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ANNUAL PERFORMANCE REPORT NO. 2 PISAF – INTEGRATED FAMILY HEALTH PROGRAM

DECEMBER 18, 2007This publication was prepared by University Research Co., LLC, and produced for review by the United States Agency for International Development.

OCTOBER 1, 2006 – SEPTEMBER 30, 2007

PISAF - Integrated Family Health Program ANNUAL PERFORMANCE REPORT NO 2 October 1, 2006 – September 30, 2007

Distributed to:

Mr. Pascal Zinzindohoue, USAID/CTO Cotonou, Bénin

Dr. Thossa Avesse, DDS du Zou et Collines

Dr. Orou Bagou Yorou Chabi, DDS de Borgou et Alibori

Dr. Aguima Tankoano PISAF Benin

PISAF Technical Staff

Dr. Tisna Veldhuijzen van Zanten, URC

Mr. Yann Derriennic, Abt Associates

Ms. Aminata Mbaye, Abt Associates

Dr. John Borrazzo, USAID/Washington

Dr. George Greer, USAID/Washington

Dr. Mary Harvey, USAID/Washington

File

PISAF, Projet Intégré de Santé Familiale, is funded by the United States Agency for International

Development (USAID), under Cooperative Agreement No. 680-A-00-06-00013-00. PISAF is

managed by University Research Co., LLC (URC) in collaboration with Abt Associates.

DISCLAIMER:

The author’s views expressed in this publication do not necessarily reflect the views of the

United States Agency for International Development of the United States Government.

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TABLE OF CONTENTS

TABLE OF CONTENTS ........................................................................................................................... I

1. INTRODUCTION .................................................................................................................................. 1

2. PERFORMANCE REVIEW AND ANALYSIS ................................................................................... 2

2.1. INTERMEDIATE RESULT 1: A SUPPORTIVE IMPLEMENTATION ENVIRONMENT CREATED 2 2.1.1. SUB IR 1.1: SELECTED HEALTH POLICIES AND APPROACHES IMPLEMENTED ...................................... 2 2.1.2. INCREASED HEALTH SYSTEM MANAGEMENT CAPACITY CREATED ..................................................... 5 2.1.3. MORE EFFECTIVE CIVIL SOCIETY PARTICIPATION CREATED ............................................................. 11

2.2. INTERMEDIATE RESULT 2: ACCESS TO QUALITY SERVICES AND PRODUCTS INCREASED 17 2.2.1 SELECTED PRODUCTS AVAILABLE AT PUBLIC SECTOR FACILITIES .................................................... 17 2.2.2. SELECTED PRODUCTS AVAILABLE AT PRIVATE SECTOR OUTLETS .................................................... 23 2.2.3. QUALITY FAMILY HEALTH PACKAGE AVAILABLE AT TARGETED PUBLIC SECTOR FACILITIES .......... 23 2.2.4. FINANCIAL ACCESS TO HEALTH SERVICES INCREASED ..................................................................... 34

2.3. INTERMEDIATE RESULT 3: DEMAND FOR HEALTH SERVICES, PRODUCTS, AND PREVENTATIVE

MEASURES INCREASED 44 2.3.1. SUB IR 3.1: KNOWLEDGE OF APPROPRIATE BEHAVIORS AND PREVENTATIVE MEASURES IMPROVED

.................................................................................................................................................................... 44 2.3.2. SUB IR 3.2: APPROPRIATE RESEARCH-BASED INTERVENTIONS AND SERVICES INTRODUCED .......... 51

3. PROGRAM MANAGEMENT ......................................................................................................... 51

3.1. ADMINISTRATIVE AND PERSONNEL MANAGEMENT 51 3.2. FINANCIAL MANAGEMENT 52 3.3. BUILDINGS AND EQUIPMENT 52 3.4. VISITORS AND CONSULTANTS 53

4. CHALLENGES AND OPPORTUNITIES ..................................................................................... 55

FINANCIAL REPORT – FY2007 ............................................ ERROR! BOOKMARK NOT DEFINED.

ANNEXES ................................................................................................................................................. 56

ANNEX 1: PERFORMANCE MONITORING AND EVALUATION PLAN .................................... 59

ANNEX 2: PROGRESS TABLE ............................................................................................................. 63

ANNEX 3: 2008 WORKPLAN ............................................................................................................... 79

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ACRONYMS ACT Artemesinin-based Combination Therapy AMD African Malaria Day AMTSL Active management of the third stage of labor ANC Antenatal care consultation BCC Behavior Change Communication CAME Centrale d’Achat des Médicaments Essentiels (Central Medical Stores) CBO Community-based organization CBS Community-based Services CIPEC Centre d’Information, de Prospective et de Conseil en VIH (HIV

information, planning and counseling center) CHW Community-based Health Worker CODIR Comité de Direction (Management/Steering Committee) COGEC Comité de Gestion de la Commune (Communal Management Committee) COGEA Comité de Gestion de l’Arrondissement (Arrondissement Management

Committee) CVS Comité Villageois de Santé (Village Health Committee) DDS Directeur Départemental de la Santé (Departmental Health Directorate) DDZS Direction du Développement des Zones Sanitaires (Health Zone

Development Department) DH Direction des Hôpitaux (Hospital Management Department) DHC District Hospital Center DPP Direction de la Programmation et de la Prospective (Department for Health

Planning and Programming) DRFM Direction des Ressources Financières et du Matériel (Material and Financial

Resources Department) DRH Direction des Ressources Humaines (Human Resources Department) DSF Direction de la Santé Familiale (Department of Family Health) EEZS Équipe d’Encadrement de Zone Sanitaire (Health Zone Supervision Team) EONC Emergency Obstetric and Neonatal Care EQGSS Évaluation de la Qualité de la Gestion du Système Sanitaire (Evaluation of

the quality of health system management) FECECAM Fédération des Caisses d’Epargne et de Crédit Agricole Mutuel du Bénin

(Benin Federation of Savings Banks and Agricultural Credit Societies) GEM Generic Essential Medicines IEC Information, Education, Communication IMCI Integrated Management of Childhood Illnesses IPT Intermittent Preventive Treatment LLITN Long-lasting insecticide-treated bed nets MCDZS Médecins Coordonateurs des Zones Sanitaires (Health zone head physicians) MOH Minister of Health MPT Musique Populaire Traditionnelle (traditional popular music) NGO Non-governmental organization ODMA Organisation pour le Développement en Milieu Agricole (Agricultural

Development Organization) OIS Offre Intégré de Services (Integrated provision of services) ORTB Office de Radiodiffusion et Télécommunications du Bénin (Benin Office of

Radio and Telecommunications) PMA Paquet Minimum d’Activités (Minimum package of health services) PMI President’s Malaria Initiative PMP Performance Monitoring Plan

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PMTCT Prevention of mother-to-child transmission of HIV PNC Postnatal consultation QA Quality Assurance RDT Rapid Diagnostic Test SEPD Service d’Etude, Planification et Documentation (Department of Study,

Planning and Documentation) SHP Swiss Health Project SIGL System d’Information et de Gestion de la Logistique (Logistics and

Information Management System) SNIGS Système National d’Information d’Gestion Sanitaire (National Health

Management Information System) SPF Services de Planning Familiale (Department of Family Planning) SSF Services de Santé Familiale (Department of Family Health) TDH Terre des Hommes (« land of people », a local NGO) UNFPA United Nations Population Fund URC University Research Co, LLC USAID United States Agency for International Development UVS Unité Villageoise de Santé (village health unit) VCT Voluntary Counseling and Testing for HIV WHO World Health Organization

1. INTRODUCTION The Integrated Family Health Project, or PISAF (Projet Intégré de Santé Familiale), is a health project funded by the United States Agency for International Development (USAID) and awarded to University Research Co., LLC and Abt Associates through cooperative agreement on March 28, 2006. PISAF partners with the Ministry of Health (MOH) and seeks to improve the health status of the people of Benin through collaboration with NGOs, government agencies, other donors and USAID projects, communities, and the private sector. The project’s activities support the Government of Benin’s national policies and strategies and USAID’s health objective, which seeks to increase the use of health services, products and preventive measures in a supportive policy environment. PISAF is a five-year project implemented by a multidisciplinary team that provides technical support to the Ministry of Health and other actors in the health sector. PISAF is based in Zou/Collines, which is the region of primary focus, and also provides support in the Borgou/Alibori and the Ouémé/Plateau regions. PISAF activities address three main results areas:

• Intermediate Result 1: A Supportive Implementation Environment Created

• Intermediate Result 2: Access to Quality Services and Products Increased

• Intermediate Result 3: Demand for Health Services, Products and Preventive Measures Increased The following report describes the main activities within each of these results areas carried out from October 1, 2006 through September 30, 2007. This is the second annual report prepared and submitted to USAID for the PISAF project.

2. PERFORMANCE REVIEW AND ANALYSIS

2.1. Intermediate Result 1: A Supportive Implementation Environment Created

This intermediate result, which contributes to USAID/Benin’s health strategic objective 2 (SO 2), seeks to create a favorable policy environment to improve access to quality health care and services through policies that support: decentralization; well-defined standards and protocols disseminated at all levels; quality management; and the effective involvement of communities in managing their health.

2.1.1. Sub IR 1.1: Selected health policies and approaches implemented

Provided technical assistance in the area of decentralization

The central government adopted a number of measures to strengthen the decentralization process. PISAF provided technical support for micro-planning these activities and for preparing the scope of work for the following three activities with the appropriate technical departments: i) Harmonizing the method of managing health workers paid through “social funds” with the Department of Human Resources (DRH); ii) Preparing an information and awareness paper on health system reform and decentralization with the Department of Family Health (DSF) and the Department of Health Zone Development (DDZS); and iii) Revising the decree that approves the zone hospital bylaws. This support, manifested by working sessions with the staff of each technical department, helped iron out problems by organizing four decentralization workshops.

Opportunities

These meetings served as opportunities for exchanges with the managers from the central level of the ministry. They are increasingly demonstrating their willingness to further the decentralization process. These meetings were also an opportunity to better share with the central level partners the USAID management principles and rules that PISAF implements, and especially to clarify the support that PISAF is able to give them.

Principal Accomplishments

• 700 persons received a presentation and discussed results of the Management Assessment in the 15 communes of Zou and Collines

• 585 COGEC (Commune Management Committee) members trained in roles and responsibilities, planning and budgeting

• 541 digests of the decentralization documents, 556 integrated ascendant planning procedures manuals and 5,200 flyers distributed in Zou/Collines and Ouémé/Plateau departments during dissemination workshops

• Action plans for 2008 prepared by 8 HZMT, the departmental hospital and the Zou/Collines DDS, using ascendant planning

• 3 decentralization documents (HZ bylaws, personnel management addressing social measures, and raising awareness of health workers about decentralization) prepared

• Results of the Management Assessment disseminated to members of the Minister of Health’s cabinet

• DDS Zou/Collines partner roundtable held on results of the Management Assessment

• Health Zone Administration and Resource Manager’s Guide finalized and validated

• Community mobilization strategy and implementation plan prepared

Held regular meetings between the ministry and the donors to coordinate and collaborate on

health policy issues

PISAF was involved in several dialogue meetings held at the central level. The PNLP, UNICEF, USAID, PISAF and PSI held exchanges on the distribution of LLITNs, and in particular on the organization of the mini-campaign in COZO and the implementation of ACTs and RDTs. The upcoming PMI was also a topic of discussion with the Ministry of Health, and as such a consensus workshop was held to develop an operational plan for implementing the PMI. This initiative will occur in fiscal year 2008 with more responsibilities for PISAF in the area of malaria control in Benin.

In the area of clinical IMCI, the exchanges that began with the MOH concluded that it was necessary to continue the 11-day course strategy pending better documentation and the validation of the short six-day model that PROSAF tested in Borgou/Alibori. Dialogue at the departmental level (Zou/Collines) made it possible to arrive at a consensus with UNICEF, which will continue to train providers in clinical IMCI, while PISAF will work in community IMCI.

Held regular discussion forums with health personnel and civil society on decentralization

Four national-level workshops and one departmental-level workshop were organized this year with PISAF technical and financial support. Each time there were stakeholders from the three levels of the health system who met to share thoughts on issues related to the implementation of decentralization. These national-level workshops addressed the following topics: Harmonization of the method for training health workers paid using “social funds” was discussed during the meeting held from July 24 to 26, 2007, attended by 36 participants, including the partners from the labor and finance sectors. A situational analysis was presented, and a management system was proposed that would be best suited to the challenges associated with human resource management in the health sector. The discussions resulted in a draft text of a decree on the legal framework for employing contractors using “social funds.” Likewise, the procedures for managing these employees, and contract models such as fixed-price contracts, indefinite quantity contracts, and contract renewal were proposed. These results are highly worthwhile inputs that should be taken into account in the current dialogue on the status of contractors other than those put in place by the Ministry of Labor. Preparation of an information and awareness paper on health system reform and decentralization in

Benin: At this workshop, held from August 16 to 17, 2007, 28 participants attended from the central level of the Ministry of Health, the DDS, HZs and other ministries, such as the Ministry of Labor and the Ministry of Administrative and Institutional Reform. The work resulted in a consensus on the content of the Benin health system and decentralization reform paper. This paper, which will be used to inform and raise awareness among stakeholders in all government sectors and institutions, will be prefaced by the Minister of Health during FY 2008.

Revision of Decree 98-300 of July 20, 1998, approving the zone hospital decentralization documents: This took place in two phases: The first phase, dedicated to a second reading and changing the wording, was carried out over three days by 18 participants from the central and peripheral levels, including the health development partners. Discussions in the plenary session and reflections in the breakout sessions culminated in a draft text that was painstakingly reviewed by a core group of three resource persons; they produced the final version to be submitted for validation.

The second phase, concerned with validation, served as a framework for studying the draft zone hospital bylaws that had been developed a month earlier. Over 40 health system stakeholders attended, as well as representatives from the three levels of the health system and the health development partners. There were occasional impassioned discussions about the autonomous management of the zone hospital while

observing the unified principles of the health zone as the health system’s most decentralized operational entity. Consensus was obtained to validate the draft documents, which the Minister of Health will submit to the Council of Ministers for review so that it can be adopted in the near future.

Dissemination of the decentralization documents and the integrated ascendant planning procedures manual: This activity consisted of several stages. After the decentralization bylaws were reproduced, PISAF technical staff were briefed on the various decentralization texts. Three teams (consisting of DDS, PISAF technical staff and MCDZS) were then organized to travel to the 15 communes of Zou and Collines to hold the dissemination workshops. To improve implementation efficiency, the activity was combined with the dissemination of the integrated ascendant planning procedures manual. After the 15 sessions, 603 persons (229 health workers, 280 COGEC members and 94 local elected officials) were briefed on the content of the two documents. All the health teams as well as the communal management committees (COGECs) each received a copy of the two documents. In total, 289 planning manuals, 274 document digests and 4,000 flyers were distributed in Zou/Collines.

For the benefit of stakeholders from Ouémé/Plateau, a workshop was organized on August 31, 2007, and 26 managers from the DDS and its five health zones attended. On this occasion, there were presentations on the decentralization bylaws and one presentation on integrated ascendant planning, followed by discussions. The importance of the concerns raised reveals that the decentralization bylaws, currently being implemented in the field, are still misunderstood. Participants thus welcomed this opportunity to get a better understanding of the documents.

At the conclusion of the work, 267 copies of the digest of the decentralization bylaws and 267 copies of the integrated ascendant planning procedures manual, as well as 1,200 copies of flyers of this manual, were given to the health zones and the Ouémé/Plateau DDS to be disseminated to the teams from the health centers and their co-management bodies. This dissemination activity effectively marked the launch of PISAF activities in the departments of Ouémé and Plateau.

A workshop for the stakeholders from Borgou and Alibori will be held in October 2007.

We also note that there was a national launch ceremony for the integrated ascendant planning manual on January 25, 2007 at the MOH in Cotonou, and a departmental launch ceremony in Abomey on February 20, 2007.

Supported implementation of the national strategic plan for commodity security

At the national level, PISAF provided technical support to the DSF/MOH through an international consultant who is an expert in contraceptive commodity management. The consultant provided an estimate of Benin’s contraceptive needs for the 2007-2009 and 2009-2013 periods, including cost estimates for these quantities.

Contraceptive commodity security, which refers to the continuing need to forecast, finance and procure a sufficient supply of a commodity, also relies on an accurate estimate of needs. For this reason, PISAF funded the training of three managers from the Ministry of Health (PLNP, PLNS and CAME) in QUANTIMED quantification software in Senegal. This training strengthened stakeholder capacities and was followed by a preliminary discussion of results at the departmental level. Among other things, it served to implement the strategy for managing malaria control products in Zou and Collines in conjunction with the PNLP.

2.1.2. Increased health system management capacity created

To strengthen the health system’s management capacities, PISAF provided support in several areas. The results of the Management Assessment, conducted in Zou/Collines the previous year, were disseminated and put to use through various planning workshops. Results of the Management Assessment in the Departments of Zou and Collines

In the context of improving performance and increasing capacity within the health system, PISAF undertook an evaluation of the quality of health system management in the Zou and Collines departments in 2006. This Management Assessment had six major objectives:

• To describe the health system in Zou and Collines;

• To assess the capacity of the health system to provide care and support services of quality;

• To assess the level of knowledge of health providers and gage their opinions about the supervision and motivation systems;

• To gage the perceptions of external clients (patients);

• To build local capacity that will allow for ownership of this and future evaluations, especially future midterm evaluation results; and

• To formulate recommendations for using the results to improve the performance of the health system and sub-systems that were evaluated

The evaluation was an exhaustive study of the health system, covering all health centers in the two departments, including the district hospital and the zone hospitals. Two major trends emerged from the analysis of the cases observed: a low usage level of the available services, especially in some areas of reproductive health, and a general lack of quality of the services being provided. Out of a total of 1,381 cases observed, there were only 58 cases of delivery, postnatal care and family planning combined—a very low usage rate for a population with a relatively high birth rate. This minimal number of observed cases makes it difficult to draw conclusions about performance, and highlights an under-utilization of available services. Levels of performance rated as “excellent” were very rare, with the majority of services falling within the satisfactory or weak performance categories. There was no excellent performance in the areas of prenatal consultations, deliveries, well child and child vaccination consultations, family planning, integrated management of childhood illnesses (IMCI), or postnatal consultations. However, excellence was attained in the area of adult curative consultations, especially in the areas of management of severe malaria (50%), counseling at the end of a consultation (18%), reception (20%) and diagnostics (11%). Overall performance was satisfactory in several areas, including adult curative consultations (71%), deliveries (80%), and family planning (67%). Areas in which overall performance was mostly weak were postnatal care (100%), prenatal care (60%), well-child and child vaccination consultations (82%) and IMCI (64%). With regards to prenatal care and IMCI, health zones that had received technical assistance demonstrated higher levels of performance. However, this was not the case with PMTCT, where although training was done in Zou, performance in meeting standards of care was higher in Collines. Reception remains the highest performing category of all the areas observed, on average meeting more than 90% of the criteria. However, client testimonies from focus group discussions are much less positive on this issue. The results show that it is often the case that health workers who handle the most cases in a particular domain have the highest levels of performance (in IMCI, prenatal care and family planning).

However, this was not the case with deliveries, where nurses handle the most cases, but midwives have the highest scores. The Management Assessment also collected data on clients of the health system. In general, client satisfaction was high (98%). In terms of accessibility of care, 99% reported that they received the care they had come for, 55% of clients reported that medicines and health products were affordable, and 66% were able to pay for their medicine. Despite the fact that 81% of clients live within 5 km of a health center, 52% found the health centers to be “far” or “too far”. People mostly receive their health information from word-of-mouth (relatives, neighbors, friends); radio only reached 3% of respondents. Clients’ awareness levels in certain domains are weak, especially with regard to recognizing signs that a child is sick and ways to treat a sick child at home (well under 30%), while on the other hand clients are well informed about several danger signs during pregnancy that necessitate seeking formal care (86%). Local elected officials, communities and families who were interviewed demonstrated that they were willing to participate in the promotion of actions to reduce maternal and neonatal morbidity and mortality, but they faced several constraints. These constraints included a lack of adequate resources (for the elected officials, allocated funds and for families, financial access), coordination systems (among donors for example), and support for managing complications. Other constraining factors (according to the elected officials) were the lack of a national plan and protocols, and the perception that this domain is solely the prerogative of the health sector. At the different health system levels, general managerial performance was as high as 66% (in zone management in Collines), but barely 45% in Zou, and less than 50% at the DDS. Not a single woman was identified by the survey as being in a key permanent position, which demonstrates a significant problem of representation within management teams at the zone level. A continuing education system is practically non-existent, and the supervision system (defined as at least four visits per worker per year) reaches fewer than 50% of workers (and even fewer workers in Collines than in Zou), due to the lack of an action plan, of financing and of transportation. In the referral and counter-referral systems, health centers and hospitals registered an overall satisfactory performance, but some operational aspects of the systems do not function well, such as transportation of the sick and management of health records. Significant insufficiencies are widespread in the sub-systems: there are stockouts of medicines, vaccines and health products, little or no maintenance of materials and equipment at laboratories and facilities, and a lack of adherence to procedures (such as maintaining the cold chain, hygiene, and infection prevention). The performance of health information systems and epidemiological surveillance is generally weak. There is also no operational research or documentation system. As for quality assurance (QA), almost three quarters of health workers have never received QA training, so the QA system is not very functional. Community health management committees (COGECs) play a well-defined role and actively participate along with health workers in the development of budgeted action plans; however they are less involved in implementing and monitoring these plans. They ensure good management of health centers in terms of availability and use of management tools and regular procurement of medicines. They are also very engaged in awareness-raising and health promotion activities, and in problem-solving with health centers. The weak points of the COGECs are the lack of representation of women in COGEC offices (at the time of the evaluation they only occupied 34% of secretarial/treasury posts and much less in other posts) and also an absence of norms and procedures for management activities.

Dissemination of Management Assessment results in Zou/Collines and partner roundtable

Departmental dissemination of Management Assessment results In December 2006, a workshop and partner roundtable were held to disseminate results of the Management Assessment conducted in Zou and Collines. Many local elected officials were in attendance, indicating an interest in health sector issues. DDS partners presented the data, showing clear ownership of the results. Six strategic pillars were identified during the dissemination process: capacity-building, IEC/BCC, human resource management, provision of care, support systems and partnerships, all of which continue to inform health system strategy. DDS staff members took ownership of the results and presented a number of lessons learned that reinforced the EQGSS survey and process used:

• It is possible to look at ourselves using quality criteria and assess our own level of performance.

• We understand that the evaluation is of the system and not of individuals.

• The links among the subsystems in the health system require a systemic approach to change to improve the situation.

• The institutionalization of a systemic approach is necessary to obtain lasting improvements at all levels of the health system.

• Partnership with the community, development partners, civil society, local elected officials and the Ministry of Health is an opportunity to accelerate the pace of developing a strategic plan that focuses on the needs of our clients in the public and private sectors.

The DDS himself presented a team vision that reflects the intention of the Management Assessment, and more broadly, PISAF’s objectives: “The Zou and Collines DDS is a decentralized structure of the

Ministry of Health, guided by a culture of quality and performance, which benefits all users of public and

private health facilities.”

Commune level dissemination of Management Assessment results Following the departmental level dissemination, the preliminary results were shared at the commune level, which was an opportunity for the DDS to broadly disseminate the key indicators and increase support for improving the health system in the two departments. With support from PISAF technical staff and the DDS, the HZMT members from each health zone presented and discussed the results. Twenty-five HZMT members, including physicians, nurses, midwives, and statisticians from Zou and Collines attended this one-day workshop. Discussions following the presentation centered around the concept of integration and its implementation, evaluation, interpersonal communications, and the minimum package of services. Community perceptions and expectations of quality of care were presented, as well as data on the performance by decision-makers and families in preparing communities for the maternal and infant mortality reduction plan. Each facility is now using the results of the Management Assessment as a frame of reference in its approach to improving the provision of health services. Lessons learned

For the communities:

• Sharing results of health system performance in each commune was a good self-critique to improve performance, and those present were able to identify a role in the improvement process.

• The communities and local elected officials furthered their understanding of the role they can play in the partnership with the health system, to improve and promote health services.

• Community participation can contribute to improved health system performance if a dynamic partnership is established.

For the health care workers:

• An acknowledgement that the quality of health services overall is poor, and something must be done.

• Understanding of the need for cohesion between health care workers and the community, which is the main constraint to providing quality services to clients.

