PISAF - Integrated Family Health Program ANNUAL PERFORMANCE REPORT N O 1 MARCH 28 SEPTEMBER 30, 2006 Distributed to: Donald Dickerson, USAID/CTO Cotonou, Bénin 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.
TABLE OF CONTENTS 1. INTRODUCTION... 1 1.1. Cross-cutting Strategies... 1 2. PERFORMANCE REVIEW AND ANALYSIS... 3 2.1. Intermediate Result 1: A Supportive Implementation Environment Created... 3 2.2. Intermediate Result 2: Access to Quality Services and Products Increased... 19 2.3. Intermediate Result 3: Demand for Health Services, Products, and Preventative Measures Increased... 25 3. PROGRAM MANAGEMENT... 27 3.1. Introductory Meetings... 28 3.2. Administrative and Personnel Management... 29 3.3. Financial Management... 29 3.4. Buildings and equipment... 30 3.5. Technical Assistance and Consultants... 31 4. CHALLENGES AND OPPORTUNITIES... 32 4.1. Challenges... 32 4.2. Opportunities... 32 5. FINANCIAL DATA... Error! Bookmark not defined. 6. ANNEES... 33 Annex 1: Performance Monitoring Plan... 33 Annex 2: Progress Table... 38 Annex 3: 2007 Draft Implementation Plan... 47
ACRONYM LIST AIDS Acquired Immunodeficiency Syndrome ART BCC CBOs CBS CBSA CDC DDSP DSF EONC FBOs FHS GFTAM HIV IEC IMCI M&E MOH NGOs PMP PMTCT PNC QA RFA SNIGS STI TA URC USAID VCT Anti-retroviral therapy Behavior Change Communication Community Based Organizations Community-based services Community Based Services Agent Center for Disease Control and Prevention Directeur Départemental de la Santé (Departmental Health Director) Direction de la Santé Familiale (Family Health Directorate) Emergency Obstetrical and Neonatal Care Faith Based Organizations Family Health Services Global Fund to Fight AIDS, Tuberculosis and Malaria Human Immunodeficiency Virus Information, Education and Communication Integrated Management of Childhood Illness Monitoring and Evaluation Ministry of Health Non-governmental organizations Performance Monitoring Plan Prevention of Mother-to-Child Transmission Prenatal Consultation Quality Assurance Request for Application Système National d Information d Gestion Sanitaire (National System of Health Information and Management) Sexually Transmitted Infection Technical Assistance University Research Co., LLC United States Agency for International Development Voluntary Counseling and Testing PISAF - ANNUAL REPORT NO. 1 v
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 March 28 through September 30, 2006. This is the first annual report prepared and submitted to USAID for the PISAF project. 1.1. Cross-cutting Strategies To achieve the desired results, the PISAF project engages the following cross-cutting strategies: Fostering Beninese investment and ownership of improvement efforts at all levels of the health system Putting decentralization into practice at zone-level Ensuring that norms are updated, communicated and integrated into service delivery Emphasizing quality assurance and institutionalizing continuous improvement Strengthening linkages between communities and health facilities to stimulate demand and quality of care Multi-sectoral approaches Using pilots and small applied research to test new or innovative approaches Over the period from March 28 through September 30, 2006, the PISAF Project began laying the ground work for advances in each of these cross-cutting areas. Project activities within each IR and directed towards each technical area were designed specifically to be integrated across the project to achieve the greatest results. The following specific activities were undertaken to ensure effective realization of these cross-cutting themes: PISAF - ANNUAL REPORT NO. 1 1
Fostering Beninese investment and ownership of improvement efforts at all levels of the health system. PISAF works to ensure that Beninese partners at the national, regional, zonal, health centre and community levels participate in the development of new approaches and tools and take them on as their own. In the first months of the project, PISAF has fully engaged the Ministry of Health and the DDS in each zone in which we are active. From planning specific activities to development and validation of tools and documents and formation of long term plans, MoH and DDS staff have been actively involved. In the implementation of the Management Assessment (MA), DDS staff provided input into the design of the assessment, participated in data collection, and were fully briefed on the results of the assessment. Selected staff at the national and departmental levels also were trained in the presentation of the data and findings. These staff were prepared to make a full presentation to Congress on their own. Putting decentralization into practice at zone-level. Many of the policies and decrees that facilitate effective decentralized planning, financial and human resource management of health zones and foster allocation of health budget by local governments have been developed by the MOH. During this reporting period, PISAF supported the implementation of decentralization by providing technical and financial support for the regular meeting of the committee to monitor the recommendations generated during the forum on health sector decentralization. PISAF also provided technical and financial support to organize a national exchange day on integrated ascendant planning as a first step toward full integration of ascendant planning into the annual planning and budgeting process. Discussion also took place between PISAF and the National AIDS Control Program (PNLS) regarding the decentralization of HIV/AIDS and STI activity planning. Ensuring that norms are updated communicated and integrated into service delivery. In consultation with departmental level partners and under review and approval by national level staff, PISAF will be working to develop mechanisms for review and revision or adaptation of standards and protocols, and to communicate them to the health workforce and community, and ensure they are integrated into M&E and supervision guides. To date, PISAF has begun its work in this area by supporting the validation workshop of the national contraceptive security strategy paper and providing logistical and financial support for the reproduction of the Five-Year Maternal and Neonatal Mortality Reduction Plan. Additionally, job aids on malaria rapid diagnostic tests (RDTs) and infant feeding practices among HIV positive mothers are being developed based on revised international standards. Emphasizing quality assurance and institutionalizing continuous improvement. Quality assurance is being promoted at all levels of the system, such that quality assurance activities, structures and values become an integral and sustainable part of the health system. To begin its work in quality assurance, PISAF conducted an assessment of the availability of the quality family health package in public sector facilities in the Borgou/Alibori and supported a collaborative improvement session there. The Zou/Collines has existing quality assurance activities in the areas of IMCI and emergency pediatric care; emergency obstetric and neonatal care; nosocomial infections and client satisfaction. PISAF will support these activities in the coming year. Strengthening linkages between communities and health facilities to stimulate demand and quality of care. During the first six months of the project, PISAF has led several efforts to strengthen community-health facility linkages. To better direct its interventions in community mobilization, PISAF organized an experience-sharing workshop for partners working at the community level. In preparation for strengthening the COGECS in the Zou/Collines, PISAF performed an inventory of the existence and operations of the COGECS in the two departments. PISAF also worked with the DDS in the Zou/Collines and the PNLP Coordinator on a community-based ITN distribution strategy that uses women s groups as PISAF - ANNUAL REPORT NO. 1 2
key partners in distribution. In the Borgou/Alibori, PISAF organized a training session on mutuelles to increase knowledge and awareness of their purpose and benefits. Multi-sectoral approaches. By building on existing contacts and networks and maintaining continuous communication with the MoH, DDS, and local groups, PISAF regularly engages players across sectors to enter into dialogue and participate in project activities. Most notably, PISAF has engaged locally elected officials, many of whom are eager and willing to participate in and support PISAF activities and objectives. Using pilots and small applied research to test new or innovative approaches, with results informing policy. Over the past several months, PISAF has begun to generate ideas and identify opportunities for small pilots and operations research studies. Several initiatives are forthcoming with focus on malaria, HIV/AIDS, and IMCI. Further details on the incorporation of these cross-cutting strategies and specific activities related to each IR are described in the following pages. 1. 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 (SO 5), 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. Principal Accomplishments Advocated for incorporating policies from the strategic plan on development of mutuelles into the policy paper on health sector development policy paper. Supported the regular session of the committee to monitor the recommendations generated by the forum on decentralization of the health sector. Held a dialogue workshop on integrated ascendant planning in the Ministry of Health. Supported the validation of the national contraceptive security strategy. Supported the finalization and reproduction of the five-year national plan to reduce maternal and neonatal mortality. Supported the preparation of the National Malaria Program s (PNLP) proposal to the Global Fund. Introduced PISAF to the the MOH and the DDS of Zou/Collines and of Ouémé/Plateau. Conducted the first management assessment in the Zou/Collines region. Purchased computers and established an Internet domain for the DDS and health zones. Identified and contacted the NGOs, CBOs, women s groups, local radio stations and local authorities in Zou/Collines. PISAF - ANNUAL REPORT NO. 1 3
2.1.1. Sub IR 1.1: Selected health policies and approaches implemented Finalized and assisted with the implementation of the policy on mutuelles Advocated for incorporating policies from the strategic plan on development of mutuelles into the policy paper on health sector development policy paper. The strategic plan for development of mutuelles, the main points of which already have been validated, will serve as a framework for all the stakeholders in the area of mutuelle development in Benin. The implementation of this plan will create an environment that is favorable to developing mutuelles. The steps for finalizing this strategic plan began as soon as PISAF started up, with work sessions involving resource persons from the Planning and Program Directorate (DPP) and the community health department of the National Health Protection Directorate (DNPS). With technical support from Abt Associates, the local PISAF team provided technical and financial assistance to the DNPS/MOH community health service team by reviewing the Benin Health Mutuelle Strategic Development Plan. These sessions made it possible for the team to deliver a final draft of the document to the Ministry of Health. One of the suggestions made during the meeting at the Ministry of Health was to hold a workshop including DPP officials; the committees in charge of preparing the Health Sector National Development Plan (PNDS) and the second edition of the Poverty Reduction Strategy Paper (PRSP 2); the Strategic Planning Directorate in the Ministry of Economic Development and Finances; the Advisor for Project and Program Monitoring in the Ministry of Health; and other partners, to encourage ownership of the contents of the strategic plan on the development of mutuelles in Benin. Such a workshop will facilitate the inclusion of the plan s policies in the various strategic papers now being prepared. PISAF will provide technical and financial support for this workshop, which is to be organized by the Community Health Service. PISAF - ANNUAL REPORT NO. 1 4
