obtained the rights to use a video song Organized a one-day mini caravan covering three health centers in Cotonou (health zone 5) whereby two key behaviors, use of long- lasting insecticidal nets (LLINs) and Sulphadoxine-Pyrimehamine (SP) were promoted Short Term Technical Assistance (STTA) (MSH, Senior Program Associate) travelled to Benin to continue to assist in the planning, preparation and implementation of the Leadership Development Program (LDP) STTA (MSH, Procurement and Supply Management Technical Officer) travelled to Benin to conduct a refresher training for the Central Medical Stores (CAME) Board of Directors (BOD) on how to conduct effective oversight of its senior management and institution’s activity STTA (MSH, Senior Technical Manager for Malaria) travelled to Benin to support the implementation of two LMIS review workshops and to Cross Sectional Activities develop a strategy to build health zone capacity in quantification of and Program Management malaria commodities STTA (MSH, Senior Program Associate) travelled to Benin to review progress of pharmaceutical management activities for project year 2 implementation STTA (JHU-CCP, Finance Officer) travelled to Benin to train JHU- CCP’s newly hired Finance Assistant in JHU’s financial and administrative procedures STTA (JHU-CCP, Consultant) travelled to Benin to provide training in the use of project design tools (curriculum and manual) that will help train and monitor patient-provider counseling activities STTA (MCDI, Senior Malaria Program Officer) travelled to Benin to provide technical and administrative support and also serve as Acting Chief of Party STTA (MCDI, Monitoring and Evaluation Officer) travelled to Benin to support field staff in the preparation of second year work plan Dr. Moussa Thior was designated as Chair of an ad hoc Committee by the NMCP Director
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Introduction
Accelerating the Reduction of Malaria Morbidity and Mortality Program (ARM3) in Benin, is funded by the United States Agency for International Development (USAID). The ARM3 consortium, led by Medical Care Development International (MCDI) as the prime recipient, includes sub-grantees Africare, Johns Hopkins University – Center for Communication Programs (JHU-CCP), and Management Sciences for Health (MSH). The ARM3 consortium works in partnership with the Benin Ministry of Health’s National Malaria Control Program (NMCP), to implement the five year (October 1, 2011 to September 30, 2016) ARM3 malaria control program. In collaboration with USAID/Benin’s President’s Malaria Initiative (PMI), ARM3 seeks to assist the Government of Benin (GOB) in improving malaria health outcomes in accordance with the NMCP’s guidelines and standards. The primary objective of ARM3 is to help the Government of Benin achieve the PMI target of reducing malaria-associated mortality by 70%, compared to pre-initiative levels in Benin. In support of this PMI objective, the ARM3 program’s specific goal is to increase coverage and use of key life-saving malaria interventions in support of Benin’s NMCP Strategy. ARM3 will also complement and expand the efforts of other donors (for example the Global Fund to Fight AIDS, TB, and Malaria (GFATM), and private sector organizations) to reach the NMCP’s goal of eliminating malaria as a public health problem in Benin by 2030. ARM3 major results are as follows: Result 1: Implementation of malaria prevention interventions in support of the National Malaria Strategy improved. Result 2: Malaria diagnosis and treatment activities in support of the National Malaria Strategy improved. Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened. This report (July 1, 2012 – September 30, 2012) details the program activities completed and key indicators corresponding to the results and sub-results described in the ARM3 Annual Work Plan and Monitoring and Evaluation Plan. It also presents the key activities planned for the quarter October– December 2012.
Start-up Activities (continued) Achievements Finalized the proposal for integration of five BASICS health zones Since MCDI’s July 17th submission of the proposal to include Integrated Community Case Management (ICCM) in the five former MSH/BASICS health zones, the USAID Contracting Officer in Accra has given approval to move forward with the proposed amendment. In order to complete the amendment, USAID requested that associated implementation costs be integrated into ARM3’s overall budget. In September, MCDI’s Home Office provided the requested updated budget to USAID/Benin. At the request of USAID, before the commencement of ICCM activities in the five BASICS health zones, MCDI will carry out a situational analysis to justify continued ICCM interventions in the five health zones or identify new intervention areas.
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Recruitment of ARM3 Staff
Name Job Title Partner Status/Date Began Location Melahele BCC Officer JHU-CCP Hired in September, 2012 Cotonou Soukouda Rodriguez Field Supply Chain Africare Hired in August, 2012 Abomey Viakinnou Coordinator TBD BCC Coordinator Africare Currently advertising this position Parakou TBD Supply Chain Coordinator MSH Began recruitment process Parakou TBD Case Management and MSH Began recruitment process Parakou Performance Improvement Coordinator A Wakil M&E Coordinator MCDI Contacted A. Wakil (presented in Parakou proposal) to confirm availability Dr. Lola Field Team Leader and MCDI Identified candidate and is Parakou Gandaho Case Management pursuing negotiations. Coordinator
Detailed Year 2 Work Plan MCDI and its partners completed and submitted a work plan and budget to USAID for the second year (October 1, 2012 to September 30, 2013) of the ARM3 Project. To support the field staff in the preparation of the year two work plan, MCDI’s Monitoring and Evaluation Officer spent two weeks in Benin to assist the ARM3 team with the development of the second year work plan. The format of the second year work plan was modified to present the analysis of the first year’s interventions, to fix targets for year two, to piece together the different sections (BCC, M&E, Case Management, etc.) and detail the activities for year two to be carried out for each intermediate result. The presentation in the form of Gantt charts has been drastically simplified to provide links between the budget and Malaria Operational Plan (MOP). During a two-day retreat in early September, ARM3 staff examined year one progress and performed a strengths, weaknesses, opportunities and threats (SWOT) analysis, after which the Home Office (HO) and the Field Office (FO) began a series of review meetings with ARM3 partners to examine their performance and ways to improve expected outputs. Several possible changes are under consideration.
Status of ARM3 Offices The MSH/BASICS project office in Parakou was leased by ARM3 and the entire inventory of office equipment and the vehicle used by the former BASICS Project in Northern Benin has been transferred to the project.
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Result 1: Implementation of malaria prevention interventions in support of the National Malaria Strategy improved.
ARM3 will scale-up prevention efforts through the expansion of IPTp and improved coverage of LLINs through the social marketing of LLINs in the private sector (supported by IEC/BCC activities). The two sub-Results are: Sub-Result 1 (IPTp increased) and Sub-Result 2 (supply and use of LLINs increased). Sub-Result 1.1: IPTp Uptake Increased Results from the DHS show that only 22.8% of pregnant women had received two doses of sulphadoxine – pyrimethamine (SP) in 2011. In support of PMI’s Malaria in Pregnancy (MIP) objectives, ARM3 will improve IPT uptake. To achieve this result, ARM3 is pursuing interventions that include upgrading the skills of government and private health sector workers both through pre-service curricula modifications at the major training institutions, INMES and the medical faculty, and in-service training for recent graduates. Additionally, ARM3 is working to provide improved supervision and support to health workers to follow case management and prevention guidelines (including IPTp, in the context of focused-antenatal care (ANC), severe malaria, and clinical ICCM. Finally, ARM3 is continuing the review/implementation of Behavior Change Communication (BCC) campaigns to promote IPTp and early care seeking behavior in addition to improving skills of government health providers on patient counseling. Achievements Enhance pre-service training on IPTp, malaria diagnostics and case management, patient counseling and community engagement IPTp, malaria diagnostics and case management are part of the pre-service training discussions with the schools/institutions and will be clearly mentioned in the MOUs as discussed. For this purpose, the clinical case management team held discussions with the BCC team to understand the scope of activities related to patient counseling and community engagement. Both the clinical case management and BCC teams have planned to work together in the coming quarter to develop all needed materials, e.g. curriculum and training materials.
Supervise and support health workers to follow case management and prevention guidelines (including IPTp, in context of focused-ANC, severe malaria, and clinical ICCM.) ARM3 and the NMCP organized a workshop which took place during September 11-14, 2012 in Porto- Novo to review the integrated supervision guidelines taking into account IPTp (see details on that activity below). All the templates (Checklist for the management of malaria in pregnancy during ANC visits; II: Interview guide #1 with the outpatient consultation during maternity; IV: Interview guide #2 with the outpatient consultation during maternity) include IPTp components. Moreover, there is a table on the maternity intake cards that will help track client consumption of SP. This will be useful for the calculation of IPTp indicators.
Include IPTp supervision and malaria diagnostics skills upgrade in PI Approach for national/departmental hospitals and health zones ARM3 worked on the development of strategic and operational plans at the Departmental and HZ level; these plans incorporated IPTp supervision and also focused on upgrading malaria diagnostics skills. In Atlantique-Littoral, ARM3 held a workshop to develop strategic and operational plans from July 24 to 26, 2012 with 35 participants (20 females and 15 males). A similar workshop was convened in Oueme- Plateau for the PAS (Porto-Novo-Aguégués-Sèmè-Podji) and the 3A (Akpro Misserte-Avrankou-Adjarra)
8 | P a g e health zones from July 21-22, 2012. ARM3 held a subsequent workshop to finalize strategic and operational plans for the PAK (Pobè-Adja-Ouèrè-Kétou), SAKIF (Sakété-Ifangni) and ABD (Adjohoun- Bonou-Dangbo) health zones from July 25-29, 2012). After the finalization sessions in Ouémé-Plateau, ARM3 organized a workshop to validate DDS and HZ plans (triennial, annual and chronogram) from September 10-11, 2012 with 18 participants. Activities in these plans focus mainly on: • Prevention: to increase the IPTp2 and also the number of pregnant women and children under five who use LLINs; • Case management: training of the health care providers that are not trained in IPTp, malaria case management, ICCM, RDT use and microscopy; • Health systems strengthening: avoid stock outs of malaria control products and improve the timeliness of reporting, i.e. RMIS, SNIGS, LMIS, etc. • Continued improvement and harmonization of the databases • Development of MOUs to be signed with HZs integrating IPTp supervision.
Results Indicator Baseline LOP Target Q4 Results Comments Result 1: Implementation of malaria prevention programs in support of the National Strategy improved Sub-result 1.1: IPTp uptake increased Women who receive 1) Percentage of women Baseline two or more doses of who have completed a 3.0% 22.8% SP during their last pregnancy in the last two DHS draft report , May pregnancy within the years who received two or Source 24% (Urban) 2012 last two years in more doses of IPTp during DHS, 21.9% (Rural) intervention areas will that pregnancy 2006 reach 85% Baseline Target is being 0 21) Number of health developed in None this Activity will take place in workers trained in IPTp with consultation with the Source quarter Q1 (Year 2) USG funds NMCP and other ARM3 stakeholders Records
Sub-Result 1.2: Supply and Use of LLINs Increased In support of this sub-result, ARM3’s innovative approaches to scaling- up interventions for impact is the inclusion of in-country private and non-governmental partners to support specific interventions. The consortium believes that efforts to scale up malaria control in the public sector are certainly critical and necessary, but probably insufficient to achieve the ambitious goals sought by the NMCP and USAID without increasing access to quality services through the private sector, non-governmental organizations (NGOs), and the active participation of community organizations.
ARM3 recognizes that social marketing is a strategy to promote changes in ideas, attitudes, and behavior and that it is based on the traditional marketing mix: product, place, price and promotion. ARM3 anticipates using a target subsidy approach that will permit employees of CEBAC-STP members to purchase nets at a subsidized price and to do so through an installment payment mechanism that may include having the installment payments deducted from their paychecks over time. The social marketing concept under consideration will permit CEBAC-STP members to utilize the proceeds generated through the sale to support complementary activities to include household LLIN monitoring BCC campaigns that focus on health promoting behaviors. 9 | P a g e
Achievements Memorandum of Understanding with CEBAC-STP On October 4, 2012, ARM3, CEBAC-STP and the NMCP formally signed the MOU that will serve to shape the relationship between the three partners. The signing ceremony was the culmination of several months of discussions and negotiations between the three parties. With the signing of the MOU, CEBAC- STP has committed to working together with its members to distribute LLINs to the employees and family members of companies within the network. Additionally, CEBAC-STP will implement activities for prevention and case management of malaria and report to the NMCP. ARM3 will provide technical and financial assistance to CEBAC-STP while the NMCP will monitor and supervise activities.