Use of the Management Assessment results to readapt the 2007 action plans and develop

2008 action plans

Revision of the 2007 action plans: The 2007 HZ and DDS action plans did not take into account the results of the Management Assessment, as these results were not yet available when the plans were prepared. In view of the importance of this assessment, it was decided that PISAF would support the DDS and the zones in revising their action plans. This was done at a workshop in Bohicon. Thus, the stakeholders took into account deficiencies highlighted in the Management Assessment (for example, lack of training of COGEC members on their roles and responsibilities, lack of documentation of health zone management team meetings and trainings organized by the DDS and health zones, etc.) in identifying corrective measures expressed as complementary activities. PISAF also provided technical and financial support for implementing most of these complementary activities. During fiscal year 2007, the HZMTs made considerable efforts in carrying out the activities in their action plans, as demonstrated by the following table:

Table 1: Implementation of the health zone action plans

HZMT performance in implementing the 2007 action plan

(At least 75% of the activities planned for the quarter were carried out)

1st quarter

2nd quarter 3rd quarter Performance

(average)

Djidja-Abomey-Agbangnizoun (DAA) 0% 100% 100% 67%

Zogbodomey-Bohicon-Zakpota (ZOBOZA) 100% 100% 100% 100%

Covè-Zangnanado-Ouinhi (COZO) 100% 100% 100% 100%

Dassa-Zoumè-Glazoué (DAGLA) 100% 100% 100% 100%

Savalou-Bantè (SABA) 100% 0% 100% 67%

Savè-Ouessè (SAO) 0% 0% 100% 33%

Zou/Collines 67% 67% 100% 78%

The results above indicate that Health Zone Management Team performance improved in 2007, rising from 67% in the first quarter to 100% in the third quarter. This considerable effort showed that the desire to carry out the planned activities in a manner consistent with available human and financial resources has now become engrained in the HZMTs in Zou and Collines. Emphasis will continue to be placed on realistic activity planning and on minimizing interference from the central level with PISAF support.

Preparation of 2008 action plans: Action plans for the six health zones, the departmental hospital and the DDS were prepared. This was the first time that the integrated ascendant planning process was completely observed in the departments of Zou and Collines as well as at the national level. To achieve this, several preliminary activities were carried out. They were: i) the dissemination of the decentralization bylaws, to provide stakeholders with a better understanding of management operations in the health zones; ii) the preparation, reproduction and dissemination of the integrated ascendant planning manual to serve as a compass; and iii) the training of COGEC members in their roles and responsibilities, which culminated in the preparation of 2008 draft action plans for the health centers. PISAF then supported the health zones in finalizing the action plans. The goal was to have these plans available no later than June 10, 2007 in order to comply with the timeline of the Ministry of Health’s Planning and Program Department (DPP). Thus, two joint teams (DDS and PISAF) traveled to the six health zones to assist in preparing the plans. The different working sessions took place with the full participation of the zone stakeholders. This experience was most enlightening since it enabled the stakeholders who had never taken part in this exercise of preparing an action plan to understand the task to be accomplished over the coming years. In total, all health zones, the departmental hospital and the DDS were able to finalize their 2008 action plan by June 10, 2007. The plans were reconciled and integrated at the DDS level and then reconciled with health sector partners. The following obversations and recommendations should be noted: i) The zone stakeholders are available to do the work and have the skills to accomplish the mission, but

their capacity to use the information technology tool needs to be reinforced; ii) It is important to take the Planning and Program Department’s (DPP) format into account in preparing

COGEC action plans, as this would improve time management in the reconciliation stage; iii) It would be desirable to involve health center and zone accountants as early as the COGEC action

plan preparation stage, as this would provide a rapid and better cost estimate and would judiciously identify financing sources;

iv) More emphasis should be placed on the zone hospital and HZMT action plans based on the Triennial Development Plan.

Provided training in financial management in Zou/Collines and strengthened this training in

Borgou/Alibori

Two activities in this area were carried out in 2007:

Identified training needs in human, financial and material resources: As the Management Assessment showed a great need for improvement in this area, persons in need of management skills training were identified through the collection of PMP indicator data at all health facilities in Zou/Collines. From these data, a group of 118 health workers, consisting of six MCDZS and 112 head nurses, was identified for training. The training was planned in collaboration with the head of the DDS Human Resources Department. However, due to considerable interferences (in particular the mini-distribution campaign for LLITNs in COZO and the national distribution campaign, which was twice postponed), it was not possible to carry out this training. This will be done in the first quarter of 2008 with the implementation of collaboratives, including the human resource management collaborative. Implemented human resource management forms in the health zones of Zou/Collines: PISAF supported the DDS in setting up human resource management forms that will be used to monitor personnel movement, record training needs, and manage continuing education in each of the six health zones, the DDS and the departmental hospital. The stakeholders responsible for using these forms were briefed on them, and practiced using procedures already implemented in 2007. An evaluation of each briefing session determined that: i) 94% of the participants felt that the forms met expectations in terms of

addressing their daily job-related concerns; ii) 92% considered the explanations given by the technical staff members relevant; iii) 79% found the use of the forms feasible; and iv) 91% agreed to use them. The staff members who used the forms were monitored after three months of use, so that it could be determined how well the stakeholders were implementing the recommendations, and to identify any problems they were encountering and correct them. The results of the monitoring revealed that all health zones came to take ownership over use of the forms, and the persons in charge of managing the forms made substantial efforts in ensuring they were filled out. However, stakeholders experienced two difficulties: i) the computer crashed in ZOBOZA health zone, and all data entered previously were lost (fortunately, the forms had been decentralized and those that had been installed in Zogbodomey were borrowed for use in this commune); and ii) there were insufficient understandings which caused the stakeholders to complete certain items incorrectly. Explanations were given and practical exercises were done to strengthen the stakeholders’ skills.

The main recommendation from this monitoring was to improve the organization of information movement that the form managers need to carry out their task. The Coordinating Physicians and the Head Physicians have an important role to play in ensuring that these documents on personnel movement and employee training are collected and sent to the form managers in real time. Finalized and validated the Administration and Resource Manager’s Guide (CAR): In 2007, the CAR’s guide was finalized and validated. The CAR is a member of the Health Zone Management Team (HZMT) and plays an important role in zone management. The Management Assessment and the work in the field revealed that the CARs in the various health zones do not all understand their role in the same way. To correct this problem, the DDS began to prepare a draft management guide for the zone stakeholders; however, it had not been completed due to a lack of resources. PISAF made a technical and financial contribution by organizing two workshops so that the work could be completed.

The first workshop, held in July 2007 in Dassa, enabled the DDS managers, two PISAF technical staff members, and four outside resource persons to finalize the guide. Several aspects of management were included, such as: i) financial and accounting management; ii) materials management; iii) human resources management; and, iv) secretarial management.

The second workshop, held in August, served to validate the guide. Stakeholders from the departments of Zou and Collines attended this workshop, as well as managers from the Ministry of Health (DRFM and DDZS). Two aspects of the guide were dealt with in this workshop:

The first involved rewriting some parts to make the content more realistic, including: i) reviewing the HZMT organizational chart, with a proposal to place the Coordinating Physician above the other members as the team leader, which differs from the former system; ii) designating the CAR organizational chart for the entity in charge of administration and resources; and iii) increasing the number of staff members leading the CAR structure to three workers to make operations more efficient.

The second aspect entailed introducing new ideas such as: i) opening a current account for the zone coordination office; ii) creating a petty cash fund; iii) paying large expenses by check; iv) preparing the monthly financial report to be sent to the DDS; v) preparing the quarterly monitoring report on the program budget to be sent to the DDS; and vi) repairing the health zone vehicles in the DDS garage.

The changes and corrections suggested by the participants in the validation workshop were included in the final document during the rereading process. The final document is scheduled to be printed, reproduced and disseminated in FY 2008 with financial support from PISAF. This document will be disseminated in Zou/Collines and in the departments of Borgou/Alibori and Ouémé/Plateau.

2.1.3. More effective civil society participation created

Developed community mobilization strategy and implementation plan

In the process of preparing a consensual community mobilization strategy, several activities were carried out in FY 2007. The community mobilization strategy document validation workshop was held in February 2007 in Bohicon, attended by 24 persons from the six health zones, the Zou and Collines DDS, the Ministry of Health, the Program to Support Health Development, the Beninese Health NGO Network, MCDI, four PISAF technical staff members as well as four former PROSAF technical staff members. The four former technical staff members, each with seven years of experience in community mobilization, participated as resource persons. Changes were made to the draft which was then finalized. The Zou/Collines DDS now has a community mobilization strategy document that includes the following six main pillars of intervention: i) STI/AIDS prevention; ii) the health mutuelles; ii) RH/FP promotion; iv) malaria control; v) C-IMCI promotion; and vi) community EONC promotion. The innovation introduced into this model pertains to the Community Participatory Assessment (CPA). The CPA is the stage during which priority health problems are identified and analyzed. This will be done through focus groups with men-only or women-only groups of 10 to 12 persons to identify health problems, their causes, and the solutions to be implemented. The focus groups will serve to shorten the duration and in particular lower the cost of the CPA compared to past experience. Reread the community mobilization strategy paper as a prelude to the launch of community mobilization activities. This rereading enabled the different stakeholders from PISAF and the DDS who are involved in implementing this strategy to: i) coordinate their understanding of the paper’s content; ii) select the pilot intervention zones; iii) determine an entry point for community-level work (C-IMCI, FP, C-EONC, etc.); iv) determine the most efficient way to organize the community stakeholder orientation workshops (health center and communities); and v) prepare an implementation action plan.

With this rereading, the three pilot health zones were selected, the number of CHWs to put in place was determined, and the entry point for implementation was selected: “Community IMCI and Family Planning.” The action plan consists of the following components: 1. The current situation in Zou/Collines: The Zou/Collines DDS is currently receiving support from

several partners to implement activities in the community. The dialogue between partners made it possible to locate each partner’s programs in order to create efficiencies and synergies among the programs. The choice of health zones to implement the program takes this partner program mapping into account as well as the results of the Management Assessment and the PMP indicators. The Zogbodomey/Bohicon/Zakpota health zone (ZOBOZA) is covered by the Ministry of Health with support from UNICEF. The entry point is through community IMCI. The Djidja/Abomey/ Agbangnizoun health zone (DAA) is already covered in terms of community IMCI through UNICEF support. The Covè/Zagnanado/Ouinhi health zone (COZO) is scheduled for coverage by community IMCI with support from the Program to Support Health Development. But these interventions will not begin before October 2008. Through USAID, PISAF has implemented an LLITN program and a major awareness campaign was carried out in the zone to foster correct use and to elicit demand for health services by the communities.

2. Choice of pilot health zones: In total, three health zones were selected for the first phase. They are Savalou/Bantè (SABA), Savè/Ouèssè (SAO) and Covè/Zagnanado/Ouinhi (COZO).

3. Estimate of the number of community health workers: This is based on the ratio of one CHW per 500 people. On this basis, a total of 303 workers (to cover a population of 151,500) will be identified in 115 villages and will be trained during this phase. The advantage of this ratio is that head nurses will have a smaller number of Community Health Workers (CHWs) to supervise than the ratio of one CHW per 300 people that the MOH proposed. Having to supervise a greater number of CHWs requires traveling greater distances and a more significant time commitment on the part of facility workers, which has in the past discouraged health facilities from training CHWs. Each village will have a pair of CHWs, who will work out a schedule to prevent both of them from being away from the village at the same time. The choice of villages is determined by the health zones and will be discussed at the community mobilization orientation sessions in each health zone.

4. Entry points: Community IMCI and Family Planning are the entry points for all three pilot zones. PISAF and UNICEF reached an agreement during the partner meetings for PISAF to provide FP training for all the workers selected in Zou/Collines, while UNICEF will provide community IMCI training for providers.

Implementation consists of two phases: i) the startup phase will last 12 months (October 2007 to September 2008) and will cover the three pilot health zones identified; and ii) the expansion phase will run from October to December 2008 and consist of the following three stages: The first stage will be an expansion of the programs in the three pilot health zones (SABA, SAO and COZO), and will include community EONC and STI/AIDS. In these same health zones, the number of CHWs will be increased and coverage will rise from 50% (the rate at startup) to 75% or even 100% coverage. The increase in the number of CHW will take the results of the initial phase and the requirements of each health zone into account. These CHWs who are called “second generation” will begin with C-IMCI and FP. Their package will be expanded according to implementation, which will be specific to each zone, nine months after their activities begin. The second stage, scaling up in the departments of Zou and Collines, will consist of an expansion to the remaining health zones: ZOBOZA, DAA and DAGLA. In this stage, 50% of the CHW in these zones will be covered and this will complement the existing CHWs.

In sum, it is important to note that the involvement of the DDS counterparts at all stages is an opportunity for DDS ownership of implementing this community mobilization strategy. An orientation workshop for all the DDS department heads will serve to integrate these activities to facilitate their coordination. Table 2: Integration of community-based activities in public health system services

% of HZMTs that included community-based activities in job

descriptions for health workers Performance

Djida-Abomey-Agbangnizoun (DAA) 0%

Zogbodomey-Bohicon-Zakpota (ZOBOZA) 0%

Covè-Zangnanado-Ouinhi (COZO) 100%

Dassa-Zoumè-Glazoué (DAGLA) 0%

Savalou-Bantè (SABA) 100%

Savè-Ouessè (SAO) 0%

Zou/Collines 33%

This table indicates that in 2007 the HZMTs in COZO and SABA, which are two of the three pilot health zones for community-based activities, have already included community-based activities in the job descriptions for the health center head nurses; this demonstrates their commitment to successfully carry out the activities. Training of COGEC members on their roles and responsibilities and on planning and budgeting

Table 3: Observance of the schedule for COGECs meetings (one meeting per month)

The above results indicate that this year the COGECs in Zou and Collines observed the monthly meeting schedule initially. Despite some difficulties such as the absence of some members who had to work in the fields, their performance improved from 31% in the first quarter to 59% in the third quarter. This was due in part to their training in their roles and responsibilities in the second quarter of 2007 and to the fact that the health workers realized they needed to work on a more cooperative basis with COGEC members.

In Zou/Collines, COGECs exist but do not operate according to the regulatory texts. The Management Assessment revealed that all the health centers that were visited have COGECs, but very few members know their roles and responsibilities (less than 40%). The Management Assessment also revealed that fewer than 50% of COGEC members know the criteria used to appoint them, and while their participation rate in preparing action plans is 60%, fewer than 30% are involved in implementing the action plans (certification, oversight, inventory, etc.). Thus, in order to strengthen community participation, training and supporting COGECs in their roles according to the bylaws is important. This is why PISAF is committed to supporting the Zou/Collines DDS in this activity.

Work method The training process consisted of two main stages: the preparatory stage and the implementation stage.

Preparatory stage During this stage, multidisciplinary teams were set up, composed of managers from the associated zones and outside resource persons. These teams took part in a two-day training to improve their facilitation skills. At the same time, this stage served as a framework for actively preparing the process. Thus, in addition to the COGECs’ roles and responsibilities, it was decided to link the teamwork module with the budget planning module. This was designed to prepare COGEC members for introducing quality assurance in the health centers, while also applying the principles of integrated ascendant planning. Implementation stage Each team of trainers consisted of four persons, and each session lasted three days. A supervision team ensured coordination and cohesion among the training teams. In order to ensure that the training was managed in a participatory fashion, the zones were given the responsibility of choosing the trainers based on the availability of human resources in the zones.

COGEC performance - holding documented meetings in 2007

1st quarter

2nd quarter

3rd quarter

Performance (average)

Djidja-Abomey-Agbangnizoun (DAA) 19% 38% 67% 41% Zogbodomey-Bohicon-Zakpota (ZOBOZA) 27% 45% 45% 39% Covè-Zangnanado-Ouinhi (COZO) 58% 92% 83% 78% Dassa-Zoumè-Glazoué (DAGLA) 55% 70% 70% 65% Savalou-Bantè (SABA) 21% 47% 42% 37% Savè-Ouessè (SAO) 8% 31% 54% 31% Zou/Collines 31% 52% 59% 47%

During brainstorming sessions, the stakeholders noted in particular: the background of community participation in managing health facility activities; the major stages in the development of the health system in Benin; the importance of an action plan/budget and the benefits of evaluating the plan in the operation of a health facility; and the principal stages of preparing an action plan and a budget. Next, based on their 2007 program budget and the monitoring results for the second half of 2006, the participants were divided into working groups where they identified the principal indicators to be evaluated in an action plan and budget. During the plenary session, participants analyzed these indicators and identified the strengths and weaknesses of each health facility. The participants used these results, which stemmed from the situational analysis, to identify the priorities and activities to be planned for 2008. Using these same techniques, the participants determined the different revenue and expense categories for 2008. They also budgeted for the activities and identified the conditions and implications of implementing their 2008 action plan and budget.

Principal results Although a number of results came out of the trainings, we present below the two main categories: quantitative and qualitative. The opportunities and prospects are described briefly in a later chapter.

Quantitative results Participants came from the co-management offices and the health centers of Zou and Collines. The following tables show the breakdown by position and gender.

Table 4: Breakdown of persons trained according to original position and by health zone

Health Zone

COGEC members

Administrative Total Community Dispensary

Maternity

Center

COZO 40 10 13 1 64

DAA 72 19 26 4 121

DAGLA 85 25 23 3 136

SABA 67 19 14 0 100

SAO 42 17 09 2 70

ZOBOZA 63 21 20 8 112

Total 369 111 105 18 603

Percentage 61.2% 18.4% 17.4% 3.0% 100%

Group work in Savalou (left) and Bantè (right)

In total, 603 persons were trained (585 COGEC members and 18 administrative workers in charge of supporting the COGECs).

Table 5: Breakdown of COGEC members trained by gender and health zone

Health Zone Gender

F M Total

COZO 18 45 63

DAA 40 77 117

DAGLA 47 86 133

SABA 34 66 100

SAO 21 47 68

ZOBOZA 28 76 104

Total Number 188 397 585

Percentage 32% 68% 100%

The table above shows that one of every three training participants was a woman. If only COGEC members from the community are considered (in other words, non-health workers), the ratio of men to women is even lower (15%, or 57 women out of a total of 369 community members). Of the 630 people invited for the training sessions, 603 actually took part, for a participation rate of 96%, which demonstrates an acceptance the process under way. Qualitative results Feedback from local trainers

Although several training sessions for COGEC members had been held in certain health zones in the past, trainers unanimously recognized a difference in the methodological approach during these sessions. All of the local trainers, who are health system stakeholders, welcomed the approach and the content used during training. Mr. Anselme Hounsou, a nurse at the Bohicon center (trainer) said the following about the training: “There was so much excitement that it looked like the participants were looking forward to the

training. Now I hope the clerical workers will be trained in using the management tools.”

Feedback from participants The trainers’ report gives the details of participant feedback and a summary is presented in this report.

If this training is to be repeated, we would want to improve our knowledge of planning, particularly for

the different components such as indicators, objectives, and budgeting. We would also like for PISAF to

organize this type of training sessions.” President of the Tanvé COGEC. “This training is excellent, and it gave us an edge. I hope that in the future we will improve our

knowledge of preparing the action plan to do a better job of budgeting.” President of the Adingnigon COGEC .

“This is very good training that showed everyone their responsibilities. We have never been given this

type of training and everything was clear to me. In the future, you should stress the aspects of analyzing

the status of the action plan and the budget.” Djidja Health Center bookkeeper.

“We were very much looking forward to this training. We thank the facilitators because we did not know

our roles and responsibilities before this. Now, we will master them and we will work in close

cooperation with the health care workers. In the future we should revisit budget preparation. Since we

are not bookkeepers, it is a bit difficult for us to prepare budgets.” Secretary, Mougnon COGEC.

“I am very satisfied because in the past, we prepared the budgets at the end of the year. But now, at the

end of the first quarter of 2007, the 2008 budget has already been prepared. Likewise, we knew nothing

about action plans and I think that the training demonstrated to us how important they are and that we

should no longer simply improvise as we go along. In the future, we should review the indicators in detail

because developing them was problematic for us.” Head nurse of DAN.

This feedback demonstrates the gap that was filled through training, and it helps us determine the work that remains to be done to meet the legitimate expectations of the participants and the system. Prospects

Strengthening COGEC operations:

With the new bylaws that bind the COGECs to the zone coordination offices for their operation, COGEC monitoring has become irregular. PISAF provided assistance to the DDS in setting up a scoreboard to facilitate COGEC activity monitoring by the HZMTs. The data collection sheets and the electronic data management files have already been prepared and discussed with the DDS’s counterparts. They will be validated and used beginning in the first quarter of FY 2008.

COGEC replacement:

A guide was prepared and given to the health zones to standardize the method of replacing the COGECs in the health zones and health facilities. This guide makes the communities sufficiently aware of the benefits of observing the criteria and of increased participation by women in the co-management structures.

Table 6: Family health product inventory management

Performance of COGECs who participated in managing

the family health product inventory in 2007

1st quarter 2nd quarter

3rd quarter

Performance

(average)



Covè-Zangnanado -Ouinhi (COZO) 100% 100% 100% 100%



Savè-Ouessè (SAO) 92% 100% 100% 97%

Zou/Collines 94% 94% 93% 94%

As demonstrated in the above table, COGEC participation in managing the family health products inventory in Zou/Collines health facilities was nearly stable in 2007. The change in their performance in certain health zones such as ZOBOZA (95% to 82%) and DAGLA (90% to 80%) between the second and third quarter is due to family health product inventory irregularities in some of the health facilities in these health zones.

Involvement of community-based organizations in health activities

Table 7: Integration of health activities in community-based organizations

This table indicates that in 2007, of the 22 CBOs that were selected, ten were able to carry out health activities in the health zones of ZOBOZA, COZO, DAGLA and SAO; this shows a 45% performance rate for the departments of Zou and Collines. We would point out that the activities the CBOs carried out in 2007 are focused on malaria awareness and HIV/AIDS prevention.

2.2. Intermediate Result 2: Access to Quality Services and Products Increased To achieve this objective, PISAF is striving to contribute to improving the availability of family health products, the quality of care and services, and to increasing financial access to health services.

2.2.1 Selected products available at public sector facilities

Percentage of community-based organizations (CBOs) selected that carry out health activities

Number of CBOs

selected Number of CBOs that carried out

health activities Performance

Zou/Collines 22 10 45%


• 23,918 LLITNs distributed to 24,796 children under five in the COZO health zone

• 605 health workers from Zou/Collines trained in the new malaria case management protocols

• 136 public health facilities in the department of Zou/Collines received supplies of ACTs (Coartem®) and RDTs (Paracheck)

• 118 providers trained in the integrated offer of care and services in Banikoara and Sinendé

• 65 providers from Banikoara and Sinendé and 29 providers from Savalou/Bantè trained in EONC and AMTSL

• 49 members of communal union management bodies trained in financial management

• 7,000 membership cards, 160 receipt booklets and 34 registers given to the health mutuelle

management bodies

• 25 newly assigned workers and new health mutuelle managers trained in health mutuelle

management concepts and tools

• 23 departmental trainers trained in adult education

• 22 managers at the DDS and health zone levels trained in QUANTIMED in Zou/Collines

• 8 general assembly meetings held in the health mutuelles of Banikoara

• 8 CHW training curricula drawn up

• QA strategies prepared in Zou/Collines and Borgou/Alibori

• A delegation of ten (10) employees from the Benin Ministry of Health participated in a study trip to Niger on collaboratives

• PISAF supported a mid-term evaluation of the health mutuelles in Borgou/Alibori

• Network of Sinendé and Banikoara health mutuelles operationalized the hospital case management system

• Community mobilization strategy and implementation plan prepared

In FY 2007, PISAF developed many activities to strengthen the ability of health workers in Zou/Collines to manage drugs. The implementation of the new malaria policy was a positive factor that united stakeholders at a very early stage around the issue of drug management. The first activity was a workshop on the quantification of needs for long-lasting insecticide-treated nets (LLITNs) for the priority targets, which are women and children under five. At this workshop, the needs in Zou/Collines for ACTs also were quantified to cover health facility needs in 2007. Next, training was organized for all the health zone and zone hospital managers in the new method of quantifying product needs (QUANTIMED), and 22 managers were trained.

Health facility procurement of ACT and RDTs in the departments of Zou and Collines

In April 2007, ACTs and RDTs obtained directly from USAID/Benin were shipped to the Zou/Collines DDS. Once the providers had been trained in the new case management of malaria in June 2007, the ACTs and RDTs were delivered to the public health facilities. A joint DDS-PISAF team monitored product utilization for three months following delivery. Usage can be summarized in the following table:

Table 8: Changes in ACT, Artemether and RDT (Paracheck) inventories

Items DDS inventory as of end- Sept. 07

HZ inventory

as of end- Sept.

