In Burkina Faso Generally, Childbearing Typically Occurs Within the Context of Marriage

ss Evidence to Action for Strengthened Family Planning and Reproductive Health Services for Women and Girls Supporting Reproductive Health Services for Young, First-Time Parents (FTP) in

Burkina Faso

Final Report September 2020

About E2A

The Evidence to Action Project (E2A) is the US Agency for International Development’s (USAID) global flagship for strengthening family planning and reproductive health service delivery. The project aims to address the reproductive healthcare needs of girls, women, and underserved communities around the world by increasing support, building evidence, and leading the scale-up of best practices that improve family planning services. A Cooperative Agreement awarded in September 2011, E2A will continue until September 2020. E2A is led by Pathfinder International in partnership with ExpandNet, IntraHealth International, Management Sciences for Health, and PATH.

Contact Information E2A Project 1015 15th Street NW Suite 1100 Washington, DC 20005 Tel. 202-775-1977 Fax 202-775-1988 www.e2aproject.org

This publication was made possible through support provided by the Office of Population and Reproductive Health, Bureau for Global Health, U.S. Agency for International Development, under the terms of Award No. AID-OAA-A-11-00024. The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of the U.S. Agency for International Development.

Acronyms

ANC Antenatal care

CHW Community health worker

CPR Contraceptive prevalence rate

DHC District Health Committee

DHS Demographic and Health Survey

DSF Direction de la Sante de la Famille

E2A Evidence to Action Project

EMC Enquete Multisectoral Continue

EmONC Emergency obstetric and neonatal care

FP Family planning

FTM First-time mother

FTP First-time parent

HF Health facility

HTSP Healthy timing and spacing pregnancy

ICP Infirmier Chef de Poste

IPT Intermittent preventive treatment

IUD Intrauterine device

MCD Medicin Chef de District

MNCH/FP Maternal, Newborn, and Child Health/Family Planning

MoH Ministry of health

NGO Non-governmental organization

PNC Postnatal care

PPFP Postpartum family planning

RH Reproductive health

RMNCH Reproductive, maternal, newborn and child health

SRH Sexual and reproductive health

WHO World Health Organization

Acknowledgements The E2A Project gratefully acknowledges the generous support of USAID and the Burkina Faso mission.

Special thanks are due to the Direction de la Santé de la Famille (DSF), the Ministry of Health (MoH), and the Government of Burkina Faso for their continued collaboration on this project.

E2A also thanks the heads of the regional health directorates of the Center North and East regions, to the Médecins Chefs de District (MCDs) of the districts of Kaya, Diapaga, Fada, Tougouri, Bogandé and Manni, to the Infirmiers Chefs de Poste (ICPs) and Community Health Workers (CHWs) working in the health areas of the various health facilities on the project sites, and to the mayors of the various communes. Lastly, E2A thanks the hundreds of young first-time mothers, their partners, and mothers-in- law who participated in the program for sharing their experiences and helping to advance programming for young FTPs around the world.

It is our sincere hope that the work started on this project will continue and improve the health and wellbeing of first-time parents, their families, and their communities.

Contents ...... 1 About E2A ...... 2 Acronyms ...... 3 Acknowledgements ...... 5 Executive Summary ...... 8 Introduction ...... 9 Background ...... 9 Burkina Faso Health Context ...... 9 Proposed Solutions and Technical Strategy ...... 11 Project Goal and Objectives ...... 12 Phase 1 Goal and Objectives ...... 12 Phase 2 Goal and Objectives ...... 13 Geographic Scope ...... 13 Phase 1 Geographic Scope ...... 13 Phase 2 Geographic Scope ...... 13 Key Interventions ...... 14 Baseline Health Facility Assessments...... 14 Provider Capacity Building and Mentorship ...... 14 Provision of Supplies and Tools to Health Facilities and CHWs ...... 15 Monitoring of FP and Environmental Compliance ...... 16 Provision of Facility-Based Services to FTMs ...... 17 Social Mapping/FTP Recruitment ...... 17 Peer Leader Selection and Training ...... 20 First-Time Mother Peer Groups ...... 21 Outreaches with Husbands of FTMs ...... 22 Outreaches with Mothers-in-Law of FTMs ...... 23 Joint FTP Couple Sessions ...... 24 Home Visits ...... 24 Engagement with Government and Collaboration with Other Partners/Stakeholders ...... 26 Results ...... 26 Phase 1 Result Highlights ...... 27

Phase 2 Result Highlights ...... 29 Lessons Learned ...... 31 Challenges ...... 32 What Worked to Mitigate these Issues ...... 32 ANNEXES ...... 34 Annex 1: Villages, districts, and intervention areas covered by phase 1 of the project ...... 34 Annex 1: Villages, districts, and intervention areas covered by phase 2 of the project ...... 36

Executive Summary

The E2A project received field support funding from USAID Burkina Faso mission to implement a project aimed to increase access and use of quality maternal, newborn, and child health/family planning (MNCH/FP) services among first-time parents (FTP)—adolescents and young women under the age of 25, married or unmarried, who are pregnant or have a child that is younger than two years old, and their partners. The Youth project was implemented in two phases, which combined spanned from March 2018-June 2020. The project worked at the facility- and community-levels in the East and Center North regions of Burkina Faso, which are marked by high frequency of early marriage and childbearing as well as poor MNCH/FP outcomes for young mothers.

The project included a package of interventions, including: provider capacity building and mentorship, support to health facilities and community health workers, peer-led small groups with first-time mothers (FTM), small groups with FTMs’ husbands, joint couple sessions bringing together FTMs and their husbands, informational sessions with mothers-in-law of FTMs, home visits for the benefit of FTMs and members of their household, and collaboration with the government and coordination with other partners and stakeholders.

The first phase of the project saw some promising results, including an increase in the percentage of women that had given birth who had received at least 4 antenatal care (ANC) visits—from 59.3% at baseline to 66% at endline. Program participants also reported increased awareness of ANC, including the importance of using services early in pregnancy, as well as improved healthy timing and spacing of pregnancy (HTSP) knowledge and attitudes among FTMs and their husbands. Based on these promising results—and building upon the lessons learned from the first phase—the second phase of FTP programming was implemented with the addition of new topics and revised approaches. The second phase of the project was also able to demonstrate some strong results, including improvements in early initiation of breastfeeding among program participants, which increased from 53.3% at baseline to 91.3% at endline. Contraceptive use also increased substantially from baseline to endline, rising from 18.9% to 45.7% during this period.