Supply of LLINs Pertaining to the provision of LLINs to employees in the private sector, ARM3 will receive from USAID/ DELIVER a onetime order of 100,000 LLINs expected to be delivered to Cotonou near the beginning of December 2012. ARM3 provided specifications (to USAID/DELIVER) for the LLINs to be used for social marketing with the private sector be a different color (green) from the nets supplied to Benin for routine distribution to pregnant women during prenatal consultation visits. ARM3 has prepositioned itself to distribute 40,000 of the 100,000 nets directly upon their arrival to the CEBAC-STP network enterprises. The remaining 60,000 will need to be warehoused. . ARM3 is working with CEBAC-STP to take the necessary steps in securing the safe and proper storage of the remaining 60,000 LLINs.
Participation in NetMark training From September 19 to 20, 2012, ARM3’s Private Sector Coordinator and two members from CEBAC-STP took part in the training workshop on new planning tools for continued routine distribution of LLINs. The training workshop for the NMCP and partners was organized by the NetMark Project, (JHU-CCP) and partially funded by ARM3. Through this training, participants received useful information on the following three tools: (1) Guide for the design and planning of continuous distribution of LLINs, (2) NetCalc software, a new tool for modeling and quantification of LLIN needs and (3) Country guide for those responsible for the continuation of the routine LLIN distribution. Results Indicator Baseline LOP Target Q4 Results Comments Result 1: Implementation of malaria prevention programs in support of the National Strategy improved Sub-result 1.2: Supply and use of ITNs increased
Baseline Proportion of pregnant 75.5% 2) Percent of pregnant 20% women who slept under women who slept under an ITN the previous DHS report, May 2012 73.9% (Urban) an ITN the previous night Source night in intervention 76.5% (Rural) DHS, 2006 areas will reach 85%
Proportion of children Baseline under five who slept 71% 3) Percent of children 20% under an ITN the under five who slept under DHS report, May 2012 previous night in the 70.5% (Urban) an ITN the previous night Source intervention areas will 71.3% (Rural) DHS, 2006 reach 85%
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Indicator Baseline LOP Target Q4 Results Comments Proportion of households Baseline 79.8% 4) Percent of households with a pregnant woman 25% with a pregnant woman and/or children under 78.2% (Urban) DHS report, May 2012 and/or children under five five that own at least one Source 81% (Rural) that own at least one ITN ITN will reach more than DHS, 2006 90% Please note: ARM3 is not responsible for mass distribution of ITNs
Result 2: Malaria diagnosis and treatment activities in support of the National Malaria Strategy improved
ARM3 supports improved case management of both severe and uncomplicated malaria and improved diagnosis of malaria through use of microscopy and RDTs. Result 2 consists of two sub-results: Sub- Result 2.1 (diagnostics capacity and use of testing improved) and Sub-Result 2.2 (case management of uncomplicated and severe malaria improved). Sub-Result 2.1: Diagnostic Capacity and Use of Testing Improved ARM3 assists the NMCP in enhancing capability and utilization of quality malaria diagnostic services via the implementation of enhanced supportive supervision at government health facilities. Prior to ARM3, MCDI implemented a supportive supervision program throughout the country through the IMaD program. Achievements Develop Guidelines for RDT use at the Community Level The Supply Chain and Case Management divisions collaborated on the elaboration of a plan for the introduction of RDT use at the community level. A draft plan has been finalized.
Malaria diagnostics and clinical case management in pre-service training ARM3 continued holding separate meetings with the Director of INMES (Institut National Médico-Social, Cotonou), Dean and Vice Dean of FSS (Faculté des Sciences de la Santé), and Dean of the Medical College of the University of Parakou to discuss how ARM3 can collaborate with these pre-service training institutions. Based on the discussions and given that changing curricula is a complex matter, ARM3 is exploring the possibility of signing MOUs and assist these institutions with funding to provide access to practical training in diagnostics techniques; labs and RDT use.
Malaria diagnostics training in the PI approach for newly hired health providers
ARM3 and the DDS and health zones from the Atlantique –Litoral and Oueme-Plateau Departments are in the final stages of developing their strategic and operational plans in support of strengthening malaria diagnostics and case management.
Outreach Training Support and Supervision (OTSS) Round 10 Implement quarterly OTSS visits (diagnostics) in 16 private and 102 government health facilities ARM3 is supporting the implementation of the national malaria QA/QC plan through the Outreach Training and Support Supervision (OTSS) program for laboratory health workers. OTSS is an on-site supervision program designed to provide ongoing support to diagnostic services in health facilities by identifying areas in need of improvement and supporting clinicians and laboratory staff through on-site training. Standardized checklists are used to assess quality and to collect laboratory diagnostic data for 11 | P a g e program management. Malaria slides are collected from sites as part of the malaria microscopy Quality Control (QC) program. The implementation of the 10th round of the national malaria QA/QC plan through OTSS has been successful. 12 supervisory teams (laboratory and clinician supervisors) were formed. A total of 118 health facilities (102 public and 16 private) were visited. Private facilities included 9 AMCES, 2 CEBAC, 2 ACPB and 3 other private organizations (CS Ahmadiya, CS Clinique Cooperative Calavi and Hospital El Fateh). Health Facilities visited by ownership During the OTSS exercise:
• 236 healthcare providers were trained AMCES, CEBAC, ACPB, 2% OTHERS, in their place of work; 8% 2% 2% • General information about the health facilities was collected; • Office Equipment and laboratory PUBLIC consumables were counted and AMCES verified; • The quarterly report of the total CEBAC number of confirmed malaria cases in OTHERS children under five (outpatients and PUBLIC, ACPB inpatients) and patients up to five 86% year was calculated; • Blood smears were validated; • The conformity between prescription and negative results was verified; • Supervised healthcare providers were observed while preparing blood smears, coloration, slide reading and RDT attainment in clinical services; • Restitution session was held; and • Plans to solves identified issues was elaborated with the supervised healthcare providers;
The original group of 72 facilities (70 public and 2 private) are now on a semiannual supervisory scheme whereas the new group of 46 (32 public and 14 private) laboratories will continue to be visited quarterly for the first year of implementation of OTSS. Follow on visits will then become semiannual for all participating laboratories. Detailed information related to the results of OTSS Round 10 will be provided in the next report. The results of the 46 new facilities that were part of Round 9 can be found in Annex 2: OTSS Data – Round 9 (Group D Baseline) vs. Round 8 (Comparison Groups A, B, and C). Regarding the study on the Evaluation of the Diagnostic Capacity of Malaria in Benin, Ghana and Zambia, the survey protocol was submitted to the focal point of the ethics committee in Benin on Thursday October 4, 2012. Clarifying questions were asked by the committee. We are working on them to provide answers in the best time. A final decision is expected during the next quarter.
Tracking Staff – Malaria Diagnostics Training In order to determine health worker needs in malaria diagnostics in Ouémé-Plateau, ARM3 has begun gathering information on staff trained. A sheet to collect related information was sent to the DDS. In Ouémé-Plateau, 882 skilled health care providers were trained and 357 are not trained on malaria diagnosis (microscopy or RDT).
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Training area Concerned skilled Already Trained To be trained health care providers Number percentage Number percentage
RDT 1267 882 70 385 30
Microscopy 40 21 52 19 48
Results Indicator Baseline LOP Target Q4 Results Comments Result 2: Malaria diagnosis and treatment activities in support of the national malaria strategy improved Sub-result 2.1: Diagnostic capacity and use of diagnostic testing improved 5) Percent of targeted health centers that have Indicator describes Proportion of health the following: 1) OTSS facilities only. Baseline centers with the ability to personnel trained in 95.7% 95.8% perform biological malaria diagnostics, 2) no (44 of 46 Results shown are for diagnostics for malaria stocks outs affecting facilities) round 9 of OTSS1. Source (either microscopy or malaria diagnostics for OTSS Round 7 rapid diagnostic testing) more than 2 weeks, 3) a Round 10 data is will be 85% functional microscope being complied. (non-RDT facilities only) 6) Number of health Q4 Result Baseline: 153 clinical and lab workers trained in malaria Lab: 72 facilities with Target now only health workers laboratory diagnostics Clinical : 81 laboratories includes facilities with received on the job rapid diagnostics tests (46 facilities Public: 102 labs training during Round (RDTs) or microscopy reporting for 9 with USG funds Q4)
Sub-Result 2.2: Case Management of Uncomplicated and Severe Malaria Improved Upgrading the skills of health workers is critical to proper case management of severe and uncomplicated malaria. ARM3’s vision is to assure quality enhancement through developing/updating clinical case management guidelines and related tools, supporting the training of private and government health staff, and implementing a Performance Improvement Approach (PI) in health zones and hospitals. An integral part of quality assurance requires an enhanced and integrated supervision approach which includes IPTp, malaria diagnostics, and clinical case management. Achievements Review of NMCP Malaria Case Management Guidelines ARM3 team, in collaboration with the NMCP, has already planned the necessary activities related to the revision of all training materials. Apart from the previously reviewed training manual for RDT use, during Q3 of FY12 the ARM3 team and the NMCP reviewed the training manuals for malaria in pregnancy (comprised of a participant manual and a facilitator’s guide). These revised documents are awaiting final validation. Review of the additional manuals has been reprogrammed for the next quarter. These manuals include:
1 Annex 2 presents a summary of OTSS Data – Round 9 (Group D Baseline) VS Round 8 (Comparison Groups A, B and C) 13 | P a g e
the training manual for non-qualified health workers on malaria case management (participant manual and facilitator’s guide); the malaria case management training manual for health facility staff (participant manual and facilitator’s guide) the supplemental training manual for qualified health workers on pharmacovigilance, RDTs, ACTs, LLINs and others products (participant manual and facilitator’s guide) and;
Training health providers on management of uncomplicated malaria Finalizing IMCI training modules The ARM3 team, in collaboration with the MOH’s DSME team, organized a validation workshop in Ouidah (July 2nd to 6th 2012) of the IMCI training materials and templates integrating observations from the IMCI training session for Nikki-Kalale-Perere (NKP) and Banikoara health zones organized last quarter. Participants included 11 IMCI facilitators and instructors that came from all departments of the country. IMCI documents were reviewed and finalized and sent for printing.
The objectives of the workshop were to: (a) finalize the updated training modules for IMCI clinical training; (b) validate the training modules for clinical IMCI participants in order to ensure compliance with the new guidelines of care for malaria and nutrition; and (c) update the database to monitor the performance of training course participants. And more specifically: (a) review the training modules for IMCI clinical participants, (b) complete the integration of observations from the review of the revised training modules, (c) integrate changes adopted at the end of the NKP-Banikoara training program, (d) develop the module for IMCI infant care, (e) review all modules and records to ensure compliance with current guidelines for the management of malaria and nutrition, (f) incorporate the changes to the performance database for monitoring of trainees adopted at the end of the NKP-Banikoara session, and (g) test the performance monitoring database for participants to ensure its adequacy with changes in training modules. Training government/private health providers on IMCI By using the validated training modules referenced above, ARM3, in partnership with the DSME team, organized the second session of the IMCI training. Twenty-four (24) health workers (17 women and 7 men) from the Ouidah-Kpomassè-Tori-Bossito health zones were trained in IMCI at the Abomey CHD from July 16-27, 2012.