07

Quantity delivered to

the health facilities

thru end-Sept. 07

Inventory identified by

PISAF in the Z/C health

system as of end-Sept. 07

Coartem® Blister 6 42,720 27,567 68,433 138,720

Coartem® Blister 12 7,200 7,878 30,522 45,600

Coartem® Blister 18 3,840 1,957 10,523 16,320

Coartem® Blister 24 4,950 12,004 41,996 58,950

Artemether injectable (blisters)

2,264 2,590 2,410 7,264

TDR/Paracheck (units) 86,400 18,185 73,815 178,400

This monitoring task highlighted the following salient points:

• The new malaria case management using Coartem and the Paracheck RDT for patients over five years old is being effectively implemented in the 135 public health facilities in the department of Zou/Collines,

• Coartem® has permanently replaced Chloroquine as the first-line drug for the integrated management of childhood illness (IMCI) affecting children under five.

However, to improve the quality of care and services, some aspects should be upgraded:

• Coartem®, Artemether and RDT management is not yet standardized in the departments of Zou/Collines. Standardization must happen immediately.

• Post-training monitoring of the trained providers has not yet taken place. PISAF has prepared a draft post-training management form and it will be submitted to the DDS and tested with the collaboration of the departmental and communal trainers next quarter. The final version will then be submitted to the PNLP for validation.

• To strengthen the quality of care a job aid for RDT/Paracheck has been pre-tested in cooperation with the departmental trainers and will be finalized, reproduced and disseminated in all the public health facilities in Zou/Collines before the end of 2007. Other job aids, such as those that pertain to infection prevention, also need to be prepared/adjusted or revised.

Needs also were quantified for ACTs, RDTs, LLITNs and primary care for the entire PISAF project period. PISAF used these results to advocate with the PNLP and USAID to meet the needs in its intervention zone.

Table 9: Average number of days with product inventory shortages in the health centers in 2007

The table above indicates that in the first and second quarters, ACTs and LLITNs showed the highest number of days with inventory shortages. The significant decrease in this average number in the third quarter is due primarily to the fact that all the health centers received supplies of ACTs and LLITNs from USAID in all the health zones in the second quarter.

The inventory shortage of condoms can only be explained by the fact that this product is in very high demand and is used extensively, since the presence of PSI in the zone ensures that condoms are supplied regularly. In contrast, there are always inventory shortages of oral and injectable contraceptives, even at the national level.

The graph below provides an illustration of the average number of days of inventory shortages for selected RH products.

Average number of inventory shortages in the departments of Zou and Collines in 2007

Period ACT Oxytocin LLITNs Condoms Oral

contraceptives Injectable

contraceptives ORS

Average # of days with inventory

shortages for the 7 products

1st quarter 07 30 6 25 14 10 7 3 14

2nd quarter 07 18 5 15 13 9 6 2 9

3rd quarter 07 3 7 5 11 7 6 2 6

2007 17 6 15 12 8 6 2 9

Average number of days of inventory shortages for selected products

in the departments of Zou and Collines in 2007

17

6

15

12

8

6

2

9

0

2

4

6

8

10

12

14

16

18

20

ACT Oxytocin LLITNs Condoms Oral

contraceptives

Injectable

contraceptives

ORS Average number

of days of

inventory

shortages for the

7 products

Selected products

Day

s o

f in

ven

tory

sh

ort

ag

es

We observed that after EONC/AMTSL was introduced in some health zones, there were artificial inventory shortages of Oxytocin in a few health facilities, even though the maternity center managers need this product for AMTSL. To meet client needs, they had to obtain products on the black market, and this creates illegal sales in the health facilities. Therefore, a formal system must be found for supplying the maternity centers with Oxytocin. We note that one of the reasons for most of the inventory shortages is that the CAME does not deliver the entire quantities of products that are ordered, or the health facilities incorrectly estimate drug needs.

This situation will be resolved in part because USAID has decided to make annual deliveries directly to the health facilities in Zou and Collines of the quantities of Oxytocin they need to implement AMTSL. This will be expanded to the health facilities in Borgou and Alibori.

Facilitated the creation of departmental and zone warehouses in Zou and Collines In 2007, PISAF assessed the operations of the five zone warehouses in the departments of Zou and Collines.

The method used consisted of: (i) an interview with the zone managers, the warehouse managers and the Coordinating Physicians; (ii) a documentary analysis; and (iii) a visit to the stores. There were interviews with the health facility managers and warehouse clients to evaluate their satisfaction.

Feedback was given to all of the Coordinating Physicians at the end of the evaluation in the zone to make them aware of the strengths and weaknesses in the warehouse in their health zones.

All of the results show that only the warehouses in the Savalou/Bantè and Dassa/Glazoué health zones are operating on a near-normal basis. The Bohicon/Zogbodomey/Zakpota health zone has no distribution warehouse. The following recommendations were made to help strengthen the warehouses and lower the risk of drug inventory shortages: For the health zones

• Document experiences of setting up and running warehouses

• Establish formal warehouse management structures and clarify the stakeholders’ roles

• Put in place structures to control and monitor product traceability

• Train/retrain the clerical workers and other Essential Generic Drug (EGD) management stakeholders in the zones

Recommendations for the DDS

• Organize a reflection workshop on the standardization of warehouse management

• Strengthen HZMT capaciy to control Essential Generic Drug management and the inventories of the distribution warehouses and retail pharmacies,

• Harmonize the SIGL tools for all health products in the two departments, health zones and in particular for the operation of the distribution warehouse.

Recommendation for PISAF

• Support the ZOBOZA health zone to conduct a feasibility study on setting up its distribution warehouse

• Support the DDS to set up/strengthen the zone warehouses.

The recent MOH decision to give the departments of Zou and Collines a regional CAME warehouse will bolster PISAF’s effort to find solutions to the frequent drug inventory shortages in the health facilities of these two departments.

Built management and logistical capacity

This year, PISAF began training activities on logistics training in Zou/Collines. The results of the Management Assessment showed that the percentage of providers observed who were trained in logistics varies from one zone to another between 7% and 38% with a departmental average of 16%. Thus, training for the DDS department heads and health zone drug managers was held on the use of the QUANTIMED

software in the second quarter of 2007 with technical and financial support from PISAF. QUANTIMED is a tool for quantifying and evaluating the costs of pharmaceuticals. The 22 participants that attended the QUANTIMED training learned about: i) the logistics system (goal, drug management cycle and logistics management concepts); ii) quantification methods (morbidity and consumption); and iii) therapy plans recommended by the WHO and Benin for HIV, malaria and post-partum hemorrhaging. The photo here illustrates a practical session during this workshop.

Table 10: Availability of family health products

Percentage of health service delivery points that correctly estimated their order of essential family

health products and that submitted the order on time in 2007

1st quarter 2nd quarter 3rd quarter

Performance (average in 2007)

Djida-Abomey-Agbangnizoun (DAA) 23% 14% 95% 44%


Covè-Zangnanado-Ouinhi (COZO) 31% 46% 100% 39%



Savè-Ouessè (SAO) 36% 43% 50% 43%

Zou/Collines 53% 46% 81% 50%

The results above indicate a fluctuation in health facility performance in managing orders of essential family health products in 2007. However, we note an improvement from the second to the third quarter in the year, as the graph below indicates, due in part to the QUANTIMED training given to RH product managers with PISAF technical and financial support during the second quarter. The average annual health facility performance level is 50% in 2007. Special effort will be made to improve this performance as it is critical for reducing essential drug inventory shortages in the health facilities of Zou and Collines.

Practical exercise with QUANTIMED

Change in health center performance in managing orders of essential

family health products in 2007

53%46%

81%

0%

20%

40%

60%

80%

100%

1st qtr. 07 2nd qtr. 07 3rd qtr. 07

Zou/Collines

Updated CHW training materials

In training the community health workers (CHW), several training modules were prepared, including the following:

1. Community-based services and CHW module. This module deals with the concept of community-based services and community health workers.

2. Facilitation module. This module helps the CHWs better understand and carry out the

counseling and facilitation task that the community assigns to them. This module consists of the following eight sessions: i) facilitation methods; ii) group discussions; iii) the stages of group discussions; iv) the stages of image box use; v) the qualities of a good group discussions facilitator; vi) home visits; vii) individual interviews; and viii) demonstration.

3. Family planning (FP) module. This module improves CHW knowledge about FP and includes

the benefits of FP, contraceptive methods, and FP counseling..

4. Integrated Management of Childhood Illnesses (IMCI) module. This module is on offering community services that lead mothers to adopt behaviors that promote the development and survival of children up to age five. The introduction of Coartem® to treat simple malaria at the community level as a replacement for chloroquine necessitated a fundamental revision of the sessions that deal with in-home malaria treatment. Likewise, the introduction of Sulfadoxine Pyrimethamine (SP) as a presumptive treatment for malaria in pregnant women created the need for a fundamental revision of the ANC and PoNC module.

The other modules on STIs/HIV/AIDS, community EONC and CHW activities management were reread to adapt them to the new requirements of the changes in the national health policy and the new PISAF strategy for putting the CHWs in place. It is important to note the necessity of developing appropriate communication materials for the community level that take into account the changes introduced by the new national malaria policy, and introduce the ORH packages with zinc.

2.2.2. Selected products available at private sector outlets This year the Ministry of Health and USAID decided to distribute LLITNs at no cost to children under five. As a result, LLITNs could not be made available to women’s groups, mutuelle members, or NGOs as initially planned.

2.2.3. Quality family health package available at targeted public sector facilities

Table 11: Family health package access

Number of persons with access to the package of family health services in 2007

Djidja-Abomey-

Agbangnizoun (DAA)

Zogbodomey-Bohicon-Zakpota

(ZOBOZA)

Covè-Zangnanado -Ouinhi (COZO)

Dassa-Zoumè-Glazoué (DAGLA)

Savalou-Bantè (SABA)

Savè-Ouessè (SAO)

Zou/

Collines

1. Women of childbearing age with access to at least one maternal health service

Counseling 45,818 29,593 13,520 14,881 18,884 11,271 133,967 Antenatal consultation

19,909 23,312 10,021 12,634 17,866 9,014 92,756

Assisted deliveries 6,175 6,435 3,177 4,112 4,954 2,815 27,668 Emergency obstetrical and neonatal care (EONC)

1,067 90 180 474 178 258 2,247

Postnatal consultation

8,165 3,797 3,474 3,032 3,417 2,282 24,167

2. Women of childbearing age with access to the following services:

Family planning (contraceptive administration)

1,601 1,382 1,324 2,127 2,863 385 9,682

3. Pregnant women who receive:

HIV/AIDS counseling

5,485 3,065 680 908 1,112 681 11,931

PMTCT screening 5,355 3,065 680 871 852 487 11,310

4. Children under five with access to the following services:

IMCI 1,429 1,041 0 1,105 35 513 4,123 Total number of

persons with access

to the family health

services package

95,004

71,780

33,056

40,144 50,161 27,706

317,851

Total population of Zou/Collines 1,345,008 % of the population that has access (receives at least one package component) to the family health services packages in the targeted zone

24%

The table above indicates that in FY 2007 access to the Family Health Services Package in Zou and Collines is 24%, which is lower than the average for the department of Zou/Collines in 2006 (34%). We observe that EONC, IMCI and FP have the lowest access rates (these are the services that are offered least). The factors that explain this situation are as follows:

• For EONC, the low access is due to weakness in documenting this activity, because all of the workers who carry out the activities in this area are trained. For example, EONC/AMTSL access in SABA increased from 0 to 178 in the third quarter just after all the maternity center providers were trained in EONC/AMTSL in the second quarter. The EONC/AMTSL collaborative will ensure that a particular emphasis is placed on documentation.

• For IMCI, we note that those health zones that did not receive clinical IMCI training have poor access (COZO), and that those zones that have no IMCI register and that do not supervise workers trained in IMCI (SABA and SAO) also have low access. During fiscal year 2008, PISAF, in collaboration with UNICEF, will support the DDS and the health zone management teams (HZMT) in conducting post-training supervision visits to health workers trained in clinical IMCI, as well as in setting up IMCI registers in health centers.

• For FP, low access is linked to frequent contraceptive inventory shortages, even at the national level. PISAF is already helping to build capacity in the Department of Family Health to accurately estimate the country’s contraceptive needs, and in mobilizing donors to assist the Ministry of Health in implementing its reproductive health product security strategy, which includes contraceptives.

Reagents for the HIV/AIDS screening test are no longer available in some PMTCT site laboratories, and this reduced access to the HIV/AIDS screening test for PMTCT in the third quarter of 2007. Ensure the availability of norms and standards for the expanded minimum package of care in

Zou/Collines and Borgou/Alibori A visit to the DDSs and HZMTs in the departments of Borgou/Alibori and Zou/Collines showed that the protocols for the intermittent treatment of malaria using Sulfadoxine-Pyrimethamine (SP) are available at every level of the health system and the providers have received orientation. A meeting with the managers of the Zou/Collines CIPEC showed that 39 maternity centers and the six hospitals in the two departments provide PMTCT services. The results of Management Assessment I revealed poor performance in the provision of family health services in Zou/Collines. To improve this performance, PISAF updated the essential norms to make them available to the providers in an effort to promote self-learning. Free distribution of LLITNs in the Covè/Zagnanado/Ouinhi health zone

LLITN distribution in COZO was necessary for two reasons: i) the first is that since USAID acquired the nets for the departments of Zou and Collines back in February 2007, the nets had to be distributed to the communities during the winter period when malaria activity increases; ii) the second reason is that USAID did not provide enough LLITNs to cover all children under five in Zou and Collines, so that distribution had to be limited to a well-defined zone. That is why a mini-campaign was organized in COZO after discussions between USAID/PNLP/PISAF and the Zou/Collines DDS; they reached an agreement to consider this mini-campaign a test as a prelude to the national mass distribution campaign of LLITNs at no charge. Distribution took place in two phases: the mini-campaign and the follow-up/adjustment campaign to cover beneficiaries who were missed the first time. Mini-campaign: This necessitated micro planning meetings and coordination meetings between the PNLP and the DDS and PISAF and the mobilization of material and human resources, all of which resulted in the establishment of 110 distribution points run by 660 distributors. A total of 22,850 LLITNs

were distributed, covering 23,217 children up to five years old, with a 76% coverage rate for the

entire zone. Ouinhi had the lowest coverage, at 68%. It was observed that despite the 15% LLITN safety

margin, 6,421 registered children did not receive LLITNS, or 21.6%.

Follow-up campaign in Ouinhi Because the results of free LLITN distribution in the Covè/Zagnanado/Ouinhi health zone showed insufficient coverage (68%) in Ouinhi, a recommendation was made during the debriefings that took

place at the DDS and the Ministry of Health to carry out follow-up campaign to cover anyone missed the first time in this commune in order to raise the rate to 80%. This follow-up campaign was carried out in two stages: i) a preparatory stage with social mobilization and the pre-positioning of 50 cartons of LLITNs and ii) the distribution stage, which mobilized thirty (30) distributors. This stage consisted of providing one treated net to mothers with one or more children under five. This distribution was combined with immunization outreach with strong community mobilization.

During this follow-up campaign, 1,435 LLITNs were distributed and covered 1,579 children under five. LLITN coverage in Ouinhi increased from 68% to 80%. The following lessons learned came out of this campaign, which was carried out in COZO with PISAF financial and technical support: i) The estimates of children under five based on data from the National Institute for Statistics and

Economic Analysis (INSAE) and EVP led the PNLP to revise its estimates for LLITNs for the national campaign, because the mini-campaign revealed a 21.6% gap in the field.

ii) The people recognized that LLITN use is a method that protects them from mosquito bites. iii) The integration of LLITN distribution with immunization is a strategy that can lower immunization

dropout rates.

Introduced integrated offer of services in Zou and Collines

Updated the training curricula for the Integrated Provision of Services (IPS): The PROSAF reference manual consists of six (6) chapters and is somewhat theoretical. It does not sufficiently take the following into account: working environment and organization; client circuit; technical functions (IPC); and dimensions of the integration process in the practical implementation of the Integrated Provision of Care and Services. The manual was adapted to bring it in line with the requirements that will facilitate the practice of integrated provision in the health facilities. A manual was prepared and consists of five (5) chapters: i) the role of the first-contact health facilities; ii) the organization of labor, reception and the circulation of patients in the health centers; iii) the Integrated Provision of Family Health services; iv) Interpersonal Communication; and v) teamwork. The manual was used to draw up the provider training curriculum.

Training in the Integrated Offer of Services One hundred eighteen (118) providers—48 from Sinendé and 70 from Banikoara—were trained in the Integrated Provision of Services. The goal is to make the providers capable of providing integrated family health care and services and to improve client-provider interactions to increase the use of services and

A woman receiving her LLITN after her child

was vaccinated

client satisfaction. This training took place according to the curriculum that was derived from the training manual. This training was also planned for the departments of Zou and Collines but has been postponed several times. Interference, and provider training in the new malaria directives in particular, are the main reasons for the postponement. Arrangements are being made to hold this training during the first quarter of FY 2008.

Trained the Zou and Collines departmental training team in adult education skills

This training, supported by PISAF, enabled the Departmental Health Directorate to have a team of local trainers. There were 23 participants from the six health zones, comprised of six government-trained nurses, one nurse’s assistant, six managers, four physicians and six midwives. This adult education training is based on the principles of adult learning and behavior modeling. There are two stages in the training: i) the theoretical phase, led by trainers with interactive presentations and exercises; and ii) the practical phase, during which each participant prepared and led 15-minute micro teaching, followed immediately by feedback from the other participants and facilitators after an evaluation based on participant materials and checklists. At the end of this training, a consensus was reached on the next steps that will include: (i) a presentation and discussion of the results to the HZMT; (ii) a performance assessment carried out by each HZMT; (iii) the expression of needs and the preparation of a training plan; and finally (iv) validation of the training.

Trained health workers on the new malaria case management protocols

The change in the malaria policy caused the directives previously used in malaria case management to be altered. The introduction of ACTs and RDTs in case management made it necessary to train the employees in the health centers. PISAF provided technical and financial support to organize training sessions for all the public health care sector providers in the departments of Zou and Collines. However, some employees in the private health centers who work with the Health Zone Management Teams (HZMTs) were trained as well. First the trainers were trained with PNLP support. Twenty-two (22) HZMT members from Zou and Collines participated in this training on the new malaria policy directives. The participants came from the six zones; there were eight (8) laboratory technicians (all categories) and fourteen (14) physicians. In addition to these departmental trainers, ten (10) other trainers from the national courses were brought in to train the providers in the health zones. In the departments of Zou and Collines, 605 providers (414 nurses, 122 midwives, 14 physicians, 53 laboratory technicians and two nurse’s assistants) from the public health facilities were trained. To accomplish this, a training manual and a facilitator guide were prepared in cooperation with the PNLP. Laminated algorithms for the case management of each patient category (children<five, patients>five and pregnant women) were given to each participant as job aids. Twenty-eight (28) training sessions were

Facilitation of a session by a participant

necessary to train all the providers, during which 32 departmental and communal trainers collected information essential for upgrading and finalizing the facilitator guide. Implementation of PMTCT in Zou/Collines

Training of health providers in the new PMTCT norms: The 39 PMTCT sites in Zou (29 sites) and Collines (10 sites) carry out prevention and screening activities to direct patients to the departmental referral center for care. Most of the providers from these PMTCT sites were trained using the old protocol, but new norms have been adopted. Others, in contrast, who are newly assigned employees, have not received any training. To correct this deficiency, PISAF provided financial support to train twenty-four (24) providers identified in the different sites (three physicians, five midwives, ten nurses, and six laboratory work technicians and engineers). The problems to be resolved by site were identified and a solution plan was prepared during the training held in Abomey from June 11 to 15, 2007. These trained providers were monitored from August 6 to 10, 2007, which was seven weeks after the training. A total of eight (8) sites where the 24 trained providers work were visited. Most of the trained providers were seen during this visit. All the managers and department heads we saw made a commitment to the success of PMTCT in the centers. Arrangements have been made in the centers to effectively implement the recommendations. The following observations were made as a result of this monitoring: i) a shortage of reagent curtailed PMTCT activities in July; ii) some health centers have new employees that have not been trained (three in Glazoué and six in Covè); and iii) the training results have not yet been presented or discussed at some sites. Recommendations were made in view of this observation: i) advocate with the PNLS so that the PMTCT sites have trained/retrained personnel; ii) encourage providers to present and discuss the results immediately after the training; iii) give priority to untrained PMTCT employees for the next training sessions; and iv) organize regular monitoring or supervision visits to make the accomplishments sustainable and to improve provider performance. Monitored children of HIV+ mothers

It has not been possible to organize this activity ever since the reference laboratory was set up to monitor children. PISAF provided financial support to organize monitoring of children of HIV+ mothers. This activity, carried out every two months, covered all the sites in Zou. This year, two monitoring visits were organized (May and July) and 27 children were monitored, 21 of whom had blood drawn to determine their viral load and six for serology. The results are not yet in because blood sampling is centralized at the reference laboratory in Cotonou. Discussions have begun with the national laboratory to clarify the procedure for disclosing test results to the CIPEC and to make it possible to finally have an idea of PMTCT program effectiveness in effectively reducing mother-child HIV transmission.

Implementation of EONC and AMTSL

Trained providers in Borgou/Alibori and Collines in EONC and AMTSL This year 65 providers were trained in five sessions in Banikoara and Sinendé (Borgou/Alibori) and 29 providers were trained in two (2) sessions in the Savalou/Bantè (Zou/Collines) health zone.

Table 12: Breakdown of EONC and AMSTL training participants by occupational category and by

commune

Commune Employee category Number Total

Banikoara

Physicians 2

39

Midwives 3

Female nurses 13

Male nurse 1

Nurse’s assistants 20

Sinendé

Physician 1

26 Midwives 5

Female nurses 7

Nurse’s assistants 13

Savalou/Bantè Midwives 14

29 Female nurses 15

Total 94 94

In both cases, the topics the training covered are grouped into two main parts: i) obstetrics, with eleven modules (the problem of maternal mortality; the effects health mutuelles have on the quality of care and health services; being prepared for complications in EONC; infection prevention; severe anemia during pregnancy; complications from high blood pressure; hemorrhaging; obstetric infections; refocused ANC; and community AMTSL and EONC); and ii) neonatal, consisting of five modules (essential care for newborns; infection in newborns; neonatal suffering; jaundice in newborns; and low birth weight in newborns). There were two stages in these training sessions: i) the theoretical stage, led by trainers with interactive presentations, exercises and role play; and ii) the practical stage, during which the theories learned by providing care for obstetric emergencies were applied, and by labor and delivery according to the AMTSL technique under trainer supervision. At the end of the training, all the participants prepared an action plan on the changes to be introduced once they returned to their jobs. Monitored providers trained in EONC and AMTSL in Borgou/Alibori

The providers trained in Borgou/Alibori have already been monitored. The 65 providers trained in EONC/AMTSL are working in the 21 health facilities in Banikoara and Sinendé. This monitoring was performed with the management team members of the two health zones about two months after they were trained. The objective is to assess the performance of providers trained in obstetric and neonatal emergency management and the prevention of post-partum hemorrhaging. In general, we noted the following in the two communes:

• The AMTSL implementation rate is 81.6% in Banikoara and 87.4% in Sinendé

• The percentage of AMTSL incidents is 1.2% in Banikoara and .96% in Sinendé

• 85% of deliveries are clean and safe

• Delivery labor surveillance is over 85%

• Immediate post-partum surveillance is over 85%

• The high rate of justified referrals: over 98% of cases in Banikoara and Sinendé

• The action plan preparation rate is higher than 80% for skilled providers and 85% for nurse’s assistants

• Ensuring intravenous access is routine in 80% of cases prior to evacuation in the event of referral to a higher level of care

The monitoring team suggested that the health zone management teams carry out monitoring in the context of the formative supervisions.

Built capacity in QA and supervision in Zou/Collines and Borgou/ Alibori

Table 13: Supervision system implementation

HZMT performance for formative supervision at the health centers

in Zou and Collines in 2007

1st quarter 2nd quarter 3rd quarter Performance (average)

Djidja-Abomey-Agbangnizoun (DAA) 1/22 (5%) 7/22 (32%) 21/22 (95%) 44%

Zogbodomey-Bohicon-Zakpota (ZOBOZA) 1/22 (5%) 2/22 (9%) 22/22 (100%) 38%

Covè-Zangnanado-Ouinhi (COZO) 1/13 (8%) 0/13 (0%) 12/13 (92%) 33%

Dassa-Zoumè-Glazoué (DAGLA) 0/21 (0%) 14/21 (62%) 9/21 (43%) 35%

Savalou-Bantè (SABA) 1/20 (5%) 9/20 (45%) 10/20 (50%) 33%

Savè-Ouessè (SAO) 0/14 (0%) 2/14 (14%) 13/14(93%) 36%

Zou/Collines 4/112 (4%) 34/112 (30%) 87/112 (78%) 37%

The table above indicates that the average annual performance of the Zou/Collines supervision system is just 37%. Yet we note a striking increase in this performance during the year: In the first quarter of 2007, this performance was 4% in the first quarter, 30% in the second quarter and 78% in the third quarter. The factors that explain this improvement are: a preliminary presentation and discussion of the results of Management Assessment I and the results of the PMP occurred during the physicians’ collective in July 2007 and all the health zone coordinators were able to realize the actual performance in their zones and become aware of the necessity of making efforts to improve the situation. Afterwards, the HZMT and the Z/C DDS made efforts and oriented the supervisions on strengthening health worker knowledge of Diseases With Epidemic Potential, the EVP, IMCI, PMTCT, EONC/AMTSL and financial management. The formative supervision training of HZMT members and DDS department heads in the first quarter of 2007 strengthened this supervision performance.

