THE USAID/WEST AFRICA REGIONAL HEALTH PROGRAM: A MID-TERM ASSESSMENT JULY 2006 This publication was produced for review by the United States Agency for International Development. It was prepared by the Academy for Educational Development, Africa’s Health in 2010 project. Photo on the front cover: Mothers waiting with their children at an infant welfare clinic in Niger; taken by Dr. Adama Kone, AWARE-RH Child Survival Specialist. This is a report of the assessment carried out by: Joyce Holfeld, Team Leader Enyantu Ifenne, Nigeria Robert Leke, Cameroon Subhi Mehdi, USAID/Washington Emily Osinoff, USAID/Washington Michele Seibou, Benin The field work was conducted in West Africa from April 30 through May 18 2006, for this report. THE USAID/WEST AFRICA REGIONAL HEALTH PROGRAM: A MID-TERM ASSESSMENT July 2006 DISCLAIMER The authors’ views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. i ACKNOWLEDGMENTS The authors wish to extend hearty thanks to the USAID/West Africa health team and its field implementers throughout West Africa as well as colleagues in Washington who contributed to the preparations of this assessment. A special acknowledgment goes to the Regional Mission Director, Jatinder Cheema and Deputy Mission Director, Felix Awantang, who generously offered their vision, time and expertise. The acting health team leader Jamie Browder and the entire health team provided outstanding support in coordinating the visit and dealing with a myriad of substantive, scheduling, and logistical details to make it all work. In this regard, Winston Allen and the Africa’s Health in 2010 Project staff at the Academy for Educational Development, under the auspices of the Africa Bureau, provided preparatory arrangements and travel support for the consultants on the team. The AWARE teams were especially helpful in bringing their operational point of view and vast regional experience to the review. USAID/WA staff Kristin Cooney and Letitia Sam and AWARE-RH Director Isaiah Ndong, who accompanied the team on their field visits, were especially helpful in showing how the program’s theory translates to practice. To the many field partners--in Ghana, Togo, Benin, Cameroon, Mali and Burkina Faso--who took time out of their very busy schedules to provide constructive comments and allowed the validation of the conclusions presented in this report, the authors are especially grateful. The team was fortunate to have access to quality written materials which provided background and contributed to our understanding of the program. The authors particularly appreciated the questionnaires that were thoughtfully completed by all of the bilateral and centrally-funded actors. The comprehensive work provided by all laid the foundation upon which this assessment was conducted, the findings of which are presented in this report. ii ACRONYMS AED Academy for Educational Development ALCO Abidjan-Lagos Corridor Organization ARV anti-retro viral ARI acute respiratory infection AWARE Action for West Africa Region AWARE-HIV Action for West Africa Region – HIV/AIDS AWARE- RH Action for West Africa Region – Reproductive Health BCC Behavior Change Communication BASP Bureau d’Appui à la Santé Publique C-IMCI Community-Integrated Management of Childhood Illnesses CBCHB Cameroon Baptist Convention Health Board CBHFS Community-based Health Financial Schemes CEFA Centre d’Etudes de la Famille Africaine CEFOREP Centre Régional de Formation et de Recherche en Santé de la Reproduction CESAG Centre Africain d’Etudes Supérieures en Gestion CERPOD Centre d’Etudes et de Recherche sur la Population pour le Développement CHUS Centre Hospitalier Affilié à l’Université de Sherbrooke CHA Centre Hospitalier Affilié à l’Université de Québec CHP Care and Health Program CICDoc Center for Information, Documentation, and Counseling CSH Child Survival and Health CILSS Comité Inter-état de Lutte contre la Sécheresse dans le Sahel COPE Client-Oriented Provider-Efficient ECOWAS Economic Community of West African States DFA Director for Foreign Assistance FBO faith-based organization FFP Food for Peace FHA Family Health and AIDS Project FP Family Planning GAIN Global Alliance for Improved Nutrition GAVI Global Alliance for Vaccines and Immunizations GSMF Ghana Social Marketing Foundation GFATM Global Fund for AIDS, Tuberculosis, and Malaria (Global Fund) HACI Hope for African Children Initiative HFPI Health for Peace Initiative IDPs internally displaced persons INSAH Institute of the Sahel IPC Interpersonal Communication IR Intermediate Result IRC International Rescue Committee IRSP Institut Régional de Santé Publique JHPIEGO Johns Hopkins Program for International Education in Gynecology and Obstetrics KATH Komfo Anokye Teaching Hospital KfW Kreditanstalt für Wiederaufbau MARP most-at-risk populations MCA Millennium Challenge Account MCH Maternal and Child Health MHO Mutual Health Organizations MSH Management Sciences for Health NAP Network of African People Living with HIV/AIDS NGO non-governmental organization NHA National Health Accounts OFDA Office of Foreign Disaster Assistance iii OGAC Office of the Global AIDS Coordinator OVC orphans and vulnerable children PDI Policy Development Initiative PEPFAR President’s Emergency Plan for AIDS Relief PHRplus Partners for Health Reformplus PMTCT Prevention of Mother-to-Child Transmission PSAMAO/C Prévention du SIDA sur les Axes Migratoires de l’Afrique de l’Ouest et du Centre PLWHA Persons Living with HIV/AIDS PSI Population Services International REDSO Regional Economic Development Support Office RPM+ Rational Pharmaceutical Management Plus RH Reproductive Health RLC Regional Learning Centers SAILD Service d’Appui aux Initiatives Locales de Developpement SFA Strategic Framework for Africa SO Strategic Objective SS Strategy Statement STI sexually-transmitted infection SWAA Society for Women Against AIDS in Africa TAACS Technical Advisors in AIDS and Child Survival TFGI The Futures Group International TLI Technical Leadership Institutions TLN Technical Learning Networks UNFPA United Nations Population Fund UNHCR United Nations High Commissioner for Refugees UNICEF United Nations Children’s Fund USAID United States Agency for International Development (the Agency) USAID/AFR USAID Bureau for Africa USAID/GH USAID Bureau of Global Health USAID/WA USAID/West Africa (the Mission) USG United States Government VCT voluntary counseling and testing WAAF West Africa Ambassadors’ Fund for AIDS WAHO West Africa Health Organization WAPCAS West Africa Project to Combat AIDS and STIs WB World Bank WHO World Health Organization WHO/AFRO World Health Organization/Africa Regional Office v TABLE OF CONTENTS ACKNOWLEDGMENTS ACRONYMS I. EXECUTIVE SUMMARY........................................................................................... 1 II. PURPOSE OF THE MID-TERM ASSESSMENT.................................................... 4 III. CONTEXT OF THE REGIONAL HEALTH PROGRAM ......................................5 A. Political Context B. Socio-Economic and Health Context in West Africa Region C. Programmatic Evolution of the USAID/WA Health Program D. USAID/WA Health Strategic Objective and Results Framework E. Geographic Scope F. Major Implementing and Collaborating Partners G. Collaboration with Other Donors H. Overview of Program Financial Resources IV. PROGRAM ACHIEVEMENTS AND RESULTS....................................................17 A. Overall Approach and Assessment of Results B. IR 1: Improved Approaches (Best Practices) in Selected Technical Areas C. IR 2: Increased Regional Stakeholder Advocacy for Policy Change D. IR 3: Increased Capacity of Regional Institutions and Networks E. IR 4: Health Sector Reforms V. SPECIAL PROGRAM INITIATIVES ......................................................................38 A. West African Ambassadors’ Fund for AIDS B. Cross-Border Interventions C. Obstetric Fistula Repair VI. MAJOR FINDINGS, CONCLUSIONS AND SPECIAL QUESTIONS.................43 A. Major Findings B. Special Questions Addressed by the Assessment Team VII. ISSUES AND RECOMMENDATIONS ...................................................................48 A. Strategic B. Technical and Tactical C. Organizational and Management VIII. PERFORMANCE MONITORING AND EVALUATION..................................... 60 IX. OPPORTUNITIES AND CHALLENGES ...............................................................62 vi APPENDICES ....................................................................................................................64 APPENDIX A: USAID/WA Mid-Term Assessment Terms of Reference APPENDIX B: References APPENDIX C: List of Informants APPENDIX D: Socio-Economic and Health Indicators APPENDIX E: USAID/WA Health Program Geographic Matrix 1 I. EXECUTIVE SUMMARY The United States Agency for International Development, West Africa (USAID/WA or the Mission) commissioned a six-person team to conduct a mid-term assessment of its Health Strategic Objective (SO5): Increased adoption of sustainable RH, STI/HIV/AIDS, and child survival policies and approaches in West Africa. The assessment team reviewed health program achievements to date, assessed the impact of the current programs, and developed recommendations to improve the current program and to assist in future strategic planning.1 Timing of this assessment was fortuitous for multiple reasons. First, USAID (the Agency) is reformulating its structure, and the Mission is preparing to submit a new country operational plan in December 2006 per the guidance from the Office of the Director of Foreign Assistance (DFA). Second, the Office of the Global AIDS Coordinator (OGAC) completed a review of all regional contributions to the President’s Emergency Plan for AIDS Relief (PEPFAR). Finally, the Global Fund for AIDS, Tuberculosis and Malaria (GFATM or the Global Fund) is now providing significant funding for national health programs in most of West Africa. The Mission implements its current $17.1 million annual budget for the regional health activities through two major cooperative agreements: Action for West Africa Region for Reproductive Health (AWARE-RH), a consortium led by EngenderHealth; and Action for West Africa Region for HIV/AIDS (AWARE-HIV), a consortium led by Family Health International.2 The Mission also directly funds two capacity development grants--one to the West African Health Organization (WAHO), the health secretariat of the Economic Community of West African States (ECOWAS); and the second to the Centre d’Etudes et de Recherche sur la Population pour le Développement (CERPOD), a research organization under the direct supervision of the Institute of the Sahel (INSAH), and under the aegis of the Comité Inter-état de Lutte contre la Sécheresse dans le Sahel (CILSS). Finally, the Mission provides complementary and specialty services by utilizing field support through the Bureau of Global Health (USAID/GH) mechanisms. Because of available earmarked funding and need, the program has primarily focused on reproductive health which includes reproductive health (RH), maternal and child health (MCH), and family planning (FP); and HIV/AIDS which includes support for the prevention, care and treatment of HIV/AIDS and other sexually-transmitted infections (STI). The assessment team spent three weeks in the field reviewing the regional program results, collecting data through in-depth interviews with key informants, reviewing relevant documents, and visiting the field programs. To maximize field exposure, the team split into two groups. One group traveled to Burkina Faso and Mali and the second group went to Togo, Benin, and Cameroon. The team interviewed policy makers, Embassy and USAID representatives, inter￾governmental officers, donors, stakeholders, and implementing partners as well as government officials, public/private managers and service providers. The findings and recommendations are 1 The team would like to acknowledge the excellent materials provided both by USAID and partner staffs—much of which was the basis for the observations, findings and recommendations in this paper. 2 To simplify discussion, the team has combined the ‘projects’ and when discussing all projects uses the term ‘program’ or the ‘AWAREs’. When these diverge and specific partner mandates, accomplishments, activities and/or challenges are ‘project specific,’ these are discussed separately with the relevant project cited. 2 included in this report. This report has three themes: background and context for the Mission’s regional health program; achievements, results and lessons learned; and findings and recommendations for more strategic and tighter programming in the future. The annexes include supporting data and reference information. In summary, the team was most impressed with the regional health program’s progress to date. The accomplishments and impact, in such a short time under the most difficult circumstances, have been formidable. The Mission and the implementing partners of the health program have had a well-conceived and executed tactical approach to disseminate best practices, advocate for policy change, build the capacity of African institutions, and introduce health reforms to the region. The health program team has a sound strategy which is on target for achieving its planned strategic objectives of improved health sector policies and approaches within the region. The regional program has worked diligently to enable a positive operating environment for national programs to plan and implement quality service delivery programs. In addition, the program has worked closely with other donors to achieve consistency between donor programs. To accomplish this, the regional activities have focused, not on services per se, but rather on establishing the conditions that make excellent service delivery possible, by: • Introducing policies and strategies that break down barriers and permit positive legal, regulatory and operational frameworks for services; • Building skills and mobilizing agents of change that can influence and impact the availability and accessibility of appropriate services; • Developing systems and tools that improve the effectiveness and efficiency of services and underpin optimal service delivery functioning; • Strengthening regional institutional capacities and forming collaborative relationships that can provide bold leadership for consensus, harmonization and technical excellence for the design and implementation of service policies and delivery strategies; • Leveraging of funding of other donors, governments, and the private sector to permit the replication of model service delivery at the national level. The regional program has successfully built on previous national, regional and worldwide efforts such as the work on commodity security, quality assurance, standard setting, and the promotion of service delivery models. The program provides regional leadership in selecting best practices, building consensus, and promoting changes in policies and approaches at the country level. Perhaps the program’s greatest achievement has been in strengthening and promoting African regional and national capacity to plan, manage, and implement health programs. The USAID staff and that of the two major implementing organizations are well-appreciated by their regional beneficiaries for the quality and appropriateness of activities, the high caliber and competence of staff, and innovation and responsiveness in meeting the strategic health challenges of the region. 3 West Africa, however, is a culturally and linguistically diverse region, with complicated logistical and communication challenges. The team believes that the result of spreading across 21 countries and promoting scores of promising and best practices has affected the depth of the program and diluted its impact. The team recommends that the Mission increase its focus and concentration by setting parameters on its geographic scope, limiting the number of best practices it promotes, and prioritizing institutional partnerships to those that demonstrate potential for growth, impact, and sustainability. Many steps and the foundation for moving forward along these lines have already been undertaken or are planned. However, in order to make more explicit the direction advocated, the assessment team developed actionable recommendations for strategic, technical and managerial aspects of the program. The findings and analysis that underlie the proposed approach, and recommendations and responses to specific questions raised by the Mission in the team’s terms of reference, are discussed in the chapters that follow. The team strongly believes that the investment in the regional health program has been and will continue to be critical to the achievement of the entire Mission’s strategic goal (2001-2008): “a politically stable and economically prosperous West Africa.” West Africa needs healthy citizens to prosper and grow. Premature adult deaths and excessive morbidity, especially of breadwinners and mothers, weaken the labor force and disrupt families. The spread of infectious diseases like HIV/AIDS, malaria, and now avian flu can slow or halt economic progress and affect political stability. Poorly managed facilities and perceived corruption at all levels within the health sector lessen citizen belief and trust in their governments. Conversely, investing in health services and reforming health systems provide well-known tools to alleviate some social ills. Fortunately, the current and planned activities of USAID/WA, through its projects, in collaboration with other donors, and most importantly with governments, non-governmental and commercial sectors, are very well-positioned to advance an agenda of better health for the region. 4 II. PURPOSE OF THE MID-TERM ASSESSMENT USAID/WA commissioned a team to conduct a mid-term assessment of its Health Strategic Objective (SO5)--Increased Adoption of Sustainable RH, STI/HIV/AIDS, and Child Survival Policies and Approaches in West Africa. The purposes were to review health program achievements to date; to assess the impact of the current programs; and to develop strategic, technical, and managerial recommendations to assist in future planning and performance improvement. As requested by the Mission, the team focused on four major questions: • How has the USAID/WA regional health program been implemented over the last three years and what are the results to date? • What lessons are learned from the implementation process and results, and what are the implications for a regional approach to health programming specifically under the new Agency strategy on transformational development and PEPFAR? • How should the USAID/WA health strategy and portfolio respond to substantially reduced budget levels for FY2006-2007 and a changing implementation and policy environment, both in West Africa and Washington? • What can USAID/WA do to strengthen the capacity of its regional partners, especially intergovernmental and regional organizations and networks, to ensure program sustainability? The team conducted field work in the region from April 30-May 18, 2006. This included interviews, review of relevant documents, and visits to the field. For the field visits, the team split into two groups: one group traveled to Burkina Faso and Mali, and the second went to Togo, Benin, and Cameroon. The team interviewed a broad range of individuals knowledgeable of the program including policy makers, Embassy and USAID representatives, governmental, inter-governmental and non-governmental officials, donors and implementing partners as well as public and private sector managers and service providers. To facilitate a quick understanding, the team asked each implementation partner to complete a questionnaire which provided detailed strategic and programmatic information on their respective programs. In addition, the team held additional meetings with the Mission program leadership and stakeholders to solicit input for final recommendations. The assessment did have some limitations: time was short and did not allow an in-depth and first￾hand view of activities in all countries and in all domains, and most of the data received was qualitative, not quantitative. Even with these constraints, the team believes it did have an excellent overview and briefs upon which to solidly base its findings, conclusions and recommendations. The scope of work of the mid-term assessment is included as Appendix A; a reference of key documents reviewed is included as Appendix B; and persons interviewed are listed in Appendix C. 5 III. CONTEXT OF THE REGIONAL HEALTH PROGRAM A. Political Context Sub-Saharan Africa, and especially West Africa, has the largest number of rebuilding and developing nations in the world, and harbors the largest number of weak and failed states. The region is marred by political instability, and populations, infrastructure and institutions in some States have been devastated by conflict. Regionally, conflict in one country generates mass movements of displaced persons into neighboring countries which themselves may be politically frail. Guinea, for example, which is politically fragile, was recently home to one million refugees from Sierra Leone. Overall, political strife remains a major obstacle to building regional institutions and alliances and to fostering overall peace and development in the region. Notwithstanding the overall weak political performance in the region, a few political initiatives still demonstrate the political will of the countries and offer hope for West Africa. Of these, the emergence of regional political and economic institutions is extremely encouraging. Of particular note is the 15-country ECOWAS and its specialized agencies, which include the ECOWAS Parliament, the Council of Health Ministers, and the WAHO. Also, many countries in the region have initiated political, economic and social reforms, including health reforms. Increasingly, these developments and institutions, though tenuous, are windows of opportunity for collaboration and harmonization of regional initiatives that can reduce the gridlock to social and economic development in the region. The USAID/WA Health portfolio, in collaboration with other donors, has provided evidence-based leadership, stimulated change, and provided a gateway to filling the needs in the health sector. The interventions proffered by the regional program have kept these hopes alive and have moved initiatives forward to uniformly support a better quality of life for West Africans. B. Socio-Economic and Health Context in West Africa Region A current snapshot of the West and Central Africa region reveals that, despite development interventions over the past several decades, basic human needs remain dramatically unfulfilled across the region (see Appendix D for an overview of the data included in this section). Of the 17 countries at the bottom of the United Nations’ 2005 Human Development Report’s Human Development Index, eight are in West or Central Africa, with the six lowest ranked countries all in this region. The major indicators describe a region that ranks as one of the poorest in the world, with the highest rate of population growth and one of the lowest levels of human capital development. The natural resource base is deteriorating, corruption levels are high, and a large part of the population does not have access to safe water, sanitation, basic education or health care services, adequate housing, or job opportunities. The status of women is extremely low. As a group, the countries in the region do not generate enough income for the average person to avoid a $2 per day poverty line. More than 45 percent of the population in the region is below 15 years old and state expenditures on health and education are extremely low. This is compounded by high population growth rates in general and even higher urban population growth rates. 