IMCI Training validation criteria
N# Criteria Norm Results of the session
1 Ratio of facilitators to trainees 1 per 3 to 4 1 per 4
2 Total duration of the course 11 days (88 h) 89h
3 Distribution of the total amount of hours 33% of total hours for 35% of total hours for practical practical
4 Number of modules read and understood 07 07 with writing exercises done
5 Mean of expositions per trainee 40 to 45 43,08%
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6 Mean of cases per trainee 25 to 30 30,08%
7 Mean of success ratio 85% 90%
Three health professionals from health facilities in the private sector participated in the training of healthcare providers in the IMCI program held from July 16 to 27, 2012 at the CHD hospital in Abomey. Two local partners, ROBS and AMCES, identified facilities within their networks that intervene in the Ouidah- Kpomasse - Tori Bossito health zone and sent participants to this training.
Participants in the classroom
Participants in the field (Health Facilities)
Training of health provides on severe malaria ETAT training The first ARM3 sponsored ETAT training started in September 17-21, 2012 in Cotonou with the training of trainers’ session that brought together 15 participants (8 female and 7 male) from Atlantique-Littoral, Ouémé-Plateau, Zou-Collines, Atacora-Donga, Mono-Couffo). Following the TOT session, the ETAT
15 | P a g e training session was held for 13 health care providers (6 women and 7 men) from four hospitals (3 public and 1 private) in Oueme-Plateau. The table below presents personnel trained:
Health Zone Facility type Public/Private # of Participants Adjohoun Hospital Public 3 Pobè Hospital Public 2 Sakété Hospital Public 4 Bon Samaritain Polyclinique Private 4
The number of health care providers trained (13) is fewer than expected due to the fact that the fifth invited hospital, Clinique Louis Pasteur, did not send participants.
Results Indicator Baseline LOP Target Q4 Results Comments Result 2: Malaria diagnosis and treatment activities in support of the national malaria strategy improved Sub-result 2.2: Case management of uncomplicated and severe malaria improved
85% of health centers Baseline 85.74% will have the ability to 6) Percent of suspected 32.8% perform biological 62.2 % of health malaria cases submitted Source diagnostics for malaria facilities reporting. to laboratory testing Source RMIS, Q3 (either microscopy or Rapport (Apr-Jun 2012) RDTs) Revue-2010 7) Percent of patients (all 95% of patients (all ages) who tested positive ages) who tested positive Baseline 81.4% <5 EUVS report, April for malaria (via (via microscopy or RDT) 85.7% >5 2012 microscopy or RDT) that will receive an effective received an anti-malarial anti-malarial 8) Percent of patients (all Baseline Target is being ages) who tested negative RDT: 34% developed in 32.2% <5 EUVS report, April for malaria (via Micro: 33% consultation with NMCP 19.5% >5 2012 microscopy or RDT) that and other stakeholders received an anti-malarial Supervision is provided Baseline to at least 90% of health All 118 of the 9) Percent of targeted 100% (N=72) workers nationwide with facilities participating health centers that malaria-related 100% (N=118) in round 10 OTSS received supervision Source responsibilities at least were supervised OTSS Round 7 once every six months Proportion of children 10) Percent of children Baseline under-five with DHS report, May under-five with suspected <1% suspected malaria (fever) 2012 reported malaria (fever) in the last in the last two weeks children that received two weeks who received Source who received treatment 12.37% treatment with treatment with ACTs DHS, 2006 with ACTs within 24 specifying “within 24 within 24 hours of onset hours of onset of fever in hours” of their symptoms targeted areas will increase to 85% 11) Percent of mothers / Baseline 90% of mothers / caretakers who sought <1% caretakers who sought DHS report, May 6.7 % treatment with the use of treatment with the use of 2012 ACTs for their under-five Source ACTs for their under-
16 | P a g e children with suspected DHS, 2006 five children with malaria within 24 hours suspected malaria within of onset of their 24 hours of onset of their symptoms symptoms 12) Number of schools of nursing and educational Baseline 2 in year 2 institutions that have None Planned for year 2 0 2 in year 3 updated their malaria guidelines and curriculum 13) Number of newly 24 (7 male and Baseline hired health workers 72 17 female) Total to date: 48 0 trained in ICCM health workers 14) Number of hospitals Baseline 29 4 that received a refresher 21 Thirteen health 17 public 3 public training for severe PISAF and professionals attended 12 private 1 private malaria case management Unicredit 23) Number of health workers trained in case Target is being management with Baseline developed in None artemisinin-based 0 consultation with NMCP combination therapy and other stakeholders (ACTs) with USG funds
Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened.
ARM3 addresses a number of serious weaknesses in the NMCP’s capabilities. Result 3 consists of three sub-results: Sub-Result 3.1: MOH/NMCP capacity to deliver and manage quality malaria treatment and control interventions improved; Sub-Result 3.2: Capacity to collect, manage and use malaria health information for M&E and surveillance improved; and Sub-Result 3.3: Capacity in commodities and supply chain management improved.
Sub-Result 3.1: MOH/NMCP Capacity to Deliver and Manage Quality Malaria Treatment and Control Interventions Improved ARM3 plans to undertake activities to reinforce the capacity of the NMCP to manage malaria interventions. One of the primary methods includes the support and promotion of NMCP Technical Working Groups (M&E, supply chain, communications, and case management) to meet regularly and to assist in coordinating with other malaria implementing partners. Additionally, ARM3 will seek out other Malaria Control Partners operating in Benin to work to improve collaboration. Achievements Malaria Related Technical Working Group (TWG) Case Management TWG The 1st Case Management Technical Working Group meeting was held on September 3, 2012 at the NMCP offices. There were 16 participants from the MOH (NMCP, DSIO, DSME, DHR, DNPS), and partners (PISAF and ARM3). Discussions focused on the new WHO directives on malaria case management. Directly following this TWG meeting, the WHO malaria case management directives changed mainly in relation to malaria in pregnancy with the use of SP. For this reason, the next TWG meeting (planned for December 4, 2012) will work to integrate these newly released directives into the guidelines for malaria case management recently adapted by Benin 17 | P a g e
Participant Composition of the Case Management Technical Working Group
Expertise/Organization Number
National Malaria Control Program (PNLP/MS) 7
Direction of nursing and obstetrical care (DSIO/MS) 1
Africare 1
ARM3 1
Direction of Maternal and Child Health (DSME/MS) 1
PISAF 1
Direction of Human Resources (DRH/MS) 1
College of Health Sciences (FSS/UAC) 1
Medical and Social National Institute (INMES/UAC) 1
National Direction of Public Health (DNSP/MS) 1
Total 16
Behavior Change Communication TWG The second BCC TWG meeting was held during Quarter 4. Attending participants included the NMCP coordination team, Africare, CRS, ARM3, AIRS, CEBAC-STP and representatives from Atlantique and Littoral departments. The group reviewed the recommendations made during the first (May 2012) meeting. In addition, NMCP partners (ARM3, Africare, CRS, Abt, and CEBAC-STP) gave presentations on their respective activities and achievements and reviewed a documentary entitled “Piqure Mortelle’, a series created by “la maison de Production Audio-visuelle de Communication et des Arts de Scène: Son Pour Son Multiproduction ». It is a series of 30 episodes of 13 minutes to be aired on the national TV stations. In addition, CRS and Africare reported on their routine outreach activities involving community health workers, Abt’s Indoor Residual Spraying (AIRS) Program informed the group about its IRS campaign in the department of Atacora and, in support of the PITA (Plan Intégré de Travail Annuel), ARM3 gave a presentation highlighting the achievements during the quarter.
Results Indicator Baseline LOP Target Q4 Results Comments Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened Sub-result 3.1: NMCP’s technical capacity to plan, design, manage and coordinate a comprehensive malaria control program enhanced 15) The number of Baseline The 4 NMCP technical Q4 Results NMCP technical 0 working groups 2 NMCP TWGs 18 | P a g e
Indicator Baseline LOP Target Q4 Results Comments working group (monitoring and met: Case (monitoring and evaluation, supply chain, Management evaluation, supply chain, communications, and case and BCC communications, and management) are meeting case management) regularly as planned meetings The activities described in section 3.2 below also directly support the strengthening of sub-result 3.1.
Sub-Result 3.2: Capacity to Collect, Manage and Use Malaria Health Information for M&E and Surveillance Improved Successful program management requires timely and accurate data to make rational and informed decisions on policy and interventions. ARM3 plans on evaluating and strengthening each of the major information systems including the HMIS/RMIS (LogiSnigs & LogiHops), LMIS (Medistock), IRSP sentinel surveillance, OTSS, EUVS and other malaria-related systems. The objective is to ensure that each system is providing high quality and timely data for decision making and that barriers to information collection, management, and utilization are addressed. Achievements Supervision of the Health Information Systems ARM3 carried out supportive supervision visits to the Alibori-Borgou and Atacora-Donga Department staff responsible for data collection, entry and transmission of data related to malaria. Specifically, the objectives were to: (a) Assess the level of RMIS data input sheets at health zones offices; (b) Check the quality of data entered at facility level; (c) Verify that collection sheets are properly filled out at the health zones; (d) Perform routine maintenance of computers reserved for SNIGS data entry (installing anti- virus); (e) Update LOGISNIGS software; (f) Brief statisticians on the use of the software; (g) Inquire about the difficulties of data collection and transmission from health zones; and (h) Make recommendations to improve the completeness of data. Actions taken during the supportive supervision visits in each of the health zones constituting the two health departments included: installing new anti-virus software; updating and compacting the data bases; briefing statisticians on the various software features; and correcting any reported malfunctions.
Health Observations Key Actions taken Zone
Quality data entry for all zonal offices Installed ant-virus on computers and Atacora- new version of software Donga Overall the data was complete (except Health Tanguieta); Database structure updated Zone Proper maintenance of computers is Database compacted to speed up relatively good (some problems in Kouande); operations The use of LOGISNIGS for data processing Briefed statisticians on various is still low software features Low quality of computers at the Natitingou Kouandé statistics office.
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Due to non-compatibility of entry mask, no The new software version has been Alibori- data has been entered for zonal offices installed on each computer Borgou Some health zones do not consistently Anti-virus installed on computers to transmit records secure the database; Computers not maintained Database has been updated Agents do not use processed/treated data for Database was compacted to speed decision making up operations Computers at the statistics office have All malfunctions reported by the viruses statistician were corrected Briefed statisticians on various software features
Recommendations: • Health zone statisticians have been urged to improve the completeness of data. In addition, zonal offices need to improve completeness of collection sheets submitted by certain health centers. • Briefings on various concepts for new agents must be presented at the monthly meetings • Statisticians were asked to compact their respective databases on a monthly basis in order to increase the speed of the LOGISNIGS. Training of staff and statisticians on LOGISNIGS ARM3 organized a training workshop on August 6-12, 2012 for statisticians from each of the six departmental directorates and for personnel responsible for the management of information systems at the national level (3 NMCP representatives and 4 SGSI representatives). The main objective was to improve the use of data from the RMIS for the purpose of making appropriate decisions. Specifically, the objectives were to: • Strengthen the capacity of statisticians in the maintenance of the database and RMIS/SNIGS • Improve the ability of statisticians to use Access software necessary for the appropriation of the database and SNIGS • Strengthen the capacity of the technical staff of the SGSI for the maintenance and further development of the LOGISNIGS software The training took place in two stages: the first three days, which involved all 13 participants, was devoted to training on database maintenance and Access software. The last three days, were reserved to the 9 employees of the SGSI and NMCP and focused on the maintenance of LOGOCIEL, its redeployment and future development. To facilitate efficient workflow, a training manual was developed. Practical exercises were organized to allow rapid assimilation of knowledge by participants. Before the training began, participants' knowledge was assessed on their understanding of the maintenance of the database and LOGISNIGS. The average assessment total was 6 out of 20. Only one of the 12 participants obtained 50%. After the training a second assessment was made which showed that the participants had grasped the appropriate techniques and knowledge provided to them, with the average score increasing from 6 to 15.5. The maximum score was 20 and the minimum 8.5.