Prepared a communication plan for decentralization policies: Supported the regular session of the committee to monitor the recommendations generated by the forum on decentralization of the health sector. PISAF provided technical and financial support for the regular session of the committee to monitor the recommendations generated by the forum on decentralization of the health sector. The session was chaired by the Director of the Cabinet, and attended by the Assistant Director of the Cabinet, the Secretary General of the Ministry, the Assistant Director of the DPP, and the PISAF Chief of Party in attendance (see photo below). Approximately 30 people attended this session, held on Tuesday, June 27, 2006, at the Ministry of Health in Cotonou. The work of the session consisted of two presentations, made by the Director of Health Zone Development and the Head of the DPP s Research, Strategies and Planning Service respectively. The first dealt with the Monitoring Committee s mission and the results of the work done by the five (5) technical subcommittees set up to implement the recommendations of the forum on decentralization of the health sector, which was held in April 2002. The Director of Health Zone Development shared each technical subcommittee s progress in the decentralization and health system reform process. PISAF - ANNUAL REPORT NO. 1 5
The second presentation highlighted the remaining tasks that each of the technical subcommittees would be likely to carry out in 2006. The tasks are as follows: Technical Subcommittee Human Resource Management Financial and Material Resource Management Document Review Programs and Planning Integration Information and Awareness Tasks Prepare an operating plan for the human resource management policy Disseminate Decree No. 465 of September 29, 2000, and the new standard contract model Establish a 2-year duration for contracts of workers addressing social issues Conduct a mapping of the disadvantaged/isolated zones Update the order on personnel turnover based on operational level Reflect on the placement of budgeted positions at the decentralized level Finalize the study on procedures for transferring the funds of decentralized project and program activities by delegating appropriations Make consistent the bylaws for the COGECS and the order providing approval for zone hospital charters. Prepare the implementing documents for the decree on reorganization of the base of the health pyramid Prepare and have adopted the laws on the new names of the health zones and commune-level health centers with special status Establish mechanisms for implementation of the integrated ascendant planning cycle Finalize the order on the duties, organization and operation of the Department Health Directorates Prepare the information and awareness guide on decentralization Mobilize resources for carrying out the information and awareness plan Organization in charge Human Resource Directorate DRFM DDZS DPP SGM DSF with support from the DDZS The analyses of the members of the Monitoring Committee in response to these presentations made it possible to highlight the challenges faced and to adopt an action plan as indicated above. The Ministry s technical director are responsible for implementing the established action plan from this point forward. At the end of the session, the Director of the Cabinet and Chair of the Monitoring Committee expressed the Ministry of Health s satisfaction with USAID support for the decentralization process: Through PISAF, I wish to sincerely thank USAID for waking us up by supporting the organization of this session, because truly, we were asleep. We will do everything to stay awake in order to rise to the challenges we have identified for 2006. PISAF - ANNUAL REPORT NO. 1 6
The PISAF Chief of Party spoke of the project s commitment to support the Ministry when these activities are implemented. A report on the activities carried out in 2006 pointed out that only two subcommittees, Program and Planning Integration and Human Resource Management, were able to carry out the planned activities. They prepared the ascendant planning manual and held the workshop to revise the order on MOH personnel turnover respectively. The other subcommittees were unable to carry out their planned activities for various reasons, including unexpected obstacles that led to postponement of several working sessions and changes in government that resulted in the appointment of a new Minister of Health and new heads of Ministry departments. Considerable effort will be required in 2007 to carry out all the remaining activities. Regular forums to discuss decentralization issues with health care workers and civil society Workshop to revise the order on the reassignment of Ministry of Health personnel In August 2006, PISAF took part in the work of revising the order on the reassignment of health care workers. This activity was part of the 2006 planning work of the Human Resource Management technical subcommittee. The goal was to create a third level of reassignment to provide a regulatory framework for strengthening the prerogatives of the heads of the health zones in the decentralized management of human resources. PISAF, the only partner present at this workshop, was unable to bring the participants to an understanding, neither at the central nor the department level. Participants held onto the argument that much power already has been given to the coordinating physicians of the health zones in the context of decentralization. Even though the third reassignment level (the peripheral level) was not adopted, the workshop did serve to revive the debate on the decentralized management of health zones and on decentralized human resource management in particular. Likewise, the meaning and level of the debates are indicative of the large amount of information and awareness work necessary to bring a large percentage of stakeholders to the same level of understanding of the reform in progress in the health sector in Benin. Finally, the position taken by PISAF compelled the Cabinet to reconsider certain provisions of the document that was adopted but which the Minister has not yet signed. Implemented ascendant planning at all levels of the health system (central, department and zone) Dialogue on implementing integrated ascendant planning PISAF provided technical and financial support to organize a national exchange day on integrated ascendant planning. This meeting was held on August 30, 2006, at the Ministry of Health, and over 40 people attended. The workshop familiarized the participants with the eight (8) main stages in the integrated ascendant planning cycle validated by the committee to monitor the recommendations generated by the forum on decentralization of the health sector. The main recommendation dealt with the broad dissemination of the procedures manual, prepared by the Ministry of Health. PISAF indicated its intention to continue to support dissemination of the manual in the Zou/Collines. PISAF - ANNUAL REPORT NO. 1 7