6 The major health problems in the region include HIV/AIDS (while lower than in East and Southern Africa, rates are increasing in a number of countries); high infant and child mortality (among the highest in the world); high maternal mortality (20 percent of annual world-wide maternal deaths occur in West and Central Africa), and low use of modern contraceptives for achieving desired family size. Numerous factors in the region contribute to these specific health problems, including weak service delivery capacity of public and private sector organizations, poorly maintained infrastructure and an alarming exodus of trained professionals from the public sector, poor quality of services when delivered, and fragmented planning and programming of resources on the part of governments and donors. The region’s weak managerial and technical expertise is frequently cited as a fundamental constraint to health policy and program development. There are few documented examples of good human resource practices and institutional capacity building techniques. These underlying factors and issues affecting the socio-economic and health status of the region are not contained within national borders. Poor transportation and communication infrastructures and language barriers between countries have deterred coordinated solutions for prosperity and socio-economic development. Even with these massive challenges, concerted and substantive efforts by the donors, governments and non-governmental organizations (NGOs) are being made to ameliorate and change the situation. Sizeable resources for health programs are coming into the region, through the PEPFAR, the Global Fund, the World Bank loans and grants, the Global Alliance for Vaccines and Immunizations (GAVI), and the Millennium Challenge Account (MCA). C. Programmatic Evolution of the USAID/WA Health Program USAID/WA was established in 1999 and at that time was located in the Côte d’Ivoire to consolidate a number of ongoing programs, including the Sahel Regional Program (especially the CERPOD) and the Family Health and HIV/AIDS Prevention Project (FHA). Formed at a time when funding levels for health increased rapidly, the FHA filled a void which had existed since the closing of seven bilateral missions in the region in the mid 1990s and the closing of the Regional Economic Development Support Office, REDSO/Abidjan, in 1997. This proved to be a significant challenge for the regional program—to achieve coverage, impact, and accountability in so many countries with no local staff or presence. The regional program was transferred to Accra, Ghana, in October 2003. The activities of the Office of Food for Peace (FFP) and the Office of Foreign Disaster Assistance (OFDA) are currently functional units of USAID/WA but are managed out of a satellite office in Senegal. The 2001-2008 Strategic Plan of USAID/WA envisions “a politically stable and economically prosperous West Africa.” The Mission committed to achieve this goal through programs in the following areas: health, economic integration and trade; agriculture, food security and natural resource management; and conflict prevention and anti-corruption. Initially the health strategic objective (SO) was “increased, sustainable use of selective reproductive health, STI/HIV/AIDS, child survival, and maternal health services and/or products in West Africa.” In 2003, the SO was changed to “increased adoption of sustainable RH, STI/HIV/AIDS, and child survival policies and 7 approaches.” This change was made to reflect that the regional emphasis was directed to policy and strategic approaches instead of service delivery. In December 2005, the Mission developed a new Strategy Statement (2006-2010) to align its program to the draft Strategic Framework for Africa (SFA), which laid out a new paradigm for development following the Agency’s Policy Framework. The Mission Strategy Statement contributes to the SFA goals of: 1) fostering a healthier, better educated, and more productive population; 2) increasing the effectiveness of African institutions in promoting a vibrant private sector and democratic governance; 3) averting and resolving conflict; and 4) managing crises and promoting stability, recovery and democratic reform. The new Health SO9, provisionally approved in March 2006, under the Mission’s new Strategy Statement, now reads: Figure 1 Washington only provisionally approved this new Health SO for the Mission in order to facilitate obligation of funds and provide continuity in implementation. The full Mission Strategy Statement with the respective intermediate results is pending final approval. There may be additional guidance issued by the newly-established Office of the Director of Foreign Assistance. Under this new structure, USAID and other U.S. Government (USG) agencies administering foreign assistance are witnessing significant structural and functional changes. At this point, it is not clear how these changes will affect regional platforms such as USAID/WA. When further guidance is received regarding regional programs, the recently approved Mission Strategy Statement may be further revised. The SO and proposed intermediate results did not change drastically. Under the new strategic framework, the Mission simplified and made more precise its health objective, limiting it to select policies and approaches which make it within the manageable interest of the operating unit. Also, the Mission acknowledged cross-border services as an important intervention and thus included it Strategic Objective Increased adoption of selected high-impact health policies and approaches Intermediate Result 1 Increased dissemination of best practices and use of cross border services region-wide Intermediate Result 2 Increased regional stakeholder advocacy for policy change Intermediate Result 3 Increased technical and management capacity of regional institutions and networks 8 specifically within the first intermediate result. The health sector reform activities are folded, as appropriate, as specific activities under either best practices, advocacy for policy change, or capacity building of regional networks. D. USAID/WA Health Strategic Objective and Results Framework The following SO and Results Framework, under the Mission Strategic Plan of 2001-2008, have guided the current regional health program since its inception. For the purposes of this mid-term assessment, the team reviewed the health program using this framework. Figure 2 The Health SO also supports PEPFAR: organizing dissemination and supporting replication of best practices in non-focus and limited presence countries; (in Côte d’Ivoire, these HIV/AIDS activities have been funded directly under the PEPFAR at a level of approximately $9 million per year in FY2005/2006); managing the West Africa Ambassadors’ AIDS Fund (WAAF) for limited presence countries; convening meetings on regional issues to develop and harmonize USG policies and approaches for HIV/AIDS; promoting a favorable policy environment by developing and promoting a model law for HIV/AIDS; conducting regional training to strengthen national and regional capacity to plan, manage and evaluate HIV/AIDS programs; and facilitating Global Fund proposal development and award implementation. In addition, the Health SO supports WAHO, the health secretariat of ECOWAS by strengthening its institutional capacity to facilitate regional coordination of health policies, standards, and training; promoting and sharing best practices; and advocating at the level of ECOWAS Ministers of Health and Heads of State on health issues of the region. Strategic Objective Increased Adoption of Sustainable RH, STI/HIV/AIDS, and Child Survival Policies and Approaches Intermediate Result 1 Improved approaches to reproductive health, STIs/HIV/AIDS, child survival and infectious disease services disseminated Intermediate Result 2 Increased regional stakeholder advocacy for policy change Intermediate Result 3 Increased capacity of regional institutions and networks Intermediate Result 4 Health sector reform models developed and disseminated region-wide 9 E. Geographic Scope The Mission serves an extensive region, in fact, the largest number of countries served of all the USAID regional offices. Originally designed to support 18 countries, USAID/WA’s geographic mandate was recently expanded. With the addition of Equatorial Guinea, Gabon and São Tomé and Príncipe, USAID/WA is now responsible for serving 21 nations: Benin, Burkina Faso, Cameroon, Cape Verde, Chad, Côte d’Ivoire, Equatorial Guinea, Gabon, The Gambia, Ghana, Guinea, Guinea Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, São Tomé and Príncipe, Senegal, Sierra Leone, and Togo. Figure 3 MAP OF WEST AFRICA REGION USAID/WA The Mission’s geographic scope is as diverse as it is expansive. Eighteen of the 21 USAID/WA countries have a US Embassy presence (Equatorial Guinea is supported by Cameroon, Guinea Bissau by Senegal, and São Tomé and Príncipe by Gabon). Seven of its 21 countries have USAID bilateral missions. Since October 2005, the Mission has been responsible for providing support to the remaining 14 limited presence countries in the region. Two of the USAID/WA countries, Côte d’Ivoire and Nigeria, are PEPFAR focus countries. The USAID/WA health program also includes activities in all fifteen member countries of ECOWAS. The countries in the region speak three official languages: French, English and Portuguese, as well as hundreds of local languages. Appendix E provides an overview of the 21 USAID/WA countries and a comparison of their various geographic configurations and nomenclature (such as ECOWAS countries, CILSS countries, Embassy-limited presence countries and those with USAID bilateral missions, PEPFAR countries (focus, non-focus and limited presence). 10 F. Major Implementing and Collaborating Partners The Mission’s health program is implemented in close collaboration and partnership with a wide range of regionally-mandated cooperating agencies, institutions, organizations and networks. These include international donors, Embassies, USAID bilateral Missions, national governments, multi-lateral and intergovernmental organizations, as well as national and regional networks of commercial, community, non-governmental and faith-based organizations. Although the West Africa countries are highly diverse in terms of language, population size, culture, politics, and economics, they all share common public health challenges. The Mission program mandate is to develop, share, harmonize and support coordinated regional approaches and initiatives with the collaborators. The goal is to underpin national health programs yet deal with the problems common to the region. All partner programs are designed to directly contribute to the overall Mission’s health strategic objective and the four intermediate results. This approach aims to strengthen the capacity of regional, national and local institutions in order to seek positive solutions to health challenges within the region. In implementing its health programs, the Mission provides most of its direct support through two cooperative agreements: Action for West Africa Region-RH (AWARE-RH), which leads the reproductive health, family planning, child survival and malaria components; and AWARE-HIV, which leads the HIV/AIDS and sexually transmitted infections components. Both AWARE-RH and AWARE-HIV work in close consultation with Embassies in limited presence countries and bilateral USAID Missions in presence countries. USAID/WA and both AWARE projects involve these Embassies/Missions in their work planning processes and, in most cases, offer discrete technical assistance or training to motivate, stimulate and replicate selected activities in limited presence countries and, in some cases, in bilateral countries. USAID also provides direct capacity building grants to the regional institutions WAHO and CERPOD. The Mission provides these major and other implementing partners with complementary and specialized support through six field support organizations. The following narrative provides general background on these primary cooperative agreements, regional institution grantees, the main field support partners, and some other small grants funded by the Mission. 1. AWARE-Reproductive Health AWARE-RH is implemented through a five-year cooperative agreement (July 17, 2003-July 16, 2008) between EngenderHealth and USAID/WA with a life-of-project ceiling of $34,015,000. While EngenderHealth serves as the prime partner on the agreement, the program is managed as a partnership between EngenderHealth and Abt Associates, Academy for Educational Development (AED), Management Sciences for Health (MSH) and Population Services International (PSI). AWARE-RH works with multiple other partners involved in implementation; as of March 31, 2006, it managed a portfolio of four contracts, six grants, and 11 memoranda of understanding. AWARE-RH targets its strategic activities around those that: 11 • Use regional consultative processes to ensure regional ownership of best practices and approaches; • Apply systematic approaches to identify, disseminate and apply best practices that can be adapted and replicated at the national level throughout the region; • Facilitate the creation of diverse partnerships to implement activities, exchange technical information and leverage resources; • Foster technical leadership, management and organizational capacity, marketing, and business development in regional institutions and networks; • Promote health sector reform including commodity security that can support service delivery, modeling for national health accounts and the development of community-based health financial schemes (such as mutual health or micro-credit organizations). Technical and management oversight for program implementation is managed by 22 AWARE-RH staff from EngenderHealth and its four lead partners. The AWARE-RH office is co-located with AWARE-HIV and is based in Accra, Ghana. 2. AWARE-HIV AWARE-HIV is implemented through a five-year cooperative agreement (July 15, 2003 – July 14, 2008) between Family Health International (FHI) and USAID/WA with a life-of-project ceiling of $36,901,566. While FHI serves as the prime partner on the agreement, the program is managed as a partnership between FHI, PSI and the Futures Group and their five associate partners: Bureau d’Appui à la Sante Publique (BASP’96), Care and Health Program (CHP), Centre Hospitalier Affilie à l’Université de Sherbrooke(CHUS), Centre Hospitalier Affilié à l’Université de Québec (CHA) and Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO). Multiple other partners are involved in implementation: and as of March 31, 2006, AWARE-HIV managed a portfolio of six sub-contracts, 19 sub-agreements, 39 grants, and four memoranda of understanding. AWARE-HIV targets its activities around strategic objectives that: • Improve approaches to STI/HIV/AIDS and introduce and disseminate region-wide promising and best practices; • Increase regional stakeholder advocacy for policy change; • Build the capacity of regional institutions and networks to mitigate the spread and impact of HIV/AIDS; • Strengthen STI/HIV/AIDS prevention along West and Central African migratory routes; • Manage and support the West African Ambassadors’ Fund for AIDS (WAAF); • Disseminate information on health sector financing schemes applicable for HIV/AIDS affected individuals and families (in collaboration with AWARE-RH). 12 Technical and management oversight for program implementation is managed by 25 AWARE-HIV staff from the program’s three key partners FHI, PSI and the Futures Group. The AWARE-HIV office is co-located with AWARE-RH, and is based in Accra, Ghana. 3. West Africa Health Organization WAHO is the technical arm for health operating under the aegis of ECOWAS. The organization, with its Secretariat located in Burkina Faso, is responsible for providing leadership to the ECOWAS Heads of State and Parliament and the Ministers of Health from the 15 ECOWAS countries on matters related to the full spectrum of health issues. USAID/WA’s grant to WAHO allows a series of one-year renewable grants for a five-year period (September 29, 2003 – September 28, 2008). The average annual funding has been approximately $350,000/year. The grant is to assist WAHO to achieve its regional objectives, specifically: • Strengthen its institutional capacity (particularly its role as a regional leader and enabler); • Support technical priorities of WAHO to support the member States of ECOWAS in the health sector; • Identify and commission special studies and evaluations important to health in the region. Illustrative examples of activities supported through the USAID/WA grant to WAHO include: • Expansion of WAHO’s human capacity through additional personnel and training, including the hiring of one professional staff for nutrition and child survival and one for maternal and perinatal health; • Introduction and dissemination of improved approaches to family planning and reproductive health, including the development of a sub-regional strategy for Reproductive Health Commodity Security; • Development and launch of the Regional Young Professionals’ Internship Program, including the placement of six interns in the program’s first round; and ten interns in its second round; • Development and launch of the Applied Health Research Small Grants Program under which five West Africa research institutions have each received the first installment of a small grant ($50,000 or less) to conduct key research into key health challenges in the region and to propose solutions that can be implemented. 4. Centre d’Etudes et de Recherche sur la Population pour le Développement CERPOD is a regional institution under the auspices of the Institute of the Sahel; both institutions answer to the CILSS Secretariat in Ouagadougou. The overall objective of CERPOD, located in Bamako, Mali, is to better address questions of population and development in the CILSS countries. CERPOD aims to document issues related to the interrelationship of population and development; inform decision-makers to better understand the relationships between population and development and how these questions relate to food security and poverty reduction; and build the capacity of Sahelien regional organizations to analyze and investigate issues that relate to population and development. 13 USAID/WA awarded CERPOD a five-year capacity building grant (September 24, 2002– September 23, 2007) with a life-of-project-ceiling of $1,750,000. AWARE-RH assisted CERPOD in conducting a capacity development assessment. CERPOD has also benefited from AWARE￾organized trainings and workshops in: advocacy for food security, development of marketing plans, proposal writing, and organization of religious groups, youth and journalists networking for advocacy. Illustrative examples of activities supported through the USAID/WA grant to CERPOD include: • Strengthened institutional capacity, particularly in equipping of the center and salary support for CERPOD’s three core staff; • Support for specific technical and training activities executed by CERPOD at the request of the AWARE project; • Development of computer-generated HIV/AIDS profiles using the AIM and SPECTRUM modeling; • Participation in the workshops to develop model laws and implementation plans for HIV/AIDS and reproductive health. USAID/WA support represents 74 percent of the INSAH budget and over 85 percent of the budget of CERPOD. Support from the CILSS secretariat only represents 8.8 percent of the annual budget of INSAH and a much smaller proportion of the CERPOD budget. The capacity of the institution has been reduced by about 90 percent since the organizational reforms of INSAH in 1994. CERPOD has recently raised “off budget” support for conducting discrete program activities in collaboration with the European Union, USAID collaborating projects (SARA, the AWAREs, and YouthNet), Virginia Technical Institute and the University of Michigan. CERPOD is currently in negotiations for support funding from the African Development Bank and from the United Nations Population Fund (UNFPA). 5. Major Field Support Partners and other Grants To bring specialized expertise and worldwide experience to the program, the Mission utilizes field support services provided through the USAID/GH to technically support the major implementing partners and their recipients. The major field support entities are: • The Futures Group/Policy Development Initiative (PDI), with the AWARE groups, focuses on developing supportive legal-policy frameworks and more effective institutional arrangements in the public sector; seeks to increase political commitment and articulation of policies and operational guidance for reproductive health and HIV/AIDS; assists stakeholders in the development of model laws and implementation guidelines for reproductive health and HIV/AIDS. • John Snow, Inc/DELIVER, with AWARE-RH, provides technical assistance to improve the availability of contraceptives and other essential commodities in selected countries; improves resource mobilization for commodity security, particularly contraceptives; strengthens local 14 institutions to provide technical assistance for commodity security and management; and supports the Global Fund in the development and management of integrated procurement and logistics systems. • Management Sciences for Health/Rational Pharmaceutical Management Plus (RPM+) provides technical expertise and assistance to Global Fund recipients to develop and finalize procurement and supply management plans that are required for the release of funds for the grants; provides technical assistance and training to implement the plans; and provides capacity building and training to select regional institutions to support pharmaceutical management for AIDS, tuberculosis and malaria. • Johns Hopkins Program for International Education in Gynecology and Obstetrics /ACCESS formulates long-term training capacity of national programs and regional institutions; and integrates various reproductive health components into a continuum-of-care that maximizes maternal and newborn health survival at all points along the household-to￾hospital continuum. • Macro International/MEASURE improves the collection, analysis and presentation of data for use in planning, policymaking, management, and monitoring and evaluation; provides technical assistance to select regional institutions to improve their monitoring and evaluation capabilities. • USAID Global Health/Central Contraceptive Procurement provides an efficient mechanism for consolidated USAID purchases of contraceptive and other reproductive health commodities for Mission designated programs. Two other field support activities have been involved with malaria prevention, control and treatment, namely, the Malaria Action Consortium and AED/Netmark. These programs will not continue under field support as the Mission was not allocated any funds for malaria for either 2006 or 2007. It is hoped, given that the disease is a significant and pressing problem in the region, that Washington will reconsider this allocation decision. Also, activities developed under these malaria initiatives may continue in some countries under malaria prevention and control programs funding with Global Fund monies. There are two additional small seed grants that have been funded by the Mission: first, the International Rescue Committee (IRC) directs activities to the fragile states of Sierra Leone and Liberia. This program initiative is to improve blood supply and related ancillary HIV services in two districts. It involves capacity building for NGOs and FBOs as well as government clinics. The program also improves techniques of surveillance with the Liberian National AIDS Control Program. The second, the Hope for African Children Initiative (HACI), seeks to improve the living conditions of HIV-infected mothers and their babies, and other orphans and vulnerable children. The program coordinates activities at a service site for the prevention of mother-to-child￾transmission of HIV in Cameroon. Both of these programs will conclude this year with the completion of the current grant period. 