The Youth project also provided some important lessons learned to inform future programming: • The FTM peer groups could be continued by the MoH through the establishment of longer-term health clubs, building upon the capacity built by the project and providing further opportunities to meet the needs of these young first-time mothers. • Inclusion of an income-generating activities component in the package of interventions for young first-time mothers would contribute to their empowerment. • Given the importance of the target, considering this group as a specific group within the adolescent and youth programs would help to better prioritize the needs of FTPs.

The project was implemented with the full involvement of the MoH, local governments, and the communities themselves, which has led to capacity building at a number of levels and will allow for the continuation of key services and interventions, even after the project has ended.

Introduction

The Evidence to Action Project (E2A) is USAID’s global flagship project for strengthening family planning and reproductive health service delivery. The E2A project received field support funding from USAID Burkina Faso mission to implement a project in the East and Center North regions targeting first-time parents (FTP)—adolescents and young women under the age of 25, married or unmarried, who are pregnant or have a child that is younger than two years old, and their partners.

In designing the RISE-FP project, E2A and Pathfinder applied three key principles: (i) alignment with the objectives of the Ministry of Health, (ii) reinforcement of the health system (focused on the district level), and (iii) complementarity with other partners, funded by USAID or other donors.

The project was implemented in two phases. The first phase of the project was implemented between March 2018-June 2019 in the Fada and Diapaga Health Districts of the East Region with the goal of increasing family planning (FP) uptake and the use of Reproductive, Maternal, Neonatal, and Child Health (RMNCH) care—especially antenatal care (ANC) and obstetric and neonatal services—among FTPs. The project worked at both the facility and community level in 20 health facilities and 57 surrounding villages. After the initial 15 months of implementation, USAID granted an extension to implement a second phase of the project between July 2019-June 2020 in five health districts across the East and Center North regions of Burkina Faso. Based on the results and learnings of the first phase of the project, and in consultation with USAID, the second phase was implemented in 20 health facilities and 20 surrounding villages with the goal of increasing access to and use of quality MNCH/FP services for first-time parents and their children.

Both phases of the project aligned with key national policies and strategies including: the Burkina Faso Costed Implementation Plan, the National FP Acceleration Plan, the Universal Health Coverage strategy, and the policy providing free healthcare to pregnant women and young children. The project worked in close collaboration with the MoH at both the central level with the DSF (Health and Family Directorate) as well as the decentralized health district level. The project was introduced to the district management team, representatives of local authorities, administrative authorities, and representatives of youth and women's organizations in the project areas, and project activities were integrated into the annual action plan of the health districts. The project also held quarterly program review meetings with the DSF to review project progress and ensure alignment with the Directorate’s goals and initiatives.

Background

Burkina Faso Health Context The East and Center North regions of Burkina Faso are characterized by high frequency of early marriage and childbearing as well as poor RMNCH and FP outcomes for young mothers. In these regions, sexual debut is early and generally occurs within the context of marriage, and the interval between marriage and first birth is relatively short. According to the 2010 Burkina Faso Demographic and Health Survey (DHS), the median age of marriage for women is 17.2 years old in the East region and 17.9 years old in

9 the Center North region, and the median age at first birth is 18.4 and 19.7, respectively1. These two regions also have amongst the highest total fertility rates in the country at 7.5 children per woman in the East Region and 6.7 children per woman in the Center North Region2. Furthermore, contraceptive use in these two regions is low and unmet need for family planning is high, at 23.1% (East) and 20.0% (Center North)3. Given early childbearing, it is also important to note that national levels of contraceptive use by younger women are particularly low, with just 5.9% of adolescents aged 15–19 years using a modern contraceptive method4. Furthermore, utilization of antenatal care services nationally is poor, with only 33.7% of women receiving at least four antenatal care visits and only 41.2% of women receiving at least one antenatal care visit within the first four months of pregnancy5. While the 2014 Burkina Faso Enquete Multisectorielle Continue (EMC) shows some improvements in early marriage and childbearing, as well as modern contraceptive prevalence rate (mCPR) and unmet need, these broader health concerns persist, and the East and Center North regions continue to lag behind the country as a whole6.

In addition to the health issues presented above, FTMs face unique challenges that limit their reproductive health choices and actions—challenges that are different from other adolescents and different from older married women. In the Eastern Region and in Burkina Faso generally, childbearing typically occurs within the context of marriage. Early marriage and the expectation to begin childbearing shortly thereafter can put adolescent girls at a disadvantage by limiting their mobility and isolating them from supportive social networks7. Furthermore, even if they have access to reproductive health services, young women and girls often must get permission from their husbands and other household influencers to visit the health center or obtain services8. Unequal power and gender dynamics, along with other factors such as socio-cultural preferences around fertility and health provider bias, can fuel early, rapid, and repeat pregnancies, compromising the health of young women and their newborns. These early or closely spaced pregnancies pose significant risks for young FTMs. Pregnant adolescents are at increased risk for multiple adverse health consequences for both the mother and child. Young women who become pregnant during their teenage years are at an increased risk of developing eclampsia, puerperal endometritis, systemic infections, and maternal death; and children born from adolescent mothers have increased risks of low birth weight and premature birth, which contribute to early neonatal death91011.

1 Institut National de la Statistique et de la Démographie (INSD) et ICF International, 2012. Enquête Démographique et de Santé et à Indicateurs Multiples du Burkina Faso 2010. Calverton, Maryland, USA : INSD et ICF International. 2 Ibid. 3 Ibid. 4 Ibid. 5 Ibid. 6 INSD, Rapport du Module Démographie et Sante (MDS) de l’Enquête Multisectorielle Continue (EMC), 2015 7 Anna Engebretsen and Gisele Kabore, Addressing the needs of girls at risk of early marriage and married adolescent girls inBurkina Faso (Population Council, May 2011) 8 Ibid. 9 Ganchimeg, T., E. Ota, N. Morisaki, M. Laopaiboon, P. Lumbiganon, J. Zhang, B. Yamdamsuren, M. Temmerman, L. Say, and Ö. Tunçalp. 2014. “Pregnancy and Childbirth Outcomes among Adolescent Mothers: A World Health Organization Multicountry Study.” BJOG: An International Journal of Obstetrics & Gynaecology 121(s1):40-48. 10 Chen, X.K., S.W. Wen, N. Fleming, K. Demissie, G.G. Rhoads, and M. Walker. 2007. “Teenage Pregnancy and Adverse Birth Outcomes: A Large Population Based Retrospective Cohort Study.” International Journal of Epidemiology 36(2):368 11 Conde-Agudelo, A., J.M. Belizán, and C. Lammers. 2005. “Maternal-perinatal Morbidity and Mortality Associated with Adolescent Pregnancy in Latin America: Cross-sectional Study.” American Journal of Obstetrics and Gynecology 192(2):342-349.