The presence of representatives from the Ministry of Development (formerly the Ministry of Planning), Economy and Finance and their awareness of the ascendant planning process will enable this strategic ministry to place greater importance on budget forecasts submitted by the health sector in the future. Regular meetings between the Ministry of Health and donors for coordination and collaboration on health policy issues PISAF s introduction to authorities at the central level and in the departments Following the official launch of PISAF, which was co-chaired by the Minister of Health and the U.S. Ambassador, the project was introduced officially to the DDS of the Zou/Collines on August 3, 2006, to the Ministry of Health on August 8, 2006, and to the /Ouémé-Plateau DDS on August 23, 2006. At the Ministry of Health level, the introduction was made by the Minister s Director of Cabinet, and, at the Department Directorate level, by the Department Director. The primary concerns expressed by the participants were the sustainability of the accomplishments made by prior USAID projects and the coordination of PISAF programs with the involvement of Ministry officials. In particular, the issue of the six-day IMCI training was mentioned, as well as questions about the possibility of a project annex in Ouémé/Plateau, similar to that in the Borgou/Alibori. PISAF staff, with the support of the USAID family health Team Leader during the introduction at the Ministry, provided detailed responses to questions. After each introduction, brochures and project summaries were distributed. Due to scheduling considerations, the next phase of introduction of PISAF to the Borgou and Alibori authorities has not yet occurred. This series of introductions was an opportunity for PISAF to describe the project s framework and to refocus partner expectations of the project at each level. It is important to note how the Director of the Cabinet expressed the Ministry of Health s satisfaction: We are truly excited to see that the PISAF team consists almost entirely of national technical staff who are familiar with the health issues and behaviors of the people of Benin. That is what sustainability is about. The fact that there is confidence in nationals will enable them to develop expertise through PISAF. This is a great honor for us and we will do everything in our power to make this project a success, because we know everything that PROSAF accomplished in Borgou/Alibori. Zou/Collines health partner coordination meeting To ensure the effectiveness of the support from the Zou/Collines DDS health partners, a partner dialogue meeting was held in Abomey on July 10, 2006. This meeting, initiated by the USAID Family Health Team, received financial and technical support from PISAF. The meeting included all the partners working in both departments, as well as some Technical, Project and Program Directorates in the Ministry of Health. PISAF took advantage of this opportunity to share the major pillars of its work with the partners. Participants also became more familiar with the work of the other partners which should facilitate coordination of activities and avoid duplication of programs in the field. All partners and their activates were mapped. It was agreed that the partners meeting will be held every three months. PISAF - ANNUAL REPORT NO. 1 8
Supported the DSF to finalize and implement the national strategy to reduce maternal and neonatal mortality: This year, PISAF provided technical and financial assistance to the DSF in different areas. The workshop to validate the national strategy on contraceptive security was held in Lokossa on May 30 and 31, 2006: This workshop was an opportunity to: i) validate the major axes of reproductive health product (contraceptives, blood and blood derivatives, and oxygen) security, including, ii) validate the list of contraceptives, and iii) amend the draft collaboration contract between the CAME and the Ministry for signature. This contraceptive security plan is one of the pillars of the maternal and neonatal mortality reduction strategy. Holding this workshop was positive for the plan established by the DSF to release contraceptives acquired for the Ministry of Health that were in the port of Cotonou and pending clearance. A mini-workshop was held again in Lokossa on June 1 and 2, 2006, to distribute three separate planning documents for implementing the national maternal and neonatal mortality reduction strategy at each level (central, department and health zone). By participating in this workshop, PISAF was able to obtain these tools as soon as they were launched. The Five-Year Plan for Reduction of Maternal and Neonatal Mortality reproduced: After providing technical and financial support for the workshop to finalize the five-year plan, PISAF provided financial support for printing the plan, which will be distributed to the health facilities in the Zou/Collines. A dissemination campaign will be organized for this purpose in collaboration with the DSF. Other support to the Ministry of Health: Several activities were carried out that helped strengthen collaboration with the central level: Technical support for the PNLP to prepare terms of reference PISAF provided technical support to the PNLP for the preparation of the terms of reference to obtain technical assistance from USAID consultants in three areas: 1) preparing the MOH s malaria proposal for the 6 th Global Fund round; 2) preparing a monitoring/evaluation plan for the PNLP; 3) preparing a procurement and management plan for ACTs and long-lasting insecticide treated nets (ITNs). Support to the PNLP in preparing its proposal to the Global Fund: PISAF supported PNLP officials to develop a proposal for Global Fund funding, both in the preparatory and finalization stages. An international consultant was made available to the PNLP using PISAF funding. PISAF technical staff gained considerable experience in this process, which is one for which local expertise is scarce. This is an asset that can be used for subsequent support from PISAF for similar processes. Support to the DPP for disseminating national health account reports In this quarter, the printing of 5,000 brochures and 500 national health account reports was completed with PISAF funding. The printed items were made available to the DPP which, starting October 9, 2006, must organize the dissemination of these documents to all the departments in the country. Financial support also was provided to the DPP to organize a national dissemination session in November 2006 for the members of the government, deputies and heads of the country s institutions. PISAF - ANNUAL REPORT NO. 1 9