15 G. Collaboration with Other Donors The USAID/WA and implementing partners coordinate with multilateral, bilateral and international donors and collaborating agencies to harmonize strategies and approaches, to conduct joint planning when possible, provide the technical assistance needed to integrate or expand best practices into existing programs, advocate for a specific policy or approach, and strengthen the implementing institutions. Specifically, examples of donor collaboration include: coordination with UNFPA to support reproductive health commodity security and distribution, as well as obstetric fistula treatment. The Mission health team members serve on the donor working group for Orphans and Other Vulnerable Children as well as the World Health Organization/Africa Regional Office (WHO/AFRO) Reproductive Health Task Force and the Child Survival Task Force. Also, team members serve on the West Africa Regional Network for Malaria. The Mission and its partners often collaborate with the United Nations Children’s Fund (UNICEF), for example, on community-integrated management of childhood illnesses. Project teams work closely with the World Bank-funded Project for cross-border intervention for HIV/AIDS. The new player on the block is the Global Fund. GFATM has committed, since 2003, over $1.4 billion to support national programs in AIDS, tuberculosis and malaria. The Global Fund has awarded grants in 20 of the 21 countries in the West Africa region. The Mission has been increasing support to the Global Fund by providing assistance for scaling up of national government programs for AIDS, tuberculosis and malaria; supporting technical assistance to develop country proposals and support country coordinating committees; helping countries to meet requirements for commodity planning and supporting general improvement of program accountability. The relationship is mutually beneficial. H. Overview of Program Financial Resources Trends for USAID/WA health funding are presented in Table 1, which displays actual FY2005 and FY2006 funding. Also noted in the table is the changing nature of the Mission’s portfolio. In FY2005, health accounted for 46 percent of the Mission’s operating year budget, while only 32 percent was for health in FY2006. As depicted, new obligation authority for health has decreased as a total dollar amount and also as a percentage of the overall USAID/WA operating year budget. TABLE 1: USAID/WA: RECENT HEALTH FUNDING AS TOTAL OF OPERATING YEAR BUDGET (IN MILLIONS OF DOLLARS) FY 05 FY06 Health 19.7 17.1 USAID Total OYB 42.7 53.1 Health as percent of OYB 46% 32% As highlighted in Table 2, Mission funds for the health program come from the Child Survival and Health (CSH) Account, primarily as earmarked funding. This favors funding for population/reproductive health, child survival, and HIV/AIDS. In FY2005, these three line items 16 account for 92 percent of the total health budget. Within the population/reproductive health funds, a small earmarked amount was allocated for fistula treatment and repair. Within the child survival budget line, USAID received malaria funds in the past. However, funds have not been allocated to the Mission since 2005 and are not expected to be included in either the 2006 or 2007 budgets. In the third quarter of FY2006, the Mission received a total of $1.5 million for improvement of drinking water ($1.0 million from the Development Assistance Account and $500 thousand from the CSH Account). The Health Office is likely to participate in the management of the drinking water activity and administer the portion of funds from the CSH account. Whether or not this is one-year funding or the initiation of a longer-year program is not clear at this time. While the child survival line item provides limited funding, even this amount gives USAID a place at the donors’ table. In recent years, a majority of the program funds (65 percent in 2005; 71 percent in 2006) were programmed through the Mission’s fully-competed cooperative agreements with AWARE-HIV and AWARE-RH. A small percentage goes to the direct grants for capacity building for WAHO and CERPOD. In order to obtain specialized or support services, USAID/WA has secured specialized and support services from four field support and several small contracts (e.g., personal service contracts, a TAACS advisor) using approximately $3.0 million in 2005 and $1.9 million in 2006. A small portion of program funds goes to Mission staffing and administrative costs. As a historical carry-over from previously funded bilaterals, USAID allocated an average of $1.4 million annually to provide contraceptive products to phase-out countries. Now the program is using contraceptives as a leveraging point for the reproductive health commodity security initiative, as an incentive for best practice initiatives for family planning, as a bridge to other donor funding for contraceptives, and for special needs in fragile countries. TABLE 2: USAID/WA: HEALTH FUNDING BY CSH ACCOUNT LINE ITEM (IN MILLONS OF DOLLARS) FY 03 FY04 FY 05 FY06 FY 07 Population/Reproductive Health 8.6 8.1 8.0 7.7 6.6 Child Survival 0.9 1.0 0.8 1.5 1.0 HIV/AIDS 8.7 9.3 9.3 7.9 8.2 Infectious Diseases (Malaria) 0.5 1.5 1.6 0.0 0.0 Economic Support Fund 0.0 1.2 0.0 0.0 0.0 Total (dollars in millions) 18.7 21.1 19.7 17.1 15.8 17 IV. PROGRAM ACHIEVEMENTS AND RESULTS A. Overall Approach and Assessment of Results The unique value of the Mission’s regional health program is that it works to enable a positive operating environment for service delivery in the areas of reproductive health, HIV/AIDS, child survival and malaria. The mandate is to operate at the regional level to develop, support, harmonize and coordinate activities that create conditions where quality services can be effectively delivered at national and local levels. The program has used the identification, dissemination and demonstration of best practices; advocacy for policy change; the building of organizational capacity; and health sector reform as its primary vehicles to develop a positive operating environment. The regional program interventions focus not on services per se, but rather on: • Introducing policies and strategies that break down barriers and permit a positive legal, regulatory and operational framework through enactment of laws, national planning, operating and service delivery standards, norms and guidelines; • Building skills and mobilizing agents of change that can influence and impact the availability and accessibility of appropriate services. These include change agents such as key leaders, decision makers, service providers, program implementers, local communities and civil society; • Developing and reforming systems and tools that improve the effectiveness and efficiency of services and underpin that operating structure. These systems include repositioning programs, curriculum design and training for skill enhancement, quality assurance, information management, logistics, commodity management, and financing; • Strengthening institutional capacities and forming collaborative relationships that can provide bold leadership for consensus, harmonization and technical excellence for the design and implementation of service policies, strategies and approaches. These institutions and alliances include national, regional, bilateral and multilateral organizations; national governments and public sector leaders, private sector and commercial entities; professional and academic training, research or service organizations; and local and indigenous networks through non-governmental organizations, community and faith-based organizations; • Leveraging of funding of other donors, governments and the private sector to permit the replication of model service delivery at the national level. In doing these activities, the regional program has developed several major functions through which it provides conceptual, technical and monetary support to create an enabling environment for change aimed toward the adoption of policies, strategies and programs. These major functions include: • Advocacy, by setting agendas, framing messages and targeting specific legislative or programmatic changes; 18 • Brokering, by getting the right people ‘to the table’, determining division of labor and resources, and getting consensus around issues/problems, standards or resolution approaches; • Catalyzing, by mobilization around a problem, issue or solution, proactively propelling change and building capability with regional and indigenous organizations, and planning and implementing service delivery activities; • Disseminating, by sharing information on best practices, developing tools to plan and organize, and evaluating new policies, strategies and approaches; • Leveraging, by garnering political will and technical support among leaders, donors and gate keepers; and mobilizing additional financial and human resources for the region to advance and implement actionable programming; • Supporting technically, by providing technical services, training, and systems prototypes in a wide range of subject areas to enable the design and implementation of successful health programs. To date, the regional health program’s progress, accomplishments and impact have been formidable, which is quite remarkable given the short time of operation and the very difficult circumstances of operating in the region. The Mission’s health strategy has proven to be sound and implementation is on schedule. The program has successfully built on regional and world-wide efforts such as the work on commodities security and promoting service delivery models. The program has effectively provided leadership in selecting needed best practices, building consensus and promoting changes in policies and approaches at the country level. Perhaps the program’s greatest achievement has been the strengthening and promoting of African regional and national capacity to plan, manage and implement health programs. This measure has helped to further African leadership and ownership. The AWARE partners are well-appreciated by their client institutions for the quality and relevance of their activities, the high caliber and competence of their staff, and their innovation in meeting the policy and strategic challenges of the region. On the downside, West Africa is a very culturally and linguistically diverse region, with complicated logistical and communication challenges. Spreading the program across 21 countries and promoting scores of promising and best practices has affected the depth of the program and has diluted its impact. The program will gain from focusing and concentrating by setting parameters on its geographic scope, prioritizing best practices to promote, and limiting partnership to those that demonstrate potential for growth and sustainability. The mid-term assessment terms of reference asked the team to determine: a) how has the USAID/WA regional health program been implemented over the last three years and what are the results to date; and b) what lessons are learned from the implementation process and results, and what are the implications for a regional approach to health programming. The narrative which follows offers specific programmatic examples on how the regional health program has approached the dissemination of best practices, conducted advocacy for change, built the capacity of local 19 institutions and impacted health sector reform. This section highlights achievements, gives supporting examples, and provides general observations and findings. Each section concludes with a brief assessment of performance as well as lessons learned to date. B. IR 1: Improved Approaches (Best Practices) in Selected Technical Areas A best practice is defined as “an evidence-based experience, initiative or program that can serve as an example or inspiring model for others.” The Mission program partners used a participatory process to develop a list of best practices and subjected each to a process of documentation and dissemination with some selected for replication. Ultimately, the regional program identified 19 practices for reproductive health and other health services and 15 for HIV/AIDS to share within the region. To date, the program has focused on ten best practices for reproductive health and other health services, and seven promising and best practices for HIV/AIDS. For these, the regional health program partners sought to gain consensus and acceptance, harmonized the approach, developed consistent strategies for replication, and started the replication process. For each of the major technical areas, the narrative below provides a brief mention of the surrounding issues and the program actions taken to address the problem. 1. Reproductive Health The reproductive health statistics of West Africa indicate very high rates of maternal mortality (880 per 100,000 live births) and infant mortality (123 per 1000 live births) and very low rates of contraceptive use (eight percent). These factors are coupled with poor service delivery by an insufficient number of service providers at all levels of health care and an inadequate use of limited financial resources. It is with this poor reproductive environment that the program has focused on improving services by introducing high yield practices, including: community-to-facility continuum for emergency obstetrical care; development of national norms and standards for family planning and reproductive health; revitalization of intrauterine devices and other long-term methods; integration of post-abortion care into routine maternal care services; use of social franchising in reproductive health/family planning services; integration of family planning messages into HIV prevention programs; and community-based distribution of family planning methods. The reproductive health and family planning activities (including maternal health) are implemented through the AWARE-RH Project, with supplemental support provided by the ACCESS Project, the PDI project, and the DELIVER Project. Ten countries in the region are implementing at least one best practice in reproductive health and family planning. In addition to the best practices, the program has initiated a special emphasis on repositioning family planning. Highlights of Achievements Two examples for the reproductive health and family planning best practices and approaches are highlighted below: • Community-to-Facility Continuum Model of Emergency Obstetrical Care The model has a facility component and a community component. At the facility level, norms and standards are developed and the clinical skills of the providers are improved through training. When needed, equipment is provided and facilities and infrastructure are improved. 20 At the community level, social mobilization prepares members of the community to better plan for and support women who need to seek emergency obstetrical services. Concurrently, behavior change communication raises awareness about the warning signs of complications during pregnancy and where to seek emergency obstetrical care, and where trained service providers are located. Collaborating with other donors and partners, this strategy has been successfully applied in Cameroon, Mauritania, Niger, Togo and Mali. In addition, through this strategy the project developed skills in social mobilization of one of its partners--Mwangaza Action--which now plays a leadership role in giving technical assistance in this area to develop country programs in the region. • Post Abortion Care Expansion Abortion and particularly induced abortion remains one of the major causes of maternal mortality in the West Africa. The project promotes three major practices: quality clinical management of the complications of abortion, provision of family planning services if desired, and referrals for other reproductive health services if needed. After organizing a regional workshop to promote post-abortion care in collaboration with the Centre Régional de Formation de Recherche en Santé de la Reproduction (CEFOREP), which also provided technical assistance, the project initiated services in four francophone countries. The project has also conducted regional workshops to standardize clinical skills for consultants who are working in post-abortion care and who oversee the service’s replication activities. In a region like West Africa where abortion is illegal and where the complications of abortions constitute a major public health problem, strengthening post abortion care is an effective strategy to manage complications and encourage the alternative of family planning. In addition to the introduction of best practices, the program has taken on the “repositioning of family planning.” Countries of West Africa have the lowest rate of utilization of modern contraception in Africa. USAID and its partners, Advance Africa, POLICY, and AWARE-RH, with WHO/AFRO, co-sponsored a four-day conference, “Repositioning Family Planning in West Africa,” in February 2005. Two hundred and fifty-three participants from 16 countries (Benin, Burkina Faso, Chad, Côte d’Ivoire, Eritrea, Ghana, Guinea Conakry, Guinea Bissau, Madagascar, Mali, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, and Togo), and 26 partners gathered to reposition family planning as a strategic objective within each country’s health and development goals. In addition, the project supported implementation of activities of the national plans of action in five additional countries in the region. These repositioning activities varied from country-to-country: For example, in Sierra Leone the priority is developing norms and standards in family planning as a tool to provide a regulatory and policy framework for the provision of family planning services. In other countries of the region like Burkina Faso, Cameroon, and Togo the principal activity focus is directed to management of contraceptive commodities. In Benin, repositioning of family planning took the form of replication of the social franchising model of the Pro-Fam Network. This innovation involves private practitioners to improve the quality of services in their clinics and to better market their services, thereby expanding the accessibility and availability of family planning and other maternal health services. 21 Observations/Findings The best practices and approaches for reproductive health and family planning were well selected. Significant demand for and application of these best practices have demonstrated that new approaches for improved services can be quickly introduced to respond to specific needs in the country context. It also indicates that better knowledge and sharing of lessons learned can accelerate successful adaptation within the region. Strengthening institutions to replicate the strategies in the region is especially commendable. The regional program functions do include seed money to test, adapt and demonstrate, and technical assistance to leverage other donors for the long-term and for national scale-up of programs. The measures of repositioning family planning coupled with the reproductive health commodity security program (see Section E.1, page 34), when fully implemented, will go a long way to ensure the procurement and availability of contraceptives, HIV/AIDS drugs, and other reproductive health commodities. Moreover, stock-outs in the supply chain, as are so often the case in the region, can be avoided. Getting the national programs to implement these best practices in family planning is a long process which, when completed, will enhance the utilization of family planning in the region. The real impact specific to this project is difficult to measure as many partners, donors, and governments have been involved in implementation, replication and scale-up. Quantitatively, however, it should be noted that the project is fully meeting its targets of practices introduced and disseminated in the region. In implementing these best practices/approaches initiatives, several key finding and lessons learned have been noted: • The high demand for implementation of best practices in the countries of the region signifies a) the importance of regional programming, advocacy and standardization of practices, and b) the utility for countries to share experiences and learning from each other. • Often there is great pressure for the projects to “implement” rather than just “disseminate” best practices at the national level. Despite the high need for improving country programs, the project, with its limited resources, must resist the temptation of getting involved in large-scale replication which should be reserved for national programs and other partners in the field. • Where involved in social mobilization, franchising and marketing, the communities and the private sector are very interested in strengthening their reproductive health services. Governments are not the only players in service delivery. 2. Child Survival and Malaria Africa, with 20 percent of the world’s live births, has 42 percent of the world’s under-five deaths. Among the countries with the ten highest under-five mortality rates, six are in West Africa.3 While child mortality has steadily declined since the early 1980s throughout the world, in recent years the 3 Sierra Leone, Niger, Liberia, Mali, Guinea-Bissau, and Burkina Faso. 22 downward trends have stagnated or reversed in many African countries, especially in West Africa. The high infant and under-five mortality rate is exacerbated by high levels of malnutrition (12.3 percent), low immunization rates (54 percent for DPT3), and high levels of malaria, diarrheal diseases and acute respiratory infections (ARI). Many of these health problems require a regional response. For example, the spread of cholera and dysentery ignores national borders and ARI and malaria are increasingly resistant to standard treatment. Control of these diseases necessitates coordination and cooperation across countries. Highlights of Achievements The child health activities are primarily implemented through the AWARE-RH Project. Specific best practices/approaches include the community case management of malaria and acute respiratory infections as part of integrated management of childhood illnesses. Very limited resources have been available for child survival and malaria. • Community-Integrated Management of Childhood Illnesses (C-IMCI) The project identified as a best practice a community-IMCI model in Senegal that includes acute management of respiratory infections and malaria at the community level by community health workers. The model encourages health authorities to sensitize community leaders to select community health workers that can be trained to assess sick children for signs of pneumonia and malaria; administer the proper doses of antibiotics and anti-malaria drugs or refer children to health care centers; and counsel parents on how to follow the recommended treatment regimen and provide supported home care. AWARE-RH convened a meeting of regional and international partners to develop a common strategy for replication of this model in the region. At the request of Burkina Faso, Niger, and Togo, and in collaboration with their respective Ministries of Health, UNICEF and WHO; AWARE-RH conducted assessments in and developed replication plans for these three countries. Niger is the farthest ahead in replicating the model and has conducted sessions in training of trainers for community health workers. • Focused Antenatal Care including Malaria in Pregnancy The traditional approach to antenatal consultation is based on risk assessment. However, numerous studies have demonstrated that all pregnancies and deliveries should be considered “at risk” whether or not a specific problem has been identified. AWARE-RH identified an approach called focused antenatal care as a best practice that assumes that all pregnancies are at risk, and that antenatal care should emphasize quality rather than the quantity of consultations. This model has been adapted in Cameroon, Mauritania, Niger, Togo, and Mali. • Peer Health Education Program The Peer Health Education Program aims at improving the health and well-being of youth through empowering them with knowledge, skills, and confidence to take responsibility for their own health. The goal is being accomplished through the establishment of well-informed, well-trained teams of school-based peer health educators in senior secondary and upper basic schools. The methods used by the peer educators include a variety of strategies (drama, small group, in-class presentations, and special events) to engage their peers and encourage healthy behavior and attitudes. The AWARE-RH project identified a successful peer education strategy 23 in The Gambia and is currently replicating it in Sierra Leone, specifically targeting malaria messages. Observations/Findings In addition to promoting these best practices, other child health and malaria activities include advocacy, institutional capacity building, technical assistance, and facilitation and networking to promote better child health policies and programs in the region. For example, in the advocacy area, with AWARE-RH’s assistance, WAHO successfully advocated to the ECOWAS Health Ministers to adopt C-IMCI as an integral part of their health program. AWARE-RH strengthened the institutional capacity of the Centre de Recherche d’ Etudes et de Documentation pour la Survie de l’Enfant, a state-funded child health research center attached to the Ministry of Health of Mali. The AWARE-RH, RPM+, and DELIVER projects provided technical assistance in forecasting malaria commodities to Global Fund recipients. AWARE-RH facilitated the Health for Peace Initiative (HFPI) for Malaria meeting for the Ministers of Health in Banjul in 2005. As a result of the meeting, an action plan was developed to implement best practices in malaria in the HFPI countries (The Gambia, Guinea, Guinea-Bissau, Liberia, Sierra Leone, and Senegal). With malnutrition contributing about 54 percent to the under-five mortality rate and the tragedy of the recent famine in Niger, the assessment team identified nutrition as an area of special need that is not receiving much attention in the region. USAID/WA, along with the Offices of Foreign Disaster Assistance (OFDA) and Food for Peace (FFP) are currently examining the causes of the Niger situation. AWARE-RH is assisting WAHO in facilitating the nutrition focal points meeting. The Helen Keller International submitted a proposal to USAID/WA for oil fortification in the region. USAID secured complementary funding in two missions (Mali and Senegal) and then submitted a proposal for joint funding to the Global Development Alliance (GDA). Unfortunately, the Alliance has indicated that funding for West Africa is not available. Unless some other sources are identified or USAID/Washington comes forward with funds, this promising opportunity will most likely be lost. There does need to be a major revitalization of nutrition in the region, and the regional program has a comparative advantage to promote basic interventions such as early and exclusive breastfeeding, appropriate infant and child feeding, micronutrient supplementation, and appropriate management of diarrheal diseases in the region. The Mission’s health program’s response to the serious child health situation in the region has been modest. This is due to the low level, $1.7 million for FY04 and FY05, of Child Survival and Health Account (primary cause sub-account) funds available to the Mission. The funding for malaria (infectious disease sub-account) was higher at $3,150,000 for FY04 and FY05, but the Mission will not receive any malaria funds for FY06 and no more is anticipated for FY07. The low level of funding does not allow the Mission to have as robust a program in child health as in reproductive health and HIV/AIDS. Regardless, through these activities, a major lesson has been learned, namely: • Even with minimal funding, the Mission is able to maintain a seat at the table with other partners, stay on top of key issues in the region, and play a catalytic role in influencing the child health and malaria agenda for the region. 