AWAREII_2009-12: Frome Consensus to Action: Promoting Best Practices by Strengthening Policy by Nicholas Edlund

AWARE II 2009â&#x20AC;&#x201C;2012

FROM consensus to Action

Promoting Best Practices by Strengthening Policy and Capacity in West and Central Africa

Table of Contents EXECUTIVE SUMMARY

“Leadership is about unlocking potential, whether individual potential or that of a group, company, or organization. It is not about telling people what to do, but inspiring them to see what they are capable of and then helping them get there.”

INTRODUCTION 6 Context and Objectives Program Overarching Strategy and Principles Summary of Major Results

6 9 11

Shared Regional Vision and Priorities

Establishing and Using Technical Working Groups Regional Consensus-Building Conference Disseminating Conference Conclusions

15 15 17

Policies Developed and Implemented to Foster Effective Health Programs

Establishing the Regional Policy Agenda and Strategies 18 Advocacy through RAPID Presentations 20 Advocacy for Regional Engagement in FP at Regional Conferences 20 Policy and Advocacy Support for Implementation of the Integrated Package in Togo 21 Policy Assessment for Most-At-Risk-Populations 23 Major Achievements in Fund Leveraging 24 Country Fact Sheets 25 Regional Policy Impact 25

Replicating Best Practices

Implementation of Selected Evidence-Based Best Practices

Using Strengthened African Capacity: Selected West African Institutions and Networks

West African Ambassador’s Funds Institutional and Individual Capacity-Building

41 45

Leveraging Funding: New Funds Mobilized for USAID West Africa Health Programs

Fund Leveraging Assessments Private Sector Alliance Established

49 49

Sustaining and Expanding the Project Impact 50 Challenges

Lessons Learned

Conclusion 55

— USAID AWARE II training participant

FROM CONSENSUS TO ACTION:

Promoting Best Practices by Strengthening Policy and Capacity in West and Central Africa 2009-2012

Mauritanian midwife (member of Mauritania CSO) at the Dakar CSO conference for Repositioning Family Planning

EXECUTIVE SUMMARY The United States Agency for International Development (USAID)/West Africa’s flagship project, Action for West Africa Region II (USAID AWARE II), was a three-year project (July 2009-July 2012) that aimed to create a positive and collaborative operating environment for expansion of health service delivery at the country level throughout the region. In addition to improving the policy environment, USAID AWARE II developed an integrated package of interventions in three technical areas: reproductive health/family planning (RH/FP); HIV & AIDS; and maternal, newborn, and child health (MNCH). The USAID AWARE II in West and Centr al Afr ica 2009-2012

project worked in 21 countries in West and Central Africa1 and was implemented by Management Sciences for Health (MSH) and its partners, EngenderHealth, and Futures Group International.

The project mobilized NGOs to help HIV patients recieve treatment and, when strong enough, return to work.

From the start, USAID AWARE II inspired unprecedented collaboration in the region, setting the stage for uptake of the project’s key intervention packages. In the first months of the project government stakeholders from 18 nations convened to discuss the health needs in West and Central Africa. At this meeting, the delegates jointly committed to address the poor health of women and children within their nations. This political momentum was a catalyst for the project’s next three years. In the project’s first year, USAID AWARE II brought the region’s leaders together and worked with them to reach a consensus on a regional vision, priority health areas, and evidence-based best practices. Later, the project expanded to engage civil society partners in the process by inviting them to participate in a meeting with several of the region’s country representatives. USAID AWARE II built on this foundation of collaboration and commitment by using a holistic approach to address health concerns at various levels: from policy limitations within governments to operational vulnerabilities within grassroots organizations.

USAID AWARE II advocated for policy changes that would enhance health care access among the poorest and most vulnerable people in the project’s target countries. 2

USAID AWARE II advocated for policy changes that would enhance health care access among the poorest and most vulnerable people in the project’s target countries. The project engaged local religious and political leaders to address deeply-rooted misconceptions and resistance to FP, and the special needs of the populations most at risk for HIV & AIDS infection. In collaboration with local nongovernmental organizations (NGOs) in Togo, the project demonstrated how policy and action can lead to health improvements. The project’s research informed the development of regional assessments, tools, and methodologies for use by local and traditional leaders to promote healthrelated policy improvements in four countries. In Togo, these efforts resulted in revisions to national policy that empowered volunteer community health workers (CHWs) to administer antibiotics and oral and injectable contraceptives. Within seven months of the policy change, 158 rural villages that previously had no access to health care were 1.

Togo, Mauritania, Burkina Faso, The Gambia, Côte d’Ivoire, Sierra Leone, Niger, Guinea Bissau, Cape Verde, Cameroon, Gabon, Chad, Sao Tome & Principe, Equatorial Guinea, Nigeria, Benin, Senegal, Mali, Guinea, Liberia, Ghana

USAID AWARE II in West and Centr al Afr ica 2009-2012

USAID AWARE II partnered with local NGOs to mobilize health services for thousands of rural residents throughout West and Central Africa.

receiving health services from CHWs. CHWs provided contraception to 9,558 women and treated 6,022 ill children. The project supported several NGO partnership projects, 12 of which were funded through the West Africa Ambassador’s Fund (WAAF).2 To disseminate the technical success and results of these projects, USAID AWARE II developed the WAAF grantees’ capacity to communicate their achievements through reports, fact sheets, public presentations, the use of an on-line database, and proposals to donors. These dissemination efforts improved the grantees’ prospects for engaging partners to support 2.

The WAAF is a fund administered by the US government to support HIV and AIDS service delivery in countries in West and Central Africa that do not have a USAID mission. The fund is administrated by Ambassadors’ offices.

USAID AWARE II in West and Centr al Afr ica 2009-2012

their health services after the initial WAAF grants ended. Grantees achieved the following: ■■ Provided HIV counseling for 64,854 people ■■ Tested 23,594 people for HIV ■■ Referred the 602 people who tested positive for HIV to treatment centers ■■ Distributed 245,285 condoms ■■ Distributed 61,165 educational and communication materials ■■ Trained 1,324 peer educators ■■ Provided modern contraceptives for 7,088 users USAID AWARE II conducted a needs assessment and evaluation of MARPs in the 21 countries in which it worked. The evaluation involved an extensive literature review and detailed interviews with donors and organizations implementing activities reaching MARPs. The study underscored the growing importance of MARPs in new HIV infections in the West and Central Africa region and exposed major policy limitations and absence of strategic national and regional responses to HIV among MARPs. The results and recommendations were distributed to partners and key stakeholders to inspire change. The project developed fact sheets for each of the project’s 21 countries that included the latest information on the countries’ health policies, progress towards the Millennium Development Goals, and support by major donors. English and French versions of each fact sheet were developed and 6,300 copies were distributed to stakeholders. USAID AWARE II leaves behind a legacy of improved health policies, an unprecedented regional and country-level vision, and commitment and greater capacity among governments and NGOs to address the RH and MNCH needs among the poorest and most vulnerable people of West and Central Africa. This legacy is documented in the project’s reports and tools but, most importantly, in the enhanced operational and technical ability of government ministries, local NGOs, leaders, health care workers, and the patients themselves. The project team is honored to have worked with the many skilled professionals who are now equipped to maintain and build upon the project’s strategies and success. This potential was well-articulated by Namga Djarki, a staff member from the USAID AWARE II’s partner NGO, Force en Action pour le Mieux-être de la Mère et de l’Enfant (FAMME), who noticed that her patients’ behavior is already reflective of the project’s success: “[My patients] know that, somewhere, there is a team thinking of them. USAID thinks about them. They come… because they want to be here with those who help them.” 4

USAID AWARE II in West and Centr al Afr ica 2009-2012

“[My patients] know that, somewhere, there is a team thinking of them. USAID thinks about them. They come… because they want to be here with those who help them.” — Namga Djarki, staff member from Force en Action pour le Mieux-être de la Mère et de l’Enfant

INTRODUCTION Context and Objectives The population within West Africa’s 15 countries increased from 70 to 318 million between 1950 and 2010 and is projected to reach 650 million by 2050.3 This growth is apparent in the 21 countries covered by the USAID AWARE II project where, in 2010, the population was estimated at 328.2 million. Over-population compounds a number of problems in West and Central Africa, including poverty, conflict, unemployment, and high rates of maternal and child mortality.4

For many years, donors and governments in West and Central Africa promoted FP as a means to improve MNCH and enhance economic development. Although the region had made progress in FP policy and capacity building, the recent focus on HIV & AIDS has diverted attention from RH initiatives. Today, the average West African woman has five to seven children in her lifetime; 23 percent of these women wish to avoid future pregnancies but are not using any form of contraception.5 Less than 10 percent of women have access to modern contraception. Without the means to control the number and spacing of their children, many families are unable to meet their children’s needs for health care and education. Frequent and close pregnancies also weaken women’s bodies and many mothers either die or become very ill during pregnancy and labor.

CHWs at Haho launch. in Togo.

Within West and Central Africa, the maternal mortality ratio is 3.5 times higher than that of other developing regions and over 500 times higher than in some developed regions.6 Between 1995 and 2000, the region’s high fertility rate, in combination with a lack of contraception, resulted in 9,579,572 abortions and 648,342 maternal deaths.7 Today, 225 women and 1,200 children die from complications of childbirth each day.8 In 1987, the West African Health Organization (WAHO) was founded as the health branch of the Economic Community of West Africa States (ECOWAS). Ministries of health from the 15 participating nations have pledged their commitment to attaining “the highest possible standard and protection of health of the peoples in the sub-region.” WAHO, through a 10-year partnership with USAID, has helped governments adapt model legislation to protect the rights of people with HIV and serve over one million infected individuals. USAID has also been commited to RH interventions throughout the region and currently devotes 63 percent of its funds to RH/FP initiatives, 24 percent to HIV & AIDS, and 13 percent to MNCH.9 From 2003 through 2008, the agency funded an RH project (AWARE-RH), which ran parallel to an HIV & AIDS project (AWARE-HIV/AIDS). The two projects, together called USAID AWARE I, were designed to improve the health of West Africans and contribute to economic and political stability.

Young adolescents enjoying themselves at the launch of the 250 CHW, Haho district, Togo.

3. 4.