Support to the PNLS for the decentralization of HIV/AIDS and STI activity planning With the goal of developing collaboration between the National AIDS Control Program (PNLS) and PISAF, the PISAF Chief of Party paid a visit to the PNLS Coordinator. At this meeting, the highest official in this program was briefed on PISAF s objectives, with emphasis on its mandate from USAID to support implementation of PMTCT activities and decentralization of PNLS activities. This meeting made the PNLS Coordinator more comfortable with PISAF objectives. He was the only official from the central level that attended the health partners meeting of the Zou/Collines DDS to better understand the content of PISAF s interventions. During this meeting of the Zou/Collines health partners, the PNLS Coordinator said I need to better understand how PISAF can help us decentralize our activities, because the providers consider AIDS activities additional activities that overburden them and thus are the responsibility of the PNLS, which to date has been implementing a vertical program. In light of these remarks, two important events allowed PISAF to demonstrate to the PNLS the advantages of decentralizing its interventions. The first was the session for the MOH adoption of integrated ascendant planning with PISAF support. At this session, the DPP presented to all Ministry of Health programs the process to be used henceforth to prepare budgeted annual workplans, a process that must be implemented to if all health sector programs are to comply with decentralization. This process requires the different programs to provide the health zones with the information necessary to prepare budgeted annual action plans with the participation of the community, the health zone partners and the DDS. Once these plans have been developed, each level must play its assigned role in the context of decentralization. For example, the central level designs, monitors and evaluates, while the operational, or zone, level implements. Each level also must have the appropriate resources to play its role. The second event that demonstrated the advantages of decentralization was the PMTCT partner roundtable. At this event, the difficulties related to PMTCT implementation were brought out, including a lack of financial resources. In addition, the PNLS mentioned that health care workers that provide PMTCT services do not consider PMTCT activities to be health zone activities; rather, they are central-level, PNLS activities, and thus add to the zone level workload. Thus, they believe they should be given financial incentives to carry out these additional activities. PISAF pointed out that the verticalization of PNLS activities has led them to this conclusion. By including PMTCT activities in the health center and health zone action plans, the resources required for these activities will be set aside by the providers who will carry them out. PMTCT activities must be owned by the providers, which means transferring the planning of these activities to the level where they are executed. Advocacy with the PNLS will intensify in 2007 and will be facilitated by having the DPP implement integrated ascendant planning with PISAF support in early 2007. The startup of the IMPACT Project activities, which include a component for institutional support to the PNLS and CNLS, is a positive factor since PISAF and IMPACT will be working together in synergy. Attended dialogue meetings/workshops with partners Dialogue for the distribution of free long-lasting insecticide-treated nets (ITNs): Along with the other MOH partners, PISAF participated in the meeting to establish a procedure for distributing free ITNs, which is scheduled for the first quarter of 2007 with guidance from the World Bank s Booster Program. Two important points came out of this exchange: 1) a technical PISAF - ANNUAL REPORT NO. 1 10
committee should be established immediately to discuss the details of this distribution; and 2) distribution should take place in both the health facilities and in the community. Workshop to prepare the National PNLP Monitoring/Evaluation Strategy (Lokossa): PISAF made a technical contribution to this workshop, which was recommended by the World Bank prior to implementation of the Booster Program. Several aspects of the M&E strategy were addressed during this workshop, including: i) review of all indicators ii) development of a monitoring and evaluation plan and iii) discussion of the areas of monitoring and evaluation, the system for implementation and the different levels of intervention. The PNLP technical staff were given the task of finalizing this document so that it could be validated. Exchange meeting on IMCI between PISAF and the DSF: To foster the continued implementation of IMCI, PISAF initiated a meeting with the DSF and the head of the maternal and child health unit. At the end of the meeting, the proposal to hold a workshop on the implementation of the IMCI directives was accepted. Also, a decision was made to conduct an evaluation of the experience of implementing the six-day IMCI course in the Borgou/Alibori, present the preliminary findings to the decision-makers and discuss the results with them, so they could make an informed choice. Participation in the PMTCT partner roundtable On September 13 and 14, 2006, in the CODIAM conference room, a roundtable was organized by the PNLS on the progress made in expanding the PMTCT program in Benin. Financed by UNICEF, forty (40) participants from the central and department levels attended, as well as other partners working in PMTCT. The workshop began with a presentation of the workshop s objectives and a reiteration that once the work is complete, a