24 3. HIV/AIDS Data on the HIV epidemic in West and Central Africa is generally weak and varies considerably in quality from country to country. While less severe than in other parts of Africa, HIV is spreading at an alarming rate in several countries and seroprevalence in adults, ages 15-49, in the majority of the countries in the region ranges from approximately two percent to ten percent. High risk populations and geographic ‘hotspots,’ even within countries with a generalized epidemic, have exceptionally high rates. The impact of increasing HIV prevalence in the region is becoming apparent. The total number of People Living with HIV/AIDS (PLWHA) within the region is approximately 6 million, with approximately two million orphans and vulnerable children affected by AIDS. The growing number of people infected and affected by HIV/AIDS has increasing social and economic impact on families, already weak health care systems, and country economies. In general, the factors in the region that contribute to population vulnerability in other health and socioeconomic areas are also fueling the rapid expansion of HIV/AIDS: migration for economic opportunities; high levels of poverty and growing inequalities; numerous armed conflicts with high levels of sexual abuse and violence against women and children; rapid urbanization with a lack of basic services; unemployment and a growing recourse to prostitution as a source of income; high levels of illiteracy; early sexual initiation; and gender and cultural norms leading to inequality and the economic and social dependency of women. To address these issues, AWARE-HIV, with support of AWARE-RH, is promoting the replication of best and promising practices/approaches in voluntary counseling and testing; prevention of mother-to-child transmission; and increasing access to care and treatment, with referrals for treatment of sexually-transmitted infections. Most of the activities of this component are carried out by AWARE-HIV, with support where helpful from AWARE-RH and targeted collaboration in procurement and supply management with two field support partners, RPM+ and DELIVER. The HIV/AIDS portfolio is rounded out by a refugee condom effort with UNHCR, interventions for orphans and vulnerable children with HACI, and a project to improve the blood supply in Sierra Leone and Liberia, with IRC and USAID/Liberia. Highlights of Achievements Some best practices and approaches for HIV/AIDS conducted under the aegis of the regional program are highlighted below: • Voluntary Counseling and Testing (VCT) The program works to improve access to voluntary counseling and testing for HIV/AIDS. The documentation, dissemination and replication of this VCT best practice are being coordinated by two associate partners: Care and Health Program (CHP) based in Cameroon is working with PSI and JHPIEGO to integrate VCT into: a) the PSI cross-border program, and b) health centers that are currently part of the cross-border program to enhance service delivery capabilities to include VCT. This includes necessary renovations and equipment purchases, training of trainers and counselors, and development of monitoring and evaluation systems. CHP has completed integrating VCT into the four AWARE-supported cross-border sites in Niger, Chad, Burkina Faso, and Togo. 25 CHP provides on-going technical assistance to the Center for Information, Counseling and Documentation (CICDoc) based in Burkina Faso, to build its institutional capacity as a Regional Learning Center (RLC). CICDoc is a network of seven HIV/AIDS associations specialized in VCT. The network operates seven clinics in Burkina Faso and maintains regional representation through the participation of Benin, Cameroon, Chad, Côte d’Ivoire, Guinea, Mali and Mauritania in its network. At a recent workshop, Burkina Faso showcased it efforts to improve youth access to VCT, and all participants were asked to draft action plans on how they might apply this experience in their respective countries. AWARE-HIV is looking to establish an additional VCT regional learning site for anglophone countries. An assessment was conducted, and the School of Nursing, Kano in Nigeria was identified as the potential regional anglophone VCT learning site. • Prevention of Mother-to-Child Transmission (PMTCT) Under promising and best practices, AWARE-HIV has identified two practices for dissemination: the rapid scaling-up of PMTCT and human resource capacity development in PMTCT through the integration of pre-service training into national training institutions. During the first years of the project, emphasis has been placed on the replication of the Cameroon experience of rapid scale-up of services. Under a joint activity between AWARE￾HIV and AWARE-RH, the integration of PMTCT into routine antenatal care is being promoted in the region. The Cameroon Baptist Convention Health Board (CBCHB) is designated as a regional learning center for PMTCT. CBCHB has developed a very successful bottom-up PMTCT program involving 184 sites which as of March 2006, had counseled more than 129,000 pregnant women, of which 90 percent voluntarily accepted to be tested and 60 percent of children born to HIV+ women received nevirapine at birth. CBCHB has also developed a strong partnership with HACI in the area of community-based comprehensive care for OVC, using the “foster a family approach” for food, nutrition, health care, and education (school fees and school materials for children). This is done through income-generating activities that include PLWHA as priority beneficiaries. The AWARE projects have worked with CBCHB to improve the quality of several components of their program. Trainings in clinical family planning skills, facilitative supervision, facilitation skills, infection prevention, COPE for PMTCT, grants management and reporting have been conducted. Assessment and action plans have been developed to increase male involvement in facility-based activities and to create support group activities to convince men to get tested. CBCHB has begun assisting other countries in the region to develop or strengthen their PMTCT programs through trainings and technical assistance. Training has been conducted and technical assistance visits have been made to the ten countries. This assistance has resulted in policy development, action plan finalization, additional skills training and start-up of new sites. 26 • Care and Treatment Under care and treatment, AWARE-HIV has identified three promising and best practices for dissemination: a medico-social assistance center; decentralization of antiretroviral therapy; and the role of disclosure and treatment monitors in ensuring high adherence in a clinical care setting. During the first years of the project, emphasis has been placed on the replication of the practices focused on decentralization and use of treatment monitors. Two RLCs have been established, a francophone center at Service des Maladies Infectieuses et Tropicales (SMIT) in Senegal, and an anglophone center at the Komfo Anoyke Teaching Hospital (KATH) in Ghana. A training curriculum for care and treatment was developed and trainers from six countries have been trained. Both institutions have conducted technical assistance visits to facilitate replication. Replication of the Senegalese experience has taken place in Guinea, Guinea Bissau, Niger; and replication of the Ghanaian experience in Liberia and Sierra Leone. • Integrating Sexually Transmitted Infection (STI) Services The “adapted services” model focuses on expanding existing networks of STI clinics to attract most-at-risk populations (MARPs) by enhancing the quality and level of services provided. To encourage utilization by these populations, particularly female sex workers and their partners, community outreach activities are conducted to create demand for and encourage referral to the adapted STI service centers. Outreach activities are complemented by adaptations in clinical services, including increasing the quality of STI services and making them ‘user-friendly’ to prostitutes and their clients (e.g., focusing on confidentiality, integration of VCT, referral for psychosocial support and other specialized services). Two “adapted services” centers have been established: The Cotonou STI clinic, managed by CHA, serves as the regional center supporting best practice replication in the francophone countries and the Adabraka STI clinic, managed by CHUS, serves as replication in the anglophone countries. To date, the two centers have trained service providers from ten countries (Benin, Burkina Faso, Guinea, Liberia, Mali, Mauritania, Nigeria, Senegal, Sierra Leone and Togo) to serve as providers and disseminators of the “adapted services” model in their respective institutions. In addition, CHUS and CHA staff have conducted a total of seven technical assistance visits to six countries to facilitate implementation. Observations/Findings The Mission’s HIV/AIDS program is strong. The examples cited above are only a few of its many accomplishments. Fourteen AWARE-HIV supported applications of “promising and best practices” in HIV/AIDS are on-going. Eight countries are implementing at least one best practice, and seven countries are participating in 39 cross-border sites which are delivering integrated FP/RH and HIV/AIDS interventions. One of the key accomplishment has been the building of African-led institutions to carry out the training and technical assistance in the region in HIV/AIDS. In regard to voluntary counseling and testing, CHP is an established regional leader in VCT. The program partnership between CHP and AWARE builds on previous experience with Family Health Project to increase CHP’s experience to provide technical assistance to the less-established CICDoc network. While this relationship is seen as beneficial, it is also important that CHP and CICDoc have clearly defined roles and responsibilities to avoid duplication of efforts. In addition, with these two partners already involved, it is unclear what the strategic advantage is to developing an 27 additional regional learning center (in Nigeria). It would be more useful to further build additional institutional capacity of the existing learning centers, particularly in light of expected budget reductions. With regard to care and treatment, two well-functioning centers, one anglophone and one francophone, have been developed and are fully operational, for teaching and training as well as technical assistance. It may be that these institutions’ capabilities in VCT could be developed, thus building on the existing capacities. The CBCHB PMTCT program has been extremely successful and they are quite confident and capable to train providers in other countries in PMTCT. It is not easy to discern which best practices for rapid scale-up of services should be encouraged. It seems that a compilation of best and promising practices together have contributed to strengthening and creating a successful PMTCT program. Under their program CBCHB has used a number of approaches that may merit replication as best practices of their own, for example: the bottom up approach of starting in the community with information on HIV/AIDS, and particularly PMTCT, before women come to the health centers; starting at the community level instead of the central level and involving traditional birth attendants to increase coverage; integration into routine prenatal services; and using opt-out and same day results. In addition to the technical elements above, rapid scale-up was made possible by the close collaboration with the government and financial support of other donors (UNICEF, European Union, Elizabeth Glaser, and Centers for Disease Control (CDC). The CBCHB is well qualified to assist other countries in the region in strengthening or initiating PMTCT programs. Without similar levels of funding and donor and government support, however, other countries may not be able to replicate the program used in Cameroon. It may be more beneficial to break the package down into its component parts and identify each of the best practices and context in which they should be replicated. Moreover, the male involvement component of the PMTCT program has just begun and should be treated as a pilot test or operations research on the feasibility, best approaches and impact of involving men. The Cameroon experience with male involvement could provide informative results since Cameroon has both monogamous and polygamous communities. In regard to the “adaptive services,” the West Africa Project to Combat AIDS and STIs (WAPCAS) has published a number of studies, partially through USAID support, including a qualitative report on community health workers’ experiences in implementing the “adapted services” model and studies on male and female condom use. However, no evidence was presented validating the assumption that the “adapted services” model can have an impact on minimizing HIV/AIDS prevalence. In general, the HIV/AIDS program efforts to introduce new practices and approaches have been successful. The program has provided regional leadership for prevention, care and treatment of HIV/AIDS, in West Africa particularly in the non-focus programs and the limited-presence countries. The primary lessons that have been learned from the HIV/AIDS experience include: • Dissemination and adoption of best practices is accelerated by the use of existing networks. • Best practices are best accepted and adopted when they are evidence-based and are already proven to be effective 28 C. IR 2: Increased Regional Stakeholder Advocacy for Policy Change The Mission regional health program supports regional organizations to advocate for the adoption of policies which create an enabling environment for people-focused services in reproductive health and family planning, child survival, malaria, and HIV/AIDS services. Against the background of traditional obstacles such as language barriers, slow public sector decision-making, and different colonial legacies and tendencies, both AWAREs have generated advocacy movements in many countries, linked them through regional networks and elevated the profile of health issues in regional policy agenda. In the complex West African environment, this is a remarkable achievement. The regional program adopted a participatory and issues-driven advocacy approach to build regional policy consensus. First, the program managers enlisted a broad base of stakeholders to select priority issues and set a regional advocacy agenda in reproductive health and HIV/AIDS. Next, networks such as the Regional Network of Parliamentarians, the Regional National Networks of People Living with HIV/AIDS, the Society for Women Against AIDS in Africa (SWAA), the Regional Network of Journalists, the Network of Writers and the Regional Network of Religious Leaders were linked with country level task forces made up of corresponding national networks. In most cases, the AWAREs and field support through PDI reinforced the process by providing advocacy skills training, tools and technical assistance for the development of prototype reproductive health and HIV laws. The critical links in the chain have been the country task teams which implemented country-level advocacy plans. Advocacy was focused on key institutions such as legislative bodies, regional councils of health ministers or national level decision makers. This approach succeeded because the regionally determined agenda was owned and supported by country-level coalitions. Collaboration with public sector institutions, such as WAHO, Ministries of Health or local HIV/AIDS machinery, facilitated the process. Highlights of Achievements • Advocacy for Reproductive Health and Other Health Interventions AWARE-RH strengthened the policy and regulatory framework for reproductive health services using creative approaches. For example: − Advocacy by regional networks led to passage of reproductive health laws in Chad, Benin, Senegal, Burkina Faso and Mali. The passage of this law in francophone countries is significant because it replaces the 1920 law by France, which prohibits family planning. Also, the Network of Parliamentarians was supported to produce the regulatory texts and operational guidelines that translated the law into actions. − AWARE-RH supported networks in Ghana, Burkina Faso, Mauritania, Mali and Togo to develop national advocacy plans for maternal health. In Burkina Faso, the cost of emergency obstetric care was reduced by 80 percent and funds were provided for procurement of contraceptives. In Ghana, a new policy mandating reporting and audit of maternal deaths within seven days was adopted. 29 − AWARE-RH supported networks monitor the implementation of selected international agreements and treaties which addresses key determinants of access, demand and use of reproductive health services. The treaties included the International Conference on Population and Development Statement, the Ouagadougou Action Plan, WHO/AFRO Road Map for Reproductive Health, the Convention on the Elimination of all Forms of Discrimination against Women, and the Convention on the Elimination of Harmful Practices against Women and Children. − High impact malaria policy advocacy initiatives were brokered by WAHO through its access to ECOWAS Health Ministers. For example, WAHO influenced the ECOWAS Health Ministers to adopt the C-IMCI model for management of childhood diseases. AWARE-RH and NetMark worked with WAHO to introduce an advocacy tool (commonly known as “MoreNets") to ECOWAS countries for the reduction of taxes and tariffs on insecticide-treated bed nets. Taxes and tariffs have successfully been reduced in Cameroon, Nigeria, Sierra Leone and Togo − Creation of line items for contraceptives was adopted by ECOWAS countries following advocacy by program partners. This has been implemented in Burkina Faso and Niger. • HIV/AIDS Advocacy The AWARE supported regional HIV/AIDS advocacy agenda has focused on priority issues. These are: greater involvement and support of the civil society and the legislature including PLWHA, religious leaders and women; improvement in the legal framework; campaign against stigma and discrimination, including HIV/AIDS prevention in the work place; improvement in access to care and treatment, including access to ARVs; impact reduction on orphans and other vulnerable groups; and increasing funding and sustainability of funding, including effective use of resources. Advocacy by program partners have achieved remarkable results. For example: - Benin, Guinea and Togo have adopted HIV/AIDS laws while six countries are in advanced stages of the ratification process. - Six national HIV advocacy action plans have been developed and implemented to address stigma and discrimination against people living with the virus. An interfaith Network of Religious Leaders conducts a high impact cross-border sensitization caravan which travels across Mauritania, Senegal, Mali, Burkina Faso, Niger and Nigeria to sensitize the population to issues involved in stigma and discrimination. - Evidence-based legislative advocacy training in data analysis and use has been provided to 226 policy makers and parliamentarians from 17 countries. - Advocacy for increased access to ARV has been supported in Chad, Guinea Bissau, Liberia, Cameroon and Gambia. 30 - In Sierra Leone, program partners successfully advocated for adoption of standardized blood transfusion and universal precaution guidelines. Observations/Findings The Mission’s implementing partners adopted a highly successful issue-based advocacy approach which has promoted broad stakeholder participation and ensured ownership of regional reproductive health and HIV agendas. Significantly, beyond policy ratification, the program supports country-level task forces to monitor implementation of the laws. Overall, advocacy for policy change has created a groundswell of regional health advocacy networks and facilitated the emergence of innovative advocacy coalitions such as regional religious interfaith networks. Furthermore, the program engaged expertise at multiple levels and engaged gatekeepers at the critical end points of the policy process. These are faith-based leaders who are the gatekeepers of community health behavior and parliamentarians. In sum, the Mission’s policy advocacy initiatives were successful in facilitating collaboration across a broad swath of stakeholders, which strengthened legislative effectiveness. And, the stakeholders endowed the region with capable and growing advocacy networks and proactive health advocates. From these efforts, the following observations have been made and lessons have been learned: • Adopting a regional policy agenda and developing a plan of action at inception gives direction to the initiative, builds ownership of the agenda among stakeholders, and facilitates implementation by providing a road map to action. • Advocacy initiatives which respond to needs identified by grassroots stakeholders generate accelerated achievement. For example, although key players in legislative advocacy were newly-established, they discharged their mandate effectively because the civil society groups formed around identified issues and niches. • Regional approaches which generate multiplier effects and healthy competition have greater potential for impact. For example, national task teams competed to accelerate the ratification of reproductive and HIV laws. Conventional legislative ratification takes much longer in the region. Competition among countries participating in the cross-border caravan certainly contributed to its success. • Linking advocacy to existing treaties and other policy efforts can accelerate adoption of policy changes. D. IR 3: Increased Capacity of Regional Institutions and Networks The Mission regional health program strives to increase the capacity of regional institutions and networks. The two-fold strategy is: 31 • Build leadership capability and influence to aggressively develop, advocate and evaluate policies, strategies, tools and systems for health within the region. This group is known as “Technical Leadership Institutions" (TLIs). • Develop and utilize institutions and their networks as learning channels that can be used for technology transfer and skills development in the process of replication and scale￾up of programs in the region. These institutions are known either as “Technical Learning Networks (TLN)” or “Regional Learning Centers (RLCs).” The two AWARE Projects are working with a combined total of 17 leadership institutions and ten learning networks/centers. The AWARE Projects have a variation of approaches to capacity building, but the process and objective are effectively the same--to identify a cadre of regional institutions/networks with potential; conduct an assessment and formulate a capacity development plan; and systematically strengthen the technical, management, organizational and marketing skills. The ultimate aim is to enhance these institutions’ ability to play a stronger leadership role and to serve as a dependable source of leadership, technical assistance and advocacy for national and regional programs. The capacity development activities also help institutions to broaden their resource base, making their programs more sustainable. During the initial assessment phase, the institutions identify appropriate and realistic indicators to track “progress.” Starting this summer, the AWAREs will initiate a round of reassessments of the institutions, the purpose of which is to monitor and quantify progress. Updates and mid-course corrections in capacity development plans can be made if necessary. Highlights of Achievements Even though the capacity building program is in its infancy, the preliminary results are encouraging. The institutions and networks are not only benefiting organizationally, but many are already playing significant and visible roles by providing technical assistance to governments, donors, private sector, and NGOs. In fact, African institutions are taking the helm and providing extraordinary leadership in the accessibility and availability of quality policies and service delivery programs. Several concrete examples, articulated as results, demonstrate how the capacity building process has worked. • African capability developed to provide training and south-to-south assistance To provide a few examples, the Institut Regional de Santé Publique (IRSP) in Benin and Centre Africain d’Etudes Supériores en Gestion (CESAG) in Senegal have developed new technical expertise in procurement supply management (PSM), commodity security, mutual health organizations (MHOs), and national health accounts (NHAs). Both of the institutions are updating their curricula to include these subjects in their masters programs or their regularly scheduled training courses for health professionals in the region. In addition, both of these institutions are becoming increasingly involved in providing technical support in procurement planning and management for countries needing to meet Global Fund requirements. The Centre d’Etudes de la Famille Africaine (CEFA) in Togo and the Ghana Social Marketing Foundation (GSMF) have been trained and are now conducting management and technical assessments for other institutions. The CEFOREP in Senegal is now equipped and is providing 32 training in clinical reproductive health services. Mwangaza, a community action NGO, is providing technical assistance in community social mobilization for maternal and neonatal health. The CBCHB has not only improved the quality of its own services, but has provided training and technical assistance for the expansion of PMTCT programs in ten countries. In addition to the training and technical assistance for the expansion of HIV care and treatment programs mentioned earlier, the KATH has developed a patient monitoring tool and adapted it to be used in Sierra Leone. The national program in Sierra Leone has requested additional training of providers for which the national program will pay for the tuition. Liberia’s primary medical school has requested to “twin” with KATH. • Network established to give “voice and choice” to people living with HIV/AIDS The Network of African People Living with HIV/AIDS (NAP) in West Africa lacked autonomy from the NAP headquarters in Nairobi, did not have legal recognition, could not sign contracts with donors, and could not initiate activities within the region. The collaboration with the country networks was very limited and inefficient. With AWARE-HIV support, NAP was able to finalize its legal registration in Côte d’Ivoire and established four country chapters. Moreover, supporting NAP to market technical skills has enhanced their visibility and credibility among donors allowing them to leverage over $500,000, with the award of two service contracts. • A cadre of young health professionals developed in the region Through its institutional strengthening grant with WAHO, the Mission funded the creation of the Young Professionals’ Internship Program which aims to create a cadre of young bilingual and computer-literate health professionals who will work to strengthen national health programs. The program places those selected in health programs in partner institutions where the interns acquire practical skills. Prior to their placement they participate in an orientation program at WAHO where they take courses in a second language as well as in computer use. Since the launch of the program, a first cohort of six persons drawn from various ECOWAS countries have completed the 52-week program and a second cohort of ten have just begun the second year of the program. • Capacity of partners enhanced to effectively respond to funding opportunities AWARE collaborated with the Global Fund and provided technical assistance to countries in the region to develop proposals for GFATM. For example, through this initiative, Burkina Faso was supported to develop a malaria proposal during the sixth round of calls for applications. Furthermore, Mission field support of RPM+ supported the region’s francophone countries that received GFATM funds to develop and implement pharmaceutical supply management and procurement plans for tuberculosis, malaria and HIV commodities. In addition, the AWAREs and field support partners provided technical assistance to strengthen Country Coordinating Mechanisms in selected countries and provided training to five technical leadership institutions to develop proposals in response to GFTAM. Finally, AWARE collaborated and RPM+ to train Global Fund recipients in the quantification of malaria commodities to be used in service programs. 