OECD. “Settlement, market and food security,” West Africa Futures, http://www.oecd.org/pages/0,3417, en_38233741_38246608_1_1_1_1_1,00.html Mark Weston, “The Dangerous Demographics of West Africa” (talk, Demos Leadership Master Class on International Challenges and Counter-Terrorism, Home Office, February 13 2009). http://www.globaldashboard.org/2009/02/18/the-dangerous-demographics-ofwest-africa-2/

USAID AWARE II in West and Centr al Afr ica 2009-2012

5. Jay Gribble, “Family Planning in West Africa,” Population Reference Bureau, March, 2008, http://www.prb.org/articles/2008/ westafricafamilyplanning.aspx 6. WHO, UNICEF, UNFPA, World Bank, Trends in maternal mortality: 1990 to 2008 (Amsterdam: Elsevier Science Publishers, 2011), 40. http://www.who.int/reproductivehealth/publications/monitoring/9789241500265/en/index.html 7. Fred T. Sai, “Repositioning Family Planning,” Keynote Address, Accra, February, 2005, http://advanceafrica.msh.org/RAC/docs/ presentations/1_KS_Sai.pdf 8. Searchlight 9. Jeannie Friedmann. “Overview of the USAID regional programs for West Africa,” WAHO and USAID Regional Consensus Meeting on the Vision and Priorities, General Report, Dakar, December 2009.

USAID AWARE II in West and Centr al Afr ica 2009-2012

USAID AWARE II advocated for policy changes that would enhance health care access among the poorest and most vulnerable people in the project’s target countries. 7

USAID AWARE II Results Framework STRATEGIC OBJECTIVE: AN ENABLING ENVIRONMENT Countries in the region to plan and implement selected high-quality health service delivery programs EXPECTED RESULTS

Launched in 2009, USAID AWARE II built on the success of its predecessors by meeting with the regional organizations that had been involved in USAID AWARE I to develop a baseline for future activities.

RESULT 2

POLICIES DEVELOPED AND IMPLEMENTED to foster effective regional and national health programs

RESULT 3

REPLICATING BEST PRACTICES Selected high-impact best practices adopted and replicated

RESULT 4

USING STRENGTHENED AFRICAN CAPACITY A selected number of West African institutions and networks strengthened

RESULT 5

LEVERAGING FUNDING Eliminated New funds are mobilized for health programs, existing donor and national resources effectively used

RESULT 1

CHW at the Arasma village health centre in the Halo district, Togo

USAID AWARE II was instrumental in creating policies for improved access to RH/FP and MNCH services and strengthening West Africa’s technical and management capacity to reduce unwanted pregnancy and risky sexual behavior. Promotion of best practices in health care and program management has been of immediate benefit to the region and the stage has been set for replication by other regional donors and governments. Among its many accomplishments, the project helped improve the reliability of FP services in 21 West and Central African nations through new and revised national policies, increased human resource capacity, and the promotion of high-impact evidence-based best practices. MSH implemented USAID AWARE II in collaboration with EngenderHealth and Futures Group International. The project’s expected results are summarized in Figure 1, at right. The main strategies to achieve these results included: ■■ Facilitating regional coordination and leadership towards common health priorities, with WAHO and other technical institutions serving as resources to national health programs; ■■ Building and strengthening national health institutions and programs in government, private sector, and civil society; ■■ Advocating for enabling policies that are harmonized throughout the region; ■■ Identifying sources of proactive, coordinated public and private funding to leverage the replication of high-impact interventions; ■■ Implementing fully-functional and integrated health services through key intervention packages for RH/FP, HIV & AIDS, and MNCH. The project’s geographic and technical scope was adjusted three times during the contract amendment process, reflecting the rapidly changing donor and West African needs. As a result, the project’s focus shifted and Expected Results 1 (which was achieved early in the project) and 5 were removed. At the same time, the geographic focus became narrower and more in-depth.

USAID AWARE II in West and Centr al Afr ica 2009-2012

COMMON VISION AND PRIORITIES Regional common strategic vision and priorities for improving the health status of West Africans Completed Year 1

Figure 1. USAID AWARE II Project Overview

Program Overarching Strategy and Principles Throughout the project, USAID AWARE II worked with WAHO and other regional partners to advocate for policy changes that increased both access to and funding for health care. Additionally, the project relied on strong African leadership and proven best practices to design the most effective health interventions. Project implementation was guided by five principles: 1. Achieving high impact through the project’s role as facilitator and catalyst 2. Implementing local interventions, to gain regional health results 3. Aligning policy frameworks with and by regional and national stakeholders 4. Launching evidence-based interventions for maximum health impact 5. Facilitating integration across the four key interventions: introducing best practices, advocating for enabling policies, creating capable institutions, and leveraging funding With its new geographic focus, the project developed a selection strategy that divided the participating countries into three tiers. The project and its stakeholders agreed that the most effective approach would be to offer in-depth technical assistance to countries with the greatest likelihood for expansion and replication of services. The technical working USAID AWARE II in West and Centr al Afr ica 2009-2012

Original Target Countries CAPE VERDE

TIER 1 COUNTRIES Implement full package of interventions to achieve depth and penetration

YEAR 1: Togo, Burkina Faso, Sierra Leone, Mauritania YEAR 2: Guinea Bissau, The Gambia, Niger, Cameroon YEAR 3: Gabon, Côte d’Ivoire, Chad TIER 2 COUNTRIES Respond to requests for assistance; look for opportunities such as leveraged activities with other donors

MAURITANIA

SENEGAL THE GAMBIA GUINEA GUINEA BISSAU SIERRA LEONE LIBERIA

MALI

NIGER CHAD

BURKINA FASO BENIN NIGERIA CÔTE D’IVOIRE GHANA CAMEROON

TOGO

EQUATORIAL GUINEA SAO TOME & PRINCIPE

GABON

Nigeria, Benin, Senegal, Mali, Guinea, Liberia

Figure 2. Planned Interventions for the Original USAID AWARE II Countries*

TIER 3 COUNTRIES Countries with USAID presence or wellfunded programs; focus on advocacy and information sharing

Cape Verde, Sao Tome and Principe, Equatorial Guinea, Ghana

*In its second year, USAID AWARE II’s geographic scope was adjusted and Togo became the project’s only Tier 1 country.

groups (TWGs), stakeholders, and partners helped the project assign the countries as described in Figure 2, above. Instead of simply promoting best practices within these nations, the project’s strategy included a holistic set of interventions called key intervention packages (KIPs). These KIPs were tailored to the technical focus areas of RH/FP, MNCH, and HIV & AIDS. Table 1 shows the four elements included in each KIP (left column) and, as an example, corresponding components from the project’s RH/FP KIP in Togo (right column).

Table 1. Components of the Key Intervention Packages

The KIP strategy was the cornerstone of successful, sustainable interventions. The RH/FP integrated package used in Togo, for example, led to the provision of contraception to over 9,000 women in just seven months and the development of plans to extend the intervention in two additional districts. The KIP strategy also strengthened the policy environment, health care staff capacity, and funding opportunities, which set the stage for adoption of the KIPs by additional donors and organizations, and scale-up throughout the region.

KIP Components

Example from Togo

A best practice

Community-based distribution of contraceptives

An enabling policy

The Togolese MOH signed a Memorandum of Understanding which authorized CHWs to administer contraceptives

An implementing organization supported by a regional institution

USAID AWARE II and WAHO provided technical assistance to ATBEF and ADESCO who then trained the CHWs to properly administer contraceptives

Leveraged funding

Togolese MOH provides supplies to CHWs. USAID AWARE II is currently exploring opportunities for UNFPA funding of project operations.

USAID AWARE II in West and Centr al Afr ica 2009-2012

Summary of Major Results USAID AWARE II’s first challenge was to align the team and establish strong partnerships with USAID, WAHO, and other partners. In its first months, the project worked with 80 stakeholders from 18 of the 21 target nations and various regional partners to build consensus on a regional vision, health priorities, and evidence-based best practices. By advocating for health policy changes, USAID AWARE II inspired the Togolese Ministry of Health (MOH) to authorize CHWs to distribute antibiotics and oral and injectable contraceptives. The project worked with civil society partners as well as religious, traditional, and government leaders to develop advocacy tools in three countries. The project then trained these leaders to use the tools to educate their communities about HIV & AIDS and RH/FP and improve national health policies. To improve the policy environment for members of most-at-risk populations (MARPs) in the region, the project conducted an assessment of the regional policies effecting MARPs. The subsequent reports and recommendations were shared with various regional partners, leaders, and policymakers.

The RH/FP integrated package used in Togo led to the provision of contraception to over 9,000 women in just seven months and the development of plans to extend the intervention in two additional districts. USAID AWARE II in West and Centr al Afr ica 2009-2012

USAID AWARE II MAJOR RESULTS Among other results, the project developed an innovative model of service delivery and demonstrated that trained and supported CHWs can correctly provide contraception and treat childhood malaria, diarrhea, and pneumonia.

■■

USAID AWARE II used the Resources for the Awareness of Population Impacts on Development (RAPID) model to show the positive effect that increased FP use can have on health and development in four countries. These results were used to train religious and traditional leaders in FP policy advocacy and monitoring. The governments of two nations supported local leaders in disseminating the RAPID model results and other advocacy messages through radio broadcasts. To promote best practices in the region, USAID AWARE II worked with two local NGOs to conduct a pilot test of the RH/FP and MNCH integrated package in Togo. This project trained, equipped, and regularly supervised 432 CHWs who provided contraception to 9,558 women and treated 6,022 ill children. Best practices were also promoted through 12 local NGOs that earned WAAF grants to implement the selected key interventions in HIV & AIDS and RH/FP in eight countries, with technical and managerial support from USAID AWARE II. Collectively, grantees counseled 63,739 people, including 24,403 for HIV, and referred 526 people who tested positive to HIV treatment centers. NGOs also distributed 245,285 condoms and 47,702 brochures and other educational materials. They trained 1,324 peer educators and distributed contraception to 7,088 women. USAID AWARE II established an online monitoring and evaluation (M&E) database and trained the 12 grantees to use it for reporting. USAID AWARE II developed fact sheets for each of the project’s 21 countries that summarized the countries’ health policies, current projects, and donors. The project printed 6,300 fact sheets and distributed copies to national and regional stakeholders to advocate for a response to the health and policy needs in these 21 nations. As the project concluded, the team held end-of-project meetings and WAAF closeout ceremonies where they presented project strategies, tools, and achievements to local stakeholders and urged these leaders to sustain and expand the project’s key interventions.