Proposed Solutions and Technical Strategy Most maternal deaths are preventable, as the healthcare solutions to prevent or manage complications are well known. To improve maternal health, the World Health Organization (WHO) states barriers that limit access to quality maternal health services must be identified and addressed at all levels of the health system. Skilled care before, during, and after childbirth can save the lives of women and newborn babies. The WHO recommends: 1) ensure universal health coverage for comprehensive reproductive, maternal, and newborn health care; 2) address all causes of maternal mortality, reproductive and maternal morbidities, and related disabilities; and 3) strengthen health systems to collect high-quality data to respond to the needs and priorities of women and girls.

All women need access to ANC including intermittent preventive treatment (IPT) of malaria in pregnancy, skilled care during childbirth, and support in the first few weeks after childbirth. Poor women in remote areas are the least likely to receive adequate health care. This is especially true for regions with low numbers of skilled health workers, such as sub-Saharan Africa and South Asia. Safe delivery by a skilled birth attendant and strong neonatal care are essential to bring immediate attention to breathing and warmth, hygienic cord and skin care, and early initiation of exclusive breastfeeding.

Overall, the project aimed to support the Burkina Faso MoH in the provision of FP and MNCH services to young women and men. The Burkina Faso MoH routinely provides maternal and child health care through health facilities. The project reinforced health facilities’ capacity for service provision through training, equipment, supervision, and leveraging CHWs to reach beneficiaries in remote areas. The MoH identified two CHWs in each village for basic health services management, and the project worked with these same CHWs. The project aimed to strengthen family planning and reproductive health (FP/RH) service delivery, focusing on the needs of FTPs. The project interventions were designed using innovative and complementary approaches based on the E2A/Pathfinder sexual and reproductive health (SRH) Lifestages Framework.

The SRH Lifestages Framework lays out a normative progression of sexual and reproductive activity across an individual’s lifetime and builds a layered understanding of that individual as s/he moves through SRH lifestages, transitions, and milestones. This framework uses three ‘layers’ to analyze and contextualize the specific SRH needs and situation of an individual at any lifestage: 1. SRH Markers – Defines key sexual and reproductive events that occur across an individual’s lifetime. While primarily intended to focus on health markers, this can include related life events that affect SRH risks or activity, such as marriage or leaving school. 2. Socio-Ecological Factors – Defines the different people and systems that directly or indirectly influence an individual’s SRH situation, using the familiar socio-ecological concept. 3. Relational Dynamics – Defines the varied interactions and social/gender factors that affect an individual’s agency and ability to navigate through SRH lifestages.

When designing the first phase of the Youth project, E2A and Pathfinder applied the first layer of the SRH Lifestages Framework to depict the SRH lifestages of women in the East region of Burkina Faso. Drawing on available data, the framework highlights the rapid sequence of life events that shape a young women’s transition from the pre-sexual activity lifestage to the lifestage of sexual and reproductive activity. While not necessarily true for all women, the data suggests that the first year after marriage is often the catalyst for young married women to experience their first sexual activity, pregnancy and childbirth.

SRH Lifestages of Women in East Region, Burkina Faso

From a programming standpoint, this figure highlights the opportunity for interventions that aim to influence RMNCH outcomes. Although the interval between marriage and first pregnancy is short, it is a strategic opportunity to work with newly married women/couples on healthy timing and spacing of pregnancies (HTSP) and planning for safe pregnancies and birth of their first children. Understanding that social and gender norms stress early childbearing within marriage, there is also the potential to work with young women and their families after they have had their first child to shape their subsequent childbearing. E2A and Pathfinder also set out to address child health outcomes through the implementation of the two phases of the FTP project.

Project Goal and Objectives Phase 1 Goal and Objectives The first phase of the project was implemented between March 2018-June 2019 in the Fada and Diapaga Health Districts of the East Region with the following goal and objectives:

Overall Project Goal

Increase access to and use of quality maternal, newborn and child health/family planning services for first-time parents and their children in the East and Center North regions.

Project Objectives

Strategic Objective 1: Increase FTP access to and utilization of clinical antenatal/postnatal (ANC/PNC), delivery services, newborn care and FP

Strategic objective 2: Increase demand among FTPs for RMCNH care, facility-based delivery, healthy timing and spacing of pregnancy (HTSP), and FP

Strategic objective 3: Create a friendly environment for FTP health action among household and community influencers, including health providers

Phase 2 Goal and Objectives The second phase of the project was implemented between July 2019-June 2020 in five health districts across the East and Center North regions of Burkina Faso. Based on the results and learnings of the first phase of the project, and in consultation with USAID/Burkina Faso, the second phase established the following goal and objectives:

Overall Project Goal

Increase access to and use of quality maternal, newborn and child health/family planning services for first-time parents and their children in the East and Center North regions.

Project Objectives

Strategic Objective 1: Increase access to clinical MNCH care focusing on FP/postpartum FP (PPFP) for FTP peer group participants

Strategic objective 2: Increase demand among young women, with a focus on first-time mothers, for FP/PPFP and MNCH services and related health behaviors, such as exclusive breastfeeding

Strategic objective 3: Create an enabling environment in the project zone for FP uptake and utilization of MNCH services and ensure sustainability of services.

Geographic Scope Phase 1 Geographic Scope Phase 1 of the E2A Youth Project in Burkina Faso was implemented in the Fada and Diapaga Health Districts of the East Region. The project covered 20 health facilities and 57 surrounding villages across these two regions. The project prioritized rural and semi-urban facilities and used several baseline indicators, such as the number of deliveries, the size of the population, the security situation, and accessibility to select high-volume facilities that would most benefit from project support.

Phase 2 Geographic Scope For Phase 2 of the Youth project, E2A and Pathfinder, in consultation with USAID/Burkina Faso, selected 20 health facilities and 20 surrounding villages in five districts across the East and Center North regions

13 of Burkina Faso. The five districts covered by the project include: Fada, Bogande, and Manni in the East region and Kaya and Tougouri in Center North. The project was able to capitalize on provider and health system capacity that was previously built through Phase 1 of the Youth and RISE-FP projects by selecting to work in districts and facilities that were already covered by these projects. Furthermore, the project locations were selected based on the context/needs as well as logistical considerations, such as the local security situation. Population size and accessibility were also determinants in the choice of intervention sites.