Moreover, the graph below shows the annual average HZMT performance in Zou and Collines for formative supervision. Only the DAA HZMT achieved 44% performance; the others vacillate between 33 and 38%. These HZMTs will have to make considerable efforts to improve this performance in 2008. PISAF will provide the financial support, but first and foremost it will provide the technique necessary through HZMT coaching in carrying out supervision trips to make them truly formative.

Average HZMT performance in formative supervision in the Zou and Collines

health centers in 2007

44%38%

33% 35% 33% 36% 37%

0%

20%

40%

60%

80%

100%

DAA

ZOBOZA

COZO

DAGLA

SABA

SAO

Zou/Colli

nes

Health Zones

Development of PISAF’s QA Plan PISAF prepared an implementation plan to develop Quality Assurance in Zou/Collines and Borgou/Alibori. This plan presents the PISAF QA strategy in a document divided into six (6) chapters: i) a historical summary of efforts to improve quality; ii) goals and objectives for improving quality in Zou/Collines and Borgou/Alibori; iii) implementation strategy; iv) the improvement collaborative; v) the implementation timeline; and vi) institutionalization.

The management and implementation structures for the collaboratives have been identified and the following areas were targeted to contribute to the themes of the collaboratives: EONC/AMTSL, malaria, human resources management, FP, HIV/AIDS, mutuelles and the quality of care, and the Integrated Provision of Services if possible.

Orientation of PISAF staff in QA, collaboratives and facilitation: For three (3) days, this orientation was provided for the twelve (12) PISAF technical staff members and the administrative assistant. Facilitated by a team comprised of Lynne Franco, Zakari Saley, Aguima Tankoano and Gaston Kékin, the purpose was to clarify QA and collaborative concepts and to show how these two concepts can be used in PISAF implementation. Furthermore, workshop facilitation techniques were discussed during this workshop in order to strengthen technical staff capacities in leading the many workshops they will be required to organize during PISAF implementation. There was a presentation for the participants on the context of QA in PISAF and on an introduction to QA. They performed exercises in breakout sessions followed by a plenary in which they came to better understand the notions of quality, quality assurance, improvement concepts and the four principles of quality assurance (emphasis on the client, teamwork, the process and systems as well as data). Afterwards they discussed the links between QA and their work in PISAF based on a four-stage model known as “ORID,” which includes: i) Observation; ii) Reflection; iii) Interpretation; and iv) Decision. The participants also heard a presentation on the collaborative and performed exercises to better grasp this concept.

There was a presentation on workshop planning and facilitation followed by breakout sessions. The plenary showed that workshop planning is based on a series of questions and a range of techniques. You must always develop what you are seeking to achieve and channel people toward the desired goal.

Implementation of the collaborative model in Zou/Collines and Borgou/ Alibori

Organized a collaborative-sharing workshop in Borgou and Alibori: The highlight of this workshop, attended by 37 members of the EONC, IMCI, Infection Prevention and Client Satisfaction network, was the presence of the Vice President of URC’s International Division. After listening to the presentations on the results of each network, the participants divided into four working groups to reflect on network structure, resource/planning, monitoring/supervision and network communication/coordination. At the conclusion of the work, the following recommendations were made: (i) each network must prepare its charter; (ii) the participants must present and discuss the workshop at their base; (iii) At every level, the network teams are formed and meeting frequency is set; and (iv) the meetings must be held quarterly for each network and twice yearly for all the networks together.

A monitoring inspection of this collaborative-sharing workshop’s recommendations culminated in the following observations:

• 26% of the scheduled activities were carried out and 32% are in the process of being carried out

• The departmental and zone quality management structures are beginning to function through the network committee’s supervisions

• The process indicators that were adopted were updated at the thought-sharing meetings that the DDS and network committees organized

• An indicator calculation guide is in the process of being adapted

• Training needs were identified at the departmental level and an integrated training plan will be prepared for them.

Workshop on QA implementation lessons learned in Borgou/Alibori and QA scaling-up In order to document the Quality Assurance model implemented in Borgou/Alibori under PROSAF and to obtain information essential for scaling-up, PISAF held a workshop in Parakou on the lessons learned on implementing Quality Assurance in Borgou/Alibori. There were eighteen (18) participants, consisting of a PISAF team led by the Vice President of URC, the Departmental Health Director, DDS managers, Coordinating Physicians, Health Zone Management Team members and community facilitators (facilitators under the PROSAF project), all of whom took part in implementing PROSAF activities. The participants heard presentations and worked in breakout sessions that achieved the following results:

Essential components of the QA model implemented in Borgou/Alibori: There were the following seven (7) essential components: i) norms for each level; ii) QA training for workers (establishment of pools of trainer and dissemination of norms); iii) strengthening the working environment (equipment and infrastructures); iv) monitoring/evaluation; v) documentation of the entire experience; vi) a worker motivation system; and vii) strengthening community participation (CHWs and COGECs).

Status of institutionalization of QA in Borgou/Alibori: This is assessed based on whether certain practices remain stable or regress. We note i) ownership of QA at the DDS level; ii) the existence of the QA concept in the department; iii) a quarterly review of the indicators; iv) routine formative supervision; and v) functionality of certain Prevention of Nosocomial Infection and EONC networks. In contrast, i) the CHWs and COGECs are more or less functional; ii) QA training is no longer routinely budgeted in the COGECs action plans; iii) the health indicators are regressing; iv) stakeholders are not highly motivated for quality; and v) the QA teams in the arrondissements are no longer functional.

Lessons learned from the QA experience in Borgou/Alibori: These lessons are in the table below.

Table 14: Practices that are recommended and practices that are not recommended in the

implementation of QA

Type of practices Practices

Practices that are not recommended

• Lax human resources management

• Confiscation and concentration of power by the leader

• Failing to circulate information

• Failing to involve all the stakeholders

• Improvisation and haste

• Dealing only with theory before moving on to practice

• Unfair human resources management

• Introducing several problem-solving approaches

• Excessive concentration of the pilot phase in one small geographic area

• Make employee motivation orientation relative to a program (activity)

• Having a project spirit in activity implementation

• Obtaining incorrect results under pressure

Practices that are recommended

• Identifying what motivates stakeholders

• Implementing a stakeholder motivation system

• Implementing a plan to orient new employees

• Promoting self-evaluation

• Establishing a package of fundamental values for the team to operate properly

• Signing a contract with the workers to decrease employee mobility

• Budgeting QA activities in the health zone action plans

The lessons learned from this experience will guide QA implementation in the departments of Zou and Collines and will contribute to preparing the QA scaling-up strategy at the country level.

Quality of care and Health Mutuelles in Borgou/Alibori

A study on the quality and cost of the care administered to the mutuelle members of Sinendé and Banikoara revealed that the level of compliance with care norms/protocols was just 40% among mutuelle

members who received care. The providers themselves analyzed the reasons for this gap, and the analysis identified problems related to the skills of the employees who provide the care and inventory shortages of essential drugs. A plan to improve the quality of services was prepared in each commune and each partner made a commitment. PISAF will provide technical and financial support to implement these plans, in which provider training plays a very important role. For this purpose, a summary of training needs was included in a training plan that PISAF will incorporate into a collaborative that will integrate the quality of care and health mutuelles.

Study trip to Niger on collaboratives

A Beninese delegation of ten (10) members was in Niamey from August 11 to 18, 2007 for a study trip on quality improvement collaboratives. This delegation included PISAF technical staff members (the Director of PISAF, Quality Assurance Advisor, Malaria Advisor and Technical Advisor for Borgou/Alibori) and the partners from the Ministry of Health (the Minister’s Quality Assurance Advisor) and the Zou/Collines and Borgou/Alibori Departmental Health Directors and the Coordinating Physicians from the health zones of Covè/Zagnanado/Ouinhi, Dassa/Glazoué and Bembèrèkè/Sinendé. The goal of this trip was to better understand the quality of care improvement strategy through Niger’s experience in collaboratives. The visit included three phases:

Participation in the national workshop on the experiences of quality improvement collaboratives in Niger’s reference hospitals and maternity centers. This also enabled the delegation to better understand the role the collaborative plays in improving the quality of care and services, to adopt the best practices that have a positive impact on the SONNE, ETAT and NUTRITION. Six (6) strategies were selected to make sustainable the accomplishments of the three collaboratives (ETAT, SONNE and NUTRITION): i) strengthening staff skills; ii) promoting teamwork; iii) coaching, iv) learning/experience-sharing sessions; v) monitoring of self-assessment indicators; and vi) institutionalization of the acknowledgement of work well done. During a visit to the hospitals and maternity centers in Niamey and working sessions at the Ministry of Health and URC’s Niger office, interviews were conducted with the quality improvement teams. In addition, the genesis of collaboratives in Niger and the stages for implementing the collaborative and the operations of the improvement teams came to be understood, and information on IMCI training was provided in six days.

The debriefing for the Beninese delegation involved identifying the lessons learned and making recommendations. The principal lessons learned can be summarized in eleven (11) points:

• Stakeholder commitment at every level of the health pyramid,

• Massive acceptance of change,

• Teamwork,

• The existence of a concept of duty, reporting and the obligation to produce results,

• The importance of data management and monitoring,

• Dominant intangible motivation,

• On-site training,

• Organization of coaching sessions for just-in-time training,

• Including basic QA in clinical and management training,

• A six-day IMCI course,

• An improvement approach based on the trial philosophy after a baseline assessment. The delegation made recommendations and agreed to support the implementation of the collaboratives in Zou/Collines and Borgou/Alibori and to promote Quality Assurance in Benin.

Table 15: HZMT performance in using data for decision-making

HZMT performance in organizing decision-making sessions based on the data in 2007

1st quarter

2nd quarter 3rd quarter Performance

(average)



Covè-Zangnanado -Ouinhi (COZO) 100% 100% 100% 100%



Savé-Ouessè (SAO) 0% 100% 100% 67%

Zou/Collines 83% 83% 100% 89%

The table above indicates that average HZMT performance in decision-making based on data is 89%. This is excellent in a quality assurance implementation context and particularly in the collaboratives in view of the importance of QA data. The use of data for decision-making is thus widespread in the departments of Zou and Collines, and this will facilitate the implementation of the collaboratives. We note that this performance remained stable in the first and second quarters (at 83%) before reaching 100% in the third quarter of 2007 as the following graph illustrates.

HZMT performance in organizing decision-making sessions

based on data in 2007

83% 83%100%

0%20%40%60%

80%100%120%

1st qtr. 2007 2nd qtr. 2007 3rd qtr. 2007

Zou/ Collines

Support for the refurbishing of health facilities in Zou/Collines

After visiting ten health centers in poor condition in Zou and Collines, six (6) centers consisting of 11 health infrastructures were selected to be refurbished. The requests for proposals are being prepared in

order to obtain estimates for each infrastructure to be refurbished/rehabilitated. Proposal selection is scheduled for November 2007. Table 16: Health centers selected for renovation/rehabilitation

Zou Collines

Observations Health centers

Infrastructures to be renovated/rehabilitated

Health centers

Infrastructures to be renovated/rehabilitated

Avlamè Maternity center Glazoué Maternity center

Housing for midwives Gbanlin Maternity center-dispensary-housing

Entire building

Housing for nurses Doyissa Maternity center-dispensary-housing

Entire building

Akiza Maternity center

Dispensary

Housing for nurses

Housing for midwives

Tanvè Maternity center-housing Entire building

Identification of technical medical equipment and materials

It was found that medical/technical materials and equipment must be provided to improve the quality of care in the public health facilities of Zou and Collines. That is why an inventory of the health facilities’ needs in this area was taken by the DDS and HZMTs in 2007. It remains to be checked in the field whether these needs are accurate in order to avoid duplication, especially since other partners such as UNICEF, the Swiss Health Project and the Program to Support Health Development have planned to provide the health facilities in their coverage zones with equipment and materials.

2.2.4. Financial access to health services increased

Documentation of best practices and lessons learned from the experience of implementing

health mutuelles in Borgou/Alibori

Analyzed the quality and cost of the care administered to mutuelle members in Sinendé and Banikoara

This analysis was initiated to evaluate the level of quality of care administered to mutuelle members and to identify the factors that impact the cost of care in order to introduce a change package to improve the quality of care. There were several steps: i) data collection using vouchers for care administered to the mutuelle members of Sinendé and Banikoara; ii) processing and analysis of data collected on the quality of the care administered to mutuelle patients from Sinendé and Banikoara; and iii) support for holding thought-sharing and self-assessment workshops between the health mutuelles and care providers in Sinendé and Banikoara.

Data collection using the vouchers for care administered to the mutuelle members of Sinendé and Banikoara between January 1 and November 30, 2006

The members of the Banikoara and Bembèrèkè-Sinendé Health Zone Management Teams (Coordinating Physician/Head Physician, Central Midwives and Lead Nurses) were fully involved in this. Their

effective participation was an advantage and a chance to make this activity a success. This activity consisted of a documentary analysis to assess the quality, the cost of care administered to the mutuelle

members, and the availability of generic drugs in the health facilities. A meeting with the mutuelle

managers and the health workers was held to obtain their opinions on the relations between care providers and mutuelle members. This support from PISAF seeks to improve the quality of the care and services offered to the mutuelle members as well as the financial viability of the health mutuelles in Sinendé and Banikoara. Visits were paid to all of the health mutuelles in Banikoara and Sinendé. This made it possible to review the 224 care vouchers for the 597 mutuelle members treated in Banikoara and the 297 care vouchers for the 1,390 mutuelle members treated in Sinendé during the period. It was noted with satisfaction that the mutuelle members in Fô-Bouré (Sinendé) today account for 20% of the patients treated in this health center. This study identified much care that was avoidable, as well as abuses by certain mutuelle member households and even health workers, with a significant financial impact. Immediate on-site feedback to the health workers is leading them to promise positive behavior changes over the coming months. The results of this analysis will be used as inputs for the workshops that assess collaboration between the health mutuelles and care providers. According to the lead nurse in Founougo: This activity will expose the [practices of the] health care workers, but if it continues, it will straighten out the workers and will be beneficial for the mutuelles. We

never thought that one day a team would assess the care vouchers we have administered to mutuelle patients over the last year.”

Processing and analysis of the data collected on the cost of care administered to mutuelle members from Sinendé and Banikoara

This was made possible by Epi info 6.4 software. Thus, an input screen was created and the 521 forms that were entered represent the total number of care vouchers analyzed in Banikoara and Sinendé, which was 26% of all care vouchers. By analyzing these results, we found that:

• The health care services usage rate by mutuelle members is 64.6% in Sinendé and 53.9% in Banikoara.

• In terms of the quality of care, around four out of ten patients in Sinendé and Banikoara receive quality care.

• On the average, 15% of the costs of care in Sinendé are deemed avoidable, versus 13% of the costs of care in Banikoara.

Thus, the factors that explain the high cost of the care administered to mutuelle members were identified in both communes.

Support for holding thought-sharing and self-assessment workshops between the health mutuelles and care providers In an effort to improve the partnership between the health providers and the mutuelles, PISAF facilitated the organization of thought-sharing and self-assessment workshops in Sinendé and Banikoara. Held on Wednesday, February 7, 2007, there were 33 participants (eight of whom were women) at this workshop, including 12 care providers from Sinendé and the Bembéréké/Sinendé HZMT, 14 mutuelle managers, three partner representatives (PROMUSAF, UNFPA and the Program to Support Health Development), three representatives from the Mayor’s office and the Borgou/Alibori DDS, the Director of PISAF and PISAF’s QA Advisor. In contrast, in Banikoara, the workshop was held on Thursday, February 8, 2007, and 44 participants attended (nine of whom were women). The Mayor of the commune opened the workshop, along with the DDS and the Department Head of Community Health from the Ministry of

Health. There were 20 health workers/HZMT members from Banikoara, 22 mutuelle managers, and the Borgou/Alibori DDS and a representative from the Ministry of Health also attended. At these workshops the participants shared thoughts on the results of the two years of service for health mutuelles and the difficulties, which include low membership rates, poor dues collection and, in one case, a high level of claims in the Sinendé centre health mutuelle. In particular, of the ten mutuelles in Banikoara, two are in arrears (Founougo and Kokey). The main reason mentioned is the influence of local leaders with different political leanings. In this regard, advocacy was conducted at the same time with the Mayor by the DDS, the Banikoara zone hospital director and the head of the community health department. A proposal was made to have the DDS in person organize an awareness meeting for the people of these localities. The major challenges to be met are volunteerism and member retention. The presentation and discussion of the quality analysis and the cost of the care administered to the mutuelle members in 2006, which are a reference database, sparked much interest and made it possible to understand the factors and the behaviors of care providers as well as mutuelle members that generate avoidable costs for the mutuelles. The reflections of the participants during the breakout sessions were validated in the plenary and were used to set objectives to improve and identify activities to upgrade the quality of the care the providers offer and the relationship between these two stakeholders. To finalize this process, the Director of PISAF said the project was ready and willing to support the DDS and HZMT to prepare action plans for each arrondissement mutuelle. Preparation of these plans was scheduled from February 20 to 23, 2007.

Mid-term evaluation of the health mutuelles supported by USAID in Borgou/Alibori The mid-term evaluation of the health mutuelles supported by PISAF in Borgou and Alibori is the option selected to document the best practices and lessons learned from the experience of implementing the health mutuelles in Borgou/Alibori. This activity received support form an international consultant, Jean Damascène Butera, of Abt Associates. There were six principal stages in this evaluation, as follows: i) installing the evaluation steering committee and validating the data collection strategy, methodology and tools; ii) training the members of the evaluation team; iii) collecting the quantitative and qualitative data; iv) transcribing the focus groups cassettes; v) processing and analyzing the quantitative and qualitative data; and vi) presenting the preliminary results to the steering committee and discussing the results.

(a) Installing the evaluation steering committee and validating the data collection strategy, methodology and tools: To involve the stakeholders in the health system, the mutuelle members, local authorities of Sinendé and Banikoara and the promoters of the health mutuelles, an evaluation steering committee was set up. This committee was established to serve as a framework for orientation and for monitoring the evaluation. The committee consists of sixteen members who represent the institutions and partners involved in health mutuelle development in Borgou, Alibori, Zou and Collines. The committee members were identified and appointed specifically by their respective structures. The steering committee’s principal assignment is to: i) validate the evaluation methodology, including the data collection instruments; ii) support the implementation of the evaluation by giving the data collectors the contacts, files and documents they may need; iii) validate the results of the evaluation with the mutuelle

representatives, care providers, local elected officials and other civil society associations; and iv) contribute to disseminating the results of the evaluation. A steering committee installation and strategy, methodology and data collection tools workshop was organized in April 2007 in the Borgou/Alibori DDS conference room. Fourteen of the 16 expected

steering committees attended. The Borgou/Alibori DDS and the DNPS community health department head co-chaired the workshop. (b) Training the members of the evaluation team The evaluation team is a multidisciplinary team comprised of six members. To give the team members the same vision and perception of the evaluation, an orientation session was organized for them on health mutuelles and data collection strategy, methodology and collection tools. (c) Quantitative and qualitative data collection The data collection phase occurred in two stages; the first was the quantitative data collection stage and the second was the qualitative data collection stage. (d) Quantitative data collection The quantitative data pertain to the results of the health mutuelles from the time they were created until the first quarter of the current year. These data were collected in the four (4) health mutuelles in Sinendé (Fô-Bouré, Sikki, Sékérè and Sinendé centre) from April 3 to 6, 2007, and then in the ten health mutuelles

in Banikoara from April 23 to 27. Data was collected from 2004, 2005, 2006 and the first three months of 2007. All the registers (of members, beneficiaries, dues and services), membership receipts, care vouchers, ledgers, CLCAM booklets and monthly health mutuelle monitoring sheets were examined. (e) Qualitative data collection The qualitative data pertain to stakeholder opinions, impressions, attitudes and behaviors relative to health mutuelles. The data were collected from April 23 to 26, 2007 in Sinendé and from April 27 to May 5, 2007 in Banikoara. During these periods the evaluation team members held sixteen (16) focus groups consisting of 156 persons; they held interviews with the key informants comprised of health mutuelle

officers, HZMT members, the DDS, care providers (nurses and midwives), COGECs members , local elected officials (mayors and arrondissement heads), farmer organizations (UCPC and UCGF), development associations, health mutuelle promoters (PROMUSAF, BORNEFONDEN and PISAF), and the central level (Ministry of Health). (f) Transcribing the focus groups cassettes The focus groups were held in the local language, and in “Bariba” in particular; they are recorded on audio tapes. To enable the lead consultant to use the data from the focus groups judiciously, the data collectors transcribed the data from these focus groups into French.

(g) Processing and analyzing the quantitative and qualitative data The data are processed and analyzed using conventional interview analysis techniques. In particular, the thematic analysis is done with Atlas.ti5.2 software, which generated some preliminary results that were presented to and discussed with the steering committee members. (h) Presenting the preliminary results to the steering committee and discussing the results This workshop, which took place on May 11, 2007 during a workshop held in the Borgou/Alibori DDS conference room, was attended not only by the steering committee members, but also by a few community representatives. Thus, 24 participants took part in the workshop from the Ministry of Health (DNPS and DPP), the departmental health directorates of Borgou/Alibori and Zou/Collines, the Bembéréké/Sinendé and Banikoara health zones, the mutuelle representatives and producers, and the development associations of the two communes, with the Mayor of Sinendé. The lead consultant presented the preliminary results to the steering committee. In terms of results, the evaluation made it possible to observe that the health mutuelles have:

i) improved the use of health care and services for the members who are current in their dues three to five times more than for non-members;

ii) contributed to funding the health centers by 2 to 12% by regularly reimbursing care services, and they have a credit balance at the end of each year;

iii) protected revenue and the physical property of the mutuelle members who are current in their dues and reduced the use of self-medication and traditional practitioners. Both members and non-members have a high opinion of the health mutuelles;

iv) induced a behavior change in the people in terms of health as shown by a Fô-Bouré mutuelle member:

However, numerous challenges must still be met. These are: i) the low membership rate and the low percentage of members who are current in their dues; ii) the people’s ignorance; and iii) the fact that some health mutuelles are dysfunctional. The decision was made to disseminate the final results of the evaluation to the central and department levels and to the two pilot communes. Supported organizational and managerial capacity building for existing mutuelles in

Borgou/Alibori

Introduced the QA/collaborative model in the health mutuelles The QA/collaborative model was introduced in the health mutuelles supported by PISAF through three main activities: i) holding workshops to prepare care quality improvement and health mutuelle

performance plans in the health mutuelles of Sinendé and Banikoara; ii) training the care providers in EONC/AMTSL and IPS to strengthen their skills in providing quality care; iii) providing orientation to the care providers in the Sinendé and Banikoara health centers on the “link between the quality of care and health mutuelles.”

(a) Prepared the health mutuelle performance improvement plan and the plan to improve the quality of care in the health centers in Sinendé/Banikoara In accordance with the recommendations of the thought-sharing and self-assessment workshop for the presentation and discussion of the results of the study of the quality and cost of care administered to mutuelle members, PISAF provided technical and financial assistance for holding workshops. The purpose was to prepare the plans to improve health mutuelle performance and to improve the quality of care provided by the health centers. Held in the UCPC conference room in Sinendé on February 20 and 21, 2007, 47 people participated in the workshop, including 15 health workers, five COGECs members, 15 mutuelle members and the Director of PISAF, the Borgou/Alibori DDS, and the Mayor’s representative. In Banikoara, where the workshop was held on February 22 and 23, 2007, 50 participants attended, including 22 health workers, five COGECs members and 14 mutuelle members, with the Director of PISAF, the PISAF/QA Advisor, and the Borgou/Alibori Advisor. To achieve the results of the workshops the participants identified the commune’s objectives and selected cross-cutting activities to be carried out by all the mutuelles. Three objectives were thus identified for the commune: i) improving membership rates; ii) collecting dues; and iii) improving the quality of care. Thus, each arrondissement mutuelle, together with the health workers and COGECs members, specified their objectives and proposed and budgeted the activities to carry them out with a monitoring plan. To implement these plans, the participants decided to put in place one team per arrondissement that would be in charge of presenting the workshop results and carrying out and monitoring the planned activities. A communal monitoring committee will also be set up to serve as a framework for periodic experience-

“We were not in the habit of paying dues and waiting for illness to come; today, the health mutuelle has changed our behavior toward illness, because illness took us by surprise.”