USAID AWARE II in West and Centr al Afr ica 2009-2012

■■

■■ ■■ ■■

■■

Revitalized and repositioned RH/ FP services in West and Central Africa by assembling leaders from 21 countries who, for the first time ever, developed a shared regional vision and made a collective agreement to prioritize FP, MNCH, and HIV & AIDS services in the region Developed an innovative model of service delivery and demonstrated that trained and supported CHWs can correctly provide contraception and treat childhood malaria, diarrhea, and pneumonia Effectively built the capacity of over 23 organizations to implement project interventions at the regional and country levels Established an innovative online database and successfully trained 12 WAAF grantees in eight countries to use this database for direct monthly reporting Developed capacity, tools, and approaches in the public and private sector to continue and sustain the project’s innovations and services Developed 21 country factsheets that highlighted each nation’s major health problems, programs, and donors; distributed 6,300 copies Achieved significant policy changes and improved behavior change programs through advocacy, lobbying, and education and by engaging local leaders in the interventions Provided technical and managerial support to 12 WAAF grantees who successfully implemented HIV and FP best practices, thereby demonstrating the power of small grants combined with organizational capacity building to scale up health services

USAID AWARE II in West and Centr al Afr ica 2009-2012

Expected result 1:

Shared Regional Vision and Priorities Establishing and Using Technical Working Groups To ensure that the project approach was both collaborative and evidence-based, USAID AWARE II and WAHO created TWGs to assist in developing the project’s strategic plan. These groups were composed of the project’s technical staff and WAHO’s technical experts and consultants. Prior to meeting with the TWGs, the project team created four documents based on a regional literature review and local expert interviews. The project team then met with the TWGs and worked to revise each document to include an accurate and complete summary of the health problems, current solutions, and suggestions for alternative solutions in terms of best practices. To refine the project’s strategy, TWGs first selected priorities for each technical area and then developed a list of evidence-based interventions and monitoring indicators. This work was accompanied by the TWGs suggestions for fund leveraging strategies, technical leadership institutional partners, and health-related policy issues that the project could address. These contributions were used to develop the first draft of the project’s Strategic Framework for Priority-Setting and Implementation. As seen in Figure 3 at left, the strategic framework involves a linear process which, from left to right, provides key steps for combining the vision, mission, and selection criteria to develop regional priorities. These priority areas then inform the implementation of best practices that lead to effective interventions. This collaborative and evidence-based process enables the project to generate the expected results and have a lasting impact on the region.

In its very first months, the USAID AWARE II team worked with the region’s key stakeholders and experts to refine their strategy and action plans.

Strategic Framework for Priority-Setting and Implementation Vision and Mission

Figure 3. Regional Priority-Setting and Implementation Framework 14

Regional Consensus-Building Conference

Technical Areas FP • HIV & AIDS MH • NCH

Regional Priorities

Best Practices at Country Level

Selection Criteria

Support Areas Policies, Training & Funding

Civil society group members discuss their action plans at the CSO conference in Dakar, Senegal.

Effective coverage of target group

Better health for population

USAID AWARE II in West and Centr al Afr ica 2009-2012

Eighty participants from 18 of the project’s target countries attended a regional prioritysetting conference held by USAID AWARE II. The conference built consensus around the project’s regional vision and priorities as well as the key interventions that the stakeholders would implement in each of their countries.

Mission: To work with WAHO and other partners to improve the policy environment, strengthen organizational capacity, and leverage funds to support countries in West Africa to implement and scale up best practices in health. USAID AWARE II in West and Centr al Afr ica 2009-2012

Vision: Harmonized health policies and standards among committed countries, allocating adequate funds for quality health services, and achieving health impact. Goal: Create a positive operating environment that enables countries to plan and implement selected high-quality health service delivery programs. Once agreement was reached, the countries were asked to select and discuss the steps they would follow and the activities they would conduct to implement the key interventions in their specific context. The priorities and the key interventions for each technical area are presented in Table 2 below.

Table 2. Key Intervention Packages

Technical Area

Priority Areas

Key Interventions

Family Planning

Unmet needs

■■ Community-based distribution of

contraceptives

■■ Contraceptive security

Maternal Health

■■ Post-partum hemorrhage ■■ Eclampsia ■■ Complications of abortion

■■ EmONC ✧✧ Active management of third stage

of labor

✧✧ Magnesium sulfate/eclampsia

prevention and treatment

✧✧ Postabortion care

Newborn Health

■■ Neonatal Infections ■■ Asphyxia and breathing

difficulties

■■ Low birth weight and

prematurity

Child Health

■■ Acute respiratory infections ■■ Diarrhea

■■ Essential newborn care at facility/

community level

Clean delivery Use of antibiotic Newborn resuscitation Prevention and management of hypothermia ✧✧ Kangaroo mother care (KMC) ✧✧ ✧✧ ✧✧ ✧✧

■■ Community-integrated management of ✧✧ ARI treatment with antibiotic ✧✧ Oral rehydration salts low osmolarity

■■ Malaria

and zinc

✧✧ Artemisinin-based combination therapy

and insecticide-treated bed nets

HIV & AIDS

■■ Prevention, Voluntary

Counseling and Testing (VCT), and Prevention of Mother-to-Child Transmission (PMTCT)

■■ M&E

Cross-Cutting

guidelines

■■ Prevention services focused on most at

risk population

■■ A national computer-based data

■■ Planning and evidence-based

■■ An integrated, national computerized

■■ Financial access to health

■■ Establishment of alternative health

care services

■■ Updated national PMTCT and treatment

management system

decision-making procedures

One of the participants from Mali contributes to the discussion at the CSO conference in Dakar, Senegal.

childhood illnesses

database

financing mechanisms

USAID AWARE II in West and Centr al Afr ica 2009-2012

Disseminating Conference Conclusions The USAID AWARE II project director attended the 11th Ordinary Meeting of the Assembly of Health Ministers’ of ECOWAS and used this opportunity to share the project’s vision, selected health priorities, and adopted interventions. One month after the meeting, the project visited eight countries10 to review their strategic plans and inspire the ministries to take ownership of project. In each nation, the MOH, stakeholders, and representatives from WHO, UNFPA, UNICEF, and UNAIDS committed to collaborate with USAID AWARE II in rolling out the KIPs and assisting in fund leveraging opportunities. 10. All eight countries earned WAAF grants; seven of these were also originally selected to implement the integrated package (Sierra Leone, Burkina Faso, Togo, Mauritania, Niger, The Gambia, Cameroon, Gabon, and Chad).

USAID AWARE II in West and Centr al Afr ica 2009-2012

expected result 2:

Policies Developed and Implemented to Foster Effective Health Programs Establishing the Regional Policy Agenda and Strategies USAID AWARE II developed a list of policy actions based on the KIPs, which acted as a guide for the project’s advocacy efforts to improve national-level legislation and create a supportive regulatory environment for project implementation. The project’s policy strategies were designed alongside the region’s most experienced and influential stakeholders. In Mauritania the project worked with 20 religious leaders to promote enabling policies for the implementation of FP and HIV & AIDS interventions. A sick young girl is being transported to the health centre by her parents using a cow drawn cart in Niger.

These leaders worked with the project to develop advocacy tools that demonstrate how the Quran supports the fight against HIV & AIDS and promotes healthy timing and spacing of pregnancy (HTSP). Stakeholders from Mauritania’s Ministry of Health and Social Affairs team were invited to participate in this process along with the nation’s US ambassador. Mauritania’s advocacy tools were subsequently used by religious leaders to advocate for HTSP and against HIV discrimination. Anecdotal evidence suggests that their advocacy efforts encouraged more people to seek FP services. For instance, providers from the Aleg health center reported an increase from 40 to over 100 clients per month after the religious leaders began HTSP advocacy. The success of this intervention inspired USAID AWARE II to expand the approach in three additional countries. In total, the project conducted 12 advocacy and dissemination training workshops for 566 religious leaders in Burkina Faso, Togo, Mauritania, and Niger. USAID AWARE II also supported religious leaders in disseminating health messages on local radio stations, which ultimately reached over two million people in Burkina Faso, Togo, and Niger. The project also addressed policies that prevented CHWs from providing contraceptive pills and injectables. This limitation is particularly concerning because many West African women, especially in rural villages, cannot afford to travel to local clinics for contraception. As a result, 90 percent of women in the region do not use modern contraception.11 In response to these conditions, USAID AWARE II conducted a policy analysis and a review of regional studies showing that properly-trained CHWs can safely provide injectable contraceptives. This evidence then equipped the team to design advocacy tools and strategies to promote related policy changes. The project then signed memorandums of understanding (MOUs) with the ministries of health in Niger, Mauritania, Togo, and Burkina Faso that authorized CHWs to administer oral contraception and, in Togo, also permitted CHWs to administer injectables.

Mauritania’s advocacy tools were subsequently used by religious leaders to advocate for HTSP and against HIV discrimination. Traditional leader from Arasma village attending the launching ceremony in the Halo district, Togo

USAID AWARE II helped WAHO identify the policy issues most pertinent to its operational plan and then trained 26 WAHO staff members to use the Policy Implementation Assessment Tool (PIAT), which enabled them to monitor policy actions and engage in effective policy advocacy. The project also facilitated an M&E training for 19 WAHO staff members in Burkina Faso. 11. Gribble.

USAID AWARE II in West and Centr al Afr ica 2009-2012

Advocacy through RAPID Presentations Waning donor and government support for RH/FP programs is of critical concern in West Africa. To revive regional commitment to RH/FP, USAID AWARE II developed a number of evidence-based advocacy tools and used the RAPID model. Data produced through the RAPID model shows policymakers the impact of fertility and population growth on social and economic development. The project used the RAPID model in Ghana, Seirra Leone, Togo, and Burkina Faso to show the positive effect that increased FP use could have on health and development. Once finalized, the RAPID assessments were used to train government stakeholders, religious leaders, and traditional leaders in policy advocacy and monitoring. Many countries also supported these local leaders in disseminating the RAPID model and other advocacy tools through radio broadcasts and trainings.

Advocacy for Regional Engagement in FP at Regional Conferences

The project worked with WAHO,WHO, and countrylevel partners to identify policy areas that USAID AWARE II could address in order to create a more enabling environment for project implementation.

Ouagadougou Conference: “Population, FP and Development: The Urgency to Act” In collaboration with the French Development Agency, USAID organized a FP conference in Burkina Faso. As part of the steering committee, USAID AWARE II assisted in planning this event. Conference participants included ministers of health, government officials, traditional leaders, and NGOs from eight West African countries. Representatives of WAHO and WHO advocated for improved FP policies and regional governments presented their country-level action plans, which used best practices to revitalize FP. The conference resulted in the Ouagadougou Declaration, which reflects the political commitment of policymakers, donors, and services providers and was signed by the government representatives from each attending nation. A number of donors also expressed their readiness to support FP programs and called for a closed-door meeting to begin this collaboration. During the meeting, USAID committed to implementing a number of the prioritized FP activities and the French Development Agency offered to support these efforts as well. Donors agreed that each country should host its own donor meeting to discuss the FP commitments and establish a country-level action plan. USAID AWARE II co-financed and facilitated the first of these meetings, held shortly after the conference in Burkina Faso.