Key Interventions The Youth project was initially approved in March 2018 for one year of implementation. The program was then extended through June 2020. Over the two years of implementation, the following key interventions were implemented:

Baseline Health Facility Assessments At the beginning of Phase 1, the project conducted an assessment of the project-supported health facilities in the Fada and Diapaga health districts in order to obtain updated baseline data on all project health facilities and their area of coverage. The general objective of the baseline assessment was to describe the availability of reproductive, maternal and neonatal health services, including family planning, with a view to strengthening the operational capacities of health facilities. Specifically, the baseline assessment:

• Assessed the availability of medico-technical equipment for the provision of reproductive, maternal and child health services including FP; • Assessed the training needs of providers in the health facilities; • Identified intervention villages and CHWs in the intervention zone; • Collected data on current reproductive, maternal and child health indicators.

For the second phase of the project, which was extended to the health districts of Bogandé, Manni, Tougouri, and Kaya, a second assessment was not conducted, because all of the health facilities were assessed (using the same tool) during Phase 1 of either the Youth or RISE-FP projects implemented by E2A in the East and Center North regions.

The findings of the baseline assessment of the health facilities mainly revealed a lack of equipment to offer certain contraceptive methods, particularly the intrauterine device (IUD) and the contraceptive implant. Also, some providers did not have a good understanding of IUD and implant methods. In addition, there were shortcomings in infection prevention and in the quality of data collected. These findings were noted for the project to address during implementation.

Provider Capacity Building and Mentorship Beginning in September 2018, the project conducted a series of training sessions on emergency obstetric and neonatal care (EmONC) and FP for 69 providers from the 19 basic health facilities included in phase 1 of the Youth project, with the involvement of gynecologists from the CHR in Fada (the 20th facility). For phase 2 of the project, no new trainings were conducted as the providers had previously been trained through either the Youth or RISE-FP E2A projects.

Throughout phase 1 and phase 2 of the Youth project, providers in the project-supported health facilities received monthly clinical mentorship by Pathfinder mentor-trainers as well as quarterly supportive supervision conducted by Pathfinder mentor-trainers alongside representatives from the health districts. The mentorship approach employed by the project involved identifying the skill-improvement needs for each provider, developing a field visit plan, and conducting ongoing mentorship to improve the providers’ skills for quality clinical service provision.

During the start-up of both phases, CHWs, who were already working under the MoH, were identified and trained on communication and counseling approaches and how best to reach FTMs and their key influencers. The training used the MoH’s official CHW training curriculum, with the addition of FTP-specific materials related to project activities. While CHWs were directly supervised by their facility-based supervisors, Pathfinder staff provided them with monthly coaching and quarterly joint supportive supervision in collaboration with the nurse in-charges at the facilities.

Provision of Supplies and Tools to Health Facilities and CHWs During the health facility assessment conducted at the beginning of the E2A Youth and RISE-FP projects, the project discovered that on average the project-supported facilities were lacking in the following essential supplies: • Medical-technical supplies • Implant and IUD insertion and removal kits • Maternal and child health record adapted for data collection • CHW animation kits To support the health facilities, the project equipped 20 health facilities with basic medical technical supplies and IUD and implant insertion and removal kits. The project also provided 113 CHWs with bicycles and animation kits and provided program participants with the Mother and Child health record.

Photo: Delivery of medical equipment to the MOH

Photos: Bikes provided to CHWs to better enable them to travel to complete project activities

Monitoring of FP and Environmental Compliance

FP and environmental compliance monitoring was carried out by Pathfinder staff during the two years of project implementation. Compliance monitoring was integrated into supervision visits, and annual assessments of FP and environmental compliance were conducted for all project-supported health facilities.

Provision of Facility-Based Services to FTMs Through provider capacity building, as well as the provision of supplies, the project’s aim was to ensure that the project-supported health facilities were equipped and trained to provide quality healthcare to young women and first-time parents, with a specific focus on: • Systematic FP counseling for women who arrive at the health facility for pre- and post-natal care or who have been referred by CHWs to the facility • Provision of FP services (counseling and methods) to young women in the post-abortion period • Provision of FP services to young women under 25 years of age who already have a child

Social Mapping/FTP Recruitment Prior to the start of the FTM peer groups and other community-based interventions, the project conducted a social mapping exercise to identify FTMs in the project villages. The social mapping exercise was conducted in close coordination with locally based CHWs who were known resource persons in the community and trained and paid by the Burkina Faso MoH. The primary purpose of the social mapping exercise was to develop a list of potential program beneficiaries that met the project’s recruitment criteria: young women (married or unmarried) residing in the identified project villages under the age of 25 who are pregnant for the first time or have one child under 24 months of age. In most cases, staff and CHWs first met with the entire household to inform them of the project and gain support for participation from FTMs, their husbands, and their mothers-in-law. Once the household was informed of the program, the project staff enrolled FTMs individually and collected basic baseline health data. By providing a sense of the potential pool of FTM participants, the mapping exercise helped define the final set of community- and facility-based interventions included in the FTP project.

Specifically, the social mapping exercise allowed the project to: • Develop a database of young FTMs for program participation and individual-level follow-up for provision and tracking of RMNCH services • Identify households, partners and peer leaders • Estimate key project indicator targets

For the Phase 1 program, the social mapping activity was carried out in 60 villages in the health districts of Fada and Diapaga. A total of 853 FTPs were identified with the support of 113 CHWs. To tailor home visits to individual needs and monitor lifestage-specific interventions more effectively, participants identified through the phase 1 social mapping exercise were classified into one of three segments based on their status at the time: Segment 1: 0–3 months pregnant; Segment 2: 4–9 months pregnant; and Segment 3: has one child under 24 months of age.