Words of a Fô-Bouré mutuelle member

sharing among the teams of the four (4) arrondissements. These teams were set up in each of the 14 mutuelles and received PISAF support for introducing the QA collaborative in the health mutuelles.

(b) Trained care providers in EONC/AMTSL and IPS to strengthen their skills for providing quality care. The analysis of the reasons for the poor quality of care found by the study of the care vouchers identified training needs for the care providers. The training needs the stakeholders identified were: EONC/AMTSL and the Integrated Provision of Services (IPS). This training was conducted jointly with the PISAF technical staff members who are in charge of the “Quality Assurance” component. (c) Oriented the care providers from the Sinendé and Banikoara maternity centers on the link between health mutuelles and quality of care In anticipating of implementing the collaborative on health mutuelles and the quality of care, PISAF technical staff members oriented all the midwives, nurses and nurse’s assistants from the maternity centers in Sinendé and Banikoara on “the link between the health mutuelles and the quality of care” to strengthen their knowledge and skills to satisfy the mutuelle clients. Skill-building was integrated with the training of the providers from the maternity centers of the two communes on Emergency Obstetric Neonatal Care (EONC) from May 27 to June 29, 2007 in Banikoara and 65 health care workers were trained (physicians, midwives, nurses and nurse’s assistants). PISAF took this initiative because the stakeholders identified and expressed the needs for strengthening the health workers in EONC based on the analysis of the quality and cost of the care administered to the mutuelle members. The topics discussed were: i) the effects of health mutuelles on the quality of care; ii) the contribution mutuelles make to financing health and reducing the three levels of delays in providing care for obstetric and neonatal emergencies; and iii) care provider and HZMT roles and responsibilities in promoting health mutuelles.

During this training, the care providers were trained through role-play to make pregnant women aware of health mutuelles during Focused Antenatal Care and through the organization of referrals and counter-referrals. With this EONC training, health mutuelle awareness was incorporated into the delivery plan, which includes the key points that care providers are to address during antenatal consultations. Provided technical support to build the capacity of mutuelle managers in the area of social

mobilization

Communication for the social mobilization of the people to join health mutuelles is a main pillar of choice for PISAF in supporting health mutuelles because the communities do not have a health insurance culture. Several types of support were given to the local stakeholders to motivate the communities of Sinendé and Banikoara to join and remain members of health mutuelles. These are: i) support in preparing health mutuelle communication plans through local radio stations; ii) preparation of technical data sheets to produce radio programs on health mutuelles; iii) signing a partnership contract with FM Nonsina, the community radio station in Bembèrèkè, and Radio rurale Banigansé in Banikoara. (a) Prepared communication plans on the health mutuelles through the local radio stations To facilitate communication and to promote the health mutuelles through local radio stations, PISAF provided technical and financial assistance to the health mutuelle stakeholders of Sinendé and Banikoara to prepare communication plans. These plans were prepared during workshops organized at the same time in Sinendé and Banikoara on January 17 and 19, 2007. In Sinendé, 17 participants attended, including five mutuelle managers, the community facilitator from the Sinendé mutuelles, five health workers, three radio hosts and four COGECs chairpersons. In Banikoara, 26 participants attended the workshop, including eight health workers, three radio hosts, 11 mutuelle managers and three COGECs members, as well as the Banikoara mutuelle community facilitator. The general goal of the workshops was to have the stakeholders identify a frame of reference, a compass in the area of communication to promote health

mutuelles through local radio stations. By the end of these workshops, the participants had assessed the problems health mutuelles face in the area of communication, identified the themes for the program, and prepared the communication plan through FM Nonsina de Bembéréké, the community radio station, and Radio rurale Banigansé in Banikoara. By the end of these workshops, the participants recommended organizing training for the mutuelle managers, radio hosts and a few resource persons involved in producing the radio programs so that they would have the tools they need as well as reference documents for the different themes that were identified.

(b) Prepared technical data sheets for producing the radio programs on health mutuelles For the purpose of providing documentation to the Banikoara local radio hosts and the Bembéréké community radio hosts to produce effective programs on the health mutuelles, the technical staff persons from PISAF prepared technical data sheets on the priority topics for the local health mutuelle

development stakeholders. Eight themes were developed: i) health mutuelle benefits for individuals, their families and for the community; ii) mutuelle member duties; iii) the procedures for joining a health mutuelle; iv) women’s contributions to developing health mutuelles and the merit health mutuelles have for women; v) stakeholder contribution to the development of health mutuelles (local elected officials, care providers, the Health Zone Management Team, the Departmental Health Directorate, opinion leaders and promoters); vi) the relationship between care providers and mutuelle members; vii) the role of the commune level committee to support the development of health mutuelles; viii) low buying power and alternatives for joining a health mutuelle. The radio hosts have now received orientation on the goals by theme, the essential questions to be asked of the persons who will be interviewed, followed by answers, and the profiles of persons to be involved in producing the program on each theme. These data sheets may also be used by mutuelle managers and care providers at the social mobilization sessions (group facilitation, individual interviews, advocacy, etc.). Likewise, a flyer on health mutuelles was designed for use as an Information, Education and Communication (IEC) tool for the people in general, and for students and schoolchildren in particular, to generate higher membership rates in health mutuelles.

(c) The health mutuelles and local radio stations signed the partnership contract

The partnership contract is part of the support that PISAF provide to promote and develop health mutuelles in Sinendé and Banikoara. Through this partnership, these radio stations are to produce and broadcast radio programs, communiqués, spots and Information, Education and Communication messages on health mutuelles in Bariba and Peulh, the local languages. The annual cost of the contract with each radio station is one million six hundred eighty thousand francs (FCFA 1,680,000, which amounts to about US$4,000). A system for monitoring compliance with the contract clauses has been implemented to assess program quality and the impact on the communities and health mutuelles.

Supported capacity building of health workers in Sinendé and mutuelle managers in Banikoara

on their roles and responsibilities

(a) Trained health care workers newly assigned to Sinendé and of the new mutuelle managers in health mutuelle management concepts and tools

PISAF provided technical and financial support for this training attended by 25 participants, consisting of 18 health workers and seven mutuelle managers. The goal of this training was to strengthen the knowledge and skills of these stakeholders in the health mutuelle approach to facilitate the medical care of mutuelle members in the health facilities and to negotiate the partnership between the care providers and health mutuelles. The main topics addressed were: i) health insurance; ii) the fundamentals, specific features, principles and bases for health mutuelle operations; iii) internal organization and services that a health mutuelle provides; iv) the role of health workers and the partnership agreement between care

providers and mutuelle members; and v) the health mutuelle management system, with emphasis on management tools, completing them, membership management, dues, the provision of care and the problems mutuelle members and care providers face. At the end of this workshop the participants expressed their commitment to support and participate in the development of the health mutuelles in the commune. (b) Trained the new elected mutuelle managers from Banikoara in their roles and responsibilities At the general assembly meetings of the Banikoara health mutuelles organized in 2006 some mutuelles

replaced their management bodies, such as the officers, board of directors and supervisory committee. Thus, new mutuelle members were elected. To enable these new democratically elected managers to fully play their roles, a session was organized to strengthen their knowledge about mutuelles and management tools. This training was held in the Banikoara HZMT conference room from September 4 to 6, 2007 and 22 participants attended, four of whom were women. They were the new officers for the health mutuelles

of Gomparou, Goumori and the members of the health mutuelle supervisory committees of Toura, Kokiborou, Ounet, Soroko and Gomparou. Through various facilitation techniques, the participants were trained in the method of operating a health mutuelle, techniques and tools to manage membership, dues, the provision of care, the management of the principal risks related to a health mutuelle, monthly monitoring, techniques for auditing the management of a health mutuelle, and organizing and holding meetings. The participants are now proud and able to take on their responsibilities to improve the management of their health mutuelle by carrying out the activities they planned at the end of the workshop.

Provided technical and financial support for eight general assembly meetings of health

mutuelles in Banikoara.

In the first quarter of 2007 (USAID), PISAF provided support to eight (8) health mutuelles in Banikoara for holding their general assembly meeting. They were the mutuelles of Goumori, Gomparou, Sompérékou, Soroko, Kokiborou, Banikoara centre, Ounet and Toura. This enabled them to introduce the mutuelle members to comprehensive management with special emphasis on how the management bodies operate in terms of activities carried out, the care provided to the beneficiaries, and the difficulties encountered in making decisions to improve results. The local authorities who took part in these assemblies grasped the extent of the efforts made by the mutuelle managers, as the Ounet arrondissement head stated. After the activity report of his locality was presented, he expressed his great satisfaction as follows: “I didn’t know that the mutuelle did so much work: 374 beneficiaries paid dues of 606,200

francs and 119 obtained care at the health center through the mutuelle.” It should be indicated that most of these mutuelles face consumption problems and low dues collection rates. The decisions that the mutuelle members make democratically pertain to limiting the use of care, annual dues and rejuvenating the mutuelles though a major information and awareness campaign carried out by the stakeholders and through the local radio station. Technical support for jump-starting the Founougo and Kokey health mutuelles To have these two communities make their health mutuelles operational, PISAF supported the mutuelle

development stakeholders to carry out several activities:

• The HZMT held a working session with the mutuelle managers, health workers and some COGECs members from Founougo and Kokey to identify ways and means to reenergize these mutuelles.

• Support for the mutuelle managers for organizing and holding the general assembly meetings of the two mutuelles.

At these meetings it was noted that the members of the Founougo mutuelle are highly motivated; they wanted to start providing services in February 2007. In contrast, in Kokey, the officers and the members of the board of directors must be replaced to ensure that the mutuelle is operational. Created continuing local technical support mechanisms for mutuelles in Borgou/Alibori

These are primarily advocacy and monitoring activities that PISAF technical staff members carried out for the mayors’ offices and the commune level committees to support the development of the mutuelles in Banikoara and Sinendé in a way that is integrated with activities in the field. Thus, along with training for the care providers in the Banikoara zone hospital, PISAF technical staff members carried out advocacy with the Mayor of Banikoara to request his support for the Communal Union of Health Mutuelles in Banikoara. The Mayor gave his commitment to provide the union’s headquarters with furniture and office supplies by the end of 2007, and to provide fuel to the union’s managers for their activities. Likewise, there was an advocacy activity with the Office of the Mayor of Sinendé, which agreed to finance the arrondissement health mutuelles and the Communal Union’s social mobilization activities scheduled for the fourth quarter of 2007 up to the amount of eight hundred thousand francs (FCFA 800,000). The advocacy was organized by monitoring the implementation of the health mutuelle communal support committee 2007 action plans. Supported the creation of a regional federation of mutuelles in Borgou and Alibori

Operationalized the hospital case management system by the Sinendé and Banikoara health mutuelle

networks

PISAF provided technical and financial support for the Sinendé and Banikoara communal health mutuelles so that they would be able to operationalize their technical function, which is to organize management in pools of referral care. The stakeholders were heavily involved in this process, which took about ten months. The different stakeholders carried out the following activities which were the principal stages of setting up referral care for the mutuelle members in Sinendé and Banikoara:

• Prepared data collection tools to identify services packages/supplemental dues,

• Collected data in the peripheral health centers of Sinendé and Banikoara and in the zone referral hospitals (Bembèrèkè and Banikoara),

• Processed and analyzed data that had been collected,

• Identified scenarios for the case management of referral care,

• Held consensus and validation workshops for the mutuelle members and care providers for case management scenarios and proposed referral cares,

• Designed and produced communal union management tools (7,000 membership cards, 160 receipt booklets and 34 registers provided to the management bodies of the mutuelles in Borgou/Alibori,

• Trained communal union officers of the health mutuelles of Sinendé and Banikoara in the communal union management system (49 members of management bodies),

• Raised the awareness of the people to encourage them to join the base mutuelles and the Union,

• Prepared draft partnership agreements between the zone hospital care providers and the communal unions of health mutuelles,

• Organized information sessions for the personnel of the peripheral health centers on the system for providing care for traveling mutuelle members and procedures for referring mutuelle members to the zone hospitals (62 health workers were met),

• Trained care providers in Bembèrèkè and Banikoara in the system for providing care for referred mutuelle members. During the training sessions, the partnership agreements between the zone

hospital care providers and the communal health mutuelle unions were amended and validated (124 zone hospital care providers were trained),

• Monitored the establishment of the management system and took stock of membership in health mutuelle communal unions,

• Organized advocacy in Sinendé to negotiate lower patient transportation costs to the zone hospital for referrals,

• Prepared the list of members/beneficiaries current in their dues to the union of health mutuelles. This list was submitted to the different units of each zone hospital.

At the end of the partnership contract validation workshop, the Director of the Bembèrèkè-Sinendé zone hospital evaluated the participatory process used to support the stakeholders in these words: “the participatory approach PISAF used to validate the contract, which contains sufficient detail, will help

avoid the stumbling blocks between the care providers from the Bembèrèkè zone hospital and the

beneficiaries on the one hand, and between the officers of the Sinendé communal union of health

mutuelles and the hospital administration on the other hand.” The network of mutuelles for providing hospital care actually began providing services on August 1 in Sinendé and on September 1, 2007 in Banikoara, even though the number of members and beneficiaries are relatively small (62 members with 460 dependent beneficiaries in Sinendé and 50 members with 283 beneficiaries in Banikoara). Developed a partnership between promoters to support health mutuelles

Creating synergies in the stakeholders’ role is one requirement generated by the emergence of health mutuelles. That is why PISAF, as part of UNFPA support to the DSF/MOH for EONC case management, agreed to provide technical assistance to the DFS/MOH to prepare the action plan to support the health mutuelles in the Bembèrèkè-Sinendé health zone. One of the results of this partnership is that five Yamaha motorcycles were provided to the health mutuelles in Sinendé through the DSF/MOH using UNFPA funding. Likewise, to facilitate collaboration between the health mutuelles in the Bembèrèkè-Sinendé health zone, the Support Program for Health Mutuelles in Africa (PROMUSAF) organized a workshop to identify avenues for collaboration between the health mutuelles of the two communes. The programs that were selected will be carried out next year.

Technical support for the Borgou/Alibori DDS to train researchers and support social mobilization Guided by the desire to make the research and social mobilization support managers working in the health zones more functional, the Departmental Health Directorate in Borgou/Alibori organized a training session for them with support from Swiss Cooperation. To enable the participants to better grasp the challenges inherent in the health mutuelles for Benin’s health system, the Borgou/Alibori DDS requested technical support from PISAF. To this end, PISAF supported the training session by presenting a paper on health mutuelles in Benin. This helped the participants better understand the overall context in which the health mutuelles are emerging in Benin, the health micro insurance systems in Benin, the current situation of health mutuelles in Benin, and in Borgou/Alibori in particular, the issues the mutuelles present for Benin’s health system, and finally, the outlook for health mutuelle development in Benin. This presentation was the opportunity for PISAF to explain the role the research and social mobilization support managers will have to play in the development of health mutuelles in Benin.

2.3. Intermediate Result 3: Demand for health services, products, and preventative measures increased This Intermediate Result is the third that contributes to USAID/Benin strategic objective 5. The activities that contribute to achieving IR 3 are: improvement of community knowledge and attitudes toward prevention measures and appropriate behaviors; and support for the creation of a sociocultural environment that fosters the use of services and prevention measures.

2.3.1. Sub IR 3.1: Knowledge of appropriate behaviors and preventative measures

improved

Involvement at the national level in discussions about key messages and media

The national level was heavily involved in pretesting PMTCT teaching tools through the PNLS, the DSF and the DNPS’s IEC Department. The relevant observations made by the National PMTCT Manager told us that heat-treating breast milk to feed newborns of HIV+ mothers has not yet been adopted in Benin’s national nutrition guide. We also held three working sessions and exchanged emails with the Head of the DSF Family Planning Department on the content of the FP flyer that is now being adapted. Technical assistance from URC in the development and implementation of a BCC strategy

This technical assistance consisted of a consensus about the behavior change continuum model to be proposed in PISAF’s BCC strategy. The change continuum that was selected is based on a BCC strategy that begins with raising awareness and evolves into a positive attitude and the actual adoption of the desired behaviors. Our exchanges with headquarters also helped to develop the main points of the strategy and the potential partners to be involved in implementation. Thus, we made the decision to begin development of BCC teaching tools with family planning and with nutrition and feeding for infants born to HIV-positive mothers. We had a detailed discussion with URC on understanding the role BCC plays in achieving PISAF’s Intermediate Results. Thus, other than the advocacy role that BCC plays, we reviewed the three basic components to be taken into account in preparing a BCC strategy. They are: i) use of advocacy to change people’s attitudes; ii) improving people’s knowledge; and iii) getting people to change their practices.


• PISAF’s BCC strategy was prepared and validated

• In COZO, 25,735 persons were made aware of how to correctly use LLITNs

• In DAGLA, 17,826 persons were made aware of how to prevent malaria

• 7,500 persons were made aware of HIV/AIDS prevention and transmission methods

• 152 blood pouches were collected during the social mobilization week for blood donations in Savé/Ouèssè

• 30 door-to-door health and sanitation awareness days were carried out by 20 NGO workers in the city of Bohicon for malaria prevention

• Six IEC/BCC tools on food for newborns of HIV+ mothers were adapted and printed

Capacity building of health workers and other partners in BCC/IEC and Interpersonal

Communication

The involvement of the BCC counterpart from the DDS in the process of pre-testing the PMTCT teaching tools is an excellent opportunity for learning to develop communication tools. The BCC counterpart from the DDS participated in all stages of pre-testing the PMTCT tools in the community with beneficiaries –mothers— and with potential users of the tools—service providers. Moreover, we strengthened the capacities of nine NGOs and Women’s Associations, four local radio stations, three performers of Popular Traditional Music (PTM), and two Popular Theater Companies to design, translate into local languages, and disseminate prevention messages on malaria and STIs/HIV/AIDS. Supported the development and implementation of innovative BCC strategies

The innovative BCC strategy that was developed and implemented this year is the combined approach that we used for the malaria social mobilization campaigns in Dassa/Glazoué and Bohicon. The strategy involves mobilizing and involving several stakeholders in the community social development component for implementing BCC activities. This strategy proved to be quite effective because it brought together the NGO community facilitators, radio hosts, PTM artists, and town criers who disseminate the same messages, in the same words and languages, during the same period, and to the same target populations. This assures the communication of unified messages and avoids the confusion resulting from contradictory messages. Provided support for IMCI and community EONC

The process of implementing community IMCI and EONC began with the preparation and validation of the Community Mobilization Strategy paper. Next we identified the principal stages in the process, which led to the choice of the pilot startup zones, estimating the number of community health workers, and the choice of the startup theme. The actual community mobilization activities will begin in FY 2008. Updated the inventory of IEC materials, analyzed them for use at the community level, and

adapted or translated the materials into local languages

The IEC materials inventory showed that there are very few materials available, particularly on malaria and PMTCT. For malaria, the change in treatment policy at the national level requires that we revise all existing materials that deal almost exclusively with chloroquine. The existing materials will be translated into local languages and new materials will be produced to meet the national malaria and HIV/AIDS policy requirements in 2008.

Printed and disseminated IEC materials and job aids

We adapted and printed the following six job aids on nutrition and feeding for infants born to HIV-positive mothers: a flyer on exclusive breastfeeding; a flyer on feeding using infant formula; a flyer on feeding babies after the age of six months; a poster (job aid) on the requirements to be met for feeding with infant formula; a poster (job aid) on the risk for 20 newborns born to HIV-positive mothers when they are exclusively breastfed versus the risk of feeding with infant formula; and a poster (job aid) on the best choice for breastfeeding newborns of HIV+ mothers. For family planning, the only material we inventoried was a flyer which is now in the adaptation process.

These different materials will be disseminated in FY 2008 following user training for providers and CHWs. Identified key BCC priorities for the year, including LLITNs, IPT, PMTCT, VCT, etc.

Three BCC priorities were identified for FY 2007: 1. For malaria: the efficient and effective use of Long Lasting Insecticide Treated Nets (LLITNs) to

prevent malaria in children under five. This is was the basis for the three major social mobilization campaigns in the health zones of Dassa/Glazoué, Covè/Zagnanado/Ouinhi and Zogbodomey/ Bohicon/Zakpota

2. For HIV/AIDS: feeding newborns born to HIV-positive mothers. The tools have been developed and will be disseminated in 2008

3. For Family Planning: a flyer explaining the FP methods available in health facilities is now being adapted. This flyer is intended to benefit providers and clients.

Implemented multimedia campaigns (by radio, TPM, etc.) on family health themes

Malaria campaign in Bohicon

The Bohicon campaign is centered on hygiene and sanitation to prevent malaria in this town, which has the highest health facility usage rate for malaria. Thus, over a period of ten days, ten teams of 20 community facilitators crisscrossed 20 neighborhoods in the town of Bohicon and raised the awareness of 8,460 persons (5,286 women and 3,174 men) in 129 homes. To accomplish this, the 20 community facilitators had an orientation day where the key messages on malaria, hygiene and environmental sanitation were presented. All the messages were completely translated into Fon, the main local language. Ten town criers (one per neighborhood) were involved in conducting the campaign. Each town crier delivered the messages in their neighborhood for ten days. All the activities were covered entirely by Radio et Télévision Carrefour (TVC) with which we signed a short-term contract to provide services. In an effort to facilitate coverage of the events and to produce high-quality segments, we invited two hosts from Radio et Télévision Carrefour to the consensus

workshop and the orientation workshop. Thus, TVC produced a report at the beginning of the campaign and broadcast it eight times.

During the period Radio Carrefour produced and broadcast, in Fon and French, 20 micro programs on malaria, hygiene and environmental sanitation. At the end of this awareness campaign, the Arrondissement Heads, in collaboration with the Neighborhood Heads and the managers of women’s and youth associations, prepared a schedule for carrying out a systematic and regular healthiness campaign in the city of Bohicon. This campaign, which was to take place every Saturday from 7 a.m. to 9 a.m., local time, began on June 16, 2007 and continued for ten days under the control of the communal authorities in accordance with the consensus and the commitments they made.

Social mobilization campaign for blood donation in Savè: The social mobilization week for blood donation took place from June 8 to 15, 2007. Participation by civil society and the administrative authorities was strong. The people of Savè sponsored the event by making 100 t-shirts for the blood donors.

Companies based in Savè participated as well. For example, SUCOBE, a sugar company, donated 200 liters of gasoline to the health center to go and pick up donors for emergencies after the campaign. During this campaign, 152 blood pouches were collected in the health zone. From this batch, 23 pouches were given to the Abomey departmental hospital, which was experiencing a shortage.

Awareness campaign on the proper use of LLITNs in COZO: Malaria is currently the leading cause of infant mortality in the health centers. Malaria accounts for 37% of consultations for all conditions combined. PISAF provided LLITNs through a pilot free distribution campaign in Cozo, followed by a major awareness campaign in the zone.

In the interest of achieving the goal, which is “to raise awareness by popular theater of the people of the Covè/Zagnanado/Ouinhi health zone on the proper use of LLITNs to prevent malaria in children under five,” PISAF sought the services of the “Gbénonkpo” theater company of Abomey to carry out the awareness campaign. This campaign lasted 20 days and covered 41 villages in the three communes of the zone. The Gbénonkpo company performed in 19 arrondissements and 41 villages, thus reaching a total of 25,735 persons (9,791 women, 3,726 men and 12,218 children).

The sketch that attracted people everywhere it went was entitled “For the Well-Being of the Children.”

All health workers, and the coordinating physician and his colleagues in particular, collaborated fully and particpated and supported this campaign. It is important to stress the predominant role that the local elected officials, opinion leaders and other resource persons played in mobilizing the community. At the end of each theatrical performance there was an educational chat session at which the participants shared the different lessons they learned with the actors, as well as the different

A mother and her child under five years old

receiving a long-lasting insecticide-treated bednet

The URC/PISAF team and Heath Zone Coordinator for

Cozo

resolutions they plan to make once they return to their families. This is one of the essential features of the session that is used to conduct a situational analysis and to measure the impact and extent of the messages that are delivered. In conclusion, we note that the different partners involved in this activity are satisfied with the importance of the messages and the method chosen to deliver them to the people. Subgrants to NGOs and CBOs and capacity building in the provision of community-based

services

As a part of the contracting process with NGOs, and in order to implement community mobilization activities, an informational workshop for NGOs was organized in Bohicon on May 22 and 23, 2007. The objective of this workshop was to inform the NGOs about PISAF’s community mobilization strategy and to evaluate their capacities to develop community health activities. Seventeen NGOs were present (15 national NGOs, CRS and TDH). The presentations by the various NGOs emphasized the intervention zones, the areas of intervention, and the accumulated successes and failures. The various presentations and discussions that ensued enlightened all the participants about the actual intervention capacities of the different organizations in the area of community health. The NGOs that attended are now more familiar with PISAF’s objectives and the results expected from the partnership. At the end of this workshop, the terms of reference were sent to the NGOs, asking them to submit a technical and cost proposal for implementing community health activities over a one-year period. The SILC approach (enhanced microfinance collectives), developed by CRS, was of interest to PISAF. This approach can be developed to strengthen people’s buying power through loans made to groups and micro health insurance for its customers through the social funds that are generated. This approach could be a prelude to implementing health mutuelles in Zou/Collines. This motivated PISAF to propose a partnership with CRS so that it could implement this approach in Zou and Collines, but CRS declined. With regard to the local NGOs, the various meetings with them to evaluate their capacities identified their institutional and managerial weakness. Moreover, most of them are working in very small geographic areas. Since PISAF has neither the mandate nor the means to strengthen NGO capacities, a decision was made to discontinue the strategy of giving grants to the NGOs. However, it was decided that the NGOs could play the role of service providers and PISAF will continue to build their technical capacities to implement health promotion activities.