plan for the acceleration of PMTCT expansion will be prepared, along appropriate strategies to be implemented to achieve expansion. The next presentation at the workshop was on the status of PMTCT in Benin and provided the background of the PMTCT program from 2000 to date highlighting that as of the end of 2005, PMTCT sites increased from 33 sites in the preparatory phase to 188 in the expansion phase, and that PMTCT is coordinated by a management committee with support from a technical unit. The accomplishments of this coordination are: i) preparation of the PMTCT policy, standards and procedures; ii) preparation and distribution of PMTCT training and management tools; iii) training of trainers and supervisors; iv) holding workshops for experience-sharing; and v) evaluation of the quality of site operations. However, the implementation of PMTCT activities is facing organizational, material, financial and human resource difficulties. Special emphasis was placed on the poor monitoring of children of HIV+ mothers; reagents, consumables and drugs that are out of stock; insufficient numbers of providers trained in PMTCT; lack of mediators at the sites; lack of funding for certain activities; and lack of means to send blood samples to the reference and CIPEC laboratories. Given these difficulties, the challenges are to strengthen the links between PMTCT and treatment sites using ARVs, implementing a system for monitoring children born of HIV+ mothers up to the age of 18 months, and the incorporation of PMTCT activities into the minimum package of activities, including supervision. The third presentation was on the CNHU s experience in treating children infected with HIV and children born of HIV+ mothers. The fourth presentation on the new WHO directives on PMTCT focused on participant knowledge. The purpose of these directives is to assist health ministries to select and obtain ARVs for women and their children in an PMTCT context. The WHO has proposed several types of arrangements to be adjusted to each country s context and realities. PISAF - ANNUAL REPORT NO. 1 11
The fifth presentation, made by the PNLS Coordinator, summarized the status of people on ARV treatment in Benin as of the end of the second quarter of 2006. It showed that the projections for treating 300 patients per quarter in 2003 were largely exceeded in 2005 when 700 patients were reached per quarter and in 2006 when 1,000 patients were reached per quarter. This is quite disconcerting because patients on ARVs receive free care and resources are limited. September 26 was the date selected for finalizing the PMTCT expansion plan with the partners, but this date was postponed and this meeting had not yet taken place as of the end of the quarter. PISAF was actively involved in the work of this roundtable by proposing several specific contributions, such as integrating PMTCT activities into health zone action plans, including PMTCT components in the health zone management team supervision grid; involving mutuelles in paying the mediators; training health providers in correctly estimating ARV needs with the support of the three MOH representatives from the PNLS, the PNLP and the CAME who were trained in QUANTIMED in August 2006 in Dakar with USAID support through PISAF. PISAF has agreed to contribute to better monitoring of children born of HIV+ mothers in its concentration department of the Zou/Collines. PISAF s contribution was very much appreciated by the chairs of the roundtable and by the PNLS and CNLS, as they saw USAID as an important technical and financial partner on which they can rely for PMTCT in Benin. Participation in presenting and discussing the preliminary results of the ProFam pilot project evaluation The ProFam project, whose purpose is to improve the quality and accessibility of family health services in the private sector, is now in its eighteenth month of implementation. This project involves the use of social franchising to improve the quality of service delivery in the private clinics in Atlantique and Littoral. Population Services International (PSI) and IntraHealth worked in collaboration with the DSF on this project, which notably targets the private health sector. Results include an improvement in the skills of workers trained in FHS protocols, better availability of contraceptives, and better integration of data into the SNIGS. This experience will be taken into account in PISAF s involvement in the authorized private health facilities in the Zou/Collines to improve access to quality family health services. Participation in the workshop to validate the three studies performed in Benin on the Standard Days Method (SDM): By invitation of the DSF/MOH, PISAF attended the workshop to validate the reports on studies performed on the SDM in Benin with technical and financial support from USAID through the Institute for Reproductive Health (IRH). This workshop was held in the Zou/Collines CIPEC and roughly 40 participants attended. After three days of work, from July 18 to 20, 2006, the reports on the three studies were validated and a plan to implement the findings was prepared. Through its support of the national strategy on contraceptive security, PISAF will contribute to the permanent availability of SDMs in the Zou/Collines. 2.1.2. Sub IR 1.2 : Increased health system management capacity created PISAF - ANNUAL REPORT NO. 1 12