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A total of eight people participated in the second three-day training whose objectives were to: 1. Resolve software malfunctions in LOGISNIGS 2. Understand the interaction between the database and the LOGISNIGS software 3. Become familiar with some basic features necessary for the development of the LOGISNIGS software 4. Manipulate the codes written in different modules without damaging the software
Routine Malaria Information System (RMIS) Support and Improvements Two RMIS newsletters (July Edition, Newsletter 5 and August Edition, Newsletter 6) were prepared this quarter. To facilitate the preparation of these quarterly newsletters, a small working group from the NMCP, SNIGS, IRSP and ARM3 was set up. The working groups met between July 25 to 27, 2012 and August 8 to 10, 2012, respectively, in Lokossa. The primary purpose of these newsletters is to inform stakeholders on the malaria epidemiological situation and malaria prevention activities taking place. Specific objectives were to: 1. Analyze the completeness of RMIS by health zone from January to June 2012 2. Make a comprehensive logical validation of the data available from January to June 2012 3. Agree on key indicators to be included in the newsletter, its editorial theme, and its overall presentation 4. Fill in the various headings of RMIS newsletter 5. Approve the first and second newsletter of 2012 Newsletter 5 (July Edition) has since been printed and was distributed while Newsletter 6 (August Edition) is waiting to be printed. RMIS Annual Review The RMIS has a number of deficiencies that continue to require work to improve the system’s scope, consistency, quality, and timeliness. During the quarter ARM3, in conjunction with the M&E division of the NMCP, conducted an annual review of the health zone data via three regional workshops that brought together the data entry staff, the chief medical officer and the departmental NMCP representative. Objectives included: 1. Appraise the completeness and timeliness of quarterly data; 2. Validate the data collected from health facilities; 3. Examine the consistency of the data collected; 4. Analyze key indicators 5. Assemble the difficulties and make recommendations for improving data quality. A working group session allowed for a thorough review of data from each health zone which revealed: 1. Completeness: Compared to the last RMIS report (62.2%), completeness has reached 80.8%. The lowest completeness was 34.0% (ZS Cotonou) and the highest 100% (ZS Porto Novo Avrankou, Bassila). 2. Error rate: At the national level, it stood at 24.8% (981 records were studied from a sample that spanned two months’ time – 243 records were noted as having input errors). The lowest rate, 2.4% was obtained by the health zone (HZ) of Savalou and the highest rate, 100%, was registered for the HZs of Pobè and Sakété. 3. Internal consistency: The frequency of inconsistent data was quite high. The main types of noted inconsistencies were: 21 | P a g e
i) Number of malaria cases tested positive was higher than the number of cases tested ii) Number of ACT treatments prescribed and the quantity declared released by the pharmacy is very high compared to the number of positive and untested patients together. iii) Some health centers express the quantities of ACT as tablets and not as treatment. These errors of internal consistency largely explain the sometimes exorbitant level of the indicators calculated in the newsletter. 4. Each health zone should produce a quarterly RMIS newsletter.
The data validation identified different types of errors that plague the data collected by the RMIS and helped to significantly improve the completeness of the data and made the following recommendations: 1. It is important to maintain permanent contact (mail and telephone) with Statisticians and MCZS to finish the pursuit of error elimination during the coming months; 2. Establish quarterly validation exercises as a routine activity to ensure quality data with good completeness; 3. Follow up on the briefing of agents on correctly filling out data collection forms to improve data quality; and 4. Improve the data circuit for community level information. Results Indicator Baseline LOP Target Q4 Results Comments Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened Sub-result 3.2: MoH capacity to collect, manage and use malaria health information for monitoring, evaluation and surveillance improved 16) Percent of targeted Q3Results facilities reporting through the 62 % RMIS results are Routine Malaria Information Baseline RMIS: (568 public from Q3, 2012. (Apr System and sentinel 37.8% and 91 private -Jun 2012). surveillance sites are 95% health facilities, out providing complete Source of 923 facilities) The IRSP has yet to information on a regular and Q1, RMIS Sentinel receive additional timely basis for decision Surveillance: 0% funding making (0of 5) IRSP
Sub-Result 3.3: Capacity in Commodities and Supply Chain Management Improved The continuous availability of high quality malaria commodities is crucial to reduce malaria related morbidity and mortality in Benin. The main objective of ARM3’s supply chain management (SCM) team is to strength Benin’s SCM activities including building the capacity and improving the performance of Benin Central Medical Store (CAME). ARM3 intends to work with CAME to improve governance practices, warehousing of drugs and financial information systems to improve their performance. ARM3 is supporting the NMCP and CAME in designing and implementing a well-designed Malaria Logistic Management Information System (LMIS) in order to reduce stock outs and overstock. The LMIS end goal is to track malaria commodities and make sure that the right product is available in the right quantity, in the right condition, at the right time, in the right place and at the right cost.
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Achievements Provided Technical Assistance to CAME Trained CAME Board Of Directors in Good Governance and Strategic Monitoring With technical support from an MSH Consultant, ARM3 organized a three-day work shop whose main objective was to ensure that good governance practices implemented in 2010 with the support of MSH/SPS are on track. The training brought together 16 members of CAME’s BOD and CAME’s Deputy Director and two technical staff from the monitoring and evaluation and procurement department. Participants were trained on (1) Strategic monitoring; (2) Tendering and bidding procedures; (3) Monitoring and evaluation; (4) Basics of risk analysis and management, and (5) Importance of Member of BoD presenting CAME’s risk strategic information. Key lessons learned and analysis recommendations made are as follows: (1) Participants found that it is important to have access to key information that can help to monitor central medical stores such as CAME including various elements of the drug management cycle (selection, quantification, forecasting, procurement, and distribution). (2) Good governance is vital in ensuring transparency in the tendering and bidding process; CAME has a very strong tendering and bidding Standard Operating Procedures (SOPs) Manual in place that promotes transparency and good governance. This manual needs to define roles and responsibilities of CAME’s BOD and technical team. (3) CAME’s main objective is to deliver the 6 rights (right product is available in the right quantity, in the right condition, at the right time, in the right place and at the right cost). Therefore, the participants were provided key elements to consider when monitoring and evaluating the performance of a central medical store. (4) Risk analysis and management are critical in ensuring that potential high risk events can be Example of indicators of Central Medical Stores performance presented to prevented and/or the COGES using the dashboard mitigated. A summary of risk s identified are: stock outs at CAME, risk of conflict of interest during the tendering and bidding process, risk of fire at CAME, etc. (5) Developed an example of an indicator dashboard and presented to CAME BOD its functionality in facilitating decision making.
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LMIS Strengthening ARM3 Led Ad Hoc Committee to Mitigate Expiration of AL (Artemether + Lumefantrin) 1X6 At the request of the NMCP Coordinator, ARM3 was delegated the responsibility to recommend strategies to mitigate the expiration of huge quantities of AL 1X6. To avoid the possibility of having drugs expire, ARM3 recommended that all the malaria drugs from the various partners (CRS, Africare, USAID and UNICEF) be managed as if in a common basket. In July 2012, Africare was about to have 184,525 Artemether + Lumefantrin 20 /120 mg blister of 6 tablets (AL 1x6) expire in the first quarter of 2013 and 304,625 expire in the second quarter of 2013. The major reason for the large quantities of AL 1x6 was an overestimation of the needed quantities procured by Africare and CRS for facilities in their respective health zones and for use by community health workers. Suggested strategies in order to make a common basket effective and to avoid expiry of malaria drugs include: (a) All AL 1x6 procured by AFRICARE should be delivered to facilities and community health workers in all health zones (including where CRS is working); (b) CRS and NMCP products will be delivered to community workers of Zonal depots in CRS interventions areas (c) Distribution will be based on First Expiry, First Out; and (d) NMCP requested that CAME implement the strategies. This strategy has since been partially implemented by the NMCP as there are now only 120,494 AL 1x6 available at CAME at the end September 2012. Sulfadoxine + Pyriméthamine (500mg/25mg) stocks were very low, especially at the central level. Only a ½ month of stock was available at the end of September 2012. Developed and validated LMIS supportive supervision tools and TOR for supportive supervision at the intermediary level To have a better idea of the malaria commodities supply chain pipeline at the intermediary level (Health Zone Depots, Health Zone Hospitals and Departmental Hospitals), ARM3 proposed to the NMCP to undertake a LMIS supportive supervision. Scheduled to take place the quarter October – December 2012, ARM3 intends to visit all 34 Health Zones depots, 27 Health Zone Hospitals and 6 Departmental Hospitals. Forecasted (one month) RDT needs for five health zones formerly supported by BASICS The ad hoc committee, led by ARM3, made a forecast of the RDT needs for the five former BASICS health zones so that community health workers can test, treat and track according to best practices. The total quantity needed to start was 690 boxes of 25 RDT that was composed of one month stock on hand and one month safety stock due to the fact that RDTs quantities in country are View of ARM3 COP, NMCP Coordinator, Ministry low. of Health Representative and one of the technical Redesigned and harmonized Malaria LMIS assistant providers ARM3 supported the NMCP in organizing a workshop to redesign and harmonize LMIS materials. On August 11 – 13, 2012 in Lokossa, 46 participants (pharmacy managers, NMCP departmental
24 | P a g e coordinators, health zone Medical Coordinators, CAME, Africare and CRS) attended this high level workshop. The work shop identified that: (1) there are least 4 different information systems in place and yet they are unable to track malaria commodities or provide information on malaria commodities consumption to the NMCP; and (2) Some systems contain this vital information, but the information is only sent to the implementing partners. The proposed new system will track and help to obtain information on malaria drug consumption and reinforce the common basket while coupling product flow with information flow. Therefore, all malaria drugs will enter in the malaria commodities supply chain in CAME’s stores. From CAME, Health Zone Depots and Departmental Hospitals will order and receive products on a push system. The Health Zone Depots will receive orders from Zonal Hospitals and will deliver them on a push system basis. Only community health workers will receive Malaria commodities on a pull system basis. The system to implement will be a maximum /minimum in order to avoid expiration due to huge quantities of malaria commodities and also to avoid stock outs. Key activities such as harmonization and development of Malaria LMIS SOP manual and printing of Malaria LMIS tool will take place during View of participants during CRS and AFRICARE the quarter October – December 2012. presentation
End Use Verification Survey (EUVS) Draft Findings: Based on MCDI’s initial feedback, MSH is in the process of finalizing French and English versions of the EUVS report. Annex 2 presents a summary of the preliminary results of the April 2012 EUV Survey. Indicator Baseline LOP Target Q4 Results Comments Result 3: The national health system’s capacity to deliver and manage quality malaria treatment and control interventions strengthened Sub-result 3.3: MoH capacity in commodities and supply chain management improved Target is being 17) Percent of quarterly and developed in LMIS was not Baseline Q4 Result annual reports generated by consultation with functional during the 0% 0% the LMIS per year NMCP and other quarter. stakeholders 85% of PMI-supported Baseline 18) Percent of government health facilities report Q3 Result 80.3% health facilities with ACTs no stock outs of EUVs EUVS April, 2012 available for treatment of malaria commodities 90.6% Source uncomplicated malaria in the last three Q1, RMIS months NB. Indicator Complete reformulated for implementation of reforms place within reforms initiated in 19) Percent reforms in place Baseline CAME in lieu of CAME so as to within CAME 0 % CAME reforms improved governance implemented by other and transparency of its facilities. Will begin operations reporting next quarter. 25 | P a g e
Indicator Baseline LOP Target Q4 Results Comments 20) Percent of facilities that Results Restitution to the submit an action plan in pending Q4 Result health zones has yet to response to the End-Use EUVS occur Verification Survey report
Cross Sectional Activities
Behavior Change Communication (BCC) Achievements Strategic communication workshop ARM3 shared the results of the literature review research with representatives from the Health Department of Littoral and Atlantique at a workshop whose goal was to design a BCC participants communication strategy to incorporate into their quarterly, annual and three-year work plans. Presentations focused on how to: (1) conduct a situation analysis; (2) identify communication problems; (3) prioritize communication problems and barriers to desired behaviors, and propose solutions; (4) segment target groups; (5) identify appropriate strategies including the choice of media support; and (6) choice of messages. At the end of the workshop, each health zone integrated the BCC component into their work plan which was compiled by ARM3.