Supported malaria mobilization days and social mobilization weeks

With the goal of improving knowledge, appropriate behaviors and prevention measures five social mobilization campaigns were organized.

AIDS social mobilization week as part of World AIDS Day 2006 This activity, organized in the Dassa/Glazoué health zone, was part of the 19th World AIDS Day. The city of Glazoué was chosen because it is a crossroads city with a 2.5% HIV prevalence rate, compared to the rates of 1.2% and 0.9% for the departments of Collines and Zou, respectively. Despite this high prevalence, Glazoué has not yet been chosen as a sentinel city for serosurveillance nor as an intense activity zone for making youth aware of HIV/AIDS prevention. Thus, to meet this need, awareness and voluntary free testing activities were organized for youth and the general public as part of the commemoration of World HIV/AIDS Day in Glazoué.

In total, eight discussion forums were organized in the middle schools of Dassa and Glazoué. Through these discussion forums, about 4,500 students were reached, and 300 of them were voluntarily screened for HIV/AIDS. An awareness booth was set up in front of the pharmacy in Glazoué, across from the international market, and about 3,000 members of the general public were reached.

Malaria social mobilization campaign during AMD 2007

A malaria social mobilization campaign was organized in the health zone of Dassa/Glazoué. This campaign was part of the commemoration of the 7th Africa Malaria Day (AMD 2007). Four types of activities were carried out in this campaign.

Educational chats Educational chats were led by the community facilitators from the Federation of Savings and Mutual Farm Credit Banks of Benin (FECECAM) and from an NGO, the Organization for Development in Rural Areas, in the cities of Dassa and Glazoué. FECECAM community facilitators covered three Idatcha villages in Dassa through educational chat sessions and 390 persons, 268 of whom were women, were reached. The ODMA NGO community

facilitators traveled to three Mahi villages in Glazoué and reached 260 persons, 167 of whom were

women.

Performances for the general public Performances for the general public were hosted by Popular Traditional Music artists (PTM) in 18 villages in Dassa and Glazoué. All the performances were covered by the two local radio stations involved in the campaign. The community facilitators from the NGO were also present at the performances to conduct the pretest before the performance, help with the contests, conduct the post-test at the end of each show, and estimate the number of attendees taking gender into account.

Mahi PTM artist Wessin performed for about 10,320 persons, including roughly 7,000 women, in the nine Mahi villages he crisscrossed with his company from April 14 to 23, 2007. Aloyo, his Idatcha counterpart, performed for about 6,000 persons, about 4,000 of whom were women, in the nine Idatcha villages to which he traveled with his company during the same period. Both artists performed at the same locations and in Dassa on April 25 for the official campaign launch attended by the political and administrative authorities and the U.S. Ambassador. The number of persons reached on this occasion is estimated at 500, including about 300 women.

Radio programs Illèma in Dassa and Collines FM in Glazoué are community radio stations that were involved in implementing this campaign. They covered all the activities of the NGO community facilitators and PTM artists. These radio stations produced audio documentaries on the educational chats and performances for the general public, and they are available in the PISAF media library. Two radio contests were organized by the two radio stations; the first ten listeners who correctly answered the questions received a long lasting insecticide treated net (LLITN). Each of the two radio stations produced and aired ten segments in Mahi and Idatcha, the local languages. Official AMD 2007 launch ceremony Following a decision by the government of Benin, the city of Dassa was selected at the national level to host the events for the commemoration of the 7th annual AMD. This led PISAF to make a minor change in its initial social mobilization schedule by moving the campaign closing, originally scheduled to be held in Paouignan (an arrondissement in Dassa), to Dassa, the seat of the commune and health zone of Dassa/Glazoué. Thus, on April 25, 2007, Benin’s Minister of Health officially launched the events of the 7th AMD in Dassa, while the U.S. Ambassador to Benin attended. The WHO Representative in Benin, a representative of the Prefect of Zou and Collines, a representative of the USAID Director and of the DDS, the Director of PISAF and several well-known figures and VIPs also attended. This was an opportunity for the U.S. Ambassador to officially deliver the Long Lasting Insecticide Treaded Nets (LLITNs) and the Artemisinin-based combination therapies (ACTs) to the Minister of Health for the Departmental Health Directorate of Zou and Collines (DDS Zou/Collines). This was done as part of USAID financial support for the DDS through PISAF, to benefit the people of Zou and Collines.

Table 10: Contraceptive distribution

Number of contraceptives sold in 2007

Djidja-Abomey-

Agbangnizoun (DAA)

Zogbodomey-Bohicon-Zakpota

(ZOBOZA)

Covè-Zangnanado-Ouinhi (COZO)

Dassa-Zoumè-Glazoué (DAGLA)

Savalou-Bantè (SABA)

Savè-Ouessè (SAO)

Zou/

Collines

Condoms 125 441 302 42 175 64 1,149

Oral contraceptives 645 654 629 801 877 89 3,695 Injectable contraceptives

680 651 503 1 130 1 773 220 4,957

IUDs 226 165 105 73 302 41 912

Total products sold 1,676 1,911 1,539 2,046 3,127 414 10,713

In this table we note that this year, injectable and oral contraceptives as well as condoms were the products that were sold the most. In contrast, the IUD method is less in demand. In general, the number of contraceptives sold during the year is very low. This can be explained by the repeated inventory shortages of contraceptives at the national level. This situation led PISAF to adopt FP as a priority theme to be developed in 2008 to contribute to increasing Benin’s contraceptive prevalence rate.

2.3.2. Sub IR 3.2: Appropriate research-based interventions and services introduced

Determine BCC topics that merit formative research

Through a collaborative effort between PISAF technical staff and their counterparts at the DDS and health zones, consensual topics for operational research that further the goals of this project will be developed. The launch of Collaboratives at the start of fiscal year 2008 will provide an opportunity to identify those issues that require operational research in order to develop innovative approaches for resolving health problems among the population.

3. PROGRAM MANAGEMENT

3.1. Administrative and personnel management In late September 2007, PISAF had thirty-two (32) permanent employees and three (3) contractors. Technical staff consisted of eleven (11) technical employees, two of whom are expatriates (TCNs), the Chief of Party and the Malaria Advisor. We note that the Malaria Advisor who was involved in starting the project was replaced in July 2007. In late September 2007, all the contracts for domestic project personnel had already been registered with the Departmental Civil Service and Labor Directorate; this indicates compliance with national employment procedures. All of these employees, who are settled in their jobs and have the necessary equipment, have made an effective contribution to project activities despite the many difficulties that arose, such as untimely power failures. At times the internet connection was not accessible and the telephone system was not working. The Behavior Change Communication Advisor left in August 2006, but PISAF filled this position with the arrival of a new Communication Advisor who had been working with the regional AWARE Project based in Accra. However, it is important to note that the Administrator, hired in August 2006, tendered his resignation after one year of work, and consequently PISAF has been functioning without an administrator since August 14, 2007. Therefore, the project is eager to fill this vacancy. To improve staff performance, Afrique Conseil provided training. The receptionist was trained from April 16 to 19, 2007 in “reception and the quality of service,” and the Administrative Assistant was trained from June 18 to 22, 2007 in “the position of executive secretary.”

A team-building meeting was held in the PISAF office for PISAF technical staff on October 16 and for all staff members on October 17, 2006. This meeting, led by Tisna and Aguima, was an opportunity for all the participants to get to know each other better, to master their roles and responsibilities, and to better understand the objectives and results expected of the project. In view of the scope of the project in terms of technical components and geographic coverage, plans were made to strengthen the administrative team by hiring an expatriate manager with considerable experience in managing USAID projects, a network administrator for managing the Intranet and Internet and the computers, and an experienced logistics expert. Moreover, a statistician was hired for the technical team to assist with quality data collection and management, as well as an interpersonal communication specialist, an HIV/AIDS and tuberculosis advisor, a malaria/IMCI technical advisor for Ouémé/Plateau,

and a midwife with practical clinical and training experience. This strengthening activity will begin in the first quarter of FY 2008.

3.2. Financial management

PISAF financial management was facilitated by the opening of an Ecobank branch in Bohicon. This helped reduce the risk of transporting large sums of money from Cotonou to Bohicon. The bank’s proximity made it possible to comply with the accounting rules and made accounting operations run more smoothly. The monthly financial reports were prepared in accordance with USAID and URC procedures and they were sent via DHL to URC in Chevy Chase on time.

3.3. Buildings and equipment This fiscal year in February 2007, PISAF moved into its permanent office facilities. This contributed to a considerable improvement in the staff’s working environment.

Buildings: Extensive finishing work was done this fiscal year, such as installing telephone lines, electrical wiring and wiring for the internet. This made it easier for the project to settle into its permanent facilities. The 60 KVA generator was installed and was used during the very frequent power outages that Benin experienced in 2007. The generator also provided more security for the computers.

The work that remains to be done includes converting the lobby of the administration building into a conference room now that the owner has approved this plan. Window installation was completed and all that remains is to finish making the wall-window joints more waterproof. Due to the growing needs for project personnel, other upgrades may be necessary in 2008 to accommodate any new employees. Equipment:

1) Equipment and furnishings

Office furniture had to be purchased when the project moved into the permanent facility. Thus, a total of eight (8) wooden desks, four (4) metal cabinets, one (1) display cabinet, thirty (30) chairs for visitors, and one office armchair were purchased. Three bookcases or filing cabinets were purchased for the documentation center (2) and for accounting (1). Additional upgrades, including shelving for the built-in closets where the landlord did not put on doors, will be necessary in 2008 in the network room and two other rooms used as an office. Eighteen (18) Sharp split air conditioners and one window unit were purchased and installed in the offices and meeting rooms. A Siemens automatic switchboard for twenty-four (24) lines and fifteen (15) telephone extensions was purchased and installed to facilitate communication inside the project and with the partners. Equipment consisting of ten (10) Sharp E29 television sets, nine (9) VCR/DVD players/recorders, seven (7) Sony multimedia projectors, one (1) small copier, three (3) medium-sized copiers, one (1) large copier and one fax machine were purchased this year for the project and its partners. Of this equipment, eight (8) television sets, eight (8) VCR/DVD players/recorders, seven (7) multimedia projectors and one (1) medium-sized copier were given to the Zou/Collines DDS, the departmental hospital and the health zones. This was done on December 22, 2006 during the Management Assessment results dissemination meeting, to support the implementation of project activities.

Moreover, the purchase of two (2) new multimedia projectors, five (5) projection screens and five (5) flipcharts facilitated the organization of the different training sessions that PISAF was called on to organize in fiscal year 2007.

2) Vehicles

The license plates (with travel logs) for four (4) all-terrain vehicles were received and placed on the project vehicles. Bumpers were purchased to protect the headlights and turn signals for the project vehicles. A V80 Moto Mate was purchased to run project errands.

The current wheels must be changed in stages on the four vehicles that were acquired when the project began, and metal rims must be purchased that can accommodate larger tires, thereby improving safety during the many trips into the field. 3) Inventory To prevent malaria, PISAF received 332 cartons of long lasting insecticide treated nets (LLITNs) from USAID. This amounts to 16,600 LLITNs for the health zones of Zou/Collines. Some of these nets were used during the free LLITN distribution mini-campaign that the Zou/Collines DDS and the Ministry of Health organized with PISAF technical and financial support in late June 2007. This mini-campaign was for children under five in the COZO health zone. There were five thousand three hundred eighty-three (5,383) LLITNs in stock as of September 30, 2007.

3.4. Visitors and Consultants

In fiscal year 2007, a number of visitors and consultants came to PISAF. Although the summary table below lists these visitors and consultants, it is important to mention two of them due to their status. They are the Minister of Health and the Zou/Collines Departmental Director of Health. The Minister of Health, Ms. Flore Gangbo, visited the project on October 27, 2006 with a delegation of managers from her ministry and the Zou/Collines DDS. This was an opportunity for her to obtain information about the vision, objectives and results expected of PISAF. The PISAF Coordinator took advantage of this working session to ask the Ministry and the Zou/Collines DDS to support the implementation of PISAF. When he took office on November 10, 2006, Dr. Thossa Avesse, the Departmental Health Director, paid an initial visit to the project with DDS Zou/Collines department heads. This visit quickly turned into a working session with the DDS and PISAF to strengthen the partnership relationship between the two parties.

The table below lists the visitors and consultants who came to PISAF in fiscal year 2007 as well as their institutions, the time of the visit and the reason for the visit or trip to the field.

No. Name Title/Organization Dates Reason for the visit

1. Dr. Tisna Veldhuijzen Van Zanten

Vice President of URC, International Division

October 8-20, 2006

Corporate monitoring and technical assistance to PISAF

2. Cyrille Zoungan Consultant Sept. 25 - Nov. 25, 2006

Management Assessment data processing and analysis

3. Dr. Flore Gangbo Ministre de la Santé Octobre 27, 2006

Visit to Zou/Collines

4. Dr. Karki Mahamane

Consultant October 30 – Dec. 19, 2006

Technical asssistance in the analysis and establishment of results for the Zou/Collines Management Assessment

5. Thossa Avesse

Departmental Health Director, Zou/Collines

November 14, 2006

Initial contact visit

6. Donald Dickerson &

Pascal Zinzindohoue FHT/USAID- Benin Novembre 29,

2006 Supervision/follow-up of PISAF activity implementation and dialogue with the Zou/Collines DDS

No. Name Title/Organization Dates Reason for the visit

Mr. Brian Dotson Mr. Cyprien Zinsou Mr. Leger Foyet

PSI/IMPACT PSI/IMPACT Technical Advisor, PSI

21. Mrs. Houndekon and Mrs. Zounmenou

Ministry of Health M&E team

June 13, 2007 To inquire about the modalities of distributing LLITNs and possibilities for support

22. Mr. Gabriel Gbedji Sokpa

Consultant, UNFP June 14, 2007 Evaluation of HIV/AIDS prevention strategies for youth

23. Waverly Rennie URC Technical Advisor July 31 to Aug. 7, 2007

Technical assistance on the malaria component

24. Tisna Veldhuijzen van Zanten

Vice President of URC, International Division

Sept. 5 – 19, 2007

Corporate monitoring and technical assistance to PISAF

25.

Suzanne Gold URC Project Coordinator Sept. 24 – Oct. 12, 2007

Administrative and financial support

4. CHALLENGES AND OPPORTUNITIES

4.1. Challenges There are three major challenges:

• The availability of skilled workers in the DDS to support PISAF’s work. The Zou/Collines DDS has neither a director of the Family Health Department nor a malaria support physician, which are two of the concentration areas for PISAF activities.

• Compliance with decentralization principles: Although the health system has in fact been decentralized, the central level is somewhat fearful about actually allowing the health zones to manage: It is not giving them the necessary financial resources on time and, in particular, it is not observing the health zone activity schedules. This results in quite a bit of interference that limits the implementation of the health zone action plans.

• Leadership at the DDS and health zone level: The DDS must reaffirm its leadership in supporting the partners and in particular should not expect PISAF to manage the support activities. The Coordinating Physicians should consider the activities the partners support to be their own activities and not partner activities. Emphasis should be placed on the supervision of the activities carried out in their areas of responsibility and the DDS should provide them with the necessary technical support.

4.2. Opportunities

There are four major opportunities:

• The Zou/Collines health partners have been coordinating with one another and are functional, and all the partners are willing to improve coordination and share information. This was evident during the integration session for the 2008 health zone and DDS action plans. It also ensures financial support for health activities.

• The political will expressed by the Head of State for good governance in all the sectors with unanimity among all the health stakeholders to promote quality of health care and services

• URC’s willingness to lend Benin its rich expertise in QA/Collaboratives through PISAF

• Ascendant planning, which provides a dialogue for the central and peripheral levels in preparing annual action plans.

ANNEXES

PISAF Annual Performance Report No 2 59

ANNEX 1: PERFORMANCE MONITORING AND EVALUATION PLAN

Les indicateurs surlignés en jaune sont ceux du PMP de l'USAID

Nom de

l'indicateur Définition de l'indicateur

Niveaux Source de données

Nat'l

Régions Evaluées Commentaires,

suppositions Target

2007 Actual 2007

Target 2008

Target 2009

Target 2010

B/A Z/C O/P

Strategic Objective 2: Expanded use of family health services, products and preventive measures within a supportive environment

1. Utilisation du paquet de services de santé Familiale

% de la population ayant accès (recevant au moins un élément du) paquet de services de santé familiale dans la zone ciblée

15% 24% 25%

(revu á 35%)

40% (revu à

45%)

60% Rapports SNIGS des CS

x

Nécessité de clarifier le dénominateur en utilisation la population cible pour chaque élément du paquet (enfant <5ans pour PCIME et femmes en âge de procréer pour la CPN) au lieu de la population générale utilisée cette fois-ci

2. Prévalence Contraceptive

% de femmes mariées en âge de procréer ayant utilisé (ou ayant un partenaire qui a utilisé) une méthode moderne de contraception au moment de l'interview

7% ? 10% 12% 15% EDS 2006, KAP 2008, 2010

x x

Cet indicateur n'étant pas dans le PMP d’USAID, il nous a demandé de le retirer de notre PMP

3. Couple Années Protection

Nombre de couples (en âge de reproduire) protégés contre une grossesse et utilisant des méthodes de planning familiale durant une année à partir de la quantité totale de méthodes contraceptives cédées ou distribuées au cours de la même année.

7000 7,371 9000 11000 13000 SNIGS x

Il pourra être pris en compte les données des centres de santé privé qui disposent de ces données ainsi que celles de l'ABPF

4. Taux de vaccination complète

% d'enfants de 12-23 mois ayant reçu toutes les vaccinations requises avant l'âge d'un an.

60% ? 65% 70% 75% EDS 2006, KAP 2008, 2010

x x

Cet indicateur n'étant pas dans le PMP d’USAID, il nous a demandé de le retirer de notre PMP


IR 1 Amélioration de l'environnement politique

IR 1.1 Mise en œuvre de politiques et approches de santé sélectionnées

1.1.1 Révision et Dissémination des Politiques

Nombre de nouvelles politiques crées disséminées et ventilées aux départements et aux zones sanitaires

2 2 1 1 1 Rapports de PISAF

x x x x

Il s'agit de la stratégie de sécurisation des produits SR et de la stratégie nationale de réduction de la mortalité maternelle, néonatale et infanto-juvénile

IR 1.2 Les capacités de gestion du système sanitaire sont accrues

1.2.1 Renforcement de la gestion aux niveaux Régional et Zonal

% de gestionnaires du système sanitaire aux niveaux départemental et zonal formés aux éléments de base de gestion (gestion des ressources humaines, financières et matérielles et assurance qualité)

50% 0% 70% 90% 100%

Base de données des formations (PISAF)

x x

Les interférences au niveau de la DDS et des zones sanitaires n'ont pas permis de réaliser cette activité replanifiée pour le début de FY'08

1.2.2 Système de Supervision mis en oeuvre

% de centres de santé ayant recus au moins quatre visites de supervision formative par an

30% 37% 50% 60% 80%

Cahiers de supervision des centres de santé

x x

Il est espère que la formation en supervision formative et en travail en équipe des membres EEZS en début de FY'08 contribuera à augmenter ce niveau de performance

1.2.3 Inventaire des Produits de santé Familiale

% de COGEC prenant part à l'inventaire de tous les produits de santé Familiale reçus

96% 94% 98% 100% 100% Cahiers des COGECs

x

1.2.4 Processus de Planification Ascendante mis en œuvre effectivement

% de EEZS utilisant la planification ascendante pour élaborer leur plan d'action

80% 100% 90% 95% 100%

Rapports d'activités des Zones sanitaires

x x

Les targets pour 2008 et 2009 ont été maintenus a moins de 100% a cause du renouvellement des COGECs qui a démarré juste après la formation de tous les membres COGECS du Zou et des collines en planification ascendante. Cela ajoute a la forte mobilité des prestataires influencera négativement la performance de 2007


1.2.5 Plans d'Action Annuels des EEZS mis en oeuvre

% de EEZS exécutant au moins 75% de leur plan annuel

75% 78% 80% 85% 90%

Rapports d'activités des Zones sanitaires

x

Le target fixe pour 08 est reste comme planifié à cause des interférences qui empêchent les EEZS de mettre en œuvre leur propre plan d'action mais aussi par ce que ces EEZS ne font pas de planification réaliste (basée sur leurs moyens en ressources humaines et matérielles)

1.2.6 Utilisation des données pour la prise de décision mise en oeuvre par les EEZS

% de EEZS organisant au moins 4 sessions de prise de décision par an basée sur les données

90% 89% 95% 100% 100%

Rapports trimestriels des Zones Sanitaires

x

En lieu et place de 4 sessions, ce sont 3 sessions car la collecte des données n'a commencé qu'au 1er trimestre 2007 alors que FY'07 a démarré en Octobre 06.

IR 1.3 La participation de la société civile est accrue

1.3.1 Participation des femmes aux Structures de la Société Civile

% de COGEC avec une femme dans le bureau exécutif

42% 42% 50% 50% 60%

Répertoire des COGECs/ zones sanitaires

x

Le renouvellement des COGECs sefaisant tous les deux ans, c'est au cours de FY'08 et 10 qu'il est prévu le renouvellement et donc avec possibilité d'avoir de nouveaux membres étant des femmes

1.3.2 Respect des réunions des COGEC

% de centres de santé avec COGEC tenant au moins une réunion mensuelle assortie de rapport

40% 47% 50% 55% 60%

Rapports des COGECs et des EEZS

x

Les targets pour FY'08, 09 et 10 restent inchangés car avec les nouveaux COGECs la performance va d'abord chuter ou stagner en 2008 avant de s'améliorer

1.3.3 Intégration des activités de santé dans les efforts des OBC

% d'OBC ayant mené au moins une activité de santé au cours de l'année

45% 45% 50% 55% 60%

Rapports des OBC et Rapport d'activité du PISAF

x x x

Cet indicateur a été reformule pour cadrer avec la réalité et les targets revue a la baisse pour être plus réaliste

1.3.4 Activités à base communautaire sont intégrées dans les services du système sanitaire publique

% de ZS ayant inclu les activités à base communautaire dans les descriptions de postes d'agents de santé sélectionnés

33% 33% 66% 83% 100%

Rapports d'activité des EEZS

x

Du fait que PISAF et UNICEF appuient tous les activités à base communautaire, leur synergie en matière de plaidoyer pour l'intégration des ASBC dans le job description des AS sera plus porteur


IR 2 L'accès aux services et produits de Santé Familiale de qualité est accrue

IR 2.1 Disponibilité des produits essentiels de santé familiale dans les formations sanitaires publiques

2.1.1 Nombre moyen de jours de rupture de stocks pour des médicaments sélectionnés survenus dans les Centres de santé au cours du trimestre

Nombre moyen de jours de rupture de stock survenu trimestriellement pour des produits sélectionnés de Santé Familiale (CTA, Ocytocine, MILD, SRO, contraceptifs oraux et injectables ne sont pas disponibles pour les patients et les prestataires de services)

12 9 10

(revu à 8)

7 (revu à

6)

5 (revu à 3)

Fiche de stock et REMECAR

x

Les targets ont été revus a la baisse a cause du fait que USAID va fournir les CTA et l'ocytocine directement aux EEZS et PISAF va appuyer la gestion de ces produits, ce qui va amoindrir le nombre de produits SR objet de rupture dans le Zou et Collines 2.1.2 Disponibilité

des Produits de Santé Familiale

Index de la gestion de la commande des Produits de Santé Familiale

60% 50% 65% 70% 75%

Fiche de stock et Bon de Commande

x

2.1.3 Disponibilité des Produits de Santé Familiale pour le niveau Communautaire

% villages ou les produits du paquet de santé familiale pour niveau communautaire est disponible

20% 17% 25% 30% 40%

Rapports de supervision des ASBC par les centres de santé

x

Les ASBC n'ayant pas été mises en œuvres cette année, le nombre de village couverts par le paquet de sante familial pour niveau communautaire n'a pas augmente par rapport au niveau donne par l'EQGSS en 2006.