33 • Regional partner promoted to donors as regional leaders and facilitators The WAHO is becoming known as a facilitator of regional change and an institution of influence in the ECOWAS countries. As a result, the European Union, Germany and United Kingdom recently signed a common pool funding agreement worth $3 million with ECOWAS, thereby supporting WAHO indirectly. Also, Canada has been in dialogue with WAHO with a view to replicating the Mission’s partnership approach. Kreditanstalt für Wiederaufbau (KfW) initiated negotiations with WAHO to further promote regional reproductive health commodity security. The Mission’s strategic focus on building the capacity of regional intergovernmental institutions, such as WAHO, has provided a springboard to leadership to other donors in the region. Observations/Findings All of the above leadership or learning institutions have significantly benefited from the institutional assessments and the capacity development planning as well as from AWARE training in leadership and management, consulting for results, and/or business development and marketing. The institutions have also gained from technical skills development and improvement. In fact, the assessment team heard rave reviews for both AWAREs on the usefulness and effectiveness of the capacity building efforts: One respondent noted: “You get a taste of the improvement methodology, and you immediately want change and improvements for the better.” Another mentioned the formation of a “committee for change” that had incrementally reformed the home organization. Almost all of those interviewed commented on the significances of building African leadership and technical capability as being critical to commitment for and execution of quality programs. The process of capacity building has been long and hard, and some of the organizations have benefited more than others and some have performed better than others. But, the overall experience has proven a significant and powerful return on investment. It has developed more reliable, relevant and available technical assistance and expertise offered by regional and indigenous institutions. Moreover, it has developed a cadre of recognized African consultants, who are well-qualified and better suited to provide technical assistance and training in the region. These experts are more knowledgeable about the issues and problems in the regions, are less costly than imported assistance, and can be quickly and easily accessed for problem solving and technical assistance in the region. An investment in capacity building is an also investment in the future. The IRSP and WAHO’s Young Professionals’ Internship Programs have demonstrated the importance of mentoring and developing the next generation. If there is a weakness, it is that the capacity building packages are similar between the two AWAREs, but the programs are somewhat stove piped. Consequently there is some failure to optimize synergies accruable from joint implementation of trainings, tools and resources. In addition, capacity building and advocacy for policy change are cross-cutting and pivotal elements of the program. To save costs and reinforce synergies, the program should ensure operational integration of AWARE-RH and AWARE-HIV capacity building and advocacy activities. At present, there is little or no exit planning, which should be considered upfront for long-term sustainability. Perhaps more upfront emphasis of the program could be placed on leadership development, succession planning, and the undertaking of work that will contribute to the long- 34 lasting viability of the organization such as active support of partners to implement marketing plans. These capacity building efforts showcase the following lessons learned: • AWARE institutional capacity building efforts involve joint planning with partners. The approach succeeds because AWARE provides resources and plays a catalytic and supportive role while allowing institutions adequate decision space for implementation. • The development of customized institutional capacity building plans which are implemented through an iterative process allows continuous quality assurance and support of institutions simultaneously. • Development of marketing plans by institutions promotes resource diversification and supports institutional sustainability. The most successful organizations in this regard were provided seed grants to specifically start operational programming. • Concurrent capacity building in leadership, management and technical competencies reinforces organizational efficiency in delivery of technical tasks. The supported regional institutions have developed leadership, systems, and managerial practices which enhance quality work. E. IR 4: Health Sector Reform The regional program has selected and addressed several health sector reform measures, most of which deal with financing of health care services. These include: 1) reproductive health commodity security, which is being expanded to include general commodities for other health interventions such as AIDS, tuberculosis, and malaria; 2) the development of community level mutual health organizations (MHOs) and community-based health financial schemes (CBHFS), which are both innovative and creative ways to finance health care at the local level; and 3) national health accounts (NHAs), which is a methodology of assessing and understanding the sources of health revenues that can aid in decision making regarding health care financing. Under the new Mission Strategy Statement for 2006-2010 (if ultimately approved), it is anticipated that these interventions will be considered as ‘best practices’ that need to be advocated and incorporated into ongoing service delivery networks, and therefore folded into one of the other three immediate objectives. The team supports that decision, as it will maintain the emphasis on this important area, but will allow the portfolio to be streamlined. These health sector reform interventions are noted below. 1. Reproductive Health Commodity Security Initiative Reproductive health commodity security seeks to create conditions where people can choose, obtain, and use contraceptives. General commodity security also focuses on other drugs, like ARVs, to have them available when needed. The commodity security approach centers on the operational elements of coordination, commitment, capital, commodity, client and context. 35 Highlights of Achievements A regional meeting was held to develop consensus around an action strategy. Countries were encouraged to develop their own national reproductive health commodity security strategic plans and to strengthen capacity in commodity logistics management. Three countries (Cameroon, Togo, and Burkina Faso) have actually moved on to adopt the approach and have garnered alternative sources of funding for contraceptives. Three additional countries (Niger, Sierra Leone, and The Gambia) are in the process of developing national strategies. With other partners like WAHO, the AWARE projects are extending this approach as a priority for the region and are responding to the enormous demand for technical assistance to put the concept in play throughout the region. Observations/Findings The impact of the reproductive health commodity security efforts has stabilized the availability and accessibility of contraceptive commodities in several countries where contraceptive prevalence of modern methods is very low. The concept of commodity security is broadening to include HIV/AIDS and malaria commodities. The reproductive health commodity security approach will probably be one of the Mission’s most significant accomplishments. Commodity security integrates with the Mission’s Global Fund support strategy. The strategy allows indirect support for malaria and tuberculosis when funding for these interventions, for all practical purposes, is zero. The reproductive health commodity support is complementary and synergistic to the Global Fund procurement management system. Support to the Global Fund program in procurement and supply management, now underway, is coordinated with reproductive health support and is expected to result in major synergies strengthening all commodity security in the region. Through these efforts, it is anticipated that this approach to commodity security will carry over to the areas of commodity management for HIV/AIDS, tuberculosis and malaria. 2. Mutual Health Organizations and Community-Based Health Financial Schemes Both AWARE projects are promoting the inclusion of a wider range of reproductive health and HIV/AIDS services into MHOs and CBHFs. CBHFS are a form of insurance that allows members to pay small premiums on a regular basis to offset the risk of paying large health care fees upon falling sick. They are based on the concepts of mutual aid and social solidarity. MHO benefits depend on the local resources, member-defined needs, and availability of services. Within the two AWARE projects, the best MHO models from Benin, Cameroon, Côte d’Ivoire, Chad, Mali, Togo, Ghana, Rwanda, and Senegal have been documented and disseminated in a similar manner. During the dissemination activities, countries that were interested in initiating or expanding MHOs using these models were identified. Assessment visits were conducted to sites to meet with local partners, assess feasibility for replication, plan replication activities and identify roles and responsibilities. The projects then provided technical assistance and grants to support replication of best MHO models. AWARE-RH is also strengthening the technical capacity of La Concertation, and two regional institutions, CESAG and IRSP, to provide training and technical assistance to MHO activities in the region. 36 Highlights of Achievements Replications of mutual health organizations and micro-credit financing are under way in Togo and Cape Verde with AWARE-HIV and in Cameroon, Burkina Faso, Guinea and Niger with AWARE￾RH. In particular, in Cameroon, the documented best practice in Rwanda of linking MHOs with microfinance projects is being replicated by the NGO Service d’Appui aux Initiatives Locales de Développement (SAILD) through utilization of the line of micro-credit from income-generating activities to enable greater participation in the MHOs. Despite the recent start-up, the three MHOs in the project have already attracted over 3,300 members. The MHOs have appointed advisory boards that interact with local health service centers to negotiate the type and cost of services to be included in their MHO. Because the MHO has the leverage of all its members, if services for its members are substandard, the MHO advisory board can negotiate with the health service providers to increase the quality of services. To increase access to the MHO, members of the micro-credit project have access to a special line of low interest credit to guarantee and cover their inscription and monthly MHO fees. Members of the MHO and their families now have access to comprehensive RH, child health and malaria services at a reduced cost. The MHO staff themselves feel strongly that the MHO has enabled them with ‘voice and choice’ and has been key in encouraging members to seek primary health care services at an earlier date as members know that they are able to pay for their care. Observations/Findings The strategy is well adapted to the local contexts and accepted across the region. It is innovative in building on and expanding the traditional methods of pooling funds that are practiced throughout the region to cover new services and expand access to cash strapped segments of the population. These model MHOs have strong local government support which is seen as key to MHO success and sustainability. 3. National Health Accounts National Health Accounts (NHA) are an internationally recognized framework that tracks the use of total health care expenditures in a country. This framework provides information on all the sources of financing of health services within a country—public, private (including the household and community), and donor funds, and includes the services that these funds are used to finance. The primary objective of the NHA is to use expenditure information to contribute to evidence￾based policymaking. Once collected and analyzed, the information is intended to help policy makers better understand health systems and improve health system performance by determining how to best allocate resources for financing both health care prevention and treatment. AWARE-RH has been promoting NHAs in the region using the Partners for Health Reformplus (PHRplus) model of providing advocacy, training and technical assistance. Exploration visits are made to countries requesting support in conducting an NHA survey to assess their readiness to implement the survey, including assessing the available human resources to conduct the NHA and donor willingness to co-fund the survey. Under this activity, in addition to technical assistance to countries conducting the survey, AWARE is strengthening the capacity of two regional institutions, CESAG and the University of Ibadan, to provide training and technical assistance in NHAs. 37 Highlights of Achievements An NHA activity has been completed in Benin and is underway in Ghana, Niger, and Mali. AWARE-RH assistance to Benin began in December 2004 and the preliminary report was completed in March 2006. Approved by the steering committee in April, the official report was to be disseminated nationally in June and data from the NHA team will be incorporated into the government's Health Development Plan. The government has created a blue ribbon steering committee and local technical support team to advocate for and support policy development. Information gathered from the survey has allowed the Ministry of Health in Benin to: • Establish an indigent health care account of 1 billion CFA (approximately $2 million); • Advocate for an increase in the national budget for health to 15%; • Review budgetary allocations to reallocate funds to put more access on prevention, generic drugs and lower prices in the private sector; and • Begin the process of identifying other systems of financing like a national health insurance and reinforcement of health mutual organizations. It is hoped that similar results can be obtained in other countries that are launching NHA. Observations/Findings The importance and benefits of sharing experiences with other countries was especially emphasized. After their experience with the NHAs, the Ministry of Health in Benin is very supportive, sees high value in conducting this type of activity, and is willing to provide technical assistance to other countries in the region wanting to conduct a similar exercise. One of the negative features of this type of activity for the project is the length of time it takes to complete the entire process and the specialized technical assistance needed for conducting and analyzing survey data. In general, the program does not have sufficient funding to support the NHAs or the scale-up of national-level MHOs and CBHFS. Therefore, the Mission proposes under its next Strategy Statement to treat these interventions as best practices. This means that these interventions will be documented, disseminated, and promoted; but country level scale-up is seen as the responsibility of the respective governments. The experience thus far has shown that these measures do offer significant results and can be critical elements for comprehensive service delivery programs. 38 V. SPECIAL PROGRAM INITIATIVES The Mission manages several major program initiatives that have fallen to the regional health program either by design, as a management or political priority, or as a congressionally-earmarked initiative. The narrative which follows gives background about each, highlights the achievements, and provides specific observations and findings. A. West African Ambassadors’ Fund for AIDS The WAAF began, with its first round of proposal requests in 2001, as a means to involve the Ambassadors in the AIDS program and to give them some funds to respond to worthy activities to assist in the prevention, care, and treatment of HIV/AIDS. The original WAAF was managed by the previous regional health project, FHA Project. Managed now by AWARE-HIV, it is a way to provide support for local efforts and supply needed HIV/AIDS funds in non-USAID presence countries through annual grants (totaling up to $100,000/year/eligible country) to small NGO projects in a variety of service delivery areas. New projects are funded each year through a proposal process managed by the Embassy against guidelines provided by USAID/West Africa. Local NGOs submit project proposals to the Embassy which selects the final recipients and submits them to AWARE-HIV for award, financing, and management of the grant and activities. Only countries without bilateral USAID Missions are eligible, except Côte d’Ivoire, which no longer participates because of its very high level of HIV/AIDS funding through PEPFAR; and Gabon and Equatorial Guinea, which recently entered USAID/WA’s support area. Highlights and Achievements WAAF is currently in the round IV cycle, and 11 eligible limited presence countries have submitted 16 proposals for this round. Under rounds II and III, 28 NGOs were supported and 41 activities implemented. WAAF has enabled a wide range of HIV/AIDS activities to be conducted in the region. WAAF funds have supported: • Training of 154 peer educators, 392 religious leaders in care and support, 61 laboratory technicians and 53 counselors for HIV counseling and testing; • 2,234 behavior change communication activities have been held, from group discussions, to awareness workshops, to public events, to outreach, TV and radio spots and interpersonal communication sessions; • Establishment of five VCT centers, one orphan and vulnerable children hospice center, two counseling centers for youth and one HIV/AIDS resource center; • Care and support activities and income generating activities for 1040 PLWHA and 74 OVCs; • 7560 persons have been counseled and tested; and • Millions of condoms have been sold through social marketing activities. Observations/Findings As noted above, the WAAF has contributed to a variety of worthy efforts to fight and mitigate the spread of HIV/AIDS. The Embassy staff interviewed by the assessment team was appreciative of the technical and management support provided by the Mission and the AWARE-HIV project and was content with the role that the small projects play within their countries. In addition, to the actual activities implemented in their countries, Embassy staff commented on the high leverage and 39 visibility they receive from funding these small projects. Most of the Embassies do not have sufficient staff to actually manage the activities themselves and appreciate the work of AWARE￾HIV in managing the activities for them, but they do feel their role in selecting activities is crucial. They know the ethnic, regional, political and religious issues within their respective countries, can add value to the process, and have high expectations of the fund. Recipients of the funds are also highly appreciative of the opportunity to expand or initiate new activities in their communities. WAAF grants often allow recipients to venture into new areas. However, continuation and sustainability of activities after the initial grant period remain an issue not well-addressed by WAAF. At the current time, there is not great precision in the criteria for program funding for the WAAF grants. In the overview of the Mission regional health program, it is stated that the WAAF grants will complement and help to implement the project’s model dissemination objective. The only indicators listed for the activity, however, are the number of countries participating in WAAF round II, III, IV activities and the number of grants allocated by AWARE-HIV under WAAF rounds II to IV. As currently implemented, WAAF is not targeted to significantly contribute to any of the other project indicators as the current system allows for a wide variety of small projects to be supported and provides little or no guidance to Embassies in which types of projects to actively seek and select. Even AWARE documents that highlight prioritized best practices have not been distributed to the Embassies. Once selected, per the original model begun under the earlier FHA Project, AWARE-HIV works on the basis that what has been submitted to and accepted by the Embassy can not be rejected. AWARE and USAID/WA staff review the proposals and make technical and management suggestions on how to improve the activities but do not have a direct say in what type or which activities are funded. Sometimes it is the capacity of the organization selected that is the issue, and measures are generally taken to support the NGO during implementation through short-term technical assistance or hiring of a consultant to work with the organization. At this junction, it may be appropriate to reassess the criteria and proposal review mechanisms for the grant applications. As the program has matured and the PEPFAR has come on line, it is time to rethink the WAAF objectives and selection criteria, as well as the full formulation of this Fund. B. Cross-Border Interventions To reduce HIV/AIDS transmission among highly mobile and high-risk populations (in particular, transport workers, sex workers and their partners), the Mission’s regional program supports a number of cross-border interventions. Such interventions are considered particularly relevant for the West Africa region due to the advent of open borders through ECOWAS and the continual mobilization of internally displaced persons (IDPs) and refugees throughout the region due to political instability and conflict. The Mission’s regional health program supports a range of approaches in cross-border interventions: 40 • Site-specific service delivery. The provision of HIV/AIDS prevention and care services is supported at a number of cross-border sites and through special events utilizing a cross￾border approach. • Intra-country harmonization of messaging and activities. Through the facilitation of information exchange and joint planning within and between countries, the Mission has taken a role in harmonizing the messages and activities promoted through cross-border interventions throughout the region. A regional workshop held in March 2005 gathered stakeholders to develop a regional document on “Communication Strategies for STI/HIV/AIDS Interventions along the West and Central Africa Cross-Border Migratory Routes.” This document has been adopted as a consensus reference document to coordinate the response of all those involved in implementing cross-border interventions. • Regional expansion of cross-border interventions through technical assistance and leveraging of resources. The Missions’ efforts have enabled the regional expansion of cross-border activities by promoting and advocating them to USAID colleagues, host country governments, and other donors to replicate its service delivery activities. In Guinea, advocacy efforts by AWARE-HIV resulted in leveraging support from USAID/Guinea and KfW to develop six cross-border sites on the two cross-border routes of Conakry-Abidjan and Conakry-Freetown. The ongoing provision of assistance from AWARE-HIV, including training on and provision of AWARE-HIV harmonized behavior change tools, ensures that the regional expansion of activities is in line with efforts to promote consistent messaging and activities in cross-border interventions. Similar replication and expansion efforts are underway in Senegal and Sierra Leone. Highlights and Achievements The multiple cross-border approaches supported by the Mission have generated a range of achievements through three main activities: • Cross-Border Caravan In 2005, in collaboration with the Mission through AWARE-HIV, the regional networks of religious leaders, journalists and PLWHA organized a caravan through six West African countries. The cross-border caravan conducted trainings for religious leaders, staged mass sensitization events to combat stigma and discrimination, and generated media coverage throughout the 26 towns that it covered. • Program for the Prevention of AIDS on West and Central Africa Migratory Routes (PSAMAO/C) 4 Developed as an FHA initiative, the support of AWARE HIV has enabled the expansion from a four-country service delivery program to a more regionally-positioned program that focuses on delivering services, setting standards and norms, and promoting a branded behavior change campaign throughout West and Central Africa. 