Finalizing Television commercial material and obtaining the right to use a video song Two television commercials were negotiated with the Beninese Football Association involving two Beninese soccer stars who play in Europe (Mr. Djigle and Mr. Koukou) for purposes of promoting the use of LLINs. After the commercial was reviewed by the BCC technical working group, ARM3 conducted a pretest in one health center during which health providers and clients (male and female) watched and provided feedback on its content. TV Commercial 1: Djigla David Djigla’s commercial was viewed as more effective because the player is wearing a soccer uniform and is surrounded by teammates and spectators while Koukou is not wearing his soccer jersey and is in an empty stadium. Based on their feedback, the commercials were reworked to be more impactful. ARM3 has been negotiating with the NMCP to secure the rights to rebroadcast a music video prepared by the Association Beninoise de Femmes Chanteuses (ABFC). ARM3 was granted approval to add the following toward the end of the TV Commercial 2: Koukou Djiman video: “Rediffusé avec financement de l’USAID”. The video content addresses malaria prevention by promoting the use of LLINs and taking SP during pregnancy, discouraging self-medication, and encouraging compliance with malaria treatment.
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Reaching People to promote malaria prevention through a caravan in Benin ARM3 organized a one day mini caravan covering three health centers in the health zone of Cotonou 5. There were three main objectives: 1) increase awareness about the importance of LLINs and the use of SP in preventing malaria during pregnancy; 2) offer an opportunity to health providers to convey the same messages beyond their usual boundary to the community and 3) inform the public about the source of information in their community and neighborhood, i.e. the community health worker. From 10 am until 4 pm, the caravan made six stops between Zogbo and St. Michel health centers in Cotonou. At each stop, people were exposed to messages on malaria prevention.
Even though the event was designed In order to enhance the credibility of the messages, health around two key behaviors, the use of nets providers from the three health centers took part in their dissemination and SP intake, the BCC team prepared a list of nine key messages which were translated in local languages and given to health providers to disseminate to the public. Three messages addressed the importance of LLINs, five messages were on SP, and one message referred to the source of information.
The caravan truck was decorated with banners with the following content: “Vers un Benin sans Paludisme”. Tous sous moustiquaire imprégnée: toutes les nuits, tous les jours et toutes les saisons. Deux doses de SP pour prévenir le paludisme chez la femme enceinte et l’enfant. A sketch on the importance and use of LLINs as well as one on the importance of SP was presented by a local theater group. Each health center had one banner which they displayed at their center. More than 5,000 people were exposed to the messages. During the short speech given by the Health Department Director, she invited people to adopt preventive behaviors to eliminate malaria in Benin. The event aired twice on the national television station, ORTB (Office de Radio et Télévision Béninoise). Annex 3 presents what participants said during the caravan. ATCHAKPODJI Radio launched “ATCHAKPODJI”, in Fon language means “under the tree, to solve a conflict”. ARM3 facilitated a A religious leader speaks during the radio reality gathering where Immaculate Conception Radio show in Allada arrondissement to encourage people broadcasted a community event that aimed at to adopt malaria preventive behaviors. educating radio listeners on malaria prevention. A woman’s group, youth and opinion leaders including the “AYO” or wise village elders from the area, the local elected people, and the general public met with the health provider to raise questions about
27 | P a g e preventive behaviors. This interaction was recorded and aired twice (on September 29 and October 6, 2012) on Immaculate Conception Radio which has a large coverage area ranging from Atlantique - Littoral to the northern part of the country.
Curriculum conception on interpersonal communication ARM3 benefited from short term technical assistance (STTA) from Diarra Kamara whom JHU-CCP engaged to develop a training curriculum for trainers in interpersonal communication and community engagement. The consultant highlighted key points which should be taken into consideration for the development of the material content including to be aware of (1) time constraints due the high attendance and limited number of health providers; (2) limited time women are able to be involved in interaction with others; (3) the need for reinforcement of negotiation skills; and (4) linkages with community health workers. In addition, the consultant recommended the following: (1) involve partners in the conception of training tools (NMCP, public and private health providers, training institutions for nurses and birth attendants) and (2) recruit a local consultant to develop curriculum and training tools including training of trainers’ curricula, trainers guide, participant notebook, training and an animation tool.
Performance Improvement Approach ARM3 seeks to implement the Improvement Collaborative (IC) learning model which merges with the Leadership Development Plan (LDP) training. Beginning in October 2012, ARM3 will implement LDP+ and IC management tools for the successful implementation of the Memoranda of Understanding (MOU) that ARM3 plans to sign with the DDS and HZ in Atlantic-Littoral and Oueme-Plateau. The DDS and HZ’s which are signatories of the MOU must prepare and implement 3-year strategic plans and annual operational plans.
MSH engaged the services of a consultant to review the formats of the MOUs, 3-year strategic plans and annual operational plans that ARM3 is developing alongside the DDS and HZs; review the progress made in the application of LDP+; provide recommendations on how to integrate the application of the IC and LDP+ within the framework of implementing the MOUs; and develop criteria for the selection of the initial health zones and ensure appropriate implementation in Oueme - Plateau (OP) DDS and Atlantique – Littoral DDS. Under the leadership of MSH, ARM3 will focus on improving selected ARM3 indicators.
Achievements Train managers on Leadership Development Program (LDP) The Senior Alignment Meeting (SAM) was held from August 2nd to 3rd 2012 in Cotonou, with the participation of Mrs. Jana NTUMBA, senior LDP consultant. The SAM gathered 30 senior executives and partners of the Ministry of Health. The goal of this meeting was to present the LDP approach and to obtain their dedication and support in the implementation at their respective level.
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SAM opening ceremony Partial view of the participants at SAM LDP workshop #1 was held from August 6th to 8th, 2012 at Grand-Popo which gathered 40 participants (17 female & 23 male) from the 12 HZs of the departments of Ouémé-Plateau and Atlantique-Littoral. The participants were primarily HZ Coordinators, Midwives of the HZ coordination team, Directors of the HZ Hospital or a District health facility Medical Doctor; Director of the departmental Hospital of Ouémé- Plateau, including the managers of Hospital Maternity and Pediatric Divisions and Hôpital de la Mère et de l’Enfant de Littoral (HOMEL). A presentation was given on LDP in order to gain their commitment to the program and also on learning how to scan/analyze their work environment, identify problems and formulate solutions.
Environmental scanning is the acquisition and use of information about events, trends, and relationships in an organization's external environment, the knowledge of which would assist management in planning the organization's future course of action. The participants practiced “scanning” to find the root causes of the problem they were to retain Group photo of the LDP team as their challenge.
The Workshop Objectives were:
Present the schedule of activities, objectives and process of the program; Align expectations with the objectives of the LDP; Explain the practical and the conceptual framework for leadership and management; Explain the work environment and tools for evaluation; Prepare a preliminary version of the model that will challenge teams to launch into their leadership project.
Finalize Memorandum of Understanding with hospitals and health zones Preliminary versions of the Memoranda of Understanding were developed between the implicated hospitals and health zones and submitted to MCDI HO and then to the NMCP for approval. These MOUs will be then aligned with each HZ, DDS, and Hospital action plan. The action plans are being developed and validated for the 12 HZs from Atlantique-Littoral and Ouémé-Plateau. 29 | P a g e
Assist DDS and HZ of Oueme-Plateau and Atlantique-Litoral in preparation of Strategic and Malaria Operational Plans ARM3 worked with the 12 HZs and the two departmental teams in Atlantique-Littoral and Ouémé- Plateau to finalize their triennial and operational plans. The ARM3 team based in Abomey finalized plans with HZs PAK, ABD, SAKIF, and DDS O-P on July 29th 2012, then with PAS and 3A on July 21 to 22, 2012. A review session was held on September 10-11, 2012 to validate the Ouémé-Plateau department plans by the Departmental Direction of Health (DDS) with the technical support of the Abomey ARM3 team.
The budget presented along with the action plans by the HZs of A-L is very ambitious and needs to be trimmed down to focus on USAID funded activities e.g. supervision and training. It will be examined by the ARM3 staff to ensure that it aligns with ARM3’s main activities and budget.
Program Management
Home Office Backstopping and Reporting Achievements Second Annual Work Plan and Budget Preparation MCDI’s HO supported the FO in the preparation of the Second Annual Work Plan and budget. MCDI’s Monitoring and Evaluation Officer travelled to Benin to facilitate the coordination of these products. They were submitted to the Mission for review who provided their feedback. MCDI is currently addressing questions raised and updating the documents as necessary.
MSH STTA Travelled to Benin Jana Ntubma, Senior Program Associate, travelled (July 28 to August 5, 2012) to Benin to provide short- term technical assistance (STTA) and continue to assist in the planning, preparation and implementation of the Leadership Development Program (LDP) which is designed to assist the NMCP in the performance improvement process.
Dah El Hadj Sidi, Procurement and Supply Management Technical Officer, travelled (July 31 to August 12, 2012) to Benin to provide STTA through the provision of refresher training to CAME’s Board of Directors on how to conduct effective oversight of its senior management and the institution’s activities.
Saydou Doumbia, Senior Technical Manager for Malaria, travelled to Benin (September 9 to September 22, 2012) to provide STTA by supporting the implementation of two Logistics Management Information system (LMIS) review workshops and helping to develop a strategy to build health zone capacity in quantification of malaria commodities. Christine Onyango, Senior Program Associate, travelled (September 3 to September 14, 2012) to Benin to provide STTA by reviewing the progress of pharmaceutical management activities and to plan activities for year 2 implementation.
JHU STTA Travelled to Benin Mohamad Sy’ar, Program Officer, (July 23 to August 3, 2012), travelled to Benin to backstop the JHU- CCP BCC Manager and attend the BCC strategy design workshop and establish next steps and an action plan. In addition, he worked with the NMCP on airing the material produced by Benin singers, selected 30 | P a g e an advertising agency to be in charge of producing two TV commercials, and reviewed the TV commercial developed with a Benin soccer star to promote the use of LLINs. Perus Nsengivuma, Finance Officer with JHU-CCP’s Office in Rwanda, travelled (September 30 to October 9, 2012) to train JHU-CCP’s Finance Assistant on their financial and administrative procedures and guidelines to ensure that they comply with all JHU/MCDI/USAID financial requirements. Diarra Kamara, Consultant, travelled (September 15 to 23, 2012), to provide training to use the project design tools (curriculum or manual) that will help train and monitor patient-provider counseling activities.
MCDI STTA Travelled to Benin Dr. Abdalla Meftuh, MD, MPH, Senior Malaria Program Officer, travelled to Benin (July 22 to August 22, 2012), to provide technical and administrative support and to serve as Acting Chief of Party.