Mbour Conference: “Engaging Civil Society for Repositioning FP in Francophone West Africa” This conference was held as a follow-up to the Ouagadougou conference and attended by 120 donors, partners, stakeholders, and civil society organization (CSO) representatives. 20

USAID AWARE II in West and Centr al Afr ica 2009-2012

Participants built on the Ouagadougou agenda by revising their country work plans to include civil society’s concerns about implementation. Additionally, a CSO representative was chosen among each country delegation to serve as a focal point to monitor and coordinate the implementation of the action plans with government and donor counterparts. Conference participants also identified the best national and regional practices to implement in five key areas: social franchising, FP integration, men’s involvement in FP, gender balance and women’s empowerment in FP, and promoting task shifting in RH/FP.

Policy and Advocacy Support for Implementation of the Integrated Package in Togo The political will inspired by these conferences allowed the project to move forward with policy initiatives in several countries. During the RAPID model presentation in Togo, for example, USAID AWARE II emphasized the need to involve CHWs in the administration of injectables. In response, Charles Agba Kondi, Togo’s Minister of Health, declared, “Yes, Togo will do it!” and then added, “All development sectors, policymakers at all levels, must support this beneficial intervention both for family planning and the entire nation. It is through this multi-sectoral approach that we will succeed effectively in the repositioning family planning which is a key priority of public health.” The project then signed an MOU with the Togolese government which authorized, for the first time, the provision of oral pills and injectables by CHWs in Togo. By the end of the seven months of implementation, CHWs had administered contraceptive services to 7,408 women in the district of Haho and 2,150 women in Blitta. USAID AWARE II in West and Centr al Afr ica 2009-2012

Technical experts and key stakeholders collaborated with the USAID AWARE II staff during its regional conference, “Engaging Civil Society to Reposition Family Planning in Francophone West Africa.”

“All development sectors, policymakers at all levels, must support this beneficial intervention... It is through this multi-sectoral approach that we will succeed effectively in the repositioning family planning which is a key priority of public health.” — Charles Agba Kondi, Minister of Health, Togo

Policy Assessment for Most-At-Risk-Populations MARPs are people most likely to be exposed to HIV. Certain behaviors including unprotected sex, multiple sexual partnerships, and injection drug use increase risk of HIV infection. MARPs are also vulnerable due to social and institutional discrimination. In West Africa, HIV is most prevalent among MARPs, specifically men who have sex with men (MSM), commercial sex workers (CSW), female sex workers (FSW), and injection drug users (IDU). In an effort to address these often-neglected populations, the project conducted a regional analysis of MARPs. Findings from this assessment are summarized in Table 3 below.

Table 3. Findings from the Assessment of HIV Epidemics Among MARPs

Prevalence ■■ MARPs contribute significantly to new HIV

infections

■■ HIV prevalence in MARPs has not changed

appreciably

■■ National HIV projects do not target

MARPs

■■ FSW programs are common but have not

helped to significantly reduce prevalence

Research and Programming ■■ Except among FSWs, HIV prevention

interventions for MARPs remain sporadic

■■ Limited response to MARPs is caused by

intransigence, discomfort, and homophobia among certain key actors and policymakers

■■ While mainstreaming interventions may

increase cost-efficiency, social stigma and criminalization may prevent MARPs from attending such facilities

Recommendations ■■ Stigma reduction programs among health

care workers

■■ Small grants to help local NGOs decrease

stigma and increase MARPs programs

■■ Country-specific research to inform

governments of the epidemics among MARPs

■■ Advocacy for MARPs by health

professionals in health care and criminal justice sectors

Togo

Benin Ghana

35.6

Burkina Faso Sierra Leone Mauritania

USAID AWARE II in West and Centr al Afr ica 2009-2012

35.5 35.3

0.1 32.7

3.6

32.7

1.3 25.5

1.2

1.9

Gabon

Senegal

39.6

5.3

23.6

5.2

Chad

3.4

19.8

0.9 16.3

1.2 1.6 0.7

50 44.5

0.8

Nigeria Guinea

2.5

Cameroon Mali

3.2

Guinea Bissau Niger

8.5

HIV Prevalence in FSW (2005–2009) HIV Prevalence in General Population (15–49) (2010)

7.6

The project team used these findings to inventory and evaluate regional policies that have an impact on MARPs. Key findings from the assessment include the following: ■■ A punitive/prohibitive approach towards CSWs is common ■■ A rights-based access policy for FSWs to HIV and general health services is rare ■■ Policies supporting FSW empowerment are less common (e.g., no female condom programs) ■■ Policies driving FSW prevention/care/treatment are underdeveloped ■■ Criminalization of MSM behavior leads to a reduced policy space for interventions ■■ Development of the MSM-related policy space is very limited ■■ Limited data on IDU populations reduces the ability to develop a response ■■ Criminalizing drug possession and use complicates interventions for IDU

Participants from the CSO conference in Dakar, Senegal discuss their country workplan for repositioning.

USAID AWARE II presented findings from these two assessments at the International Conference on AIDS and Sexually Transmitted Infections in Africa. The assessments inspired UNAIDS to collaborate with the project in establishing a multisectoral committee on human rights related to HIV & AIDS in four countries. The committee conducted a detailed review and analysis of regional policies and guidelines on human rights in relation to MARPs, which were later disseminated in the 14 non-USAID presence countries.

Major Achievements in Fund Leveraging USAID AWARE II conducted an assessment of fund leveraging options within the West African health sector and a second assessment of private sector opportunities for health funding in the region. Both assessments resulted in a report of key insights and recommendations that the project shared with their government and organizational partners. Based on these studies, USAID AWARE II then held a roundtable meeting with 20 private sector institutions and established a Regional Health Alliance of the private sector for RH/FP. Four private sector intuitions, later joined by Ecobank, expressed interest in supporting health initiatives in the region. These efforts also inspired UNICEF and UNFPA to offer their support for the project initiatives. UNFPA contributed $17,000 to fund activities of the National Reproductive Health Program in Mauritania. 24

USAID AWARE II in West and Centr al Afr ica 2009-2012

Although these initiatives were successful and promising, fund leveraging activities were removed from the project portfolio during its second year and USAID resolved to take the lead on this initiative. The project is hopeful that their research and strategies (recorded in the project legacy documents) will be replicated and expanded by future projects and partners.

Country Fact Sheets USAID AWARE II developed fact sheets for each of the 21 countries that included the latest information on the countries’ health policies and status, progress towards the MDGs, and major donors. The project developed these fact sheets in English and French and then printed 6,300 copies and sent 100 copies to each country. The team also shared these documents with USAID and distributed copies to delegates from each target country at the 2011 International Conference on Family Planning.

Regional Policy Impact The project’s policy achievements have made significant contributions to the region’s public health landscape, which is now equipped with data and recommendations from both the RAPID model and MARPs assessment results. The regional response to these critical findings will be further enhanced by the numerous advocacy tools that USAID AWARE II developed and disseminated among the region’s religious and traditional leaders. These tools and the project assessments are included in the USAID AWARE II legacy documents, which are now available and continue to be distributed throughout the region. West and Central African leaders can also learn from the project’s success in Togo, where their advocacy efforts helped change national policy and improve access to FP and child health services. This example and the project’s various assessment reports and advocacy tools will help stakeholders address remaining gaps between adopted health policies and their effective implementation. USAID AWARE II in West and Centr al Afr ica 2009-2012

Newly trained CHW wearing her jacket and bag, showing her readiness to serve her community at the launch ceremony in Haho, Togo.

Study Tour To ensure that the project’s best practice implementation was evidence-based, USAID AWARE II organized a study tour in Malawi where the community-based distribution (CBD) approach had been successfully used to administer contraception. The project invited 11 government health leaders from Togo, Burkina Faso, and Sierra Leone to participate in this tour. Upon return, these leaders were able to share the findings and best practices with their MOH colleagues.

Assessments The project conducted the following assessments to inform their implementation strategies. ■■ An assessment of prevention of mother-to-child transmission (PMTCT) of HIV services in 30 sites in Togo indicated insufficient geographic coverage of services, low involvement of the partners of HIV positive women, weak M&E of activities, and a lack of FP as a key component of PMTCT. The project responded by collaborating with the MOH to revise the national PMTCT guidelines to include WHO recommendations and information on HTSP. The project also trained health care staff in Togo on PMTCT clinical skills. USAID AWARE II trained community health workers to provide family planning services for women in 158 rural villages throughout Togo.

Expected Result 3:

Replicating Best Practices Implementation of Selected Evidence-Based Best Practices Preparation for Implementation of the Key Integration Packages Country Visits Best practice implementation began with visits to the project’s tier-one countries. During these visits, the project team worked closely with country partners to build their capacity and prepare them for effective implementation of the selected interventions. Country visits also enabled USAID AWARE II to conduct orientation sessions for 339 local stakeholders to inform them of the planned interventions and explain their role in the project’s implementation.

■■ An assessment of the Evaluation et Suivi Opérationnel des Programmes (ESOPE) revealed that this computer-based system had been useful in Burkina Faso and could be expanded in the region to enhance follow-up and services for people living with HIV. After the evaluation, the project made plans to install the software in 20 new sites and trained health care staff on its use. ■■ An assessment of newborn health services conducted in eight districts in Sierra Leone showed that the nation did not have a policy for newborn care and its intervention guidelines were underdeveloped. Referral delays are compounded by poor recognition of illness. USAID AWARE II shared these results at a national meeting attended by 30 stakeholders from the MOH, districts, NGOs, and development partners such as UNICEF, UNFPA, UNAIDS, and WHO. ■■ An FP and emergency obstetric and neonatal care (EmONC) assessment in Mauritania showed that FP use was below 10 percent and there were frequent stock-outs of critical supplies. Most providers were not trained in FP and EmONC capacity was low. In response, the project provided training workshops and worked with stakeholders to secure supplies. Performers at the Togo CHW launch celebration.

USAID AWARE II in West and Centr al Afr ica 2009-2012

Tools These assessments indicated an urgent need for improved resources and tools. In collaboration with the ministries of health in Burkina Faso and Togo, USAID AWARE II revised the countries’ PMTCT and antiretroviral therapy (ART) guidelines to include WHO recommendations and information on HTSP. Once finalized, the project printed and disseminated these guidelines in both countries. In Mauritania, the PMTCT training manuals were updated and validated by the MOH and stakeholders with support from USAID AWARE II. The project also worked with WHO, UNICEF, and the MOH to revise Togo’s tools for Community-Integrated Management of Childhood Illness (C-IMCI)/ Community Case Management. These tools now include information on HTSP and childhood illnesses. A new version of the ESOPE database was produced and the project made plans to implement this database in 11 countries. In order to reach more women of reproductive age with FP services, the project developed MNCH training materials and management tools for CHWs. During field visits the project also tested new CHW supervision tools.