4 There are two separate organizations, one serving migratory routes in West Africa and a second serving routes in central Africa. To simplify reporting these are referred to as one, “PSAMAO/C.” 41 PSAMAO/C utilizes behavior change communication approaches to promote the reduction of high-risk sexual behaviors among its target audiences of truck drivers, sex workers and communities among migratory routes. Interpersonal communications activities are conducted by health educators or community animators at the cross-border sites (ranging from individual educational sessions to mass sensitization meetings) on a variety of themes (e.g. self-risk assessment, modes of transmission, modes of prevention, importance of appropriate treatment of STIs, the benefits of VCT, and living positively with HIV/AIDS). Socially-marketed condoms are accessible and affordable at all sites. During all interpersonal communications activities, each health educator promotes the utilization of the services for sexually transmitted infections, care and treatment, and family planning at the health center linked to each cross-border site. Interpersonal communication activities are complemented by mass media approaches, including radio spots, billboards and branded educational materials. At the conclusion of FY05, 39 cross-border sites in seven countries were supported with a strategic mix of behavior change communication, social marketing, and referral activities. The program activities focused on: 1) consolidating activities at the existing routes and cross-border sites, 2) supporting the expansion of cross-border interventions to new countries, and 3) continuing data collection efforts to inform cross-border interventions. (e.g., mapping, tracking of behaviors among the target groups, improvement of monitoring and evaluation, etc.). • World Bank Abidjan-Lagos Corridor Organization (ALCO) In recognition of the similarities in their cross-border approaches, AWARE-HIV has involved the World Bank in its planning of cross-border activities since the inception of its support of the PSAMAO/C program. Key informant interviews with the World Bank support this endeavor as a positive and productive collaboration. Since the World Bank’s ALCO could not expand along the inland and north-to-south transportation corridors that PSAMAO/C operates, it welcomed the opportunity to collaborate with USAID through AWARE-HIV, as each donor supported efforts in different geographical areas of implementation, while using similar technical approaches. Observations/Findings The cross-border service delivery activities supported by AWARE-HIV represent a significant and impressive network of STI/HIV/AIDS prevention and care services throughout the region. The support of such an extensive network requires a high level of resources. For a regional program, the Mission is currently involved at a very low level, for instance, in supporting the renovations at specific clinics through JHPIEGO. It is noted as a key success, that PSI country programs like Togo have been able to leverage significant levels of funding to scale-up the cross-border program’s service delivery component. AWARE-HIV should therefore consider whether the best use of its resources are at a broader coordination and harmonization role versus its current focus on supporting specific service delivery activities. In addition, activities like the cross-border caravan represent important linkages in institutional capacity building and cross-border interventions. The regional institutions for religious leaders and 42 journalists, both of which are supported through AWARE-HIV institutional capacity activities, received additional technical assistance to support their implementation of the caravan. The caravan activity’s success provides significant evidence of the outcomes that regional institutions can achieve when their capacity is strengthened. Additional potential linkages should be proactively identified and utilized. For instance, the peer education materials developed through the PSAMAO/C activity could be distributed at the regional level through the efforts of the regional institutions that are receiving capacity-building support. C. Obstetric Fistula Repair In 2004, the Mission regional program received a direct earmark for obstetric fistula repair. Fistulas still constitute a major reproductive health problem in West Africa and especially obstetric fistulas. The major cause is complication from obstructed deliveries of adolescent mothers. Highlights of Achievements The AWARE-RH project have already sponsored two sessions to raise the awareness of the professionals on the critical problem of fistulas: one to the annual congress of the West African College of Surgeons, and a second to the African Society of Gynecologists-Obstetricians. In collaboration with UNFPA, the AWARE project has conducted a needs assessment workshop to identify the priority activities in this area. Following the assessment, the Point G hospital in Mali was identified to become a regional francophone training center in fistulas. Capacity strengthening of the center is being done through renovation of infrastructures, equipment and improvement of the skills of the surgeons. Lamorde hospital in Niger will serve as a second training site. Since the financing is primarily earmarked for surgical repair and training, three NGOs have been chosen to manage the rehabilitation component: DIMOL in Niger, and Delta Survie and IAMANEH in Mali. The project will also take care of the rehabilitation of women with fistula, including reintegration into their respective communities. Linking with the community-to-facility continuum of care model for emergency obstetrical care will strengthen the fistula prevention component of the program. Observations/Findings Without question, fistula is a devastating problem for many women in the region. The major difficulty in implementing this activity is the uncertainty about its continuity and sustainability. Currently, funds are available only for a two-year intervention. 43 VI. MAJOR FINDINGS, CONCLUSIONS AND SPECIAL QUESTIONS The assessment identified several major findings and conclusions which are highlighted in this Chapter. In addition, the specific questions that were asked of the team are answered in this narrative. Specific issues and recommendations follow in Section VII. A. Major Findings and Conclusions 1. The regional program has been highly successful in meeting targets and having impact. To date, the progress, accomplishments, and impact of the Mission’s regional health program have been remarkable given the short time of operation and the very difficult circumstances of operating in the region. The Mission’s health strategy has proven to be sound and implementation is on schedule, if not ahead of schedule. The program has successfully built on regional and world-wide efforts such as the work on commodities security, advocacy, health systems reform, and service delivery models. The program has effectively provided leadership in selecting best or promising practices, building consensus, and promoting changes in policies and approaches at both the regional and country levels. Perhaps the program’s greatest achievement has been in strengthening and promoting African regional and national capacity to plan, manage and implement health programs. The program partners, especially AWARE-RH and AWARE-HIV, are well appreciated by their regional counterparts for the quality and appropriateness of their activities, the high caliber and competence of their staff, and their innovation to meeting strategic challenges of the region. 2. Regional agenda setting has encouraged productive consensus-building, harmonization, and competition and has led to rapid country-level implementation. Regional activities in which a comprehensive set of stakeholders are brought together to establish a regional agenda for a particular issue has accelerated the agenda’s adoption. First, gaining consensus and buy-in at the beginning of the process has encouraged all involved to have an invested interest in the successful implementation of the agenda. The methodology also has created a sense of consistency which facilitates common solutions and approaches to implementation throughout the region. In addition, bringing stakeholders from multiple countries together had created a productive competition that fuels country-level implementation. For example, the process of country-level adoption of the HIV model law was accelerated by countries’ efforts to complete the process with or ahead of their colleagues. 3. Regional activities have raised expectations for continued support of country-level implementation. The majority of individuals interviewed for this assessment explained that support for their involvement in regional activities like workshops and trainings was greatly appreciated and felt to be extremely productive. Ministry of Health counterparts in Cameroon and Benin, for example, explained that regional trainings in reproductive health commodity security were extremely beneficial and resulted in country-level impact by enhancing its capacity to forecast commodity needs and troubleshoot logistical and security issues. However, the majority of individuals interviewed also explained that their involvement in regional activities raised their expectations that they would be eligible for the technical and financial support for country￾specific implementation. The process of developing action plans helped manage expectations 44 by establishing clear parameters for ongoing technical and financial support, and by providing a tool to facilitate the process of generating support from other donors and stakeholders. 4. Meeting country-specific demands has been challenging for regional programs but this demand has been eased by the provision of south-to-south technical assistance and leveraging of funding. While USAID/WA has been able to secure funding for country-level implementation in select instances, e.g., through seed funding and/or leveraging of resources, a significant level of expectations for support of country-level implementation has also been raised through regional activities. The resources and approaches to implement the same activity often varies greatly from country to country, and the process of adapting regionally-recognized activities to specific country contexts has been a key to ensuring successful implementation. While there has been a huge demand for technical assistance to support country-level implementation throughout the region, there has also been a significant supply of technical expertise within the region. Supporting regional institutions and networks to serve as regional technical leaders has enabled the regional program to meet the high-level of country-specific demands for technical assistance while building institutional sustainability. 5. USAID/WA’s ability to leverage resources has maximized the impact of its limited resources. The Mission and its partners have been very successful in leveraging resources for country level activities. However this is a function that could be further developed. As noted by the OGAC assessment team, “with over $1.4 billion in total Global Fund grants for all three diseases in the region, the Mission should continue to play a critical role by providing support for Global Fund grants.” With minimal resources, the program could further link with Global Fund Portfolio Managers, help identify and secure technical assistance, assist with grant applications to incorporate evidence-based approaches, assist country coordinating committees, and provide regional training to disseminate best practices and address implementation bottlenecks.” This team fully supports that observation and in fact encourages the team to repeat its already successful experience with the Global Fund, with the World Bank health loans/grants, other similar funds such as Global Alliance for Vaccines and Immunizations (GAVI) and Global Alliance for Improved Nutrition (GAIN), and with multi-lateral, bilateral, and foundation donors. This team believes that the Mission could fulfill an extremely important role by leveraging from all available sources. B. Special Questions Addressed by the Assessment Team The Mission raised in the terms of reference four overarching questions for the assessment. The team’s response to the first question, “How has the USAID/WA regional health program been implemented over the last three years, what are the results to date, what are the lessons learned from the implementation process…” have been addressed in Section III and IV. The remaining three questions are answered below: 45 1. What are the implications for a regional approach to health programming specifically under the new Agency strategy on transformational development and the President’s Emergency Plan for AIDS Relief (PEPFAR)? The new strategic guidance from the DFA is expected to impact all of USAID/WA’s regional health programming. Given its experience, USAID/WA is well-positioned to take a leadership role in ensuring that the USG’s health efforts regionally are in line with the new strategic thinking. While this assessment recognizes that such harmonization efforts do require a significant level of effort, the pay-off in enabling USAID/WA to streamline its operations in line with the USG’s new strategy and to better report its results to Washington is expected to balance the effort required. Specifically for the HIV/AIDS portion of the USAID/WA portfolio, USAID/WA is currently leading the region’s USG-funded activities in support of HIV/AIDS prevention, care and treatment, and its achievements have been impressive. However, the work has been done without proactively interacting with OGAC, the office in charge of coordinating the USG’s global HIV/AIDS efforts. This assessment recognizes the challenge in establishing working relationships with OGAC, as OGAC has not officially recognized the regional program and has just recently developed recommendations of how it will interact with regional programs around the world. Regardless of what was, collaboration now is crucial to ensure that USAID/WA’s efforts are in line with the USG’s HIV/AIDS strategy, technical priorities and policy guidance. In addition, enhanced collaboration with OGAC presents an opportunity for enhancing the impact of USAID/WA’s programming. USAID/WA could greatly benefit from developing relationships with OGAC Technical Working Groups (particularly in relation to its efforts in best practices) and by educating their non-focus country counterparts on the strategy and operations of the PEPFAR (which could greatly enhance the ability of efforts like WAAF to support OGAC’s technical priorities). It behooves USAID/WA to review carefully the recently issued OGAC regional guidance and to align its program accordingly. 2. How should the USAID/WA health strategy and portfolio respond to substantially reduced budget levels for FY2006-2007 and a changing implementation and policy environment, both in West Africa and Washington? The team believes that given the budget in FY2006 and the reductions planned for FY2007, that budget cuts are likely. In fact, they are projected to be as deep as 25-30 percent in FY2007. This is on top of budget reductions already experienced in FY2006 for HIV/AIDS. The team recommends that USAID proactively prepare for these budget reductions. The Mission should systematically identify and consider and put into place measures to produce cost savings in program coordination and implementation. The following offers suggestions that might be considered individually or in combination in order to optimize the way business is conducted and to minimize costs: • Prioritize program content and geographic scope (See specific recommended actions under the Strategic Recommendations 1, 2, and 3, pp. 48-49, and Technical Recommendation 7, p. 52.). This means tightening the span of activities and targeting activities for the greatest return on investment. 46 • Encourage the implementing partners to develop greater synergies and coordination to avoid duplication of effort. Although the implementing partners operate under separate contracts, there should be a degree of joint work planning and documentation of results, the sharing of staff toward the same end, and closer integration of program components. • Delineate a clearer line of demarcation on where regional planning activities end and where implementation of scale-up begins. For example, regional program emphasis on funding could move “up stream” to leverage other donors (such as with the Global Fund and other donors) in the phases of conceptualization, strategic planning, and resource allocation. It can move “down stream” to leverage funding for replication and nation-wide programming and the removal of bureaucratic bottlenecks that impede program implementation • Advocate and encourage more activities such as that done with commodity security, which enable countries to put into place the right policies, plans and management systems to produce and support nation-wide programs for service delivery. • Continue to actively seek and encourage program support through existing funding sources and cost-sharing with other donors for specific events and activities. • Encourage more cost sharing (in-kind or monetary) and track the amount of leveraged monies. There is a need to show that USAID is not footing the entire bill. • Continue to build and utilize south-to-south regional organizations and consultants as a cost-efficient way to provide technical assistance. • Discontinue funding of any institution that is marginal or non-performing. • Give preference to countries that are more accessible and cheaper for the organization of workshops, meetings, other local activities. 3. What can USAID/WA do to strengthen the capacity of its regional partners, especially intergovernmental and regional organizations and networks, to ensure program sustainability? The team believes AWARE-RH and AWARE-HIV projects should review their partnerships and focus efforts on strengthening the best performing and viable regional and national organizations and institutions. By the same token, the partnerships with those non-performing might be phased out. The AWARE projects have many partners in the field, some of which are specializing in the same areas and activities. Given the limited resources, the regional projects should focus on strengthening the existing regional and national institutions and organizations that have the most potential and can market their activities to ensure sustainability and valued contributions in the region. This modus operandi has already been demonstrated by CEFOREP for replication of abortion care, Mwangaza for community social mobilization, and CBCHB for preventing mother-to-child-transmission of HIV. Some of the organizations selected for capacity building could perform better with more resources and development attention. 47 Perhaps, there could also be more coordination with Embassies and bilateral missions to ensure synergies in capacity building are well connected with skills building activities in the various countries. In addition, the Mission and partners should seek implementation that blends capacity building with best practices and advocacy. The partners have done an excellent job with the three separate streams of programming—best practices, advocacy, and capacity building. The early results show attempts to blend the three such as with the Cameroon Baptist which promotes PMTCT (a best practice), by advocating the practice through its leadership institution, and replicating the practice through its service delivery network. Another excellent example is the advocacy for commodity security using national-level programs as the conduit to implementation. Targeting the nexus of the three programming objectives is a way to get ‘maximum return on the investment.’ The Mission and partners may want to make a conscious decision to “go for three-fers” (channel efforts so that all three objectives can be achieved) to optimize programming efforts and avoid duplication. Further, the team believes that WAHO is primed to move forward and could offer tremendous access to leaders and decision-makers that can effect change in the health sector throughout West Africa. While this may be a “high risk” proposition, there is also potential for “high gain.” As the Health Secretariat for ECOWAS, WAHO has access to and can make recommendations to the ECOWAS Parliament, the Council of Ministers and the Head of States for 15 countries in the region. The Mission and its partners should actively work with WAHO to maximize a mutually beneficial and effective programmatic relationship. Every effort should be made to better align the objectives of the USAID/WA regional health program with the possibilities offered by this important emerging intra-regional institution. Given the difficulty and tardiness that WAHO has had in receiving its portion of the ECOWAS membership levy, the team encourages the Mission to continue to have direct grants with WAHO. A memorandum of understanding with ECOWAS, rather than an SO agreement, could establish the official relationship. As with any institutional relationship, the agreement should be built with an exit strategy. To optimally work, there needs to be a mutually beneficial relationship for all parties, WAHO, and USAID and its partners. WAHO and the Mission and its partners should push forward a joint agenda. WAHO activities that are conducted under the USAID/WA grant or with partners need to lead to action and show results. USAID support should not be considered an ‘entitlement’ to WAHO, and results should be the norm. The regional program should continue to do all in its power to strengthen the capacity of its regional partners as this truly will be the legacy of the program and will lead to long-term sustainability. 48 VII. ISSUES AND RECOMMENDATIONS In a very short time span and under difficult circumstances, the USAID/WA regional health program has made impressive progress towards increasing adoption of policies and approaches in the region. This achievement has involved the challenging tasks of identifying the issues and best practices, building consensus around the solutions, advocating for their adoption, and developing institutions and systems. The team fully acknowledges the Mission’s and the partners’ Herculean efforts in this regard. In the spirit of helping the Mission maximize the effectiveness and the impact of its program, the team offers the following 20 recommendations grouped under three broad categories: Strategic Recommendations, Technical and Tactical Recommendations, and Organizational and Management Recommendations. With many of the recommendations, the team offers suggestions to make the recommendations actionable. A. Strategic Recommendations 1. Develop a clear conceptual framework: A clear conceptual framework will help communicate the Mission’s strategy for adoption of policies and approaches at the country level and help to place or frame the activities in a cohesive and meaningful manner. The Mission may consider articulating something along the way of the following figure that presents the paradigm of policy change as a convergence of three factors: Figure 4 Source: Robert W Porter with Irvin Hicks, Porter, Novelli and Associates, USAID, Africa Bureau, Office of Sustainable Development, Washington, DC, January 1995. a) identifying an issue, b) finding a solution for the issue, and c) advocating and promoting the solution. It is when these three forces come together that “adoption” occurs and one can see changes in policies and programs. However, the three forces can only succeed when sound 49 technical assistance is available, meaningful partnerships are built, and African capacity is strengthened to own and lead the process. Recommendation: The Mission should develop a clear conceptual framework to guide and communicate its overall approach for affecting policy and approach changes at the country level. 