Table 1: FTPs Identified during the Social Mapping Exercise, Phase 1

# of smalls VILLAGES tota lFTPs 1 Seg 2 Seg 3 Seg groups TOTAL MAPPED 60 67 157 629 853 # excluded* 3 1 1 8 10 # included 57 66 156 621 843 67

For the Phase 2 program, the social mapping activity was carried out in 20 villages in the health districts of Fada, Bogande, Kaya, Tougouri and Manni. These five health districts are divided into the three project zones outlined below (Fada, Bogande, and Kaya). A total of 296 FTMs, 284 husbands, and 290 mothers-in-law were identified by the project with the support of 40 project-trained CHWs. For this second phase, FTMs were no longer divided into 3 segments, but rather identified as either pregnant or having one child under the age of two. The project also put increase emphasis during this second phase on identifying and collecting baseline data on key influencers (husbands and mothers-in-law) along with the first-time mothers. The phase 2 social mapping tool was also revised to add some knowledge, attitudes, and behavior questions related to key health actions, with the intention of asking these questions again at endline12.

Table 2: FTPs, Spouses, Mothers-in-law and Peer Leaders by Project Area, Phase 2

Zone FTPs Spouses Mothers-in-law FTPs Mother Leaders

Fada 103 94 97 16

Bogande 90 88 90 12

Kaya 103 102 103 12

Total 296 284 290 40

12 Refer to the challenges section for an explanation on the status of the endline data collection

Photos: social mapping in the villages of Fada

Photos: social mapping in the villages of Bogandé

Peer Leader Selection and Training FTM peer leaders were selected from the group of FTMs identified during the social mapping exercise and were tasked to lead the FTM small group discussion sessions for their peers. FTM peer leaders (for both phases) were identified, with the assistance of CHWs, using the following criteria:

• Being an FTM from the village where the group is implemented; • Being available, dynamic and accepted by the other FTMs; • Being committed to essential newborn care and family planning services; • Having strong communication skills; • Having the capacity to mobilize their peers; • Knowing how to read and write in French is an asset.

A total of 172 peer leaders, 132 from phase 1 and 40 from phase 2, were given a three-day training focused on Essential Newborn Care/Family Planning and the use of activity cards to facilitate the small group discussion sessions.

Photos: Training of peer leaders

The role of the peer leaders included mobilizing FTMs for participation in the peer group sessions; directing FP clients to the CHWs for counseling, services, and referrals; and facilitating the FTM small group sessions using the project-developed activity cards.

First-Time Mother Peer Groups FTM peer groups were a central activity for the Youth project. Peer groups were led by young women peer leaders, and at least one CHW attended each session to support the peer leaders in facilitation, provide health information, provide referrals or services to peer group members, and track peer group member participation. The peer groups comprised young FTMs, including pregnant and postpartum FTMs, and ranged from 8–15 members each. The groups gathered twice a month to discuss a selected topic, using the activity cards—some of which were adapted from the GREAT13 project and others that were developed by E2A—as a guide.

For phase 1, the peer group intervention was implemented in the 57 project-supported villages (12 in Diapaga, 45 in Fada), and a total of 67 peer groups were active over a five-month period (January–May 2019). Ten peer group sessions were planned, and during each session the group could select which of the 11 available activity cards to cover. The activity card topics for phase 1 included:

ACTIVITY 1: PRE-NATAL CONSULTATION AND DANGER SIGNS DURING PREGNANCY. ACTIVITY 2: PLANNING AND IDEAL SPACING OF PREGNANCIES FOR HEALTH. ACTIVITY 3: ROLE OF MEN AND WOMEN. ACTIVITY 4: REPRODUCTIVE HEALTH CHOICES ACTIVITY 5: EXCLUSIVE BREASTFEEDING. ACTIVITY 6: INJECTABLE CONTRACEPTIVE: TRUE OR FALSE ACTIVITY 7: COMBINED ORAL CONTRACEPTIVES: TRUE OR FALSE ACTIVITY 8: STERILET: TRUE OR FALSE ACTIVITY 9: CONDOMS: TRUE OR FALSE ACTIVITY 10: IMPLANTS: TRUE OR FALSE ACTIVITY 11: MAMA: TRUE OR FALSE

During Phase 1,10 sessions were conducted during the implementation period.

For phase 2, a total of 20 peer groups were active over a four-month period (December 2019–March 2020). The project revised previous activity cards and created new ones to develop a package of 10 activity cards that were sequenced to align with topics discussed in the husband’s and mothers-in-law sessions. The topics of the revised activity cards include:

ACTIVITY 1: PRE-NATAL CONSULTATION AND ASSISTED CHILDBIRTH ACTIVITY 2: DANGER SIGNS DURING PREGNANCY ACTIVITY 3: HEALTHY TIMING AND SPACING PREGNANCY (HTSP) ACTIVITY 4: OVERVIEW OF FP METHODS

13 The Gender Roles, Equality and Transformations (GREAT) project was led by the Institute for Reproductive Health of Georgetown University and implemented by Pathfinder International and Save the Children in Northern Uganda.

ACTIVITY 5: ROLE OF MEN AND WOMEN ACTIVTY 6: IMPLANTS - TRUE OR FALSE ACTIVTY 7: TALKING ABOUT DIFFICULT TOPICS ACTIVITY 8: MAKING HEALTHY DECISIONS ACTIVITY 9: INJECTABLE CONTRACEPTIVE: TRUE OR FALSE ACTIVITY 10: INFANT AND YOUNG CHILD FEEDING (IYCF)

Unfortunately, only the first 7 of the 10 planned sessions were completed in phase 2 due to the suspension of community-based activities during the COVID-19 pandemic.

Photos: FTM small groups discussions

Outreaches with Husbands of FTMs During Phase 1, discussion sessions with the husbands of FTMs were held once per month, for a total of five sessions (January–May 2019). The men were initially invited by the participating FTMs, and all who

22 were interested were able to participate in discussion groups—with an average of 8 men per group. The purpose of these meetings was to raise awareness about young women’s access to critical health services during the FTP lifestage. CHWs, with support from Pathfinder staff, conducted group discussions using MoH counseling tools and Pathfinder’s Pathways to Change game14. The game was used to identify barriers and facilitators to adopting key health- and gender-related behaviors that were then discussed as a group. The sessions focused on three key topics: men’s and women’s roles, reproductive choices, and ANC.

In Phase 2, three discussion sessions were held with the husbands of FTMs between December 2019- February 2020. During this second phase, Pathfinder staff conducted these sessions using project- adapted/developed activity cards, covering the following topics:

SESSION 1: LOW-RISK PREGNANCY AND ASSISTED DELIVERY SESSION 2: HEALTHY TIMING AND SPACING PREGNANCY (HTSP) SESSION 3: EXPLORING GENDER

Given the challenges engaging men experienced during the first phase due to competing work priorities, this phase focused on strategic health gaps/concerns, especially those that touch on deeply held cultural and gender norms. The husband sessions during this phase were also timed to coordinate with the FTM discussion sessions, to encourage household communication on these topics. Due to COVID-19, the final session covering gender roles was not able to be completed.