CBD Strategy Family Planning and Child Health Key Intervention Packages ■■ Expansion of CBD of contraceptives ■■ Community case management of ARI,

diarrhea, and malaria

■■ Infection prevention and kangaroo

mother care (KMC) for preterm infants

■■ Community referral and accompaniment

of women to deliver at the facility level

■■ BCC messages on: ✧✧ HTSP ✧✧ Danger signs in pregnant/postnatal

mothers, newborns and children

✧✧ Early and exclusive breastfeeding ✧✧ Complementary feeding ✧✧ HIV prevention

28 28

During the regional priority-setting conference, the project had determined that CBD of oral contraceptives and injectables was a high-impact intervention that could help to address the region’s unmet need for FP. In response, the project team designed an integrated CBD strategy to be implemented at the district level. This strategy was one key component of the FP and MNCH intervention packages selected at the regional conference. USAID AWARE II decided to first pilot test the KIPs in Togo to demonstrate the feasibility of this strategy and create a platform for other countries and partners to adopt and expand the intervention. The project partnered with the Association Togolaise de Bien Être Familial (ATBEF) and later Appui au Développement et à la Santé (ADESCO) to conduct the pilot test. As a first step, the project and NGO teams worked to train CHWs in C-IMCI. Because the Togolese MOU had authorized CHWs to administer oral and injectable contraceptives for the first time, the project was careful to train these workers to do so safely and in line with accepted clinical norms and standards. USAID AWARE II in West and Centr al Afr ica 2009-2012

TOP: The project trained health workers on best practices for infant care. BOTTOM: CHWs received lock-boxes to safely store their clinical supplies including contraception for women and antibiotics for children.

Implementation of the Integrated Package in Togo In the project’s second year, USAID AWARE II underwent technical rescoping. The project worked closely with USAID/West Africa throughout the transition period to phase out activities in Niger, Burkina Faso, and Mauritania and refocused its demonstration efforts for the integrated package in Togo only.

CHW Training USAID AWARE II held a training workshop in Notse, Togo, where 250 CHWs learned C-IMCI best practices for treatment of malaria, diarrhea, and acute respiratory infections (ARIs). CHWs were also trained to provide kangaroo mother care (KMC) counseling and to identify acute malnutrition and refer severe cases to health facilities. CHWs practiced FP counseling and administered injections to oranges while being supervised by a master trainer. Each CHW performed three to five trials before they were authorized to practice injectables in the community. Once trained, these CHWs began working in Haho and proved successful within the first months of implementation. USAID AWARE II then extended the integrated package to a second district in Togo where they worked alongside ADESCO to implement the KIPs. With support from USAID AWARE II, ADESCO successfully trained 182 CHWs from 70 villages in Blitta.

Essential Supplies

Implementation Framework and Steps USAID AWARE II developed a guide to articulate and summarize all key elements involved in the project’s implementation process, including three interrelated steps, as shown in the Figure 4. The project implementation guide describes, in detail, all instructions that were followed by the NGOs, country representatives, ministries of health, and the project support team.

The Integrated Package: Family Planning, Maternal, Newborn, and Child Health Implementation Steps in Haho and Blitta STEP 1 1. Conduct Baseline Studies

USAID AWARE II ensured that CHWs had an adequate and consistent supply of essential drugs, commodities, and equipment. These supplies included contraceptive pills, injectable contraceptives, C-IMCI drugs, educational posters, job aids, bicycles, and a lockbox for drug storage. Prior to training the CHWs, the project calculated the districts’ supply needs and informed the MOH of these projections. Haho’s District Management Team provided CHWs with all essential FP and C-IMCI drugs. USAID AWARE II and ATBEF facilitated a number of meetings and correspondences with the MOH to assure that these C-IMCI supplies remained consistent. At times, the project worked to find alternative supply sources to address an inadequate stock of condoms, zinc, and artemisinin-based combination therapy (ACT). UNFPA provided condoms to the MOH, which then distributed these supplies to ATBEF. Throughout the project, USAID AWARE II and ATBEF monitored the drug supplies to project future needs. 30

The project also provided Togo’s health centers with equipment for newborn care, including 66 oxygen balloons and 325 mucus vacuums. This equipment was distributed according to need through discussion with the national and district health officials.

USAID AWARE II in West and Centr al Afr ica 2009-2012

STEP 2

STEP 3

2. Select NGO Partners 3. Develop Training and Management Tools

6. Train CHWs in FP and C-IMCI

4. Identify Implementation Areas

7. Launch Service Delivery Activities

5. Train Master Trainers and Supervisors

8. Deliver FP and C-IMCI Services

10. Conduct Quarterly Competency/Quality Analysis of CHWs

Supervise and Monitor Project Activities Regularly

A newly trained male CHW at ceremony showing his readiness to serve his community at the launch ceremony in Haho,Togo.

11. Provide CHW with Additional Training as Needed 12. Conduct End Line Assessment 13. Present Successful Results

USAID AWARE II in West and Centr al Afr ica 2009-2012

Figure 4. Implementation Steps in Haho and Blitta 31

Integrated Package Launch in Togo

CHW Supervision and Assessment

After completing the CHW trainings in Togo, the project held ceremonies to launch the RH and MNCH integrated packages in Haho and Blitta. These events helped increase the project’s visibility and revive the commitment of its stakeholders. The public ceremonies also improved regional awareness and accountability for the implementing NGOs and the CHWs. Haho’s launch was attended by the 250 trained CHWs and over 400 key stakeholders, including village chiefs; religious leaders; and representatives from the

USAID AWARE II worked with ATBEF and ADESCO to supervise the CHWs in Haho and Blitta. During these visits, CHWs who proved capable of correctly administering injectables were given a vest with an insignia that symbolized their certification. By the end of the project, 100 percent of the CHWs had completed this certification process. Supervision exercises were also conducted by the health center nurses and midwives along with five animateurs who had been selected by ATBEF. USAID AWARE II observed the CHWs and animateurs and reviewed their findings with the staff to enhance performance. When needed, the team provided technical assistance or recommended that the midwives provide additional technical supervision. The project also supported ATBEF in responding to results from an assessment that indicated the CHWs had strong technical skills but needed additional training in health education, treatment of pneumonia, and communication of instructions for injectable use. USAID AWARE II and ATBEF tailored their supervision to improve CHW’s skills in these areas. Assessment results were also shared with supervisors from the health centers to assure targeted follow-up.

The project invites hundreds of local stakeholders to public launch ceremonies, which improve regional awareness and accountability for the NGOs and the CHWs implementing the integrated package.

Togo Pilot Test Results USAID AWARE II implemented an integrated package of health services as a demonstration project in the Haho and Blitta districts of Togo with the purpose of showing the feasibility and efficacy of providing hormonal contraceptives and antibiotics for common childhood illnesses at the community level in a West African country. As this had never been tried before, USAID AWARE II partnered with local NGOs, ATBEF, and ADESCO, and closely monitored the quality of service delivery. ATBEF and ADESCO implemented the project in Haho and Blitta, respectively. The pilot project covered 158 villages over a seven-month period in Haho and a two-month period in Blitta. Each village selected to participate in the project had a total population of over 500 people and was located at least five kilometers from the nearest formal health facility. In Haho, the population of women of reproductive age in these villages was estimated at 18,753 and in Blitta, at 14,367; the number of children under five years of age was 15,002 and 11,494, respectively. A traditional leader in Blitta, Togo hands over logistics to a CHW for community service delivery activities.

government, the MOH, international NGOs, local NGOs, and the community. Blitta’s launch took place the following quarter and was attended by the 182 trained CHWs and 2,000 stakeholders including health professionals, religious and traditional leaders, CSOs, community opinion leaders, and women’s networks. USAID AWARE II in West and Centr al Afr ica 2009-2012

Through the two partner NGOs, USAID AWARE II trained and deployed 432 volunteer CHWs (250 in Haho and 182 in Blitta) to deliver the package of integrated health services in their communities. This group of CHWs was split between 54 percent men and 46 percent women. Their median age was 31 years and they had an average of eight years of formal education. The project trained the CHWs in the technical aspects of

USAID AWARE II in West and Centr al Afr ica 2009-2012

1520

1500

1319 1243 1113

1096 1000

919

907 772 669

500

290 218 137 0

OCT

NOV

136

DEC

125

JAN

FEB

1191

83%

Safe Injection Practices

92% 90% 97% 75% 83% 63%

Correct Treatment of Diarrhea

Correct Treatment of Pneumonia

80% 0

Correct Treatment of Malaria

100

First Assessment — Dec. 2011 Second Assessment — Mar. 2012

Figure 5. Performance of CHWs on Quarterly Quality Assessments

service delivery and equipped them with simple medical tools, regularly supplied to them by ATBEF and ADESCO, with project support. The CHWs also received a set of datacollection and service-delivery management tools. At the end of their training, CHWs were evaluated for their skills and capacity. Following the official district launches, the CHWs who scored 80 percent or more on their evaluation began delivering services in their communities. The CHWs were supported by 36 CHW supervisors, trained by the project to provide on-site follow-up training and ensure that services were delivered according to quality standards and safety protocols. Through the NGOs, CHWs attended monthly supervision sessions at health centers where they met to discuss their work, deliver monthly reports, and replenish their supplies. During the implementation period, the project conducted two assessments to evaluate changes in CHWs’ capacities. The evaluations were conducted through both practical observations and theoretical tests. Results showed that CHW compliance with quality standards was good. CHWs had learned to safely and correctly treat childhood illnesses and administer injectable contraception (see Figure 5). The evaluations also showed that among the 6,554 injections administered by CHWs, the CHWs had recorded only one case of injection abscess. USAID AWARE II conducted follow-up trainings in Haho to raise the CHW’s proficiency in categories where their performance was slightly lower. USAID AWARE II in West and Centr al Afr ica 2009-2012

7 MONTH NEW USER TOTALS

MAR

121

APR

CHWs in Haho Health Centers in Haho CHWs in Blitta

7408 Dr. Issakha Diallo, USAID AWARE II Project Director, shakes hands with a traditional leader at the CHW launch in Togo.