2. Develop a systematic process of adopting policies and approaches: USAID/WA’s health program is engaged in the right activities to achieve changes in policies and strategies. However, the process is not used ‘systematically’ in all cases nor is the process clearly articulated anywhere. The operative word here is systematic. A clear vision of a process or pathway to ‘adoption’ is helpful to understand what interventions or ingredients are necessary to make ‘adoption’ happen, what happens after ‘adoption,’ and when a regional program should step back and let the countries take over. Figure 5 offers a suggestion for developing such a process. It is important to note that the box with the dotted line is where the country takes over the replication and scale-up of a best practice and a regional program steps back. However, a regional program has an ongoing role in monitoring and evaluation of the best practice to continue the learning process and supporting its introduction in new countries. Figure 5 Pathway to Replication and Scale-Up Recommendation: The Mission should develop and consistently use a systematic process for achieving changes in policies and approaches at the country level. 3. Be a Watchman on the Wall5 for the region: To make the best program choices, USAID/WA should have its ears and eyes to the ground, continuously examining the health sector situation in the region, and seeking to understand the dynamics of change, both in terms of what is working and what is not. It should also include scanning the health sector landscape and looking over the horizon for emerging issues (for example, avian influenza), and actively developing and promoting response plans. To do this effectively may imply new staff and more active engagement with agencies such as UNAIDS, UNICEF, or UNFPA. Also, it may be a function that can be delegated to one of the regional leadership institutions. At any rate, every effort should be made to utilize and synthesize existing data and not to duplicate existing work in this area. 5 Terminology used by Jerry Wolgin in the USAID, Bureau of Africa, Office of Sustainable Development, Strategic Plan of 1998-2003, Washington, DC (February 2000) Issues Identification Documenta￾tion and Analysis Advocacy and Dissemination Adaptation and adoption Replication and scale-up Monitoring and Evaluation 50 The OGAC assessment team also made the suggestion that the Mission program “collect, interpret and report strategic information.” This suggestion was based on the dearth of data in West Africa, particularly in limited presence countries. The OGAC team recommended that CDC support, through a seconded staff member, be added to the USAID/WA team, in order to facilitate vitally needed surveillance activities. The OGAC team suggested that these surveillance “activities will form the basis for identifying ‘hot spots’ in the region, and can greatly improve program planning throughout the region.” Recommendation: The Mission should actively monitor the health trends and analyze health data and the situation to provide evidence-based rationale for choice of program activities. 4. Go deep and not wide with program content: In the nascent stage, the program has been extremely effective in promotion of identified best practices, limiting the initial number of practices, and responding primarily to those sites ready and willing to support a particular application of the practice. While this approach has worked from the aspect of both inventory￾building and gaining experience, the Mission should now go deep into the program content and concentrate on selected application of identified best practices. Locations should be sought that will maximize effectiveness of that application, provide significant return on the investment, contribute to significant impact, and leverage resources for scale-up. All interventions should be considered against set criteria (such as, low hanging fruit or complex intervention, high￾risk/high gain, intermediate result or longer term impact) and garner the best return on investment. The preference should be to focus content and not spread too thin. To achieve this, the team suggests more effort go into deepening the specific content areas rather than expanding into multiple new areas. That being said, the cumulative sum of the activities should make a significant difference. Recommendation: As the Mission and its partners move to expand the number of best practices, it should cautiously select those most promising and prioritize those that have the potential for the greatest impact and long term sustainability. 5. Develop parameters for geographic scope: Due in part to a lack of guidance from Washington, strong requests from Ambassadors within the region, and various internal and external forces driving country selection decisions, the Mission is effectively working without parameters for its geographic scope. As a result, the regional platform is used as the first line responder for any country in need in the region. This has led to “country-creep” that has spread the health program across 21 countries. A wide geographic scope such as this only allows for a superficial level of result, significantly hampering the program’s ability to achieve meaningful impact at the country levels. Such written parameters should be utilized for resource allocation, both human and financial, and provide some evaluation criteria for time and money investments when new responsibilities are thrust upon the Mission. While the Mission may have little influence when it comes to strategic or political decisions, it will have no influence unless parameters are set at the beginning of negotiations. Recommendation: The Mission should develop parameters to guide its geographic scope, and propose these to USAID/AFR for consideration. The following prioritization is offered for consideration: 51 • Focus on limited and non-USAID presence countries for adoption of high impact policies and approaches, but include the bilateral countries6 only for dissemination and sharing of information. • Within the limited- and non-USAID presence countries, give priority according to the latest country categorization guidance from the Office of the Director of Foreign Assistance, with highest priority to categories a, b, and c: a) Fast Track Countries (countries chosen as pilot cases for integrated country operational plans for FY07): Côte d’Ivoire and Sierra Leone b) Rebuilding Countries (emerging from internal or external conflict): Côte d’Ivoire and Sierra Leone c) Developing Countries (low or middle income countries performing poorly): Burkina Faso, Cameroon, Cape Verde, Chad, Guinea-Bissau, Mauritania, Niger, Sao Tome and Principe, and Togo d) Transforming Countries (low or middle income countries performing well): The Gambia e) Sustaining Partnership (upper middle income countries important to U.S. national interest): Equatorial Guinea and Gabon • In addition, the following set of criteria can be used to further prioritize the countries, if necessary, to better select those countries most in need and with greatest potential for impact: a) Magnitude and severity of the health problems b) Potential for national level impact (political will, infrastructure, and resources for scale-up) c) Potential for return on investment d) Performance and capacity of the health sector. 6. Expand leveraging and alliance-building for scale-up: USAID/WA, or USAID in general, cannot achieve any significant impact by itself. While the Mission has steadily established partnerships with African regional and local organizations, and successfully leveraged some funding, its strategic approach must include expanded and systematic leveraging of other resources and alliance-building as one of its core operating principles to enable it to successfully help countries scale-up for maximum impact. Meager regional health program resources can be used to demonstrate and to test, but should not be used for country-wide programming. Leverage of the Global Fund monies seems to be the best alternative for obtaining large financial resources for national level scale and has already proven successful in several countries. Public private partnerships should be especially explored. Recommendation: The USAID regional health program can help countries scale-up best practices by actively and systematically leveraging other sources of funds and building alliances with other stakeholders in the region. 6 Bilateral countries are: Benin, Ghana, Guinea, Liberia, Mali, Nigeria and Senegal. 52 B. Technical and Tactical Recommendations Overall the technical merit and direction of the activities of the USAID/WA health program are sound and should be encouraged and continued. Some adjustments are suggested to strengthen the potential impact of the program activities. 7. Limit replication of documented and proven best practices: USAID and other donors have supported a broad range of prevention, care and support activities in West Africa which merit attention and replication. The selection process for promising and best practices was clearly defined and described in the selection guides produced and given to task teams charged with rating and ranking the practices submitted for consideration. While rigorous, no mention was made concerning the evaluation of the promising practices in terms of realistic potential for scale-up. In this respect and with limited resources, there is little room for promoting promising practices requiring experimentation. Attention should focus on recognized best practices and practices that have been tested, proven and are applicable across contexts in the region. Evaluation of the intended and unintended outcomes and impacts of the practices should be conducted before replication is initiated or encouraged. Unless the Mission is prepared to document and test promising practices they should not be encouraged for replication. Recommendation: The Mission and the AWARE projects should limit the number of best practices selected for implementation and focus on replicating only those practices that have been evaluated and recognized as best practices in the region. 8. Context is important: One of the selection criteria used by the task teams in selecting best practices was the relevance of the activity in its response to HIV/AIDS in the context of the society in which it was implemented, including cultural traditions, political system, and economic organization, as well as the needs and conditions directly related to HIV/AIDS, such as vulnerability and risk behaviors. What happens to the relevance after the practice is selected for inclusion? The context and conditions surrounding HIV/AIDS are just as important in the country considering replication. The replication of a best practice is not just the replication of a set of services but requires the appropriate enabling environment. This concern is not just limited to HIV/AIDS, but to the entire technical portfolio. Recommendation: The Mission and partners should place more emphasis on the epidemiologic, political, socio-cultural, economic and human resource situation in both the documentation of best practices and the selection of sites for replication, in spite of diverse social and cultural histories and traditions in the region. 9. Maximize returns and avoid missed opportunities: The underlying factors contributing to the health situation of individuals, families and communities in terms of reproductive health, child survival and HIV/AIDS are often similar across health technical areas. In principle, USAID/WA program technical areas should be integrated. In practice, programmatic linkages between the two main program partners, AWARE-RH and AWARE-HIV, need reinforcement. Some success in the integration of activities for better results are shown in the cases of integrating family planning messages into HIV/AIDS cross-border programs and working 53 together on promoting best practices in PMTCT. But more effort needs to be put into facilitating integration of activities between the two projects. In addition, there is duplication in staff positions and approaches. For example, separate policy and capacity building staff positions exist for the two arms of AWARE. Yet conceptually, policy advocacy and capacity building are critical and cross-cutting strategic approaches for both the projects. In addition, strategic planning documents, workplans, annual performance reporting are duplicated. While there are some contractual limitations, there appears to be some logical and cost-saving measures that could be taken if some planning and implementation processes were not duplicated. Recommendation: USAID/WA, AWARE-RH and AWARE-HIV should be actively seeking opportunities to coordinate and integrate with each other to take advantage of synergies. The programs should review areas of duplication and work towards the integration of policy and capacity building initiatives and the Mission should also consider requiring joint planning and performance monitoring to reduce duplication of efforts 10. Look for innovative and promising opportunities for cross-sectoral involvement: The underlying factors for health are often multi-sectoral in nature. In order to be most effective, program interventions should be integrated and coordinated within wider development activities. Within the current portfolio of activities, USAID/WA’s Community Development Project in São Tome and Principe is an opportunity to demonstrate cross-sectoral programming. The participation of the health team on the ARV Transparency Initiative and the Avian Influenza committee are clear examples of cross-sectoral collaboration. Also, the regional health program promotes the participation of women and youth as beneficiaries. Youth are a target group that provides an opportunity to promote behavior change to improve gender equity through responsible sexuality and mutual respect between sexes. The health program contributes to improved governance by its emphasis on decentralized and community health programs, such as community-financed health care and mutual health organizations. These types of synergies should be encouraged and promising cross-cutting opportunities explored. However, it must be noted that for optimal results, work responsibilities should be shared by the various sectors involved in regard to decision-making, programming, funding and work responsibilities. Recommendation: The Mission and partners should continue to seek innovative and promising opportunities for cross-sectoral synergy and wider involvement of project activities. Other potential areas include re-examining possible public-private partnerships and using existing resources. For example, Embassies could possibly play a larger role in the advocacy and policy agendas supported by the project through their political and public affairs officers. 11. Use a gender lens: The issues addressed by the Mission health portfolio disproportionately impact on women and their contributions to family and community health. Aside from scattered examples such as participation of the women-focused organization, the SWAA, the encouragement of women participants in capacity building and advocacy activities, and the provision of behavior change messages and selected services for vulnerable groups and 54 obstetric fistula care, the program lacks a well-defined and coordinated strategy of initiatives that address gender. Recommendation: The Mission and the AWARE partners should develop a purposeful integrated gender strategy to address this gap and partners should review all technical activities through a gender filter before approval for implementation. 12. Use regional comparative advantage in cross-border programming: Cross-border programs are particularly important and relevant in the West and Central African regions due to increasingly open borders and the continual mobilization of populations throughout the region. Although most of the sites are existing public clinics situated along major transit routes, cross-border sites can be unique in providing integrated and harmonized messages and services to transient populations as they travel across the region. The regional program has a unique niche in its ability to look beyond national borders and harmonize the initiative across the entire region. The team discourages the implementation of direct service delivery cross￾border activities, but sees the regional program’s role, for example, as coordinating and harmonizing consistent messaging as well as policies, standards and norms between countries and encouraging the utilization of the same or similar product branding. Recommendation: The regional program should use its comparative advantages for harmonizing, coordinating, advocating for integration of services, and engaging other partners and national programs in implementation of cross-border initiatives rather than expending efforts on national level service delivery. This type of service delivery should be folded into the Global Fund Grants or other bilateral assistance programs. 13. Test the assumption of the efficiency and effectiveness of cross-border programming: A higher level of participation in cross-border initiatives by countries in the region and a greater number of cross-border sites are assumed to increase opportunities and effectively meet the critical needs of vulnerable populations in the region in all technical areas. Assumptions on utilization and the effectiveness of this type of intervention in the West and Central African regions at meeting the needs of vulnerable populations have not been sufficiently evaluated. Recommendation: The Mission and projects should conduct an evaluation of cross-border activities in the evaluation and special studies aspect of the program. 14. Program the West African Ambassadors’ Fund for AIDS to respond to PEPFAR and project priorities: Originally designed to provide support for local efforts and make the issue of HIV/AIDS visible in the region, WAAF is immensely popular with the Embassies. Despite the popular support it receives, WAAF is not necessarily providing significant support to the objectives of USAID/WA or even to PEPFAR. The WAAF Fund activities should be realigned to support the objectives of PEPFAR, the regional health projects and, where possible, closely integrated into other activities in the health or other program sectors. Recommendation: The Mission and AWARE-HIV/AIDS should configure the priorities and criteria and should give country specific technical parameters to the Embassies at the next round of proposals. This information might include the program guidance provided by 55 PEPFAR, priority best practices being promoted by the regional project for HIV/AIDS, and appropriate context specific activities, such as supporting the gaps or bottleneck in Global Fund implementation. 15. Bring the Embassies to the table for the West African Ambassadors’ Fund for AIDS: With the exception of a few select examples, the activities supported by WAAF are often too small and scattered for large-scale impact or even medium-term sustainability. The funding level is too low and spread among too many countries to make much of impact at the national level. Not only should WAAF activities be aligned to USAID/WA objectives, they should also be used in the most strategic ways possible, such as for leveraging other funds such as GFATM or bringing the Embassy to the table on other major in-country initiatives. The Mission should redesign the way WAAF funds are allocated to have a greater impact in the region. For example, instead of giving each of the 11 eligible Embassies $100,000 each, pool the money into several designated and highly specific funds that the Embassies can apply to for funding. No longer will Embassies be guaranteed money. They will be competing for funding, which may increase the appropriateness and quality of the proposals as well as limit the number of grants being managed in each round. AWARE-HIV will decide which to fund, the number to fund and how much to invest, as well as one or several specific small project funds. A portion of the money could be set aside in a special fund that exists uniquely to respond to Embassy requests for assistance in leveraging other funds like the GFATM. Recommendation: The Mission should redesign the way WAAF funds are allocated and distributed to have a greater impact in the region. 16. Graduate the Centre d’Etudes et de Recherche sur la Population pour le Développement : The team believes that the Mission should strongly consider graduating CERPOD. The team makes this recommendation based on the following reasons: a) USAID/WA is likely to experience some budgetary constraints and the funding allocations will be reduced and priorities will have to be made; b) the Mission strategic objective and expected intermediate results and the mandate of CERPOD are no longer closely aligned; and c) there is little budgetary support from CILSS or INSAH which indicates that the CERPOD activities are not a priority for its parent organizations. Given the need to prioritize program focus and to prepare for a reduced budget, the Mission should prepare with CERPOD an exit strategy which indicates that the current grant will not be renewed at the end of the current funding cycle (September 2007). There may be discrete activities such as a training or workshop on which the Mission or its partners may want to collaborate with CERPOD, and support for that activity can be made on an individual basis. Recommendation: The Mission should not continue core funding of CERPOD and should not renew its institution building grant after the end of the current funding cycle. C. Organizational and Management Recommendations 17. Keep regional collaboration and coordination on the front burner: USAID/WA, through its implementing agencies and grantees, conducts a variety of critical functions to provide strategic, technical and monetary support to a wide variety of organizations. The regional program is very complicated and involves an incredible numbers of collaborative organizations, 56 multi-lateral and bilateral donors, regional organizations, implementing partners and stakeholders. In working in 21 countries, the program interfaces in each of those countries with the US Embassy and/or USAID bilateral officials as well as host country government representatives. The program works with a variety of public, non-governmental and private sectors, leaders, service providers and managers. Needless to say, the success of the program depends on the ability of USAID and its implementing partners to manage this complex array of relationships. If planned and coordinated, regional efforts among stakeholders can be much more powerful than ad-hoc collaboration. The Mission and partners needs to utilize every possible action to keep communication and coordination lines fully open with its implementing partners, grantees and collaborative networks. Some practical actions to this end include: • Develop and formalize a communication plan that systematically keeps stakeholders on board and fully informed. • Expand the number of monitoring visits within the region to inform/update USG and host country officials and stakeholders of program purpose, activities, and successes and to closely review program activities. • Re-instate regular meetings of the “technical advisory group” to formalize channels of communications, keep everyone informed of changing policies and programs, exchange ideas and thoughts on program designs and implementations, harmonize approaches, and coordinate actions. Between meetings, committee members should be kept informed of actions, updates, and policy and programmatic changes. • Involve USAID and concerned stakeholders, to the extent possible, in the development, planning, and review of AWARE partner and other partner workplans. • Hold regular coordinating meetings with the immediate implementing partners to discuss workplans, problems, issues and successes. • Use the offices of the Mission to motivate, facilitate, and develop bilateral, embassy and USG support for program activities and interventions. • Continue to conduct regularly-scheduled specific joint coordination meetings with other donors and implementing partners. • Continue to piggy-back on conferences, workshops, and other meetings of collaborating and partner institutions to understand current technical thinking and other points of view, to identify possible points of collaboration, to meet and develop relationship with actors, and to network with program implementers. • Use, where feasible, conference calls and internet to quickly update, pass documents, and share information. Recommendation: Mission and partners should increase its use of all available coordination mechanisms to develop, facilitate and sustain productive relationships with collaborating and implementing partners. 