Outreaches with Mothers-in-Law of FTMs In Phase 1, discussion sessions with the mothers-in-law of FTMs (and other older women who were key influencers of FTM peer group members) were held once per month, for a total of five sessions (January–May 2019). The first invitation to the mothers-in-law was sent through the participating FTMs, and the sessions had on average nine mothers-in-law per group. For these sessions, CHWs—with support from Pathfinder supervisors—used MoH tools to lead discussions on thematic topics around ANC, safe delivery, and postpartum family planning with the objective of encouraging mothers-in-law to support young women’s access to services.

For Phase 2, three discussion sessions were held with the mothers-in-law of FTMs (and other older women who were key influencers of FTM peer group members) between December 2019-February 2020. These sessions were facilitated by CHWs, with support from Pathfinder supervisors. While the first mothers-in-law sessions in the first phase used MOH tools to lead discussions on thematic topics around ANC, safe delivery, and postpartum family planning, activity cards were developed for this second phase, covering the following topics:

INFORMATION SESSION I: PREGNANCY AND ASSISTED CHILDBIRTH. INFORMATION SESSION 2: HEALTHY TIMING AND SPACING PREGNANCY (HTSP)

14 The Pathways to Change game is a behavior change tool in the form of a simple game that is designed to identify barriers and facilitators to change and generate discussion and stimulate thinking that can motivate individuals and communities to change

INFORMATION SESSION 3: INFANT AND YOUNG CHILD FEEDING (IYCF) AND INFANT HEALTH

As with the men’s sessions, the topics with the mothers-in-law focused on strategic health concerns that involve deeply held cultural norms in order to encourage mothers-in-law to support young women’s access to services. These sessions were also timed to correspond with FTM and husband discussion sessions to encourage household communication.

Joint FTP Couple Sessions Based on the implementation experiences of the phase one FTP program, as well as E2A’s interest in exploring the potential for couple-focused interventions within the FTP framework, a new intervention component was added to the phase two program—joint couple sessions bringing together FTMs and their husbands to discuss key health topics. The project planned the following two Pathfinder staff-led sessions:

JOINT SESSION 1: THE FIRST ANC JOINT SESSION 2: HEALTHY TIMING AND SPACING PREGNANCY (HTSP)

Due to COVID-19 only the first joint session (discussing ANC) was able to be completed.

Home Visits Across the two phases of the project, 153 Community-Based Health Workers were trained on maternal, neonatal and child health and family planning issues in order to carry out home visits for FTPs and members of their household. The CHWs were coached by the project staff and under the supervision of the health facility managers. In their MoH role, CHWs typically conduct home visits with women during pregnancy and the immediate post-partum period. The home visits during pregnancy focused on: encouraging early initiation of ANC and attendance of at least four ANC visits; helping the family prepare for delivery at a health facility; ensuring the pregnant women is sleeping under a treated mosquito net; and encouraging continued use of prescribed treatments (iron, antiretrovirals, etc.). Home visits during the postpartum period included: assessing the newborn and mother for danger signs; encouraging exclusive breastfeeding and good infant care practices; reminding the mother to go for her postnatal care visit; monitoring the weight and health of the infant; and counseling on FP. During these home visits, they typically provide, among other services, referrals to the health facility for ANC, risk assessments, FP, and other services as well as community-based refills of some short-term FP methods such as pills and condoms. For this FTP program, CHWs were encouraged to ensure that all enrolled FTMs received the standard MOH home visits as well as additional visits throughout the FTP lifestage period, based on the needs of the individual FTM. Through the home visits, CHWs were also able to reinforce messages that were raised during peer group discussions.

Photos : Home visits

Engagement with Government and Collaboration with Other Partners/Stakeholders The project is committed to supporting the actions of the Ministry of Health alongside other actors. To that end, the project collaborated with the government, implementing partners, and other key stakeholders on a number of important activities, including: • Participation in the various national family planning weeks held twice a year. This participation took place at the national level and at the health district level. • Support for the holding of four District Health Committees (DHCs) in collaboration with PSM, another USAID-funded project. • Participation and integration of project activities in the action plan of the health districts. • The presentation of the project during the sessions of some municipal councils and to the regional health and administrative authorities. • Initiation of monthly consultation frameworks in order to improve collaboration, communication and complementarity in the planning and implementation of the action plans of the FP partners financed by USAID. • Monthly review and accountability meetings at the DSF. • Participation in advocacy actions with other actors for the effectiveness of free FP services in Burkina Faso. • Support to the Ministry of Health through the renovation of the DSF, the provision of internet and the provision of an administrative assistant to the Ministry of Health.

Results The Youth project provided a unique opportunity to work with young FTMs and their key influencers across the FTP lifestage—from those just starting their first pregnancy, through to two years postpartum. This allowed the project to address a wide range of FTP health issues, including ANC, HTSP/FP, and exclusive breastfeeding, among others. As mentioned previously, the Youth project was divided into two phases with the initial phase being conducted in two districts in the East region between March

2018-June 2019 and the second phase being conducted in five districts across the East and Center North regions between July 2019-June 2020. This results section will be divided by phase.

Phase 1 Result Highlights During the first phase, the project trained 69 providers from the project’s health facilities on EmONC/FP. This, coupled with the continued mentorship and supportive supervision provided to the trained facility- based providers and project-supported community health workers, helped strengthen service delivery in the project areas, ensuring that FTMs and other young women are able to access high-quality youth- friendly services.

Monitoring data from the FTP peer groups also indicated that the program was able to attract and retain FTMs at different stages of their FTP experience and across key demographic characteristics. When comparing enrolled program participants with those that attended at least 5 sessions and had at least one home visits, the demographic profiles are generally similar showing that pregnancy status, age, or education level did not pose a significant barrier to participation.

Table 3: Demographic characteristics of enrolled FTMs vs those that attended at least 5 peer group sessions and received at least one home visit

One key health service of interest to the project was facility-based assisted delivery. During the first quarter of project implementation after FTP enrollment (Oct-Dec 2018), there were 7 recorded home births, however, no home births were observed over the remainder of the implementation period. This points to the project’s ability—through peer groups and interactions with CHWs and facility-based providers—to appropriately communicate the importance of facility-based delivery and assist pregnant FTMs in accessing facilities for delivery.