203

194

164

2150 397

Health Centers in Blitta

Figure 6 represents the success of CHWs in administering contraception to new FP users, as compared to the districts’ health facilities. In Haho, CHWs provided contraception for 7,408 women who had never used any FP method or had not used one in the last 12 months. In the same period, Haho’s 18 health centers provided contraception to just 1,191 new users, one sixth of the number reached by CHWs. Results from Blitta after only two months also showed a sharp uptake of contraception, with CHWs providing contraception to 2,150 women who had never before used contraception or had not in the past 12 months. During the same period, Blitta’s 18 health centers provided contraception to just 262 women. These results indicate that the districts’ health centers do not reach the majority of women living in the remote rural areas who want FP and that, for a fraction of the cost, a CHW program reached six times as many women in Haho and eight times as many in Blitta. This underscores the value of using CHWs, in particular, to reach rural populations which are often underserved due to their distance from health centers and the fact that many rural residents cannot afford to travel to health centers. In both districts, results from the same implementation period indicated a strong preference for Depo-Provera injectable contraception (69 percent) as opposed to the other available contraceptives (see Figure 7). Research indicates that this preference is commonly identified in Africa and may be mainly due to the fact that injectables are more USAID AWARE II in West and Centr al Afr ica 2009-2012

Figure 6. Total New Users Reached by CHWs vs. Health Centers in the Haho and Blitta Districts of Togo

Femidom 5% Lactational amenorrhea 11% Microgynon 15% Depo Provera 69%

Figure 7. Distribution of New Contraceptive Users per Method (N=9,558)

10%

15–19

23%

20–24

28%

25–29

21%

30–34

13%

35–39

40–44

1% 0%

45–49 10%

20%

30%

Figure 8. Proportion of New Contraceptive Users Reached by CHWs per Age Group (N=9,558)

3450 3K

Jadelle

The FP service achievements in Haho and Blitta were complemented by the CHWs’ success in treatment of childhood illnesses in these districts. As shown in Figure 10 on the following page, with each month, the intervention reached greater numbers of children under five suffering from malaria, diarrhea, and pneumonia. This rapid uptake reflects that the districts were most certainly in need of assistance from CHWs with C-IMCI capacity and supplies. The challenge for maintaining this intervention now lies in securing the oral rehydration salt, ACT, and antibiotic supplies that made this intervention possible.

2151

Microgynon IUD Condom

543 0

182

269

TOTAL CYP = 6,595

Figure 9. Couple Years Protection from Total Contraceptives Distributed 36

In terms of age, the study discovered that the majority of new FP users are between 20 and 34 years old (see Figure 8). This finding shows that the majority of women were of reproductive age and, without these FP services, would most likely have had larger families. Results also indicate greater awareness of and demand for FP among younger women. Couple years of protection (CYP) is the estimated protection provided by contraceptive methods during a one-year period, based on the volume of all contraceptives distributed free to patients during that period. The CYP data in Figure 9 shows the total FP contribution of different contraceptive methods. Using the most recent conversion factors developed by USAID, the project has determined a cumulative CYP of 7,595 for the quantity of methods used in Haho and Blitta.

Depo Provera

discreet than pills and require doses just four times a year verses pills which require daily dosing. Injectables are a safe, convenient contraceptive method that could be explored in other West African nations where most governments rely on oral contraception and have yet to authorize CHWs’ distribution of injectable contraceptives.

CHWs were able to treat significantly more children for malaria towards the end of the project when ACT became available. Previously, ACT had not been available at any level of the MOH system. In response, the USAID AWARE II team had met repeatedly with the MOH and other partners to advocate for a continuous supply of C-IMCI drugs. As a result, these commodities were made available for the FP activities and the treatment of childhood illnesses throughout the implementation period in both Haho and Blitta. USAID AWARE II in West and Centr al Afr ica 2009-2012

2500 Cumulative Cases

The USAID AWARE II demonstration project in Togo showed, for the first time, that community volunteers, when properly trained and supported, can safely and effectively deliver hormonal contraceptives to women of reproductive age and antibiotics to children. It also showed that women of reproductive age, mothers, and their children use the CHW services when available. These results suggest that delivering integrated services at the community level meets an important need and can be done, effectively and safely, by volunteer CHWs, at relatively low cost. The results suggest that the integrated package developed and demonstrated by the USAID AWARE II project may be an effective, lowcost strategy to reach the millions of underserved women and children in West Africa. The project has developed the tools, methodology, protocols, and system for the delivery of the integrated package. Blitta and Haho can lead the way for replication in other districts, and Togo will serve as a learning site for other countries in the region.

2250

Population Study

USAID AWARE II conducted a baseline assessment in April 2011 and an end-line assessment in May 2012 to determine the relative effectiveness of the project’s CBD intervention in Haho and Blitta. As a first step, the project selected a sample of 400 households from three districts: Haho and Blitta, where the project was implemented, and Wawa as a control district. Within these households, the project then distributed individual questionnaires to women between the ages of 15 and 49. In addition to individual questionnaires for women of reproductive age, the study also used household, health facility, and CHW questionnaires. Because each questionnaire used the framework of the Demographic Health Survey, a lot of data has been collected and analyzed. This USAID AWARE II in West and Centr al Afr ica 2009-2012

2000 1750 1500 1250 1000 750 500 250

OCT

NOV

DEC

JAN

FEB

MAR

APR

Cases of Pneumonia treated Cases of Diarrhea treated Cases of Malaria treated

Figure 10. Trend of the Malaria, Diarrhea, and Pneumonia Cases in Children Under Five by CHWs 37

section summarizes the study’s most significant results in terms of implementing the integrated package.

Table 4. Gender Balance of CHWs in Hato, Blitta, and Wawa

Safoura Amadu, 19, was trained to care for her preemie son, Ibrahim, using Kangaroo Mother Care.

CHW Gender Haho Male 57%

Blitta Female 43%

Male 53%

Wawa Female 47%

Male 85%

Female 15%

Table 4 shows that the project successfully recruited a gender-balanced team of CHWs in both Haho and Blitta, whereas in Wawa, the CHW population was predominantly male. This gender balance in the workforce will continue to be important in West and Central Africa as the region works towards achieving the third MDG, “promoting gender equality and empowering women.”

Table 5. Knowledge and Utilization of Family Planning Methods by Females

Kangaroo Mother Care Facilities and Activities

Females’ Knowledge and Utilization of Modern Family Planning Methods Haho

Blitta

Wawa

Baseline

Endline

Baseline

Endline

Baseline

Endline

% women who said they need to use contraceptive but are not currently using any method (unmet need)

29%

30%

28%

39%

37%

36%

% women who are currently using modern contraception

23%

56%

17%

37%

26%

% women currently using injectables methods among the users

42%

73%

29%

59%

37%

54%

% women who receive FP information from CHWs

66%

52%

% women who received modern contraception from CHWs at the village level

80%

11%

73%

Table 5 shows that the unmet need for FP is still very high in all districts in Togo. In total, women who received information about modern contraceptive methods from CHWs increased by 64 percent in Haho and 48 percent in Blitta, but only by 1 percent in Wawa. Similarly, women who use modern contraception increased by 33 percent in Haho and 20 percent in Blitta, but did not increase in Wawa. We have also seen the huge role played by CHWs in that the proportion of users who said they received 38

the contraceptive methods from CHWs increased significantly in Haho and Blitta, by 76 percent and 62 percent respectively, and yet only increased by 7 percent in Wawa. This pilot intervention therefore provides very strong evidence of the critical role that CHWs played in boosting the uptake of FP and significantly increasing the contraceptive prevalence in a very short period of time in the two districts. Results from the end-line assessment are presented here to highlight the major achievements of this intervention. The full report will be available by the end of the project in July and can be obtained upon request to the USAID/West Africa regional office. USAID AWARE II has shown, with strong evidence, that well-selected, well-trained, and properly supported CHWs can effectively and efficiently implement the integrated package.

USAID AWARE II in West and Centr al Afr ica 2009-2012

In an effort to help improve West Africa’s child health outcomes, USAID AWARE II worked with regional stakeholders and health care providers to promote the following three best practices in essential newborn care (ENC): newborn resuscitation, KMC, and early treatment of infections with antibiotics and exclusive breastfeeding. As a first step, the project worked with partners to establish three national ENC/KMC referral centers. In Niger, the facility included 16 beds where low birth-weight neonates and their mothers can be hospitalized for KMC services. In Togo and Burkina Faso the project established ambulatory KMC delivery systems. Supervision exercises were conducted in each new facility and the project also provided tailored support and training to the facilities’ operations, management, and technical teams. To enhance KMC capacity among health workers, USAID AWARE II worked with partners to establish ENC/KMC training centers in Dakar and Accra. These centers trained a total of 17 master trainers who then conducted training workshops for 98 health care staff in Burkina Faso, Togo, the Gambia, Mauritania, Niger, Sierra Leone, and Cameroon. As mentioned earlier, the project also trained 432 Togolese CHWs in ENC best practices, including KMC counseling. Other project trainings took place in Ghana, Mali, and Senegal and the project conducted supervision exercises at sites that had been established in Burkina Faso, Mauritania, Sierra Leone, and Togo. USAID AWARE II in West and Centr al Afr ica 2009-2012

Expected result 4:

Using Strengthened African Capacity: Selected West African Institutions and Networks West African Ambassador’s Funds Small Grant Mechanism The WAAF grant scheme was designed to support smaller grassroots organizations conducting RH/FP, MNCH, and HIV & AIDS activities in USAID non-presence countries. In addition to providing financial support, the WAAF grants also increase the participation of US embassy officials in national health initiatives and promote activities of regional significance in the context of the President’s Emergency Plan for AIDS Relief MAURITANIA (PEPFAR) and other US-funded programs.

Mothers and children in Niger during the AWARE II visit for the needs assessment survey.

“The success of the Special Session [during the ECOWAS meeting] was due in part to the interest of your organization has in such a crucial issue and the projective deliberations aimed at ensuring significant progress towards saving lives of West African mothers, newborns, and children. Let me therefore express my profound gratitude for your cooperation and support.” — Dr. Placido M. Cardoso, Director General of WAHO, in a letter to USAID AWARE II

USAID AWARE II in West and Centr al Afr ica 2009-2012

= Location of WAAF Grantee

MALI

NIGER

SENEGAL THE As a first step, USAID AWARE II developed application guidelines GAMBIA BURKINA FASO GUINEA GUINEA BENIN NIGERIA for the 14 countries that were eligible for WAAF grants. This BISSAU CÔTE D’IVOIRE SIERRA GHANA guide included grant-writing templates and submission LEONE LIBERIA CAMEROON TOGO instructions as well as an overview of the awarding processes. NGOs EQUATORIAL GUINEA used this guide to complete their applications and 12 of these organizations GABON eventually earned WAAF grants. Once the implementation stage began, the project SAO TOME & PRINCIPE supported each grantee by reviewing their reports, providing regular feedback, and conducting site visits to provide technical assistance in financial management, M&E, and capacity development. In order to improve communication of the grantees’ many successful results, USAID AWARE II produced one-page grantee profiles. Each document contained background information on WAAF, a description of the NGO, and an overview of the grant’s content and progress, including a table of indicators. Once finalized, these 12 documents were distributed to local NGOs, USAID, and the US ambassador at each nation’s US embassy. USAID AWARE II updated these documents each month with new project data and sent the revised profile to the US ambassadors.