Matt Worges, MPH, Monitoring and Evaluation Officer, travelled to Benin (September 16 – 28, 2012) in order to support the development of the Year two work plan for ARM3.
Human Resources In the four months that Dr. Thior has been with ARM3, MCDI has come to appreciate his considerable amount of skills and experience. By fostering a closer working relationship with the National Malaria Control Program (NMCP), Dr. Thior earned the NMCP Coordinator’s confidence and was designated as Chair of a critical ad hoc committee to reply to the NMCP mission letter from the Minister with regards to the implementation of the 2012 integrated work plan or PITA and the achievement of key indicators. MCDI believes that Dr. Thior’s continued presence will strengthen and enhance all aspects of technical coordination and ensure the continued success of the project.
Other Activities Signing of a new country agreement between MCDI and the Ministry of Foreign Affairs - On September 7, 2012, MCDI and the Benin Ministry of Foreign Affairs signed a country agreement extending and renewing MCDI's 16 year old agreement.
Major Challenges (per ARM3 sub-result): Sub-Result 1.1: (IPTp uptake increased)
The World Health Organization (WHO) has recently issued new directives for administering SP up until birth, yet the Benin protocol is contradictory, requiring that SP be stopped after the 36th week. The TWG for case management needs to quickly meet to recommend steps to address this issue. Sub-Result 1.2: (Supply and Use of LLINs Increased)
Anticipated delivery date of LLINs in December 2012 and the ability of CEBAC-STP member companies to distribute all 100,000 LLINs Sustained interest of the leadership of private enterprises in distributing LLINs to their employees Sub-Result 2.1 (Diagnostic Capacity and Use of Testing Improved)
Introduction of RDT use at the community level Adequate RDT management and use at the health facility level Sub-Result 2.2 (Case Management of Uncomplicated and Severe Malaria Improved)
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The signing of the Memorandum of Understanding by the 12 health zones and the DDS of Ouémé-Plateau and Atlantique-Littoral The implementation of the activities outlined in their plans Sub-Result 3.1 (Capacity to Deliver and Manage Quality Malaria Treatment and Control Interventions Improved)
Adoption of new WHO guidelines recommending that SP be administrated up until child birth Decentralization of the quality control interventions of the malaria treatment and commodities management at the Health Zone level Sub-Result 3.2 (Capacity to Collect, Manage and Use Malaria Health Information for M&E and Surveillance Improved)
Increase the completeness of the database by 62 to 80% by the end of the year Reduce the error rate from 24.8% to 5% by the end of the year Sub-Result 3.3 (Capacity in Commodities and Supply Chain Management Improved)
Supervision of 34 DRZ and 27 HZ including a sampling of facilities visited by EUVS Implementation of Malaria LMIS Cross Sectional Activities (Behavior Change Communication)
During the caravan activity many people shared that the LLINS distributed through the mass distribution needed to be replaced. The unavailability of LLINs poses a major threat to malaria prevention efforts.
Major Activities Planned for next quarter (Oct– Dec):
RESULT 1: Implementation of malaria preventions in support of the National Malaria Strategy improved Develop a reality program with Immaculée radio Extend the reality radio programs to other local radios in Allada, Oueme Plateau and Zou Air malaria prevention TV spots and video songs on ORTB Hold a community event in Atlantique in partnership with the Health Direction Department Attend a BCC network meeting in Zou and Colline Departments Reproduce IEC flyer materials Contract with one local agency to develop 15 radio spots; Complete two new TV spots on ITN and SP with Veyvey Agency. Recruit a local consultant to develop training content on communication and community engagement skills Contract with Tokpa radio to air talk radio programs Facilitate the next BCC working group meeting Develop training content in interpersonal communication and community engagement Support from Africare to community outreach activities in Littoral and Oueme-Plateau Departments Develop a plan for distribution of LLINs in the private sector Validation of the distribution plan Develop a social marketing plan Validation of the Social Marketing Plan Identify storage areas LLINs Validation tools for monitoring data collection
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Establishment of monitoring protocol LLINs Identify beneficiaries of LLINs Planning for the reception and distribution of 40,000 LLINs Implementation of health committees in companies Training of health committees businesses Monitor bed net delivery Meet with selected FSS and INMES
RESULT 2: Malaria Diagnosis and Treatment activities in support of the National Malaria Strategy improved Development and dissemination of OTSS supervision report Validation of the training manuals for RDT use in Health Facilities; Validation of the directives for RDT use at the community level; Validation of the training manuals for RDT use at the community level; Validation of training manuals for malaria in pregnant women: Manual of Participant & Facilitator’s Guide; Update malaria case management manual and trainers’ guide for non-qualified health agents Review of the HF CCM training documents and incorporation of relevant components into the qualified health workers supplemental training manual on pharmacovigilance, RDTs, ACTs, LLINs and other products (participant manual and facilitator’s guide); Review the training manual for non-qualified health workers on malaria case management (participant manual and facilitator’s guide); Review the training manual for malaria case management at HF level (participant manual and facilitator’s guide); Train 30 more health workers in ETAT; continuing ETAT training sessions in Oueme-Plateau department and Atlantique department; Start the ETAT quality assurance process Post-ETAT training session follow up Post-training ICCM supervision up for Banikoara, NKP & OKT Finalize and validate the integrated supervision tools for malaria case management Validation of the malaria diagnostics training manual, manual of participant & Facilitator's guide. Training of supervisors in ETAT Practical session (ETAT) Post-training follow up for Banikoara, NKP & OKT. Validate PIA with the NMCP Follow-up visits between LDP workshops # 1 and 2 (two visits) LDP workshops # 2 Follow-up visits between LDP workshops # 2 and 3 (two visits) Hold the validation session of the revised supervisory tools; Reproduce the validated integrated supervision tools; Distribute to stakeholders the integrated supervision tools; Organize in collaboration with NMCP sessions of integrated supervisions. The preparation of the triennial and operational plans of Atlantique-Littoral DMT will follow the validation of Health Zones’ plans; Financial assistance from ARM3 will intervene only after validation of these plans by the DDS and the PNLP; Training of HZ accountants and finances officers on management of USAID funds; 33 | P a g e
Share MOUs with HZ Coordinators and Ouémé-Plateau DDS staff; Sign MOUs with hospitals and health zones after validation Begin Start-up activities in Zou-Collines department
RESULT 3: The national health system’s capacity to deliver and manage quality malaria treatment and control Hold quarterly meetings of Malaria Technical Working Groups Conduct LDP workshops for PNLP, DSME, DDS Atlantique-Littoral and Ouémé-Plateau Validate and finalize strategic and operational plans with DDS Atlantique-Littoral and Ouémé-Plateau Sign MOU for partially funding 12 health zones annual work plans Publish Apr-Jun 2012 RMIS bulletin Edit and Publish Jul-Sep 2012 RMIS bulletin Supervise the LMIS of each DRZ Joint review and follow up visits by Supply Chain Coordinators of quarterly LMIS reports submitted to DRZs, CHD and HZ Organize a quarterly workshop to collect logistics data Targeting other structures to achieve the supervision of data collection officers and statisticians Maintain support for the maintenance of computers in some areas relevant health Further maintenance of the database and software To update the central platform databases Preparation of the Bulletin "Palu-Info” Participation and supervision LMIS PROS Formative supervision mission managers ILP (34 DRZ, 27 HZ, 6 CHD and 68 health centers) Validation Workshop of the new harmonized tools LMIS malaria
MANAGEMENT
Submit 4th quarterly and 1st annual report Recruit and hire Parakou staff for project office
34 | P a g e Annex 1: OTSS Data – Round 9 (Group D Baseline) vs. Round 8 (Comparison Groups A, B, and C)
The newly enrolled Health Facilities (Group D; n=46) are presented below following the prescribed indicators for OTSS in Benin. For each indicator, Group D is compared against the most recent, aggregate values (i.e. weighted averages, sums) of the Health Facilities comprising Groups A, B and C (n=72). This is essentially an analysis of Round 9 (Group D visit 1 baseline values) against Round 8 (aggregate values of Group A visit 8, Group B visit 7, and Group C visit 4). The composition of Group D is such that 14 facilities are private and the remaining 32 are public.
Fiscal Year 2009 2010 2010 2010 2011 2011 2011 2012 2012 Quarter 4 2 3 4 3 4 4 2 3 Round 1 2 3 4 5 6 7 8 9 1 36 (A) 24 (B) 13 (C) 46 (D) 2 36 (A) 24 (B) 13 (C) 3 36 (A) 24 (B) 13 (C) 4 36 (A) 23 (B) 13 (C) 5 36 (A) 23 (B) 6 36 (A) 23 (B) 7 36 (A) 23 (B)
Visits by Health Facility Groups Facility Health by Visits 8 36 (A) Cumulative Sites by 36 60 60 60 72 72 72 72 46 Round
Comparison Groups A, B, C (Round 8) - 72 total Health Facilities
Baseline Group D (Round 9) - 46 total Health Facilities
Health Facility Resources The resources available to a health facility significantly influence the ability of laboratory staff and clinicians to effectively complete their tasks. This section is intended to present a picture of the resources currently available to health facilities. The resources evaluated include those that are most important for malaria diagnostics. Effective and timely diagnosis of malaria is the most important factor leading to positive treatment outcomes. Positive outcomes are significantly hindered by misdiagnoses, delays, stock outs, and malfunctioning equipment (microscopes or RDTs).
Indicators Group D FY12 Targets Number and Percent of Functional Microscopes Report Against Baseline Percent of Health Facilities Experiencing Stock-outs Interrupting Malaria < 5% of those observed Microscopy Number and Percent of Health Facilities with Recommended SOPs & Bench Report Against Baseline Aids Number and Percent of Health Facilities using RDTs Report Against Baseline
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Table 1: Number and Percent of Functional Microscopes
Ratio of Functional Functional Non-functional Total Microscopes Microscopes (Average of Facilities Microscopes Microscopes Facility-Specific Ratios) Baseline Group D 87 52 139 72.5% 46 (Round 9) Comparison Groups 144 61 205 73.9% 72 A, B, C (Round 8)
Findings:
Functional microscopes are vital to increasing volume of malaria microscopy completed and to ensure high quality of results. To monitor the level of functional microscopes, OTSS records the number of functional and broken microscopes which we can then be used to calculate a ratio of functional microscopes.
There is little difference among the ratio of functional microscopes between the Baseline Group (72.5%) and the Comparison Groups (73.9%), although the proportion of non-functional microscopes recorded by the Baseline Group (37.4%) was higher than that recorded by the Comparison Groups (29.8%).
Interpretation and Recommendations:
Among the facilities that are enrolled in OTSS, all were noted as having functional microscopes, however, there is still a large number of non-functional microscopes which, if they were functional, could provide increased capacity for microscopy and thus reduce turnaround time. While facilities with a lab are a subset of the malaria diagnostic infrastructure in Benin, they play an important role in providing low cost, consistent confirmation of malaria diagnosis as well as allow for speciation and evaluation of severity of illness. For these reasons, additional support should be given to continue to improve the ratio of functional microscopes and scale of microscopy within Benin.
Table 2: Percent of Health Facilities Experiencing Stock-outs that Interrupted Microscopy
Percent of Facilities with Stock-outs Baseline Group D 8.0% (Round 9) Comparison Groups 4.3% A, B, C (Round 8)
Findings:
The Baseline Group had a stock-out rate nearly double that of the aggregate value for the Comparison Groups, however, the percent of facilities with stock-outs in both groups was relatively low.