ANC was another priority health issue Percentage of FTM program for the FTP project, including early participants (who have given birth) that initiation of ANC and the completion of received at least 4 ANC visits at least 4 ANC visits. Over the course of 68% 66% the phase 1 program, the project saw an 66% increase in the percentage of women 64% that had given birth who had received 62% 60% 59% at least 4 ANC visits from 59.3% at 58% baseline to 66% at endline. 56% 54% A qualitative study conducted by E2A Baseline Endline that included in-depth interviews and focus group discussions with program Figure 1: Percentage of FTM program participants that received at least 4 ANC visits, phase 1 participants and implementors, also found that FTMs reported an increased awareness of prenatal care, including the importance of using services early in pregnancy.

“You carry it, but you don't know anything. You don't know if the child is in the womb, if it lives or if it is dead, you don't know. So, it's important that you go to the health center so that the health workers can see the position of the child, because they are the ones who know how to make sure it's good.” —FTM, 20 years old

The qualitative study also revealed that HTSP/FP knowledge and attitudes also improved for young FTMs and their husbands.

“If you adopt family planning, you, the mother, will be healthy and your child will be healthy too. You will be in peace and not in trouble. When I was not yet in the project, I didn't know all this.” —FTM, 21 years old

“Now people have started to understand. Before, it was not everyone who agreed to talk about it. But nowadays, people understand that it [FP] is not bad in itself. This is to really help you take care of your family, to space pregnancies up to the number you want.” — Husband of FTM, 29 years old

Phase 2 Result Highlights During Phase 2, the project continued to mentor providers that were trained during the initial phase of the E2A Youth and RISE-FP projects. Throughout the course of the two phases, 175 facility-based providers were provided with regular mentorship, including on the insertion and removal of implants and IUDs, improving the quality and availability of FP services in the project areas.

Project monitoring data also showed high participation rates for FTMs, their husbands, and their mothers-in-law in the community-based small group discussion sessions, indicating that the topics covered were relevant and of interest and that the project’s efforts to engage key influencers were successful.

Figure 2: Proportion of enrolled FTMs that participated in group sessions, phase 2

Exposure to the project messages ranges from 94.9% to 72.6%. Session 1 had the highest participation rate and session 5 had the lowest. This graph shows the participation rates only for villages with an active FTP program. Therefore, the enrolled FTMs from the 4 villages where the program stopped due to security situations15 are removed from the denominator beginning in February 2020. Participation among husbands and mothers-in-law was similarly high. Over 80% of spouses and MILs participated in two sessions dedicated to promoting safe pregnancy, assisted childbirth, HTSP and FP among male partners.

The program demonstrated improvements in some key health outcomes of interest during the FTP lifestage. In regard to early initiation of ANC, of all pregnant women observed up to the end of March

15 Refer to Challenges section

2020, 76.47% received their first ANC visit in the first trimester of pregnancy. This proportion was 62.5% at Proportion of Program Participants baseline. Furthermore, the proportion of women that Received at least 4 ANC Visits who have completed at least four ANC visits before delivery is 69.6%. This rate 68.7% among women with one child at baseline. During this second phase Less than de 4 ANC 30.4 of the project was also able to add messaging and indicators related to IPT in pregnancy. While there are still improvements to be made, during the intervention period, the percentage of program More than 4 ANC 69.6 participants that received five doses of IPT during pregnancy increase from 2.5% at baseline to 11.59% at the end of the intervention. 0 20 40 60 80

As with the Phase 1 of the Youth project, the project Figure 3: Proportion of program participants that received at least 4 ANC visits, phase 2 data shows that almost all program participants gave birth in a health facility. During the intervention, 69 women gave birth and only two women were not assisted by a skilled attendant (both of whom have birth in December 2020), representing an assisted delivery rate of 97.10%. At baseline, the proportion of women who had an assisted delivery was 96.0%, an increase of 1.1 points. It should be noted that the two unassisted deliveries took place in the villages of Djouma (CSPS of NAYIRI) and Boanga (CSPS of YAMBA) which are located in areas of high insecurity that have experienced terrorist attacks. In these centers, health personnel worked only during the day and health services remained closed at night due to insecurity. Our two young FTMs did not have the chance to benefit from qualified assistance during their delivery because of the lack of continuity of services due to insecurity. Unfortunately, one of them lost her baby after he was referred to the CHR de Fada for respiratory distress.

120 BF-430 P5 % Assisted deliveries 100 100 100 100 100 100 80 77.8 60 40 20 0 Octobre 2019 Novembre 2019 Décembre 2019 Janvier 2020 Février 2020 Mars 2020

Figure 4: Percentage of women who gave birth that did so in a health facility, phase 2

The project also saw improvements in early initiation of breastfeeding among program participants. Of all the births observed during the intervention period, 91.3% of newborns were breastfed within 1 hour of birth. This indicator improved significantly from baseline, which was 53.3%.

100 91.3

60 53.3

0 Baseline End of Project

Breastfed Within an Hour of Birth

Figure 5: Percentage of newborns that were breastfed within an hour of birth, phase 2

Lastly, contraceptive use increased substantially from baseline (social mapping) to March 2020, rising from 18.9% to 45.7% during this period. Among the methods adopted, long-acting methods represent 70.3% while they represented 46% in the social mapping. The protection year couple (CYP) for all program participants monitored was 159.4. During the intervention period, 47 women adopted a contraceptive method for the first time (new users), 5 for at least a second time (former users), 2 check-ups, and 21 women were received for resupplies. Thus, a total of 75 women accessed FP services during the intervention period.

Lessons Learned Through the implementation of the Youth project, E2A and Pathfinder have learned some important lessons about working with FTPs across the full lifestage to address a range of important health concerns. For this report, we present three key lessons for future programming with youth and FTPs:

• Use by the Ministry of the groups of young women from the different cohorts that can serve as a basis for the establishment of health clubs. This program has brought together young, first- time mothers to learn about important health topics relevant to their current stage of pregnancy or early parenthood. In order to capitalize on the capacity that was built through the training of the peer leaders and the educating of the peer group members, the MoH could consider using the format and members of these groups to establish longer-term health clubs that would continue to provide essential information and connections to services to these young women, their families, and their communities. As a reminder, the establishment of health clubs is envisaged in the national community health strategy adopted by Burkina Faso.