Implemented the management assessment in the Zou/Collines region One of the major activities of this year was to implement the first Management Assessment (MA) under PISAF with the objective of establishing baselines for indicators available for effectively starting up activities to improve the quality of clinical and management interventions in both departments. One international and one local consultant were engaged to provide extra support for this effort. Several phases of the assessment were completed over the past two quarters. Other phases were in progress at the time of the writing of this report and a report on them will be available soon. A summary of the phases is as follows: Preparatory phase: The preparatory phase involved preparing the survey protocol and data collection tools. Nineteen (19) tools were validated along with the evaluation protocol at a workshop attended by officials from the Ministry of Health, the DDS and its partners. Areas of clinical intervention as well as support activities were included in the tools, which meet the concerns of the DDS, which was seeking a broad evaluation of the deficiencies in the health system. Data collection phase: This phase was facilitated by the involvement of the Zou/Collines DDS, which provided leadership to identify a solution to the many obstacles that occurred during this phase. In addition to the commitment made by the DDS and its staff, the implementation of the management assessment received substantial support from the Ministry of Health, which visited the data collectors during the first day of their training. The MOH stressed the importance of data quality and the use of data to improve health sector indicators. Data collection took place in two major phases: the data collector training and pretest stage and the actual data collection stage. The data collectors were health care workers from the two departments. Teams from each zone were assigned to collect data in another zone to avoid having individuals collect data in their own zone. Through collaboration established with the social promotion centers, workers from this sector were able to participate. Thus, the officials of the social promotion centers helped collect data in their respective communes. Local data collectors were selected on the basis of their mastery of the local language and their ability to translate the tools. A week-long training course that included pre-tests of the tools prepared the data collectors for their work. Since the management assessment thoroughly covered the Zou and Collines, the pretest by the data collectors was conducted in the departments of Mono and Couffo. Sixty-four (64) health care workers (physicians, nurses, midwives, administrators and medicaltechnical officials), including 23 women, and thirty (30) data collectors (9 women and 21 men), collected the data over a period of about ten days. These people were divided into 16 teams. Collection was supervised by 18 people divided into 6 teams. A total of 5,523 tools were administered, which accounts for about 70% of the projections. About 50% of tool 1: observation of services and tool 4: client interviews were not well-administered due to the fact that no many clients were using the health centers visited. The great achievement of this evaluation is that ALL accessible the health facilities were included (136, including four zone hospitals and one departmental hospital. Had it not been for the flooding that made the Idadjo Health Center in Collines and the Lobeta Health Center in the Zou inaccessible, the data collectors would have visited all the health facilities. The other major achievement is that all the subsystems identified by the DDS were included. Thus, at the DDS s insistence, even the DDS s organizational capacity was evaluated. PISAF - ANNUAL REPORT NO. 1 13
Data entry and analysis phases, and report preparation, validation and results dissemination phases: The final quarter of 2006 will be spent largely on the subsequent phases of the management assessment, which include entering and analyzing the data that were collected, organizing the results validation workshop and, finally, holding the partner roundtable for disseminating these results. These phases should culminate with the preparation of action plans for the COGECs, health zones and the DDS using the validated data from the management assessment. Pending the results of this data analysis, the following preliminary observations can be made based on the two completed phases of the survey:: A strong commitment and resolve by the DDS and data collection teams PISAF was most impressed with the initiative taken by the stakeholders from the two departments, beginning with the DDS, which provided 16 vehicles to transport the teams for data precollection and collection. Further more, the data collection team leaders incurred expenses for minor vehicle repairs. These expenses were charged to the operating expenses of the health zones, which was not something that happened in the departments of Borgou and Alibori. Some of the teams had to resort to small boats to access the different sites made difficult to reach due to this period of flooding. Discoveries Individuals who have been in public service for many years discovered places they had never seen. The leader of collection team No. 7 said: Thanks to the management assessment, I realized that we have our work cut out for us if only to prevent infections, because I would not have imagined that in this day and age, health care workers would be using fire to sterilize instruments. This is an anachronism and is hazardous to client safety. Contradictions The following statement was made by a data collection team leader after his tour: Some well-built and well-equipped health centers are underused, while the usage rate is better in centers where the buildings are dilapidated. Data analysis, which is to be completed in the first quarter of FY2007, will make it possible to quantify through quantitative data and describe through qualitative data the level of these noted deficiencies. The following photos depict the management assessment data collection process in the departments of Zou and Collines. PISAF - ANNUAL REPORT NO. 1 14
A data collector administers the data collection tool to four (4) COGECS members in Tchetti in the commune of Savalou. A team leader (the woman in the white blouse seated on the bench) administers the service organization tool to a health center team while a supervisor looks on (the man in civilian dress in the background) PISAF - ANNUAL REPORT NO. 1 15
A supervisor from team 7 interviews a client after she received services in the Tchetti health center in the commune of Savalou/Collines: September 15, 2006. Observation of a curative IMCI visit by the nurse from team 6 in the Doumè/ Savalou Health Center on September 20, 2006. PISAF - ANNUAL REPORT NO. 1 16