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Interpretation & Recommendations:
The procurement practices in place for microscopy supplies should be noted and maintained as the stock-out rates across all Groups represent significant success in the overall improvement of malaria diagnostics and case management.
Figure 1a: Percent of Health Facilities with Recommended Malaria Reference Materials (SOPs & Bench Aids)
Percent of Facilities Missing SOPs or Bench Aids 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
Baseline Group D (Round 9) Comparison Groups A, B, C (Round 8)
Figure 1b: Number of Health Facilities with Recommended Malaria Reference Materials (SOPs & Bench Aids)
Number of Facilities Missing SOPs or Bench Aids 80 70 60 50 40 30 20 10 0
Baseline Group D (Round 9) Comparison Groups A, B, C (Round 8) Total Facilities (Round 9) n=46 Total Facilities (Round 8) n=72
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Findings:
Malaria laboratory standard operating procedures and bench aids are recommended to be present in every lab conducting diagnostic testing. They provide reference tools on a range of laboratory tasks to help support high quality diagnostics. This is particularly important during times of staff turnover or when diagnosticians are required to work across multiple diagnostics tests in addition to malaria microscopy and RDTs.
There was little difference between the two groups when comparing the percentages of health facilities missing recommended SOPs, in fact, the trends are strikingly similar. A clear distinction can be made between the proportions of facilities missing recommended bench aids among the Comparison Groups (~40% of facilities) versus the newly enrolled facilities in the Baseline Group (~80% of facilities).
Interpretation & Recommendations:
The IMaD project recommended that the recent bi-lateral agreement (ARM3 project) continue the distribution of the IMaD-produced bench aids and also utilize the OTSS data to quickly identify where bench aids should be delivered. Additionally, bench aids could be delivered by future diagnostic quality assurance visits.
Table 3: Number and Percent of Health Facilities using RDTs
Baseline Group D (Round 9) Comparison Groups A, B, C (Round 8) n % n % RDTs Used 27 58.7% 36 50.0% RDTs Used, but Out-of-Stock 18 2.2% 12 26.4% RDTs Not Used 1 39.1% 19 16.7% No Data/Unknown 0.0% 5 6.9% Total 46 100% 72 100%
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Figure 2: Proportion of Facilities using RDTs by RDT Status
Health Facilities by RDT Status 100.0% 90.0% 80.0% 70.0% 58.7% 60.0% 50.0% 50.0% 39.1% 40.0% 30.0% 26.4% 20.0% 16.7% 6.9% 10.0% 2.2% 0.0% 0.0% RDTs Used RDTs Used, but Out-of- RDTs Not Used No Data Stock
Baseline Group D (Round 9) Comparison Groups A, B, C (Round 8)
Findings:
RDT stock-outs continue to be a problem among the Comparison Groups (26.4% of facilities reporting RDT stock-outs), but much less so among the newly enrolled Baseline Group (2.2% of facilities reporting RDT stock-outs). Nearly 40% of the facilities in the Baseline Group do not use RDTs whereas about 17% of facilities from the Comparison Groups do not use RDTs.
Interpretation and Recommendations:
Consistent and reliable RDT stock is critical in the continued improvement of malaria diagnostics and movement to ensure confirmation of suspected malaria cases. Chronic RDT stockouts lead to multiple different problems including unfamiliarity of RDT procedures and mistrust of test results. It is imperative that supply chain and funding mechanisms are become more robust to support ongoing national malaria objectives.
Training & Staffing Health facility personnel play a key role in implementing programs that are put in place to enhance the effectiveness of a health system. This section is intended to give an understanding of the personnel that are currently working throughout the health system. The information contained in this section can be used to identify facilities where on-the-job training will improve the quality of diagnoses.
Indicator Group D FY12 Target Number of On-Site Trainings Conducted in Malaria Diagnostics 2 per OTSS visit per staff type Number of Staff Attending Formal Training During Previous Year Report Against Baseline Average Number of Laboratory Staff Per Facility Report Against Baseline
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Table 4: Number of Formal and Informal (On-site) Trainings Conducted in Malaria Diagnosis by Staff Type
Type of Training Clinical Staff Lab Staff Average Clinical Average Lab Baseline Group D Formal Training N/A N/A N/A N/A (Round 9) Informal/On-site Training 81 72 2.08 2.57 Comparison Groups Formal Training 11 33 0.16 0.46 A, B, C (Round 8) Informal/On-site Training 79 79 1.21 1.14
Findings:
On average, more laboratory technicians and clinicians were trained in the Baseline Group, which has received 1 OTSS visit at the time of this report, when viewed against the aggregate values of the Comparison Groups where facilities have received 4, 7, or 8 OTSS visits.
Interpretation and Recommendations:
Consistent trainings create an environment of accountability and interest in professional development. The longer that OTSS visits are occuring at a facility the number of trainings should natually decrease as the quality of diagnostics improves. However, it is critical to continue onsite trainings to foster a professional enviroment. Additionally, it will limit back sliding and can focus on new employees who have not benefitted from previous trainings.
Figure 3: Average Number of Laboratory Staff by Type
Average Number of Laboratory Staff by Type 6
4.93 5 4.17 4 3.7 3.48 3.07 2.88 3
2
1
0 Average Full-time Staff Average Full-time Diagnostics Staff Average Full-time Malaria Staff
Baseline Group D (Round 9) Comparison Groups A, B, C (Round 8)
Findings:
For each staff type the Baseline Group shows a greater value than the aggregate values for the Comparison Groups. Facilities assessed reported on number of full time laboratory staff, number of staff trained in microscopy (Biomedical Scientists, Laboratory Technicians, and Laboratory Assistants), and number of staff performing malaria diagnostics (RDTs included).
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Quality Assurance Proper equipment, well trained personnel and effective quality assurance systems are essential for a properly functioning health system. The purpose of this section is to present information on the quality of malaria diagnoses and the efficient use of resources. This information can help determine how quality-of- care can be increased through improved diagnoses and identifying ways through which resources can be utilized more effectively. Quality assurance activities are also important for the overall improvement of laboratory and clinical staff. These activities enable staff members to assess how well they are currently doing and to set goals for their future improvement.
Indicator Group D FY12 Target Percent of Facilities Performing Malaria Microscopy Using Appropriate 90% of tasks correct Guidance Percent of Facilities Performing RDTs Using Appropriate Guidance 90% of tasks correct Percent of Facilities Complying with Results of Negative Tests 75% compliance Number and Percent of Facilities Performing Internal Quality Assurance Tasks Report Against Baseline Percent of Health Facility Slides Read Correctly 100% agreement
Figure 4: Percent of Facilities Performing Malaria Microscopy Using Appropriate Guidance
Malaria Microscopy Tasks Performed According to Appropriate Guidance 100.0% 86.8% 90.1% 88.4% 90.0% 86.0% 85.0% 85.5% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Slide Prep Avg Score Slide Reading Avg Score Combined Slide Prep/Reading Avg Scores
Baseline Group D (Round 9) Comparison Groups A, B, C (Round 8)
Findings:
Only a few percentage points separate the performance of facilities in the Baseline Group in conducting malaria microscopy tasks according to appropriate guidelines from the weighted averages of facility scores from the Comparison Groups.
Interpretation and Recommendations:
Moving forward, many of the facilities are operating at high levels of microscopy and it could be recommended that the frequency of onsite observations could be rolled back to occur bi-annually
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as opposed to quarterly. By scaling back on the frequency this would conserve resources while still maintaining the progress that has already been made.
Figure 5: Percent of Facilities Performing RDTs Using Appropriate Guidance
RDT Tasks Performed According to Appropriate Guidance 100.0% 89.2% 90.0% 86.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
Baseline Group D (Round 9) Comparison Groups A, B, C (Round 8)
Findings:
As is apparent for malaria microscopy tasks, only a few percentage points separate the performance of facilities from the Baseline Group when compared to the performance of the Comparison Groups in conducting RDT tasks according to appropriate guidance (86.0% versus 89.2%, respectively). While nearly 60% of the total number of facilities within the Baseline Group reported using RDTs, only about 33% of them (n=15) were observed for RDT performance according to appropriate guidance.
Interpretation and Recommendations:
Historically, RDT observation scores remain flat across visits (varying between 80% to 90% performance levels according to appropriate guidance) which may be due to intermittent stock- outs of RDT supplies (i.e. if facility staff have irregular access to RDTs, their ability to master the recommended procedures may be impaired). RDT availability and logistics management must continue to be addressed. Additionally, the RDT observation component of OTSS remains valuable as it supports the maintenance of RDT diagnostics.
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Figure 6: Percent of Facilities Complying with Results of Negative Tests
Prescriber Adherence to Negative Test Results 90.0% 77.9% 80.0% 72.8% 69.0% 68.0% 70.0% 61.0% 58.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% RDT Adherence Blood Slide Adherence Overall Adherence
Baseline Group D (Round 9) Comparison Groups A, B, C (Round 8)
Table 5: Frequency and Percentage of Treatments Prescribed to Negative Tests
Coartem Total % Coartem Fansidar Total % Fansidar Quinine Total % Quinine Baseline Group D (Round 9) 47 58.8% 1 1.3% 32 40.0% Comparison Groups A, B, C (Round 8) 66 64.7% 0 0.0% 36 35.3%
Findings:
The proportion of facilities that do not prescribe antimalarial drugs to patients with negative malaria tests is noticeably higher among the Comparison Groups (72.8% overall) when viewed against the Baseline Group (61.0% overall). The majority of patients with negative malaria tests (from both groups) who were prescribed anti-malarial drugs received Coartem. The proportion of patients with negative malaria tests receiving Quinine was a not too distant second.
Interpretation and Recommendations:
Consistent trainings create an environment of accountability and interest in improving the quality of case management. The longer OTSS visits have occurred at facilities, significant improvement to case management has been observed. However, it is critical to continue onsite trainings to continue to foster a professional enviroment looking to improve patient outcomes and prevent anti-malarial drug resistant strains of the disease. Additionally, while RDT stock-outs are likely to continue in the near future it is important to encourage physcians to trust diagnostic testing rather than reverting to unconfirmed/symptomatic malaria diagnosis.
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Figure 7a: Number of Facilities Performing Internal Quality Assurance Tasks (Group D – Round 9)
Number of Facilities Performing IQA Tasks Baseline Group D (Round 9) 50 45 40 35 30 25 20 15 10 5 0 Positive pH Meter Slides Re- Results Slide Re- Slide Box Species ID Parasite Control checked Recorded Reading Storage Counting
Baseline Group D (Round 9) Not Performing IQA Baseline Group D (Round 9) Performing IQA Total Facilities
Figure 7b: Number of Facilities Performing Internal Quality Assurance Tasks (Groups A, B, & C – Round 8)
Number of Facilities Performing IQA Tasks Comparison Groups A, B, C (Round 8) 80 70 60 50 40 30 20 10 0 Positive pH Meter Slides Re- Results Slide Re- Slide Box Species ID Parasite Control checked Recorded Reading Storage Counting
Comparison Groups A, B, C (Round 8) Not Performing IQA Comparison Groups A, B, C (Round 8) Performing IQA Total Facilities
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Figure 7c: Percent of Facilities Performing Internal Quality Assurance Tasks
Percent of Facilities Performing IQA Tasks - Comparison Group vs. Baseline Group
97.2% 98.6% 100.0% 98.6% 100.0% 91.3% 90.0% 80.0% 69.6% 70.0% 60.0% 50.0% 38.9% 34.7% 40.0% 30.6% 30.0% 26.1% 26.1% 20.0% 15.2% 10.9% 8.3% 8.7% 10.0% 4.3% 0.0% Positive Control pH Meter Slides Re- Results Slide Re-Reading Slide Box Species ID Parasite checked Recorded Storage Counting
Baseline Group D (Round 9) Performing IQA Comparison Groups A, B, C (Round 8) Performing IQA
Findings:
Among the facilities in the Baseline Group, species identification and parasite counting are two IQA tasks that are already in place by a majority of facilities, overall, however, the number of facilities not performing the suite of IQA tasks far outweighs those that do. In every case except 1 (pH Meter), the proportion of facilities performing the IQA tasks among the Comparison Groups was greater than that of the facilities in the Baseline Group. One of the most drastic differences can be noted in the IQA tasks of slide re-reading and slide box storage.