CHAD

The performance of the individual WAAF projects was measured regularly to identify variances from the project management plan and to gauge progress towards set targets through monthly reporting on project performance indicators. Excel-based reporting tools were developed for the NGOs to facilitate reporting on the project indicators. USAID AWARE II also established an online database and WAAF grantees were trained USAID AWARE II in West and Centr al Afr ica 2009-2012

to enter project data into the database each month through the USAID AWARE II online database located at http://onlinedb.aware2.org.12 This tool allowed the project to monitor the granteesâ&#x20AC;&#x2122; progress and print reports for USAID and the US embassies. Each NGO received at least one monitoring visit.

In addition to the individual grantee reports, USAID AWARE II also conducted an evaluation of cumulative results for the 12 grantees. Table 6 shows that, together, the 12 WAAF grantees had exceeded 100 percent of their target for nine indicators and were above 80 percent for four indicators.

Results and Presentations at US Embassies As each WAAF grant came to a close, USAID AWARE II focused its efforts on helping the organizations communicate their results effectively. In the final quarters of the project, the project helped grantees prepare meaningful end-of-project reports and PowerPoint presentations that included a profile of the NGO and a summary of the grant itself. These reports also provided an overview of all implemented activities, the project achievements, lessons learned, and proposed next steps. Each grantee presented a summary of their accomplishments at a close-out meeting, which, in most cases, included an audience of 50 or more stakeholders such as project beneficiaries and representatives from the UN, MOH, and NGOs. These meetings were held in Cameroon, Chad, Gabon, Togo, Niger, and Sierra Leone. After learning of the granteesâ&#x20AC;&#x2122; success, many government institutions and international NGOs expressed interest in expanding the coverage of these successful practices. The responses from US embassies in these countries also indicated an interest in supporting efforts to bring these interventions to scale. Religious leaders from throughout the region were invited to participate in roundtable meetings to further inform USAID AWARE II policy and best practice implementation.

12. Guest users to the USAID AWARE II online database can login with: username: guest password: Guest123. Please note that the username and password are case sensitive.

Indicator

Target

Results

% of women who returned to providers to continue using FP services of any form

1,320

2,919

227%

% of women who use, for the first time, or after 12 months of interruption, FP services of any form

1,010

2,293

228%

130%

500

577

115%

% of PLHIV provided with medical consultation/pre-treatment support

1,369

1,619

118%

% of people (peer educators, health workers, etc.) trained

1,226

1,324

108%

% of people testing positive who were referred for treatment and care

575

526

91%

% of PLHIV provided with nutritional support

500

523

105%

% of PLHIV who received a home visit/home based care

680

850

125%

% of PLHIV provided with psychosocial support

650

682

105%

% of PLHIV who received a nurse consultation

500

472

94%

69,420

63,739

92%

% of PLHIV who were given a CD4 test

625

553

88%

% of PLHIV who begin ART for the first time

500

383

77%

% of PLHIV who are currently on ART

625

470

75%

31,920

24,403

76%

3,800

1,530

40%

93,240

47,702

51%

853,592

245,385

29%

710

12%

% of service outlets supported for VCT services % of PLHIV provided with counseling

% of people counseled on HIV & AIDS prevention

% of people who received VCT and received their results for HIV testing % of persons tested for sexually transmitted infections % of IEC/BCC materials distributed % of condoms distributed % of women tested for cervical cancer/gynecology services

USAID AWARE II in West and Centr al Afr ica 2009-2012

Table 6. USAID AWARE II Evaluation of Cumulative Results for the 12 Grantees

USAID AWARE II’s Institutional Capacity-Building ■■ 23 NGOs supported for capacity-building using MOST

Table 7. Institutional CapacityBuilding

■■ 10 NGOs supported to develop a strategic plan

Value of Small Grants in Scaling Up Services

An HIV-positive sex worker who comes for weekly counseling sessions at FAMME.

As USAID AWARE II demonstrated, the advantages of using local NGOs include their cultural competency, their capacity for innovation, and their ability to adopt a range of services to address the needs of diverse populations. The project’s local NGOs were also positioned in close proximity to the communities they served and, as a result, were able to use their connections to mobilize the community to engage in an effective response. Those links and connections also made the local NGOs more cost-effective. The success of the WAAF grant program was also largely due to the partnership with USAID AWARE II, which provided NGOs with resources and technical support. NGOs have benefited from this partnership in numerous ways, including:

■■ 2 NGOs benefited from support to develop an M&E plan ■■ 2 NGOs completed a financial manual ■■ 2 NGOs received accounting software/training ■■ 1 NGO received assistance to complete a standard operating procedures manual

Institutional and Individual Capacity-Building USAID AWARE II used the following strategies to strengthen the capacity of its partners to ensure effective project implementation and sustainable impact.

■■ Enhanced profiles and opportunities for other funding

Strategic and Financial Plans

■■ Accountability and commitment through the formal partnering process

In its first year, the project visited the eight countries that had originally been selected to implement the integrated package. These visits enabled the team to review strategic plans and inspire ministries to take ownership of the project. Later in the project, USAID AWARE II also visited four WAAF grantees to evaluate their financial systems and ensure compliance with MSH and USAID rules. The team then helped NGOs address problem areas and provided skills training as needed. USAID AWARE II also used the Management and Organizational Sustainability Tool (MOST) with three WAAF grantees and 10 NGOs implementing the integrated package to enhance their capacity in budgeting, staff administration, and financial management.

■■ Enhanced and rapid expansion of the NGOs’ existing services ■■ Knowledge and skills transfer In some cases, the grantees’ success has already inspired donors and governments to provide additional funding for project initiatives. During the close-out event for ATBEF and FAMME, for example, the UNFPA representatives asked both grantees to submit proposals for future funding. UNFPA had been impressed by the organizations’ achievements and, in turn, was inspired to support the scale-up of HIV & AIDS services to MARPs and the use of mobile clinics to increase health care access. The President of the National Commission on Women and Children and the Advisor on Social Affairs at the Presidency also pledged government support for the continuation of these health programs. The WAAF program clearly demonstrated that the combination of small grants, strong technical support, and well-positioned local NGOs is ideal for scaling-up health service delivery. Although the WAAF grants have ended, these NGOs are now equipped with enhanced local capacity and regional visibility that will enable the continuation and expansion of their programs. 44

■■ 3 NGOs assisted to complete a human resources management manual

USAID AWARE II in West and Centr al Afr ica 2009-2012

Namga Djarki shows partners at FAMME the M&E plan.

M&E Systems USAID AWARE II visited nine WAAF grantees and conducted data-quality assessments that revealed that most NGOs had implemented an M&E plan and appointed at least one M&E manager. Assessment findings were shared with each NGO and staff were trained, as needed, to improve their data management and tools. Another M&E initiative involved creating an online database to facilitate timely, routine data reporting. The project then trained each NGO to use the database for monthly reporting. USAID AWARE II also created a user manual to train future projects and partners in using this web-based system. USAID AWARE II in West and Centr al Afr ica 2009-2012

Virtual Leadership Development Program Fifty participants from seven NGOs participated in the Virtual Leadership Development Program, with support from the USAID AWARE II program facilitators. The project’s M&E advisor provided feedback to participants and helped them implement the leadership plans they developed during the course. Participant benefits included strengthened leadership and management capacity and improved teamwork and problem-solving. Data collectors assemble for baseline data collection in Niger.

Female CHWs take a break to take care of their children after the launch of community activities in Haho, Togo.

Best Practice Training USAID AWARE II participated in an assessment of HIV & AIDS services within Mauritania. Results showed that the nation had just one health center providing services for people living with HIV & AIDS and that the staff and resources at this facility were inadequate to meet the national need for HIV care. In response, the project ran a12-day training for 36 staff from two Mauritanian hospitals. This training improved participants’ knowledge of and capacity in HIV pathophysiology, HIV diagnosis, PMTCT, M&E, and ART.

Participant benefits included strengthened leadership and management capacity and improved teamwork and problem-solving.

46 46

The project also conducted 11 training-of-trainer workshops in Togo, Mauritania, Burkina Faso, and Niger. These workshops improved the capacity of master trainers to organize and facilitate training workshops, teach clinical skills to new trainees, and conduct monitoring and supervision activities. In total, the project trained 33 master trainers in EmONC, 86 in C-IMCI, and 155 in FP. The project then supported these master trainers in organizing and facilitating eight training workshops in Mauritania, Niger, and Togo. The master trainers improved FP capacity among 88 people and the EmONC skills of 105 individuals. Trainees included nurses, nurse assistants, midwives, midwife assistants, and medical assistants. Two additional training workshops were held in Accra and Dakar, where the project trained 30 nurses, midwives, pediatricians, gynecologists, and medical doctors in ENC, KMC, and Helping Babies Breathe. These trainees were also oriented on the project’s integrated package of services. USAID AWARE II in West and Centr al Afr ica 2009-2012

EXPECTED RESULT 5:

Leveraging Funding: New Funds Mobilized for USAID West Africa Health Programs Fund Leveraging Assessments USAID AWARE II conducted two regional fund leveraging assessments.The first study looked at the fund leveraging environment in West Africa, as a whole, and outlined a number of recommendations for the private sector to increase health support and for project partners to access funding.The report also highlighted strategies for leveraging funds from WAHO and ECOWAS.The second assessment explored the rising trend of corporate social responsibility initiatives within the private sector.This study included an inventory and mapping of all private sector firms operating in the project’s 21 target countries.The assessment team then analyzed these firms’ experience in financing the social sector and developed a strategic plan for the project to mobilize private sector resources throughout the region. Both assessments resulted in a report of key insights and recommendations that the project shared with their government and organizational partners. Although the fund leveraging initiatives were removed from the project’s scope of work after the first year, the assessment reports were distributed to USAID/West Africa and other project partners to inform future fund leveraging strategies.