IR 2.2 Disponibilité de produits de SF sélectionnés au niveau de vendeurs privés

2.2.1 Disponibilité des MILD à travers les groupes de la Société Civile

# MILD vendus à travers les OBC et les Mutuelles de santé

500 0 500 1000 1000 Rapports du PISAF

x x x

La politique du MS/PNLP a été de ne distribuer les MILD gratuitement aux enfants de <5ans cette année a travers une campagne massive conduite par le système sanitaire. Un plaidoyer a été fait auprès de l'USAID pour acquérir des MILD pour les OBC et Mutuelles de santé en FY'08

IR 2.3 Disponibilité du paquet de Santé Familiale dans des formations sanitaires publiques sélectionnées.


ANNEX 2: PROGRESS TABLE

Plan d'action de PISAF durant l'année fiscale 2007

TRIMESTRE Réalisations au cours de

l'année fiscale 2007 Observations

Activités du 1er Octobre 2006 au 30 Septembre 2007

T1 T2 T3 T4

Gestion du Projet

Finaliser l'installation du projet dans ses locaux définitifs

x

L'installation du projet dans ces bureaux définitifs a eu lieu au cours du 2e trimestre et a nécessité beaucoup de travaux au niveau de l'électricité, de l'internet et du téléphone.

Durant plusieurs mois, l'accès à l'internet et au téléphone a été impossible. L'installation de tout le staff a nécessité plus de meubles que prévu. L'aménagement de la salle de conférence est en cours et prendre fin en décembre 2007.

Organiser un « team building interne» avec le staff du PISAF

x

Un « team building interne» a été organisé avec l'appui de Tisna en visite de travail à PISAF au cours du premier trimestre.

La vision, la mission de PISAF ainsi que les rôles des agents de PISAF ont été les préoccupations discutées au cours d'une réunion de tout le staff.

Finaliser avec les partenaires le plan d'action 2007 avec les données de l'EQGSS

x

Une session d'harmonisation des plans d'action de l'année 2007 a été tenue au cours du 2e trimestre. Les plans d'action des zones sanitaires et de la DDS ont été revus au regard des résultats de l'EQGSS.

Cette séance a connu la participation de tous les Chefs de services de la DDS, des MCZS, et des partenaires du secteur santé de la DDS Z/C.

Disséminer le Plan de Monitoring de la Performance dans les ZC, le BA & l'OP

x

Une séance de travail, tenue au cours du 2e trimestre, a permis de discuter des indicateurs du PMP avec le chef service des études, de la planification et du suivi de la DDS, et tous les statisticiens des zones sanitaires.

Identifier les domaines de collaboration avec les autres projets de USAID, les autres projets de santé et les autres secteurs de développement

x x x

La tenue d'une table ronde des partenaires à la suite de la dissémination des résultats de l'EQGSS 1 au 1er trimestre, a permis de dégager les axes stratégiques ainsi que les domaines de collaboration avec tous les projets intervenants dans les Zou/Collines.

Des concertations ont été menées au cours du 2e trimestre avec le PADS, l'UNICEF, le PSI et IMPACT pour identifier les domaines de collaboration en vue d'une meilleure synergie des interventions. Une concertation entre PISAF, IMPACT en présence de l'USAID et de la DDS Z/C s'est tenue au cours du 3e trimestre et a permis d'identifier les activités communes au deux projets et de faire des recommandations en vue d'une synergie des interventions de ces deux projets de USAID/Benin.






T1 T2 T3 T4

Organiser un atelier de « team building» et de planification des activités avec les homologues au niveau départemental et zonal (DDS et MC ZS)

x

Un « team building » a été organisé au 1er trimestre entre le staff de PISAF, les cadres de la DDS et les MCZS et a permis de partager avec les acteurs, la vision et les valeurs du PISAF.

Cette séance a connu la participation de TISNA.

Appui technique du siège URC en matière de planification stratégique et d'assurance de qualité

x x

URC a appuyé: 1) l'élaboration de la stratégie de mise en œuvre de l'AQ et des collaboratifs, ainsi que la préparation technique de l'atelier de partage sur les collaboratifs tenu à Parakou, l'intégration de l'AQ dans la stratégie de mise en place des mutuelles; 2) l'élaboration de la stratégie de CCC/IEC surtout dans le domaine du paludisme et de la PTME, 3) l'orientation de tous les techniciens de PISAF et du personnel administratif en AQ de base, en collaboratif et en planification/conduite d'atelier.

Des sessions de partage des expériences en matière de collaboratif sur le Palu, le VIH/SIDA, les SONU et les soins néonatals ont été organisées par URC pour des techniciens de PISAF et deux DDS participant a la conférence de Global Health Council tenue à Washington.

Réunions consultatives avec les partenaires au niveau central

x x x x

PISAF a participé á plusieurs rencontres portant sur : la décentralisation, la planification ascendante intégrée, le paludisme, la finalisation de la stratégie nationale sur les mutuelles, la mise en œuvre de la PCIME, l'organisation de la campagne massive de distribution de MILD, la mise en œuvre du PMI et la redynamisation de la PF.

Etablir un consensus sur les stratégies clés du projet avec les homologues et les partenaires

x

Ce consensus a été réalisé au cours de la table ronde des partenaires ayant suivi la dissémination des résultats de l'EQGSS 1. Une confirmation a été faite par les mêmes partenaires au cours des rencontres de concertation.

Préparer un rapport trimestriel

x x x x Trois rapports trimestriels ont été élaborés au cours de l'année fiscale 2007. Ils ont tous été transmis á

USAID dans les délais impartis.

Préparer un rapport annuel

x Le rapport de l'année fiscale 2006 a été élaboré au cours du 1er trimestre 2007.






T1 T2 T3 T4

Tenir une réunion trimestrielle avec les homologues au niveau central, départemental et zone sanitaire

x x x x

L'implication des homologues à tous les niveaux a été effective et a permis de: valider et disséminer les résultats de l'EQGSS 1, élaborer un plan de livraison des MILD aux ZS, harmoniser les plans d'action budgétisés de la DDS, CHD et ZS, planifier et exécuter la formation des COGECS et celle des prestataires sur la nouvelle stratégie de lutte contre le paludisme.

Tenir une réunion des partenaires Santé de l'USAID/Bénin

x x

Une réunion des partenaires tenue au 1er trimestre a permis à l'USAID de communiquer son nouveau cadre stratégique qui est celui de la diplomatie transformationnelle.

C'était l'occasion pour PISAF de présenter les résultats préliminaires de l'EQGSS 1. En outre l'opportunité a été donnée au projet IMPACT de présenter ses objectifs, sa couverture géographique et les possibles domaines de collaboration avec les autres projets de USAID, notamment avec le PISAF.

Développer le plan d'action de l'année fiscale 2008

x

Un plan d'action pour l'année 2008 a été élaboré et transmis dans les délais à USAID.

Des notes explicatives sur le budget permettent une meilleure compréhension de ce plan d'action budgétisé.

RI 1. Amélioration de l'environnement politique

RI 1.1 Mise en œuvre des politiques et approches de santé sélectionnées

Aider à finaliser et à mettre en œuvre la politique sur les mutuelles

x

Un draft de la politique nationale sur les mutuelles de santé a été élaboré avec l'appui du OISAF.

Un atelier de validation de cette politique devra être organisé par le Ministère de la Santé en 2008.

Réviser les politiques en rapport avec les produits de SF à base communautaire

x

La liste des produits admis au niveau communautaire a été passée en revue et la chloroquine qui faisait partie de la liste des produits a été retirée à cause de la chimiorésistance constatée.

Les outils standards de mise en œuvre de la PCIME communautaire qui sont toujours en voie de finalisation prévoient l'utilisation du Coarterm pour le traitement du paludisme simple au niveau communautaire.

Elaborer un plan de communication pour les politiques de décentralisation

x x

Les termes de référence pour l'élaboration de ce plan de communication par un consultant ont été élaborés.

Un consultant sera recruté au cours du prochain trimestre pour élaborer ce plan.

Fournir une assistance technique en matière de décentralisation

x x x x

PISAF a apporté son appui technique au Ministère de la Santé pour la tenue de trois rencontres ayant porté sur le bilan, la planification et la micro planification des activités de décentralisation dans le secteur de la santé.

Douze activités ont été retenues pour l'année 2007 à l'issue de ces rencontres auxquelles ont participé les cadres du Ministère de la Santé.






T1 T2 T3 T4

Tenir des forums réguliers de discussion des questions de décentralisation avec le personnel de santé et la société civile

x x x x

Tenue de l'atelier d'harmonisation du mode de gestion des agents de santé payés sur "fonds mesures sociales"

x x x x

Tenue de l'atelier d'élaboration du document d'information et de sensibilisation sur la réforme du système de santé et la décentralisation au Bénin

L'atelier a permis de faire le consensus sur le contenu d'un document et de disposer d'un outil pour la diffusion de l'information à grande échelle sur la réforme dans le secteur de la santé au Bénin

x x x x

Tenue de deux ateliers sur l'actualisation du décret portant approbation des statuts des Hôpitaux de Zone

Ces ateliers ont eu l'intérêt, au regard des problèmes actuels de gestion des hôpitaux de zone, de faire le consensus sur le projet de texte qui a été validé et qui sera soumis au Conseil des Ministres pour son adoption.

x x x x

Tenue d'un atelier de dissémination des textes de décentralisation et du manuel de procédure de la planification ascendante intégrée dans les départements du Zou/ Collines et de l'Ouémé/ Plateau.

A cette occasion les formations sanitaires et des organes de cogestion des centres de santé ont recu: 274 exemplaires du recueil des textes de décentralisation, 289 exemplaires du manuel de planification et 4000 dépliants dudit manuel pour le Zou/ Collines; 267 exemplaires du recueil des textes de décentralisation, 267 exemplaires du manuel de planification et 1200 dépliants dudit manuel pour l'Ouémé/ Plateau.

Mettre en œuvre la planification ascendante à tous les niveaux du système sanitaire (central, départemental et zonal)

x x x

1) Appui à la DPP pour la finalisation, la reproduction et la dissémination du manuel de procédures de la planification ascendante intégrée. 2) Appui á l'élaboration des plans d'action des COGEC, des ZS et de la DDS après la dissémination du manuel.

La mise en oeuvre de la planification ascedante a été materialisée par l'élaboration des plans d'action 2008 de toutes les EEZS, les COGEC, du CHD et de la DDS de Zou/Collines dès le mois de juillet 2007.

Réunions régulières entre le MS et les bailleurs de fonds pour la coordination et la collaboration sur les questions relatives aux politiques sanitaires

x x x x

1) Plusieurs réunions de concertation sur : la distribution des MILD, des CTA ainsi la stratégie de mise en œuvre de la campagne de distribution massive et gratuite des MILD, ont eu lieu entre le MS/PNLP, USAID, PISAF, PSI et UNICEF.






T1 T2 T3 T4

Appuyer le MS à développer une stratégie nationale d'AQ

x x Un draft de la stratégie nationale AQ a été élaboré.

L'atelier de planification des collaboratifs sur les SONU, la PF, le Palu, le VIH/SIDA et la gestion des RH sera une occasion d'impliquer le niveau central dans la mise en œuvre de l'AQ.

Appui à la mise en œuvre du plan national stratégique de sécurisation des produits

x x x x

La stratégie nationale de sécurisation des produits SR a été finalisée avec l'appui du PISAF. En outre un appui technique á travers un consultant international a été donné à la DSF pour évaluer les besoins en produits PF pour les périodes 2007-2009 et 2009-2013.

PISAF a appuyé la DDS/ZC à mettre en place une stratégie de gestion des produits de lutte contre le paludisme en concertation avec le PNLP.

Aider le MS à acquérir d’autres soutiens financiers (GFATM, etc.)

x x x x

Le Bénin a été inscrit pour bénéficier de l'appui financier du "Presidential Malaria Initiative" à compter de la FY'08.

La requête du PNLP élaborée avec l'appui technique du PISAF et soumise au Fonds Mondial n'a pas reçu une réponse favorable.

Aider le PNLP à utiliser des pratiques efficientes relatives au Paludisme et les données de suivi et évaluation dans la planification des activités de lutte contre le palu, la PCIME clinique et communautaire ainsi que la Technique de la Naissance Précédente (TNP)

x x x x

1) Appui technique et financier du PISAF pour la tenue d'un atelier sur la quantification des MILD, CTA et TDR dans les Zou/Collines. 2) Formation de 605 agents de santé des Z/C sur les nouveaux protocoles de paludisme.

Appuyer l'organisation de la validation de l'expérience de la mise en ouvre de la TNP au Bénin

x

La TNP a été déjà adoptée par le MS comme stratégie de suivi de la mortalité infantile et intégrée au SNIGS avant le démarrage du PISAF.

Aider le PNLS à décentraliser la planification des activités de VIH/SIDA et IST en utilisant les données de suivi et d'évaluation

x

Dans le cadre de la décentralisation des activités du PNLS, PISAF a appuyé la formation de 24 prestataires de Zou/Collines en PTME ainsi que le suivi des enfants nés de mères séropositives en collaboration avec le CIPEC du Zou.

Assister les départements du Zou/Collines, du Borgou/Alibori et de l'Ouémé/ Plateau dans la mise en œuvre de la stratégie nationale de réduction de la mortalité maternelle et néonatale en collaboration avec la DSF

x x x x

La dissémination du document de stratégie nationale de réduction de la mortalité maternelle et néonatale a été planifiée pour les départements du Zou et des Collines.

Les interférences ont empêché la tenue de cette activité qui a été à nouveau projetée pour la 2e quinzaine d'octobre 2007.






T1 T2 T3 T4

Aider à l'actualisation et à la dissémination du paquet minimum de santé familiale avec la PTME, la CDV, la TPI et les MILD

x x

PISAF a apporté son appui technique pour la validation des standards de performance des services intégrés SR/IST/ VIH/SIDA (PTME/CDV/IST/PF).

C'est au cours d'un atelier organisé par la DSF avec l'appui de l’IMPACT/ USAID.

Conduire l'analyse des coûts relatifs aux politiques de traitement

x

Une analyse des prix de cession des médicaments a été faite lors de l'étude du niveau de fonctionnement des zones sanitaires dans le Zou et les Collines.

Les éléments disponibles seront utilisés pour conduire l'analyse des coûts relatifs aux politiques de traitement.

Aider à la mise en œuvre d'un mécanisme de communication des standards (y compris la formation en pré-service)

x x x

Une équipe départementale de formateurs formés en andragogie sont chargés de passer en revue les standards définis au niveau national pour chaque domaine et élaborer un programme de communication de ces standards aux cibles définis pour recevoir ces informations afin d'en faire l'application dans leur travail quotidien.

23 membres EEZS et de la DDS ont été formés en andragogie.

Appuyer l'évaluation de l'expérience du cours de six jours sur la PCIME clinique dans le Borgou/Alibori et la dissémination des résultats

x

Une mission conjointe Ministère de la Santé-OMS a procédé à une évaluation de ce modèle et recommande quelques améliorations dans la conduite de ce modèle.

Les résultats de cette évaluation ont été transmis à l'USAID. Mais les concertations entre les partenaires ont permis de laisser le domaine de la PCIME clinique à l'UNICEF dans les Z/C.

Fournir à l'INMES 200 curricula de formation sur la PCIME

x Les curricula de formation sont en cours de révision au niveau central.

Appuyer la DPP dans la dissémination des comptes nationaux de santé

x

Avec l'appui financier de PISAF, les documents sur les Comptes nationaux de santé ont été multipliés. Leur dissémination a été faite dans tous les départements et une cérémonie nationale présidée par le Ministre de la Santé a été organisée au niveau national.






T1 T2 T3 T4

RI 1.2 Les capacités de gestion du système sanitaire sont accrues

Organiser un atelier de dissémination des résultats de l'EQGSS dans les Zou/Collines

x

La dissémination des résultats de l'EQGSS suivie de la table ronde des partenaires a eu lieu au niveau départemental au cours du 1er trimestre et dans toutes les 15 communes des départements du Zou et des Collines au 2e trimestre.

Elle a permis aux responsables des zones de s'approprier les résultats de l'EQGSS. Aussi, ces résultats ont-ils été présentés au Ministère de la Santé au cours du mois de septembre 07.

Aider a l'élaboration des plans stratégiques au niveau régional à partir des données de l'EQGSS

x

Un appui de PISAF a permis de réviser les plans stratégiques à horizon glissant des ZS, CHD et DDS pour la prise en compte des résultats de l'EQGSS1.

Grâce à l'appui du PISAF le processus de la planification ascendante intégrée a été observé de manière rigoureuse et a permis aux ZS, CHD et DDS de disposer de leurs plans d'action 2008 à bonne date.

Aider au développement des plans d'institutionnalisation/pérennisation dans les Zou/Collines et aider à la révision de ceux du Borgou/Alibori

x

PISAF a organisé un atelier sur les leçons apprises dans la mise en œuvre de l'AQ dans le Borgou/Alibori.

Ces leçons serviront à élaborer un plan d'institutionnalisation pour le Zou/Collines et la révision de celui du Borgou/Alibori.

Appuyer le développement et la révision des plans de renforcement des capacités dans le Zou/Collines, le Borgou/Alibori et l'Ouémé/Plateau

x

L'identification des domaines de sous performances au niveau des ZS et de la DDS a été réalisée à travers l'EQGSS et une stratégie AQ développée.

Cette stratégie AQ prévoit l'utilisation du modèle collaboratif comme stratégie pour le renforcement des capacités.

Actualiser les tableaux de bord avec les éléments du PMA plus

x

Les tableaux ont actualisés avec les éléments du PMA plus au cours du 2e trimestre.

Introduire les tableaux de bords actualisés dans les Zou/Collines et soutenir leur utilisation dans le Z/C & B/A

x x x

La participation des statisticiens à la collecte des données du PMP a été une étape importante dans leur sensibilisation sur l'utilisation du tableau de bord et ses avantages dans le suivi de la mise en œuvre des plans d'action des zones.

Les résultats des PMP des 2e et 3e trimestres ont été présentés lors du Collectif des médecins tenu en Août 2007 en vue de montrer l'importance des éléments contenus dans les tableaux de bord.

Soutenir la revue trimestrielle des plans d'action annuels

x x x

La revue des plans d'action annuels a été faite lors du CODIR élargi de la DDS Zou/Collines au cours du 3e trimestre.






T1 T2 T3 T4

Soutenir la participation de cadres du MS (niveau central, DDS et ZS) á des ateliers/conférences régionaux et internationaux

x x x x

Les cadres de divers niveaux du système sanitaire ont pris part à des ateliers et conférences régionaux et internationaux: 1) Ateliers régional sur le VIH/SIDA au Togo 2) Global Health Council aux USA 3) Voyage d'étude sur l'AQ/Collaboratif au Niger 4) Atelier de formation sur le QUANTIMED au Sénégal

Fournir une formation en ressources humaines/assurance qualité dans Z/C, O/P et renforcer dans B/A

x x

L'inventaire des personnes à former au niveau de la DDS, du CHD et des ZS a été réalisé et un planning de formation conclu avec la DDS.

Les interférences ont empêché sa tenue effective au cours de la FY'07. Cette activité aura lieu durant le 1er trimestre 08.

Fournir une formation en gestion financière dans Z/C et renforcer dans B/A

x

Le guide de gestion pour le Chargé de l'Administration et des Ressources des zones sanitaires a été finalisé et validé au cours du 4e trimestre.

Le document final est disponible et les dispositions sont en cours pour sa reproduction avant la dissémination dans les zones sanitaires.

RI 1.3 La Participation de la société civile est accrue

Développer un modèle consensuel de mobilisation communautaire (y inclus l'engagement des groupes de femmes).

x

Deux ateliers ont permis d'élaborer et de valider le document de stratégie de mobilisation communautaire pour le Zou et les Collines. Le document a été revu et amendé au cours du dernier trimestre pour tenir compte des spécificités des zones révélées par les résultats de l'EQGSS.

Un plan de mise en œuvre des activités communautaires a été élaboré.

Former les COGECS à travers des sessions incluant des agents de santé et les mutualistes

x x x

603 personnes ont été formées dans le Zou et les Collines sur les 630 attendues (96%) dont 585 membres de COGECS et 18 membres de l'administration (ayant des rôles de suivi dans le fonctionnement des COGECS).

Cette formation a intégré l'élaboration du draft des plans d'action 2008 pour chaque COGECS ainsi que des notions d'assurance de qualité et de travail en équipe.

Fournir un appui aux COGECS dans la mise en œuvre de la planification ascendante et les autres activités

x x x x Cette activité a été intégrée à celle précédente lors de la mise en œuvre.



TRIMESTRE Réalisations au cours

de l'année fiscale 2007 Observations


T1 T2 T3 T4

Fournir un appui technique aux agents de mobilisation communautaire au niveau des zones sanitaires

x x x

Les responsables chargés de la mobilisation communautaire au sein des zones sanitaires sont désignés.

Leur formation interviendra au cours du 1er trimestre de la FY 08.

Introduire et soutenir les Comités Communaux de soutien aux Mutuelles dans les zones avec de nouvelles mutuelles x x x

Deux comités communaux de soutien aux mutuelles de santé ont été renforcées á Banikoara et á Sinendé et leur mécanisme de fonctionnement développé et exécuté.

PISAF a préféré renforcer le fonctionnement de ces comités dans le cadre de la mise en œuvre de l’expérience pilote menée dans le B/A et tirer les leçons apprises pour l’extension des mutuelles dans les autres communes du B/A et dans le Zou/Collines au cours de la FY’08.

Développer et tester la collaboration entre mutuelles et initiatives de micro-finance

x x x

Des concertations ont été menées avec le réseau FECECAM qui est une forme d’entraide financière communautaire en vue d’établir une collaboration entre ce réseau et les mutuelles de santé

La collaboration avec ce réseau animé par des femmes au niveau communautaire est une opportunité d’impliquer les femmes dans la mise en œuvre des activités de santé mais aussi s’inscrit dans la pérennisation des actions des mutuelles soutenues par PISAF.

Analyser les possibilités de relation entre les mutuelles et les activités à base communautaire et développer et tester une stratégie appropriée

x x x

A Sinendé, les COGECS et les mutuelles travaillent en étroite collaboration et conduisent des activités de promotion sanitaires intégrant les bienfaits des mutuelles de santé dans les villages.

La stratégie développée et qui sera mise en œuvre dans le cadre de l’extension des mutuelles de santé est le collaborative mutuelles de santé et qualité des soins qui couvrira les activités á base communautaire.

Développer un mécanisme pour impliquer les ONG, les OBC et le secteur privé dans la prévention et le traitement des IRA et du Paludisme

x

Un mécanisme d'implication des ONG, OBC et secteurs privés a été développé. Il permettra d'établir un partenariat de collaboration pour la mise en œuvre des interventions de BCC et mobilisation communautaire pour la lutte contre les IRA et le Paludisme.

Donner des subventions aux ONG et aux OBC

x x x

Le mécanisme a été élaboré mais le principe retenu est l'utilisation des ONG et OBC comme des prestataires de service.

Former les ONG et OBC bénéficiaires des subventions en gestion pour renforcer leur capacité

x x x

La pertinence de l'activité sera appréciée au regard des performances des ONG qui seront sollicitées par PISAF.






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Mobiliser les groupes communautaires locaux pour promouvoir de bonnes pratiques vis-à-vis du paludisme et des IRA dans le Z/C, B/A et O/P

x x

Des groupes communautaires locaux ont participé aux activités de promotion de bonnes pratiques à travers: i) la célébration de la Journée Africaine de lutte contre le Paludisme, ii) la campagne d'hygiène et assainissement du milieu pour la prévention du paludisme dans la ville de Bohicon, iii) la campagne de don bénévole de sang dans la zone sanitaire Savè-Ouèssè iv) la campagne de sensibilisation sur l'importance et l'utilisation correcte des MILD dans COZO.

RI 2. L'Accès aux services et produits de Santé Familiale de qualité est accru

RI 2.1 Disponibilité des produits essentiels de santé familiale dans les formations sanitaires publiques

Faciliter la création de dépôts départementaux et zonaux dans Z/C

x x x

Analyse du fonctionnement de 04 dépôts répartiteurs des zones sanitaires.

Une collecte de données devant faciliter l'analyse des conditions de mise en place d'un dépôt dans ZOBOZA qui n'en possède pas a été réalisée.

Renforcer les capacités pour la gestion de la logistique dans le Z/C et renforcer si nécessaire dans B/A

x x x

22 agents de santé dont les chefs de service de la DDS et des gestionnaires de MEG des ZS ont été formés en QUANTIMED.