Supplied computer equipment to the Zou/Collines DDS and HZMT to build their management capacities When PISAF was launched, the following computers and multimedia equipment were issued to the Zou/Collines DDS: ten desktops, ten laptops, ten printers, ten uninterruptible power supplies, ten power strips and one multimedia projector to strengthen the information system in the DDS, departmental hospital and health zones. To streamline and increase security of informationsharing between the zone offices, the department hospital, the ministry in charge and the stakeholders involved in the health sector, additional computer equipment was acquired for the DDS and zone hospitals. This consisted of eight servers, eight uninterruptible power supplies, eight voltage regulators, eight surge protectors, 41 WiFi network cards and 20 audio headsets with multimedia microphones. This equipment will enable the DDS of the Zou/Collines, the departmental hospital in the Zou and the health zones of Zou and Collines to take better advantage of Information and Communication Technologies (ICT). For this purpose, a wireless Internet connection was installed on a local server configured as a wireless client in a LAN/WiFi, and the DDS, CHD and two health zones already have Internet access. The goal is for the DDS to have an Internet identity through its own network and a professional electronic messaging service that can be used both in the Zou/Collines and outside Benin. This service should enable the users to have both a business and also a personal e-mail address. Because PISAF started while the 2006 DDS and health zone budget plans were being implemented, it was impossible for these partners to set aside funding in their budgets for monthly Internet access subscription expenses. An agreement was reached among the DDS, departmental hospital, health zones and PISAF that PISAF would pay the subscription costs for the last quarter of 2006. These expenses are included in the 2007 budgeted action plans. The work of installing the LAN for the other health zones will continue over the coming months. 2.1.3. Sub IR 1.3 More effective civil society participation created Prepared mechanisms to involve the NGOs, CBOs and the private sector in the prevention and treatment of malaria and acute respiratory infections (ARIs): Several actions were taken in 2006 that contributed to the establishment of a collaborative spirit that will facilitate future interventions. Identified and made contact with the NGOs, CBOs, women s groups, radio stations and local authorities. In this activity, seven local radio stations that cover all of the communes in the departments of Zou and Collines were identified and contacted. Stations were informed of PISAF s goals and strategies, with particular emphasis on the communication component, in which they have an important role to play. Seven (7) nongovernmental organizations (NGOs) and seventeen (17) women s groups were identified in the two health zones of Savalou-Bantè and Covè-Zangnanado- Ouinhi alone. Considering the important role that local elected officials can play in implementing communitylevel health interventions, a meeting was held with seven (7) local elected officials--mayors and/or councilors--to brief them on PISAF s objectives. Based on the information collected from the Health and Social Promotion Centers (CPS) and from NGOs, there are 110 functional women s groups in Zou and Collines. PISAF - ANNUAL REPORT NO. 1 17
All the organizations and officials met hoped for harmonious collaboration with PISAF to strengthen community involvement in health promotion and prevention. The statement made by D. Vidjogni Hounsa, second assistant to the Mayor of Savalou, attests to this: The commune of Salavou will always be by your side and will call on you whenever possible and take part in your activities so that the program reaches its goals for the greater good of the communities. Community mobilization evaluated Workshop to review community mobilization strategies To better direct its interventions in the area of community mobilization, PISAF deemed it necessary to organize an experience-sharing workshop for partners working at the community level in Benin. This exchange will be used to review each experience, its strengths and weaknesses, and the aspects that can be replicated in the context of Zou and Collines. During two trips to the field, PISAF staff met with several organizations, including Catholic Relief Services (CRS), Plan Benin, MCDI, Terres des Hommes and ROBS, as well as health zones that have carried out community mobilization activities using community-based service agents and community IMCI and EONC approaches with the support of projects. These health zones include Tchaourou (MCDI and PROSAF Borgou/Alibori), Bembereke/ Sinende (PROSAF Borgou/Alibori), Malanville/Karimama (PROSAF Borgou/Alibori) and Banikoara (PROSAF Borgou/Alibori). PISAF sought health zones participation in this activity and will write-up their experiences. After these meetings, a consensus was reached for holding this community mobilization strategy review workshop in the first half of October 2006. Trained COGECS and supported ascendant planning and other activities: Performed an inventory of the existence and operations of the COGECS An important step before implementing COGECS training is to identify the training needs of the COGECs in Zou/Collines. The different working sessions with the DDS s technical units brought out the fact that the COGECS have not received any training. One exception to this is in Djidja/Abomey/Agbangnizoun) where UNICEF trained COGECS on roles and responsibilities. Thus, an agreement was made with the Zou/Collines DDS to start training the remaining COGECS in roles and responsibilities. However, the problem remains as to which bylaws should be used as a basis for this training, because many bylaws that govern the COGECS were adopted in August 2006 and have not yet been disseminated to the HZMTs. Consequently, it is necessary to repeat the training even for COGECS that were trained earlier, as this training was based on old bylaws, the content of which is now outdated. This training activity for the COGECS will be planned so that it is carried out in the second quarter of FY2007. Grants for the NGOs and CBOs: Preparations for establishing a collaboration framework for awarding grants In preparation for the NGO grant award process, a draft grant procedures manual has been developed, which will be used as a guide for awarding grants to NGOs. The procedures manual specifies the types of organizations to be financed, the process to be used to apply for a grant, PISAF - ANNUAL REPORT NO. 1 18