Private Sector Alliance Established The project’s private sector assessment guided USAID AWARE II in organizing a meeting with 20 representatives from private sector businesses in West Africa. This meeting inspired the founding of the Private Sector Alliance and the meeting participants also suggested that a pilot project be initiated. After the meeting, the project initiated this pilot project and worked with the alliance to launch leveraging actions with various private sector partners.

The project launch in Blitta, Togo

“Money is not the only answer, but it makes a difference.” — Barack Obama, President, United States of America

USAID AWARE II in West and Centr al Afr ica 2009-2012

At the beginning of the project’s second year, USAID/West Africa determined that it was better positioned to pursue fund leveraging opportunities and removed this from the project’s work plan. Although the project was no longer responsible for fund leveraging, its work in year one produced meaningful assessment data and promising partnership plans. The project shared these results with USAID/West Africa and offered to provide additional assistance, as needed. USAID AWARE II in West and Centr al Afr ica 2009-2012

Sustaining and Expanding the Project Impact The project developed the capacity of local NGOs to use these tools and, as a result, they are now equipped to continue activities initiated by the project.

USAID AWARE II has ensured the sustainability of its accomplishments in RH/FP, MNCH, and HIV & AIDS through the development and updating of numerous tools that will be shared widely. Examples include guidelines, training manuals, supervision guides, monitoring tools, and an online database. The project developed the capacity of local NGOs to use these tools and, as a result, they are now equipped to continue activities initiated by the project. Furthermore, the region’s improved policy environment in HIV & AIDS and RH/FP, in combination with the strong commitment of governments to achieving the MDGs, gives us confidence that the project’s key interventions will continue to prosper and expand after USAID AWARE II concludes. The project has demonstrated that using CHWs to implement the RH/FP and MNCH integrated packages in West Africa is both feasible and cost-effective. We believe this strategy will be expanded in Togo; the Togolese government and its partners, including UNFPA and UNICEF, have expressed interest in and commitment to supporting the MDGs. In collaboration with UNFPA, the government of Togo is providing CHWs with the equipment and supplies needed to implement these interventions. Additionally, government nurses and midwives have been trained by the project to provide technical supervision for CHWs.

Challenges USAID AWARE II brought about a paradigm shift in the vision and commitment of West and Central African countries to making RH/FP and MNCH services widely available, especially to the majority of people who live in rural areas with little or no access to health services. However, as with any major strides in public health, the project encountered challenges that required a great deal of flexibility, innovation, and adaptability. The biggest challenges faced by the project were operational and political. At an operational level, the project required early adaptations of its original design to better respond to the rapidly changing realities on the ground. Combined with shifting donor priorities and changing geographic needs, the project’s geographic and technical scope was adjusted three times during the contract amendment process. Invariably, this 50 50

USAID AWARE II in West and Centr al Afr ica 2009-2012

process was time-consuming and caused delays in project implementation, and thus in the magnitude of the project’s overall impact. Another important, and often underestimated, operational challenge of the regional programming was the need for regional banking. In West Africa, the regional banking system and network is not as well developed as elsewhere and using it to transfer funds between countries led to long delays before funds were available and accessible in the receiving country. Forward planning and effective coordination through internet and other communication channels were instrumental in overcoming some of these challenges. At the political and environmental level, the project competed with the HIV & AIDS priority focus of the donors, regional NGOs, and governments. As elsewhere in Africa and globally, the heavy focus on HIV & AIDS over the past decade has compromised the ability of local institutions, health providers, and communities to gain and update their experience and technical capacity in RH/FP and MNCH. Bringing stakeholders together early on in the project and, subsequently, through regional and national forums, was critical to revitalize the region’s commitment to repositioning RH/FP and MNCH as critical public health areas.

USAID AWARE II sought active participation and advocacy from community and national leaders, including religious, community, and political leaders, in all steps of activity development and implementation to overcome challenges of supply lines and political controversy. 52

During the project’s three years of implementation, RH and especially FP continued to be politically controversial and sensitive issues for the governments of West and Central African nations with whom the project worked. Securing and sustaining FP commodities and RH and MNCH drug supplies continued, as it still does today, to threaten any efforts to revitalize FP in the region. The political landscape, including instability in a number of West African countries, also compromises the ability of programs to introduce FP, in general, and long term FP methods, in particular. Working through CSOs, NGOs, and local governments, USAID AWARE II sought active participation and advocacy from community and national leaders, including religious, community, and political leaders, in all steps of activity development and implementation to overcome this challenge, even when strengthening their capacity first meant further delaying some activities. These leaders, their newly acquired skills and tools under the project, and their continued commitment, advocacy, and vision hold the key to sustaining the gains achieved by USAID AWARE II in the region. USAID AWARE II in West and Centr al Afr ica 2009-2012

Lessons Learned Building Consensus ■■ A broad and detailed literature review is an essential step in project start-up and enables the team to understand their role in the region’s public health history as well as the evidence-based best practices that have been most appropriate and effective in the region.

Implementing Best Practices ■■ Project implementation must focus on a limited number of best practices that will glean meaningful results and inspire replication. ■■ MOUs that provide a clear overview of the project and expectations of the country partners should be signed with each target nation, prior to implementation. ■■ Organizations, rather than individuals, should be contracted for technical support, as their expertise often spans various and overlapping technical areas and allows for a unified approach, rather than the numerous and incongruous strategies that tend to emerge when using individual consultants.

Building Capacity ■■ Continuity is essential for effective capacity-building; revisions and amendments to the project work plan should seek to support and sustain activities that the team has already begun or else these changes will result in a significant loss of resources, funds, and time. ■■ Projects that aim to achieve ambitious goals with limited resources and time are best implemented when the project team is supported by donors, government stakeholders, and local experts who are committed to pursuing an honest, communicative, and consistent partnership. USAID AWARE II in West and Centr al Afr ica 2009-2012

Implementing Small Grant Projects

The USAID AWARE II project has demonstrated that properlytrained and equipped CHWs can provide FP and MNCH services. It has shown that small grant programs can deliver significant results. The next steps of this program now lie in the hands of the governments, organizations, health workers, and partners who have agreed to build on this foundation of strong policy and proven interventions.

■■ Project implementers are motivated by specific, quantifiable targets that allow for easy collation of project results and dissemination to supervisors, partners, and potential donors. ■■ Grant projects of this nature can be greatly enhanced by establishing clear roles and responsibilities for all partners. More specifically, project teams must provide US embassies with well-defined plans for the project’s supervision, reporting, and implementation tasks, along with the accountable parties. ■■ Supervision is more efficient when projects develop and use strong reporting guidelines and a systematic reporting technique. The USAID AWARE II online reporting tool, for example, enabled the project to monitor data submitted by the grantees in a manner that was both efficient and inexpensive. ■■ Governance needs to be a focus for NGOs in both the design and implementation stages of their projects. This instructive leadership is best provided through in-depth trainings, regular and preemptive communication, and procurement of user-friendly tools for budgeting and reporting.

Conclusion Despite changes in the project’s scope and expected results, USAID AWARE II effectively engaged the project’s 21 countries in building consensus on regional health priorities and committing support policy and programs that address these areas of need. Furthermore, the project demonstrated that properly-trained and equipped CHWs can provide FP and MNCH services and small grant programs can deliver significant results. In the project’s final month, USAID AWARE II will hold a meeting to share its results with the 21 target countries. This meeting will also allow the project to share the tools and methods used to implement and monitor its interventions. The country representatives, NGO leaders, and donors who attend this meeting will be urged to commit themselves to sustaining and expanding the project’s key interventions, particularly the integrated package that was successfully implemented in Togo. The next steps of this program now lie in the hands of the governments, organizations, health workers, and partners who have agreed to build on this foundation of strong policy and proven interventions. USAID AWARE II is confident that these parties now have the knowledge and ability to maintain and expand these interventions and, in turn, save the lives of women and children throughout West and Central Africa. n 54

USAID AWARE II in West and Centr al Afr ica 2009-2012

ACT Artemisinin-based combination therapy ADESCO Appui au Développement et à la Santé ART Antiretroviral therapy ATBEF Association Togolaise de Bien Être Familial AWARE Action for West Africa Region BCC Behavior change communication CBD Community-based distributor/distribution CD4 Cluster of differentiation 4 CHW Community health worker C-IMCI Community-integrated management of childhood illnesses CSO Civil society organization CSW Commercial sex workers CYP Couple years of protection ECOWAS Economic Community of West Africa States EmONC Emergency obstetric and neonatal care ENC Essential newborn care ER Expected result ESOPE Evaluation et Suivi Opérationnel des Programmes d’ESTHER FAMME Force en Action pour le Mieux-être de la Mère et de l’Enfant FP Family planning FSW Female sex workers HTSP Healthy timing and spacing of pregnancy IDU Injection drug users IEC Information education and communication KIP Key intervention package KMC Kangaroo mother care M&E Monitoring and evaluation MARPs Most-at-risk populations MDG Millennium Development Goal MNCH Maternal, newborn, and child health MOH Ministry of health MOU Memorandum of understanding MSH Management Sciences for Health MSM Men who have sex with men NGO Non-governmental organization PLHIV People living with HIV PMTCT Prevention of mother-to-child transmission RAPID Resources for Awareness of Population Impact on Development RH Reproductive health TWG Technical working group UN United Nations USAID United States Agency for International Development US United States VCT Voluntary counseling and testing WAAF West African Ambassadors Fund WAHO West African Health Organization WHO World Health Organization USAID AWARE II in West and Centr al Afr ica 2009-2012

Acknowledgements This publication is made possible by the generous support of the United States Agency for International Development (USAID) under Contract No. GHS-I-05-07-00006-00. The contents are the responsibility of AWARE II and do not necessarily reflect the views of USAID or the United States Government. This end-of-project report, From Consensus to Action: Promoting Best Practices by Strengthening Policy and Capacity in West and Central Africa describes achievements of the USAID AWARE II Project. The success of this project has been the direct result of the commitment, dedication, and contributions of project and the NGO teams they worked to support. The report is based on invaluable input from the project staff and was prepared by Dr. Issakha Diallo, the USAID AWARE II Project Director and Elke Konings, the USAID AWARE II Country Lead with support from MSH’s Communications Manager, Mary Burket, and the MSH Communications Associate, Jessica Charles.

Index of Acronyms

Management Sciences for Health • 784 Memorial Drive • Cambridge, MA 02139-4613 USA +1.617.250.9500 (tel) • +1.617.250.9090 (fax) • www.msh.org • communication@msh.org To order copies of this report, please send an email to bookstore@msh.org