• Inclusion of an "income-generating activities" component in the package of interventions for young mothers would contribute to their empowerment. Our experiences through the Youth project, and in learning about the needs and aspirations of FTPs, have highlighted the importance of addressing their non-health needs during this pivotal time of their lives. For many FTPs, the transition to parenthood comes with increased responsibility and new demands on

their time, energy, and finances. This can hinder their ability to take health actions and can impact their overall health and wellbeing. Programs should consider developing project-specific income-generating activities or finding mechanisms to links FTPs to existing programs or resources.

• Given the importance of the target, considering this group as a specific group within the adolescent and youth program would help to better prioritize the needs of FTPs. The promising results shown through relatively short interventions, as well as the positive experiences reported by program participants and implementors, indicate that FTP-specific programming is a worthwhile approach to address the unique needs of this important population for the benefit of themselves, their families, and the communities in which they live.

Challenges

Terrorist attacks continue to be carried out, with a significant number of internally displaced persons living in vulnerable situations, particularly women and children, who are the primary victims. The security situation has impacted project activities since the beginning of phase 1, however, due the worsening security situation in the East and Center North regions, and based on the recommendations of a security consultant hired by Pathfinder International Burkina Faso, the project suspended project-implemented community-based interventions in four of the 20 project villages, including Bongo, Bandaoghin and Djouma in the health district of Fada and Talle in the health district of Kaya during phase 2. In these four villages, the sessions with FTMs, husbands, and mothers-in-law as well as the monthly data collection with FTMs was discontinued from February 2020 onward. This decision was made based on staff’s inability to travel to these locations as well as the potential risks from the group gatherings to program participants.

The outbreak of COVID-19 infection since March 2020 is also a major challenge in the implementation of field activities, especially as we enter the last quarter of the project. Due to the suspension of community- based activities because of the pandemic, 3 out of 10 FTM peer group sessions were not able to be completed as well as 1 out of 3 husbands’ sessions and 1 out of 2 joint sessions. Furthermore, the exit questionnaire—which included demographic characteristics; service utilization information; and knowledge, attitudes, and behavior questions with FTMs and their husbands—was not able to be completed as planned in April/May 2020. . What Worked to Mitigate these Issues In order to minimize the risks related to insecurity, Pathfinder conducted a security assessment of the intervention areas and offices housing the project in the 3 regions. This evaluation allowed to make recommendations such as the abandonment of the use of motorcycles type YBR 125 by the field staff, the abandonment of some villages, the training of the staff in personal security with the designation of focal points. While the group sessions and data collection activities were suspended in these villages, locally-based CHWs were encouraged to continue ensuring that the enrolled FTMs received the MoH- recommended home visits.

Regarding COVID-19, Pathfinder has adopted a contingency plan which includes the respect of barrier measures, the wearing of mandatory masks in the workplace, teleworking and a rotation system. The

32 staff has been provided with protective equipment against COVID-19. The small group meetings were suspended to comply with the instructions taken by the government.

Photo: Delivery of certificates at the end of the personal safety training to the staff

ANNEXES

Annex 1: Villages, districts, and intervention areas covered by phase 1 of the project

Region Health Communes Health facility Villages District

1. CHR de Fada

1. KOARE 2. CSPS Koaré 2. KIKIDENI 3. PENDREDENI

4. NAGRE 5. TAGOU 3. CSPS Nagré GOURMANTCHE 6. HAMDALLAYE Fada 7. TAMBANGOU 8. NAMOUNGOU 4. CSPS 9. GBERSAGA Namoungou 10. TANDIAGA

11. KPENCANGOU 12. MOURDENI Est 5. CSPS Tanwalbougou 13. TANWALBOUGOU Fada 14. BALWIDI

6. CM Diabo 15. ZECNABIN 16. YEMTENGA Diabo 17. NIBODIN/DIABO

7. CSPS Maoda 18. NABISRABOGO Diapangou 19. BOSONGRI 8. CSPS 20. DIAPANGOU Diapangou 21. WAKOU

22. TIELBA 23. TILONTI CENTRE 9. CSPS Tilonti OLIBRAGONI

10. CM Matiacoali 24. TAMKIMBO

25. KANKANTIANA 26. BOALIGOU 27. OUBRINOU

11. CSPS Igori 28. KOGDASSALI 29. DAGOU PEULH 30. BOULMOANGOU Matiacoali 12. CSPS Ougarou 31. OUGAROU 32. GNIFOAGUIMA 33. PIEGA

34. TIASSERI 13. CSPS de 35. SOAM Tiassieri 36. KOAMPANDI

Tibga 37. TIANTIAKA 14. CSPS Tibga 38. NASSOBDO 39. TIBGA CENTRE

Yamba 40. NAYOURI 15. CSPS Nayouri 41. TAMBOANGOU 42. KONDOAGOU

43. YAMBA 16. CSPS Yamba 44. TEMBOU 45. DJANKONGOU

46. KANTARI 17. CM Kantchari 47. BANTOINI 48. BOUPIENA

49. BOUDEIRI 18. CSPS Boudieri 50. NABOUAMOU 51. POKITOUGO Diapaga Kantchari 52. DIANKONLI 19. CSPS Sakoani 53. SAKOANI 54. TIALBONGA

55. MANTOUGOU 20. CSPS Sampieri 56. PIEMPIENGOU 57. SEMPIERI

Annex 1: Villages, districts, and intervention areas covered by phase 2 of the project

Region Health Communes Health facility Villages District

1. Comboari 1.Diapangou

DIAPANGOU 2. Bolombili 2.Tilonti

3. Bandaoguin 3.Koaré FADA

TIBGA 4. Bilingtenga 4. Tibga

FADA 5. Boanga 5.Yamba EST YAMBA 6. Djouma 6.Nayouri

DIABO 7. Boulyoguin 7.CM/ Diabo

8. Maoda Centre 8.Maoda

BOGANDÉ BILANGA 9.CSPS Bilanga 9. Sékouantou

10.CSPS Bilanga- 10. Bilanga-Yanga Yanga

11.CSPS Kierghin 11. Kierghin

12.CSPS 12. Kossougoudou Kossougoudou

MANNI MANNI 13.CSPS Manni 13. Bantampèra

THION 14.CSPS Diaka 14. Siéssin

15.CSPS du 15. Silmiougou secteur 6 KAYA 16.Tangasgo 16. Tangasgo Centre KAYA 17.CM de Pissila 17. Pissila Centre CENTRE NORD PISSILA 18.CSPS de 18. Talle Lilboure

19.Toyogdin 19. Toyogdin Centre TOUGOURI TOUGOURI 20.Taffogo 20. Yangrin