40 agents de santé dont 20 de la DDS et 20 au niveau des ZS ont été formés à l'usage de l'outil informatique dans le Zou/Collines. La maitrise de l'outil informatique contribue au renforcement de la gestion de la logistique.

Actualiser le matériel de formation des ASBC en y incluant les nouveaux produits de Santé Familiale

x

Les huit (08) modules de formation des ASBC prenant en compte la PCIME et les SONU communautaires ont été révisés et adaptés.

Intégrer les indicateurs ASBC dans les tableaux de bord et les autres outils de monitoring des Zones Sanitaires

x

Les indicateurs ASBC ont été intégrés dans le tableau de bord. Les outils de monitoring au niveau des zones sanitaires intègrent déjà des indicateurs concernant les ASBC.

La collecte des données relatives à ces indicateurs se fera au cours de la FY 08.

RI 2.2 Disponibilité de produits sélectionnés au niveau des vendeurs privés

Introduire la vente des moustiquaires imprégnées par les groupements féminins et les mutuelles x x x

Conformément à la politique nationale, il a été retenu la distribution gratuite des MILD aux enfants de moins de 5 ans. PISAF a appuyé une distribution pilote dans la ZS de COZO au cours du 3

e trimestre.

Au total 23 918 MILD ont été distribuées pour couvrir 24 796 enfants de 0 à 5 ans correspondant à 80% des cibles.






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Tester la stratégie de formation des vendeurs privés de médicaments x x

Le Ministère de la Santé et la DDS sont opposés à une telle activité qui légitimera les vendeurs illégaux de médicaments.

Cette activité devrait être retirée du workplan.

RI 2.3 Disponibilité du paquet de Santé Familiale de qualité dans des formations sanitaires ciblées du secteur sanitaire public

S’assurer que les normes et standards du paquet minimum élargi sont disponibles à la DDS (Z/C et B/A)

x x

Une rencontre tenue au 1er

trimestre avec les responsables du CIPEC Zou/Collines a permis de noter que : i) 39 maternités et 6 hôpitaux offrent des services de la PTME, ii) le protocole pour le traitement présomptif intermittent du paludisme est disponible à tous les niveaux dans le Zou/Collines et dans le B/A

PISAF a réactualisé les normes essentielles du paquet minimum élargi.

Introduire la prestation de services intégrés dans les Z/C (comprenant mais non limité seulement à l’analyse du circuit des patients, redéfinition d’un circuit, le travail en équipe, la supervision formative régulière, le coaching et la fourniture de certains matériels médico-techniques ainsi que les réfections)

x x x

Les manuels de formation ainsi que le guide des formateurs ont été actualisés, ils ont permis de former 118 prestataires dans le Borgou/Alibori.

Les interférences ont empêché la tenue de cette activité dans les Zou/Collines au cours de la FY’07. Elle se déroulera dans ce département au cours du mois d’octobre 2007.

Intégrer les nouveaux éléments du paquet de SF (PTME, TPI, MILD) dans le matériel de formation, les guides de supervision et les outils de monitoring de la performance

x x

Le Niveau central a intégré les nouveaux éléments du PTME dans le matériel de formation.

PISAF a utilisé les nouveaux guides de formation du PMA plus pour former 29 prestataires en SONU/GATPA et 24 prestataires de maternités en PTME dans le Zou/Collines.

Appuyer le développement des capacités en AQ et en planification et mise en œuvre de la supervision dans le Zou/Collines, le B/A et l'Ouémé/Plateau

x x x

10 agents du niveau central, des zones sanitaires et des DDS du Zou/Collines et du B/A ainsi que du PISAF ont participé à une session d'apprentissage sur les collaboratifs SONU et nutrition à Niamey dans le cadre du développement de leur compétence en AQ.

Le staff du PISAF a été orienté sur l'AQ/Collaboratif et la facilitation des ateliers.

Appuyer la formation et le suivi-post formation en PCIME dans le Zou/Collines et le transfert des compétences au staff dans le B/A et l'O/P

x x x

En lieu et place de la PCIME, la priorité a été donnée à la formation des prestataires sur la nouvelle politique de lutte contre le paludisme et à la distribution gratuite des MILD dans la zone sanitaire de COZO à titre pilote.


Plan d’action de PISAF durant l’année fiscale 2007

TRIMESTRE Réalisations au cours

de l’année fiscale 2007 Observations

Activités du 1er

Octobre 2006 au 30 Septembre 2007

T1 T2 T3 T4

Développer une stratégie AQ transrégionale

x

La stratégie de mise en œuvre de collaboratifs dans les deux régions (Zou/ Collines et B/A) a été élaborée à partir des leçons apprises de l'expérience AQ de PISAF dans le Borgou/ Alibori et celle sur le collboratif SONE conduit dans la zone ADD par URC.

Les domaines devant être couverts par ces stratégies sont: Mutuelles de santé et qualité des soins (dans le B/A); SONU/ GATPA/SENE, OIS, Paludisme, PF, GRH et VIH/SIDA dans les Zou/Collines.

Développer, imprimer et fournir des aide-mémoires appropriés

x x

700 algorithmes sur la prise en charge du paludisme, un aide mémoire sur l'utilisation du TRD/ paracheck pour le diagnostic du paludisme, 3 cartes conseil et 3 dépliants sur la PTME ont été réalisés.

L'aide mémoire sur le TDR est une traduction/adaptation d'une version anglaise élaborée par URC/QAP pour la Tanzanie, en collaboration avec le PNLP. Un pré-test de ce matériel avec 4 formateurs départementaux palu du Zou/ Collines a été effectué dans des formations sanitaires de ce département. La version finale ayant été adoptée, il reste son impression et sa dissémination aux prestataires de soins de Z/C au cours du prochain trimestre.

Appuyer les ZS dans l’élaboration/le renforcement des modèles collaboratifs dans Z/C et B/A x x x

Une équipe de 10 membres (MS, DDS Z/C et B/A, PISAF) a participé à un voyage d'étude sur les Collaboratifs au Niger.

Un atelier de planification de six collaboratifs impliquant les MCZS et les directeurs des hôpitaux régionaux, du CHD, et des comités de coordination et de gestion des collaboratifs se déroulera au cours du mois de novembre à cet effet.

Appuyer la réfection d’infrastructures sanitaires dans le Zou/Collines x x

Visite de dix centres de santé par une équipe conjointe PISAF /DDS Zou et Collines.

Six centres ont été retenus et leurs dossiers de réfection élaborés et devront être soumis à un appel d’offre au cours du mois d’octobre 2007.

Fournir à des formations sanitaires sélectionnées du matériel médical pour améliorer la prestation de services de qualité dans le Zou/Collines x

Une liste des équipements établie par la DDS détermine les besoins par formation sanitaire. Une compilation faite par PISAF a relevé 155 instruments, groupes d’instruments et matériels médico-techniques.

Cette liste permettra au PISAF de faire les commandes en tenant compte du budget disponible et renforcera la mise en eouvre des collaboratifs d’amélioration de la qualité des soins.

RI 2.4 L’accès financier aux services de santé est accru

Documenter les meilleures pratiques et les leçons apprises de l’expérience de mise en œuvre des mutuelles dans le Borgou/Alibori

X

L’évaluation à mi-parcours des mutuelles de santé mises en place dans le Borgou/Salibori a été réalisée avec l’appui d’un consultant et les résultats préliminaires présentés aux membres du comité de pilotage.

Ces résultats ont révélé que les mutuelles ont contribué à augmenter l’accès des populations aux services de santé, ont contribué aux recettes des CS et ont impliqué les élus locaux et les agents de santé contribuant ainsi que l’amélioration de la qualité des soins. Ces résultats seront présentés au MS au cours du mois d’octobre 2007.






T1 T2 T3 T4

RI 2.4 L’accès financier aux services de santé est accru

Documenter les meilleures pratiques et les leçons apprises de l’expérience de mise en œuvre des mutuelles dans le Borgou/Alibori

X

L’évaluation à mi-parcours des mutuelles de santé mises en place dans le Borgou/Salibori a été réalisée avec l’appui d’un consultant et les résultats préliminaires présentés aux membres du comité de pilotage.

Ces résultats ont révélé que les mutuelles ont contribué á augmenter l’accès des populations aux services de santé, ont contribué aux recettes des CS et ont impliqué les élus locaux et les agents de santé contribuant ainsi que l’amélioration de la qualité des soins. Ces résultats seront présentés au Ministère de la Santé au cours du mois d’octobre 2007.

Créer des mutuelles additionnelles dans les cinq communes non couvertes par des mutuelles dans le B/A

x

La stratégie d’extension a été élaborée à partir des leçons apprises de l’évaluation de l’expérience pilote menée dans le B/A.

Cette stratégie met l’accent sur le renforcement des capacités locales en mutuelles de mise en place et de gestion des mutuelles de santé dans une perspective de pérennisation.

Appuyer les mutuelles existantes en renforçant leur capacité organisationnelle et managériale

x x x x

Des appuis techniques et financiers dans le domaine de la formation d’agents de santé de nouveaux élus mutualistes sur leur rôle et responsabilité, la tenue d’AG ainsi que dans le recouvrement des cotisations et la réalisation d’émissions radios sur les mutuelles de santé ont été fournis aux mutuelles de santé de Banikoara et de Sinendé.

D’autres appuis comme la facilitation de la signature de convention entre centre de santé et mutuelle et élaboration de fiches techniques ont été fournis. L’analyse de la qualité et du coût des soins offerts aux mutualistes a permis de mettre en place un plan d’amélioration de la qualité des prestations de soins.

Aider à la création d’une fédération régionale des mutuelles dans le B/A

x x x

Deux sessions de formations au profit des responsables des unions communales de mutuelles de santé de Sinendé et de Banikoara ont permis d’accompagner les acteurs dans la mise en place du système de gestion de ces fédération de mutuelles dans le B/A.

Le PISAF a conçu et produit les supports de gestion qui ont été mis à la disposition des fédérations de mutuelles de santé de Sinendé et de Banikoara.

Introduire un mécanisme pour soutenir l’utilisation des services préventifs par les mutualistes

x

Les plans d’amélioration de la qualité des soins et de l’adhésion aux mutuelles de santé ont pris en compte les services préventifs.

Un plaidoyer a été fait auprès de l’USAID en vue de disponibiliser des MILD pour les mutuelles de santé pour encourager l’utilisation de cette mesure de prévention du paludisme afin de réduire la morbidité palustre, premier motif de consultation des mutualistes dans le Borgou/Alibori.






T1 T2 T3 T4

Créer des mécanismes locaux de soutien technique continu des mutuelles dans le Borgou/Alibori

x x x

Appui au fonctionnement du cadre de concertation entre les responsables mutualistes, les agents de santé, les COGECS et les élus locaux.

Analyser les barrières (y inclus le cout) à l'utilisation des services de santé par les plus démunis

x

Les termes de référence d'une étude sur l'accès des indigents aux soins ont été élaborés.

Cette étude se déroulera durant FY 08.

Concevoir et tester un mécanisme de réduction des barrières à l'accès aux services de santé par les plus démunis x x x

Les résultats de l'etude sur l'accès des plus demunis aux services de santé vont servir d'intrants á l'élaboration de ce mécanisme de réduction des barrières pour les plus démunis.

Assistance Technique pour les mutuelles (STTA)

x x x

Diverses assistances techniques ont été fournies par des consultants et le home office pour la mise en oeuvre de l'évaluation à mi-parcours des mutuelles de santé dans le Borgou/Alibori et pour l'élaboration de la stratégie d'extension des mutuelles de santé dans le Borgou/Alibori puis dans Zou/Collines.

Jean Damascene BUTERA a été le principal consultant ayant appuyé l'évaluation de l'expérience des mutuelles de santé dans le B/A et l'élaboration de la stratégie d'extension.

RI 3. La demande des Services, des Produits et Mesures Préventives de Santé est accrue

RI 3.1 Amélioration des connaissances, des comportements appropriés et des mesures préventives

Impliquer le niveau national dans des discussions sur les messages clés et médias

x x x

Le PNLS et la DSF ont été impliqués dans l’élaboration de supports pédagogiques relatifs à la nutrition et à l’alimentation du bébé né de mère séropositive et du dépliant PF.

Ces supports ont été imprimés et seront distribués aux formations sanitaires au cours du premier trimestre 2008.

Fournir une assistance technique pour le développement et la mise en œuvre d’une stratégie CCC (STTA : Waverly/Tonja)

x x x x Le document de stratégie CCC a été finalisé et est disponible.

URC a appuyé techniquement l’élaboration et la revue de cette stratégie.

Renforcer la capacité des agents de santé et d’autres partenaires en CCC/IEC et CIP x x x

Les besoins de formation en IEC/CCC ont été identifiés et planifiés lors de la session d’harmonisation des plans d’action.

Ces formations seront organisées au cours du 1

er

trimestre 2008 et utiliseront les supports déjà élaborés.






T1 T2 T3 T4

Appuyer le développement et la mise en œuvre de stratégies novatrices de CCC

x x x

Les radios communautaires, les artistes de la musique populaire traditionnelle, les élus locaux, les crieurs publiques et les ONG ont été utilisés lors des campagnes de mobilisation sociale contre le paludisme et pour l'utilisation correcte des MILD, et pour le don bénévole de sang.

Ces campagnes se sont déroulées à Dassa, Glazoue, Bohicon et dans la zone sanitaire COZO. Le succès de cette stratégie amène PISAF à signer des contrats de prestation de service avec des radios locales et des structures de MPT.

Appuyer la PCIME et les SONU Communautaires

x x x

Le document de stratégie de mobilisation communautaire intègre la mise en œuvre des composantes communautaires de la PCIME et des SONU.

La PCIME et la PF ont été retenues comme porte d'entrée pour les activités communautaires dans le Zou et les Collines.

Actualiser l'inventaire du matériel IEC, analyser le matériel pour le niveau communautaire et l'adapter ou traduire en langues locales

x

En plus de l'inventaire effectué lors de l'EQGSS1 dans le Zou et les Collines, le matériel IEC pour le niveau communautaire a été inventorié auprès des autres partenaires et les discussions sont engagées pour leur adaptation notamment pour la PTME, les SONU et le paludisme.

Imprimer et disséminer le matériel IEC et les aides mémoires

x x

Sur les 6 supports adaptés à imprimer, les trois dépliants (Comment bien allaiter votre bébé, Comment nourrir votre bébé avec le lait de pharmacie, Alimentation du bébé après l'âge de 6 mois) sont déjà imprimés. Il en est de même du dépliant PF.

Il reste les affiches sur la PTME pour lesquelles le processus est en cours.

Identifier les priorités CCC clés sur une base annuelle, notamment MI, TPI, PTME, CDV, etc.

x x x x

Les priorités identifiées sont: i) le renforcement des compétences des prestataires en CIP et counseling, ii) la production et la dissémination des outils pédagogiques sur la PTME (alimentation de l'enfant né de mère séropositive), iii) la prévention et la prise en charge du paludisme, iv) promotion de la PF (méthodes modernes de contraception).

Mettre en œuvre des campagnes multimédias (radio, MPT, etc.) sur des thèmes de santé familiale

x x x

5 campagnes multimédias ont été menées sur des thèmes de la santé familiale. Elles ont connu la mobilisation de 6 radios communautaires, 3 artistes de Musique Populaire Traditionnelle, une troupe de théâtre et 8 OBC.






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Accorder des subventions aux ONG et aux OBC; renforcer les capacités pour la fourniture de services à base communautaire

x x x x

Le mécanisme a été élaboré mais le principe retenu est l'utilisation des ONG et OBC comme des prestataires de service.

Appuyer les journées de Mobilisation contre le Paludisme et les semaines de Mobilisation Sociale

x x x x

Cinq campagnes de mobilisation sociale ont été organisées au cours de l'année.

Une campagne dans la célébration de la journée mondiale de la lutte contre le SIDA, une campagne dans le cadre de la célébration de la Journée Africaine de lutte contre le Paludisme, une campagne sur l'hygiène et assainissement du milieu en vue de la prévention du paludisme dans la ville de Bohicon, une campagne de don de sang dans la zone sanitaire Savè-Ouèsse et une campagne de sensibilisation sur l'importance et l'utilisation correcte des MILD dans COZO.

RI 3.2 Introduction d'interventions et de services appropries bases sur la recherche

Déterminer les thèmes de CCC qui exigent une recherche formative

x x x

La faible mobilisation des communautés de Ouinhi et de Savè/Ouèssè pour les campagnes de vaccination a été retenue pour être objet de recherche opérationnelle.

La mini-campagne de distribution gratuite des MILD a connu une forte mobilisation de ces communautés contrairement aux campagnes de JNV. Il serait intéressant d'étudier les causes de leur manque d'intérêt pour la vaccination. Par ailleurs les indicateurs de la vaccination sont très faibles dans la zone sanitaire SAO.

Déterminer les innovations de prestation de services nécessitant un test pilot x x x

La fourniture de soins aux indigents.

Une étude sur l'accès des indigents aux services de santé est planifiée pour être réalisée au mois de Septembre 2007.

Conduire les tests pilotes et évaluer les résultats

x x x

L'expérience d'association mutuelle de santé et qualité des soins a démarré à titre expérimental dans le Borgou/Alibori.

L'objectif est d'augmenter l'adhésion aux mutuelles de santé à travers l'offre de services de qualité aux mutualistes.

Développer des stratégies pour le passage à l'échelle des innovations testées

x

L'intégration des mutuelles de santé et qualité des soins à été prise en compte dans la stratégie d'extension des mutuelles de santé dans le B/A ainsi que dans le Z/C.


ANNEX 3: 2008 WORKPLAN

PISAF FY08 Implementation Plan Q1 Q2 Q3 Q4 Estimated

Cost

Activities October 1, 2007 to September 30, 2008 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep US$

Overall Project

Continue to collaborate with other CAs, donors, and sectors and identify further areas of collaboration

500

Conduct annual workplanning activities with regional counterparts 5,000

Ongoing consultative meetings with regional and national level partners 10,000

Establish consensus on key strategies for life of project with counterparts and partners

6,000

Prepare Quarterly Performance Report 3,000

Prepare Annual Performance Report 300

Hold quarterly meetings with regional and zonal level counterparts 13,200

Hold USAID partners meeting 2,700

Develop FY09 implementation plan with partners (DDS and MCDZS) 7,500

Overall Project Subtotal 48,200 IR 1. A Supportive Implementation Environment Created

IR 1.1 Selected health policies and approaches implemented

Assist in finalizing and disseminating mutuelle national strategic plan 6,700

Revise policies related to community based family health products 6,300

Develop implement communication plan for decentralization policy 14,000

Provide regular opportunities for discussion of decentralization issues with health staff and civil society

14,000

Implement ascendant planning at all levels of the health system (central, regional, zonal)

14,000

Regular meetings between MOH and donors for coordination and collaboration on policy issues

10,000

Assist the MOH to develop national QA plan/Strategy 10,000

Assistance in implementation of national commodity security strategic plan 20,000

Implement recommendations from PISAF transparency report 10,000

Assist PNLP to implement its new malaria policy (training on new treatment protocols, follow up, LLI bednet distribution, SP)

50,000

Assist the PNLS in reviewing and implementing its HIV/AIDS/TB policy and strategy in the Zou/Collines

20,000

Assist Z/C in the implementation of the national strategy on maternal and neonatal mortality in collaboration with the DSF

45,000

Assist in updating and disseminating minimum family health package with PMTCT, VCT, IPT, ITN, etc

15,000


Assist in implementing mechanism to communicate standards (including preservice training)

5,500

IR 1.2 Increased health system management capacity created

Collect quarterly Monitoring Plan data in Zou/Collines 12,000

Provide support for the updating of health worker job descriptions to include community based activities in Zou/Collines

12,000

Support the evaluation of quality of care within targeted private clinics in Borgou/Alibori

15,000

Support development and revision of capacity building plans for Z/C, B/A & O/P 15,000

Update scoreboards to reflect expanded minimum package for family health 2,000

Introduce updated scoreboards in Z/C and support use in Z/C & B/A 15,000

Support quarterly review of performance vis-à-vis annual action plans 10,000

Support study tours for key health officials 20,000

Support attendance to regional/international workshops/conferences for key health officials/partners

25,000

Provide training in human resource management/quality assurance in Zou/Collines, Ouémé/Plateau, and reinforce in Borgou/Alibori

55,000

Provide training in formative supervision in Zou/Collines, Ouémé/ Plateau and reinforce formative supervision skills in Borgou/Alibori

32,000

Provide training in financial management in Z/C and reinforce financial management skills in B/A

30,000

IR 1.3 More effective civil society participation created

Continue COGEC training 17,000

Provide support to COGEC in ascendant planning and other activities 12,000

Provide technical support to community mobilization agents in the health zones 5,000

Disseminate results of mutuelles evaluation conducted in FY07 in B/A 2,000

Introduce and provide support to Commune Mutuelle Support Committees in areas with new mutuelles

12,000

Develop and pilot links between mutuelles and micro-finance initiatives 5,600

Develop a pilot strategy for linking mutuelles and community-based distribution 12,000

Develop grants program and award grants 100,000

Provide training to NGO and CBO grantees in improved management 12,000

Mobilize local community groups to promote good practices vis-à-vis Malaria and ARI (Z/C, B/A, O/P)

16,700

IR 1 Subtotal 677,800


PISAF FY08 Implementation Plan Q1 Q2 Q3 Q4 Estimated

Cost

Activities October 1, 2007 to September 30, 2008 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep US$

IR 2.1 Selected products available at public health facilities

Facilitate creation of departmental and zonal warehouses in Zou/Collines 8,000

Build capacity for logistics management in Zou/Collines and reinforce as needed in Borgou/Alibori

32,000

Update training materials for ASBC to include new family health products 4,000

Insert indicators of ASBC into scoreboards and other monitoring tools of health zones

15,000

IR 2.2 Selected products available at private sectors outlets

Support women's groups in the monitoring of household use of ITNs 5,000

IR2.3 Quality family health package available at targeted public health sector facilities

Implement QA plan for in Z/C & B/A 20,000

Conduct workshop on scale-up with those involved in PROSAF QA and collaborative activities

5,000

Provide training to health workers in Zou/Collines on provision of the integrated family health minimum package

48,000

Incorporate expanded minimum package topics into training materials, supervision guides and performance monitoring tools (PMTCT, malaria, ITNs)

12,000

Support training and post-training follow up on the new components of the family health package (PMTCT, malaria, ITNs) in Borgou/Alibori

25,000

Support capacity development in QA and supervision planning and implementation in Z/C, B/A and O/P

21,300

Support IMCI training and post training follow up in Z/C and for transfer-in staff in B/A & O/P

50,000

Develop and disseminate job aids 30,000

Support health zones to develop/strengthen collaboratives in Zou/Collines and Borgou/Alibori (learning sessions at zonal, departmental and national levels, coaching, data quality control)

55,000

Support infrastructure improvements in Zou/Collines 200,000

Provide selected health facilities with medical equipment to improve quality service delivery

120,000

IR2.4 Financial access to health services increased

Create mutuelles in Zou/Collines 32,000

Support and strengthen organizational and managerial capacity of existing 14,000


mutuelles

Support creation of regional federation of mutuelles in B/A 10,000

Introduce mechanism to support use of preventive services by mutuelles members

7,000

Create local mechanisms for on-going technical support to mutuelles in Borgou/Alibori

10,000

Analyze barriers to use of services by the disadvantaged, including cost 10,000

Design and test mechanisms for reducing barriers to access for the disadvantaged

20,000

IR 2 Subtotal 753,300 IR 3. Demand for Health Services, Products, and Preventive Measures Increased

IR3.1 Knowledge of appropriate behaviors and preventive measures improved

Engage the national level in discussions of key messages and media 2,000

Strengthen health workers and other partners capacity in BCC/IEC including interpersonal communications

33,000

Support development and implementation of innovative BCC strategies at regional, zonal, and commune levels

20,000

Support community IMCI and EONC 10,000

Update inventory of IEC materials, assess community tools, adapt/translate to local languages

15,000

Develop and disseminate IEC/BCC materials 40,000

Implement communications activities based on identified key BCC priorities 10,000

Implement multi-media campaigns (radios, MPT, etc) on family health topics 25,000

Issue grants to NGOs and CBOs; build capacity to deliver community-based services

100,000

Support Malaria Mobilization Days and Social Mobilization weeks 25,500

IR 3.2 Appropriate research-based interventions and services introduced

Conduct formative research on selected family health topics 50,000

Determine service delivery innovations needing testing 10,000

Implement pilots and evaluate results 30,000

Develop strategies for scale up of pilot strategies 10,000

IR 3 Subtotal 380,500

GRAND TOTAL 1,859,800

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