Interpretation and Recommendations:
Many IQA tasks are still not being performed among both the Baseline and Comparison Groups and additional supervision and encouragement must be provided to ensure that uptake of IQA tasks occur and are maintained.
Figure 8a: Number of Facilities by Number of Cross-checked Malaria Slides
Number of Facilities from Baseline Group by Number of Slides Cross-Checked 45 39 40 36 35 32 27 30 25 25 20 18 15 14 15 13 13 10 5 0 1 Slide Cross- 2 Slides Cross- 3 Slides Cross- 4 Slides Cross- 5 Slides Cross- 6 Slides Cross- 7 Slides Cross- 8 Slides Cross- 9 Slides Cross- 10 Slides Cross- checked checked checked checked checked checked checked checked checked checked
Facilities from Baseline Group
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Figure 8b: Percent of Health Facility Slides Read Correctly
Agreement, Sensitiviy & Specificity for Blood Slide Cross Checking 99.0% 100.0% 96.0% 95.9% 95.0% 93.7%
90.0% 86.0% 85.5% 85.0%
80.0%
75.0% % Agreement between Supervisors Sensitivity Specificity and Malaria Microscopists
Baseline Group D (Round 9) Comparison Groups A, B, C (Round 8)
Findings:
It was not anticipated that data would be collected for this indicator during the first round of OTSS visits, as it is the supervisor’s responsibility to introduce a slide re-checking program at the facility. However, some supervisors read a number of slides during their Round I visit. It is important to note that the number of slides read at these facilities was not standardized nor was it to be considered “slide validation”; rather it was classified as a slide re-checking exercise. Thirteen (13) facilities from the Baseline Group had the recommended 10 slides cross-checked by the Supervisors during their first round of OTSS. Thirty-nine (39) of the 46 facilities from the Baseline Group had at least 1 slide cross-checked by the OTSS Supervisors. All available values were taken into account when calculating agreement, sensitivity and specificity. In each case (agreement, sensitivity and specificity) the Baseline Group performed better than the aggregate values of the Comparison Groups.
Interpretation and Recommendations:
The data from OTSS supports the assertion that there is trustworthy microscopy available in Benin, although there is still room for improvement especially in the identification of positive cases (sensitivity).
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ANNEX 2: SUMMARY OF PRELIMINARY RESULTS OF THE APRIL 2012 END-USE VERIFICATION SURVEY
The objective of the EUVS was to verify, in particular, the continuous availability of malaria commodities at the last point of contact with malaria patients.
The facilities sampled were identified on the basis of reports transmitted in 2010 through National Health Information System (NHIS) through a combination of sampling approaches. These included: comprehensive sampling (all 27 zonal hospitals and all 34 depots répartiteurs de zone (DRZs and the main warehouse of the CAME); systematic sampling (based on the average number of consultations recorded per day in the public and private health centers; and random sampling (20% of health centers determined to be functional).
Data collection was conducted by 38 teams consisting of two data collection agents each, and 12 supervisors -- for a total of 88 persons.
This survey made it possible to make the possible conclusions about the supply chain: 1. 54 facilities visited (28.57%) were out of stock of all presentations of AL, a situation which does not guarantee the effective treatment of malaria patients during the respective period. 2. The lowest percentage of facilities with unexpired products was observed with artesunate suppository (60.9%), followed by ASAQ 25/67.5 mg (88.6%). 3. Fifty of the facilities visited (26.46%) had all presentations of AL, and therefore had the means to treat patients according to the recommendations of the National Malaria Control Program (NMCP). 4. In 77% of cases, the facility that places the order is the same structure that collects the product and transports the product back. This survey also made it possible to evaluate compliance by health providers with the guidelines for treating simple malaria. This was done by examining the registers of treatment of cases in the health centers and zonal hospitals. A total of 26,372 recorded consultations were reviewed by data collectors. Among these consultations, 33.8% concerned patients under-five years of age, and 65.6% concerned patients over five. The principal conclusions on case management are as follows: 1. A diagnosis of uncomplicated malaria was made in 45.4% of patients seen in consultation. Among the patients less than five years of age, 57.6% had simple malaria, and among those over five years, 39.1% had malaria. The great majority of these cases were diagnosed and treated in the peripheral health centers, in accordance with the organization of Benin’s healthcare system. This finding demonstrates the fact that malaria remains the primary cause of health consultations.
2. The latest guideline which requires that any suspected malaria case must be confirmed either by rapid diagnostic test (RDT) or by microscopy before a diagnosis of malaria can be made , has not yet been implemented in all health facilities.
3. Among uncomplicated malaria cases diagnosed in children under five, 86.3% of these cases were treated with Artemisinin-based Combination Therapy (ACT) , compared to 84.9% for patients over five years. The ideal would have been for 100% of uncomplicated malaria cases to be treated using ACTs in all age groups. This raises the issue of failure to comply with the new national guidelines on the treatment of cases of uncomplicated e malaria. A number of reasons that could explain this finding, including stockouts of ACTs and failure of health providers to master the content of the national treatment guidelines, amongst others.
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4. Among children under five years who had a positive RDT result, 16.9% received an antibiotic in addition to the ACT; and 13.2% of patients over five years of age with a positive RDT result were treated with an antibiotic in addition to the ACT.
5. Mono-therapy was used to treat 2.6% of patients with uncomplicated malaria. However, these were not pregnant women in the first trimester of their pregnancy, as the treatment guidelines stipulate. This result supports the argument for the need to retrain healthcare personnel.
The final sample size (by type of facility) was as follows:
STRUCTURES NUMBER
Health centers 128
Health zone hospitals 27
DRZs 34
CAME warehouse in Cotonou 1
TOTAL 190
1. PERCENTAGE OF FACILITIES HAVING NO EXPIRED MALARIA COMMODITY ON THE DAY OF THE VISIT
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2. PERCENTAGE OF STRUCTURES HAVING AT LEAST ONE EXPIRED MALARIA COMMODITY ON THE DAY OF THE VISIT
3. PERCENTAGE OF FACILITIES HAVING INVENTORY SHORTAGES FOR MORE THAN THREE DAYS IN THE THREE MONTHS PRECEDING THE SURVEY
4. INDEX OF AVAILABILITY OF ACT PRODUCTS ON THE DAY OF THE VISIT
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5. PERCENTAGE OF FACILITIES WITH UP-TO-DATE STOCK CARDS
6. NUMBER OF MONTHS OF INVENTORY AVAILABLE BY PRODUCT
7. AVERAGE DURATION OF STOCK OUTS
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8. PERCENTAGE OF AGENTS WORKING IN A PARTICULAR FIELD WHO HAVE BEEN TRAINED IN THIS FIELD
Fig. 11: Percentage of agents working in a particular field who have been trained in this field
9. PERCENTAGE OF STRUCTURES THAT HAD RECEIVED SUPERVISION IN LOGISTICAL MANAGEMENT DURING THE SIX MONTHS PRECEDING THE SURVEY
Fig. 12: Percentage of structures that had received supervision in logistical management during the six months preceding the survey 51 | P a g e
10. PERCENTAGE OF STRUCTURES HAVING RECEIVED SUPERVISION ON TREATING CASES OF MALARIA IN THE LAST SIX MONTHS
Fig. 13: Percentage of structures having received supervision on treating cases of malaria in the last six months
11. PERCENTAGE OF STRUCTURES SENDING REPORTS ON THE MANAGEMENT OF DRUGS
12. PERCENTAGE OF FACILITIES THAT HAD ACCEPTABLE STORAGE CONDITIONS ON THE DAY OF THE VISIT
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13. PERCENTAGE OF CASES OF SIMPLE MALARIA, BY DIAGNOSTIC METHOD
14. PERCENTAGE OF CASES OF SIMPLE MALARIA TREATED WITH ACT, BY AGE BRACKET
15. PERCENTAGE OF PATIENTS WITH A NEGATIVE RDT WHO WERE TREATED WITH ACT, BY AGE GROUP
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ANNEX 3: MINI CARAVAN QUOTES Jean Gedandan, male, stonemason, 36: “In the past, I bought a net for my children. I did not think that it was useful for me as the father. But with today’s message, I have decided to buy and use one for myself”. Aguey Chimene, female, 38, hair dresser: “I was invited by the Chief of Arrondissement to attend the event. I heard about protecting myself and my family against malaria. What I learned regards the use of SP and how this drug can destroy malaria in the placenta to avoid reaching the fetus. These messages are important for both men and women. My advice to the people who organized this caravan is to bring the messages to the countryside where many people are not informed about protection against malaria and the intake of SP”. Etienne Olanygnan, male, carpentry, 27: “I came to the caravan expecting to obtain a free mosquito net. I was informed by the town crier. During the event I heard about protecting ourselves against mosquito bites. Something new I have learned today is about the free medication called SP which is able to kill malaria microbes in the placenta and protect the baby. These messages are important for everybody. The caravan organizers should take it far in the villages. Thank you for choosing the rainy season to hold it”. Richard Makponsse, male, moto rider, 38: “I was at the health center when the caravan arrived. I have a restaurant nearby. What I have heard is about the intake of SP and its role. What I did not know before is about the fetus which is likely to suffer from malaria during pregnancy. I would recommend devoting more time to educate people and would like to take this opportunity to thank the organizers”. Aime Zegbe, male, welder, 30: “I was in the health center when the caravan arrived. I heard that the mosquito net and SP are necessary in fighting malaria. I learned today that the child carried by a pregnant mother is at risk of malaria. I would recommend to the organizers to intensify such effort”. Hermine Amoussou, female, restaurant owner, 37: “I just joined the caravan by curiosity. I heard that a pregnant woman is vulnerable to malaria and how she can protect herself to avoid it and its consequences. I have heard similar messages during visits to the health center. I will suggest that such sensitization should be continued because health centers never deliver all messages about malaria”. Christine AGBI, female, rice seller, 39: “I saw the moving caravan and decided to follow it. I have heard messages about mosquitoes. We have been told to sleep under the mosquito nets. I also heard about two doses of SP. Until today, I did not know a lot about SP and the danger for a pregnant woman with malaria who can lose her baby; this is very serious. These messages are for everybody including men and women because if the child or the woman is sick, it affects everybody in the family. Many times on TV I have heard messages about malaria. I encourage the organizers to continue educating the public. I have one comment: Malaria has been there for a long time. It is a disease linked to exposure to the sun. You can avoid malaria if you stay away from the sun”. Rock Takoulodjou, male, maintenance agent, 30: “I have come to collect a mosquito net. I heard some women from our neighborhood talking about it. At the caravan, I have heard about the use of the LLIN and the intake of SP by pregnant women. One thing I have learned today I did not know before is the use of SP. On mosquito nets, I have heard messages many times on TV and radios. My recommendation to the organizers is to distribute mosquito nets each six months to people because they tear after a short period of time”. Moli Vodounou, female, seller, 42: “I have come because I want to know how mosquitoes cause malaria. I was informed by the town crier. I heard messages about the net and the use of SP. Nothing is
54 | P a g e new to me. The disseminated messages are useful for both men and women. I have heard these messages on TV, radio and during prenatal consultation. My suggestion is to play more sketches to educate people”.
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