18. Stay visible and make presence known to Washington: Washington is primarily geared to bilateral programs in terms of resource allocation and performance reporting. While there is an acknowledgement by headquarters that regional programs play an important role, the significance and the impact of the regional programs is not always fully appreciated. This can 57 impact on standing, prestige, money and access to headquarters resources. It is therefore incumbent on the Mission and partners to tell their stories and make sure that the program is fully understood and its successes are well-recognized. Specifically the Mission should document, with evidence-based precision, the success and impact of the regional program. Go beyond in performance reporting, to not just give numbers, but to explain the significance of activities; pro-actively disseminate unique results; and develop market messaging to appropriate audiences and on specific issues (e.g. value of the regional platform). In order to do this, some concrete actions could be: • Educate the members of the country and regional teams so they are knowledgeable advocates in Washington. Invite them to workshops or other events so that they can see first hand the work of the regional program. Continue routine conference calls with the country/regional team so those most interested are engaged with the program on a regular basis. • With the annual report, continue to send in a supplementary document with success stories for use in the annual report. • Write special news articles for Frontlines (as was done with the religious leaders’ caravan to combat stigma). • Send in reporting cables (or emails) that can be used in the weekly reports to the Administrator of the Front Offices of the Africa Bureau and Global Health and highlight those on HIV/AIDS and Reproductive Health. • Provide material and success stories for any Congressional Report (i.e., the OGAC’s Annual AIDS Report, the Child Survival and Health Report, the Agency Annual Performance Report). • Target newsletters, dissemination of lessons learned, and other generated material to groups that care or are technically involved with the subject matter (i.e., country teams, desk officers, Africa Bureau special committees, country teams, Global Health working groups, and specific technical offices such as the Office of the AIDS Coordinator, the Office of HIV/AIDS, the Office of Population and Reproductive Health, etc). • For country-related activities, get to know the people who carry out Public Affairs for the Embassy and assist them by writing new releases for submission through State Channels. Get to know, up close and personal, the Legislative and Public Affairs “communication reporters” for the Africa Bureau, Global Health and the Office of the AIDS Coordinator whose job is to supply good stories for public consumption. • When passing through Washington, field staff should make rounds and brown bag presentations to inform the regional program constituency of recent activities. Ask for their help in communicating the good work of USAID/WA. Recommendation: The Mission and partners should be proactive in reporting to Washington the value, significance and successes of the program and to develop strong advocates in Washington for the program. 58 19. Seize the opportunity of upcoming staffing changes to completely review and re-evaluate structure and staffing levels of the USAID/WA Health Office: Over the past six months and over the next few months the Health Office staffing pattern and expertise has changed and will change dramatically: The former team leader was promoted and assumed other responsibilities; a new team leader arrived in June; the HIV/AIDS Advisor departs post in June; one staff position was recently deleted; the TAACS Advisor may convert to a foreign service limited appointment; and two personal service contracts will expire and the positions will be re￾competed. In addition to the regional activities, the Mission staff is being asked to do more Mission support activities (designs, reporting, problem resolution, etc) unrelated to the regional health program. Some staff members are close to burn-out and others are not fully utilized. Morale is low. The recent OGAC regional office assessment showed that USAID/WA had the largest number of countries to cover with the fewest ratios of staff-to-money for the AIDS program of any of the regional offices that have AIDS activities. This report, while suggesting that the Mission focus and concentrate, also recommends some expansion of duties (i.e., expanding its role in leveraging funding, serving as watchman, increasing coordination and collaborating, doing more site visits, documenting more, keeping a visible presence in Washington, etc.). In order to ensure that there are sufficient numbers of staffers with the right qualifications to conduct business and to carry out the functions of the office, there should be an in-house task analysis and management assessment to: • Determine the staffing requirements of the office; it may be that more staff is required. • Determine distinct roles and responsibilities and designate specific staff responsibilities. • Develop specific and clear job descriptions. • Look at delegation of responsibilities and whether skills now match job requirements. • Assess if the staffing numbers are adequate for the tasks at hand. • Assess whether there is an appropriate and equitable division of labor and distribution among staff positions. Determine if some roles are more appropriate for the implementing partners. • Examine the empowerment of the staff, and whether they have the support, latitude, tools and skills to do the expected work to plan, manage and evaluate the program. • Better utilize third-country nationals/foreign service nationals) in program planning and implementation at senior levels. • Assess whether there are career development plans to ensure professional and personal growth of employees that can lead to job retention and satisfaction. Recommendation: The Mission should conduct a management study on structure and personnel requirements for its Health Office and develop an effective structure that is configured so staff have authority, support and means to carry out their duties to maximally achieve results. 20. Find innovative ways to reduce the management burden: While the program has been extremely successful, the sheer number of programmatic and management tasks to be overseen in formidable--the size and breath of partners’ and collaborators’ programs; the number of cooperative agreement grants; the number of complementary and supportive activities through field support mechanisms; and the other duties as assigned--all limit the USAID team’s capacity to fully monitor and maintain strong program accountability. As previously indicated, 59 the program is a mile wide. From a management point of view, and as suggested in the strategic and technical recommendations, USAID/WA needs to prioritize and, to the extent possible, reduce the number of management units in the Health Office. Some possible actions might include: • Urge implementing partners to tighten their respective program and as previously recommended ‘go deep, not wide.’ Focus and concentrate and limit program content and geographic scope. Resist taking on new activities unless accompanied by money and staff. • Eliminate non-productive or marginally successful activities or grants. • Eliminate/consolidate field support activities that could be assumed by the key implementation partners. However, keep field support which brings complementarities that will enhance or enrich the regional program. • Close out the Annual Program Statement grant when it expires this year. • Consider reorganizing and restructuring labor intensive management units, such as the Ambassador’s Fund for AIDS. • In addition to technical responsibilities, assign country responsibilities to Mission health staff, build a level or expertise in a particular country so there is not a learning curve with each visit by different staffers. These country backstops should be sufficiently technical so they can do routine monitoring and ‘carry water’ for the technical program, but at the same time know when to bring in a particular technical specialist. • When “other duties as assigned activities” start, call on Central Bureaus for surge capacity in such areas as program design (such as, with Sao Tome), special problems (such as with Avian flu), or with Mission coverage during stress times (such as the interim period between HIV/AIDS Advisors). Recommendation: The USAID/WA should plan and undertake a variety of actions to reduce its management burden. 60 VIII. PERFORMANCE MONITORING AND EVALUATION The Performance Management Plan (PMP) is an important tool for managing and documenting the health portfolio’s performance. It is designed to enable the program to have a “timely and consistent collection of comparable performance data in order to make informed program management decisions” as well as allow for an accurate measure of the performance and progress of the program. It measures results-level indicators, program results that can be reasonably attributable to USAID efforts and for which USAID is willing to be held accountable. These indicators measure performance against the strategy statement and intermediate results of the program. Given the regional nature and level of USAID/WA’s health SO, the Mission does an adequate job of monitoring its program. However, unlike people-level indicators of a bilateral program, it is challenging for a regional program to use process level indicators to articulate the significance of its functions and activities. The team offers the following observations to guide the Mission’s PMP to go beyond simple monitoring and consider capturing the added value of its regional health program. First, USAID/WA’s indicators are largely quantitative and do not reflect the quality or significance of its activities. For example, counting the number of policies does not give any indication of the importance or scope of the policy and the role this policy may have in barriers to access to services. Second, for the most part, the indicators monitor output and not outcome. For example, counting the number of interns finishing the Young Professionals’ Internship Program does not indicate if the intern’s capacity has been enhanced in any area or whether they are finding appropriate job placements upon completion of the internship. Third, the indicators do not allow the program to measure the significance of its performance in relation to its critical regional functions such as leveraging, coordination, integration, and harmonization. Fourth, other than minor investment in the Demographic and Health Survey, the PMP does not include any plans for evaluation or special studies. USAID/WA should supplement its routine monitoring information with special studies and evaluations to better understand what is working, what is not, and why to advance state-of-the-art. Innovative approaches in the region, such as the Young Professionals’ Internship Program, should be studied to determine their value and contribution. Finally, information from routine monitoring and special studies should be used to tell a compelling story of the significance of what the program is achieving. Evaluations and special studies are ways in which the regional health program can contribute to advancing the state-of￾the-art thinking on technical programming in the West and Central Africa region specifically and in Africa more generally. Those special studies should be carefully selected against criteria that make them worth the money and time investment. Recommendation: The Mission should review its PMP and consider modifications that will allow performance reporting to indicate significance of the regional work and to report performance in terms of outcome, not output, of its critical regional functions such as leveraging, coordination, integration and harmonization. 61 Recommendation: The Mission and its partners should develop an evaluation and special studies agenda to document program experiences--failures and successes. Recommendation: The Mission and partners should ensure, that if the program continues to carry out promising practices, that the selected practices are evidenced based and documented. Where potential for impact seems great and resources make this possible, pilot-test and evaluate in order to generate lessons learned, discover optimal operating conditions, and evaluate impact to determine their potential for inclusion as best practices. 62 IX. OPPORTUNITIES AND CHALLENGES In summary, the team wishes to reaffirm that USAID/WA’s “regional health program has a sound strategy that is basically on track.” The assessment team had a dialogue with many stakeholders and viewed first hand on-going regional activities in a variety of settings. The current program has talented and capable staff who are well appreciated in the region. Most of the strategic and programmatic elements are set in place to implement a significant and dynamic regional agenda. This regional work is providing critical support to national programs to plan and implement HIV/AIDS, reproductive health, and other health interventions. West Africa, however, is a very culturally and linguistically diverse region, with complicated logistical and communication challenges. The team believes that the result of spreading across 21 countries and promoting scores of promising and best practices has affected the depth of the program and diluted its impact. The team recommends that the Mission focus and concentrate by setting parameters on its geographic scope, prioritizing the best practices to promote, and limiting partnership to those that demonstrate potential for growth and sustainability. Many steps, and the foundation for moving forward along these lines, have already been taken or planned. In the report, the team offered a number of recommendations, suggestions and operational considerations -- strategic, technical and managerial—for improving program effectiveness. In brief, the major thrusts of the recommendations revolve around the need to: • Refine the current strategy to be more focused and strategic with clearer outcome results appropriate to the regional nature of the program. • Prioritize program activities by setting parameters to limit the geographic scope, program scope, and technical interventions, and number of partner organization involved in capacity building. • Assist the national governments in defining a realistic, evidence-based, and affordable set of service delivery models yet emphasize regional coordination, advocacy, harmonization and leveraging of funds. The focus should not be on service delivery, but rather on creating the optimum conditions for services to be provided. • Continue to provide bold leadership and create and maintain an enabling operating environment for regional and national governments by promoting best practices, advocacy for policy change, and capacity building of regional efforts; but be more methodical and systematic in the process. • Enhance all communication and coordination measures in order to leverage funds and harmonize programs within the region with donors and other stakeholders. • Review and update the PMP to ensure that the indicators match results and that the Mission and the program have a sound basis for tracking, analyzing, and reporting results. 63 • Take advantage of the changing of staff in the health office to readjust the organizational structure and staffing of USAID/WA health office. The present staffing includes many talented individuals who would benefit from broader exposure to senior planning and management training. • Review carefully the current budget, realign resources, and introduce cost-saving measures to accommodate the recent budget as the program matures, USAID’s new health strategy further evolves, and new government plans become known. This assessment comes at an opportune time. The team hopes that its findings and recommendations will be useful to USAID/WA in aligning its regional program with the new Agency strategy that focuses on transformational development, finalizing its strategy statement for 2006-2010, and synchronizing its priorities with the region’s donors. 64 APPENDICES 65 Appendix A: USAID/WA Mid-Term Assessment Terms of Reference Mid-Term Assessment of USAID/WA Strategic Objective 5: Increased Adoption of Sustainable RH, STI/HIV/AIDS, and Child Survival Policies and Approaches in West Africa I. PURPOSE OF THE ASSESSMENT The purpose of this assignment is to conduct a mid-term assessment of the United States Agency for International Development, West Africa Regional Program’s, (USAID/WA) Health Strategic Objective (SO5) -Increased Adoption of Sustainable RH, STI/HIV/AIDS, and Child Survival Polices and Approaches in West Africa. Currently, USAID/WA is in the third year of implementation of a five-year program (2003-2008) to support the strategic objective. The Mission has developed a revised Strategic Statement in line with the new USAID Framework for Africa, and is waiting USAID/Washington approval. The assessment will be conducted by a team of consultants who will: 1) Assess (programmatically, technically, managerially, and organizationally) the RP/SO5 supported activities to date and their contributions towards achieving the stated SO5 results; 2) Identify and recommend appropriate activities that need to be implemented in order to reach the goals of RP’s Health Program as presented in the new regional strategy by FY2010 (if the Strategy is not yet approved by the time the Evaluation begins, the draft version would be utilized) 3) Assess USAID/WA/SO5’s added value to bilateral mission activities, non-presence countries (NPCs), and regional and national health agendas. 4) Review goals and indicators for SO5 established for FY2008 and recommend adjustments as appropriate in light of the revised Mission strategy, the President’s Emergency Plan for HIV/AIDS, (Adjustments to HIV/AIDS activities to be made in light of a separate OHA/OGAC evaluation of regional programs currently underway) and the changing implementation environment. II. BACKGROUND The USAID/WA Strategy and the Regional Context USAID/WA was established in 1999, headquartered in Bamako, Mali, to consolidate a number of ongoing programs, including the Sahel Regional Program (SRP) and the Family Health and HIV/AIDS Prevention Project (FHA). Formed at a time when funding levels for health increased rapidly, the FHA filled a void which had existed since the closing of REDSO/Abidjan in 1997. The current five-year USAID/WA strategy covers 2003-2008. The Mission was transferred to Accra, Ghana in 2003. USAID/WA is an independent USAID Operating Unit responsible for managing a development program that originally covered 18 countries, 7 of which have bilateral USAID missions. Support has begun to three recently added countries (Gabon, Sao Tome and Principe and Equatorial Guinea), for a total of 21 countries7 . USAID/WA has developed substantial programmatic linkages with key African 7 The program serves Benin, Burkina Faso, Cameroon, Cape Verde, Chad, Côte d’Ivoire, Equatorial Guinea, Gabon, The Gambia, Ghana, Guinea, Guinea Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, Sao Tome and Principe, Senegal, Sierra Leone, and Togo. For the Health Program, there will soon be HIV/AIDS activities through the West African Ambassadors’ AIDS Fund for HIV/AIDS and a community health program, in coordination with WA’s conflict management team, in Sao Tome and Principe. Limited activities, not including the Health Program at present, have recently begun in Equatorial Guinea, giving WA a total of 21 countries which are covered for some activities (e.g., Avian Flu Risk Assessment, Global Fund Technical Assistance Needs Assessment, etc.) 66 institutions, chief of which is the Economic Community of West African States (ECOWAS). In health, USAID/WA supports ECOWAS through that organization’s health secretariat, the West Africa Health Organization (WAHO), which receives an institutional strengthening grant and is a partner in many USAID/WA health activities. The USAID/WA Mission’s Program Goal for the 2003-2008 strategy period is “A Politically Stable and Economically Prosperous West Africa.” As a result, USAID/WA remains very much concerned with supporting regional stability and economic prosperity, while aligning its program with the new strategic shifts contained in the USAID White Paper focusing on transformational and fragile states, as well as global issues8 . With an annual total budget of approximately $40 million, the commitment of the USAID to assist regional development in West Africa9 is demonstrated through four major program areas supported by USAID/WA. These include: 1. Regional Health Program: This is the largest of the four program areas, with a FY2005 budget of $19.6 million, decreasing to $16.6 million in FY2006 and $15.9 million projected for FY2007. All of USAID/WA’s regional health activities work towards a common goal of increasing adoption of sustainable health policies and approaches in West Africa. The program focuses on five main technical areas: (1) STI/HIV/AIDS; (2) reproductive health (maternal health and family planning); (3) child survival; (4) infectious disease (primarily malaria); and (5) human resource and institutional capacity development. Approximately 85% of the budget is focused in the first two program components. 2. Regional Trade Integration and Trade Program: This program seeks to reduce intra-regional barriers to trade; improve trade policy coordination among West African countries; harmonize regional monetary and fiscal policies; and strengthen regional institutional capacity in energy markets and policies. In FY2005 it had a funding level of $10.2 million. 3. Agriculture, Food Security and Natural Resource Management Program: USAID/WA receives Presidential Initiative to End Hunger in Africa (IEHA) funds, implementing a regional agricultural program to raise incomes and reduce food insecurity. Funding in FY2005 was $7.8 million. 4. Conflict Prevention and Anti-Corruption Program: The overall objective of this program is to enhance the prospects for peace and stability in West Africa. Funding in FY2005 was $2.3 million. The USAID/WA Health Strategic Objective (SO5) The Health Strategic Objective (SO5) for the period under review is “Increased Adoption of Sustainable RH, STI/HIV/AIDS, and Child Survival Policies and Approaches in West Africa.” USAID/WA’s health program is seeking to achieve this objective through the support of four Intermediate Results (IRs) during a five-year program implemented from October 2003-September 2008. The IRs in the framework includes: 8 While West Africa possesses a rich resource base and enormous developmental potential, weak institutions, poor management, and very high levels of corruption, as well as prolonged armed conflict in several countries, consistently undermines efforts to put its resources to work for the good of its people. These factors are the major obstacles to the transition from poverty to prosperity. 9 U.S. interests in West Africa encompass strategic, economic, and humanitarian concerns. 67 1. Improved approaches to family planning/reproductive health, STI/HIV/AIDS, and child survival services disseminated region-wide focuses on identifying and disseminating best and promising practices to improve service delivery across the region; 2. Increased regional stakeholder advocacy for policy change focuses on regional advocacy activities with the goal of using the regional platform to encourage political and other key opinion leaders to adopt policies conducive to improving health; 3. Increased capacity of regional institutions and networks focuses on increasing the capacity of regional institutions, networks and resource centers to provide leadership and technical assistance in the region, supporting the advance of regional and national health agendas; and 4. Health sector reform models developed and disseminated region-wide focuses on the development of community financing schemes, health care management systems, commodity security plans, and other health system reforms. The regional health program has been implemented in close collaboration and partnership with cooperating agencies and institutions, networks, and organizations with regional mandates, including international donors, USAID bilateral missions, public sector organizations, national and international NGOs, and regional NGO networks, including faith based NGOs and networks. In implementing its health programs, USAID/WA supports the two key Action for West Africa (AWARE) grantees, Family Health International (FHI) which leads the HIV/AIDS component, and EngenderHealth which heads the Reproductive Health, Child Survival and Infectious Disease (RH/CS/ID) component. Also, the West Africa Health Organization (WAHO) and the Centre d’Etudes et de Recherches sur la Population pour le Développement (Centre d’Etudes et de Recherche sur la Population pour le Développement , or CERPOD) are important regional partners supported with direct grants from USAID. USAID/WA also supports about 9 Field Support partners. The activities of USAID/WA are supposed to complement and provide added value to bilateral mission programs, and limited technical assistance is provided to some missions. USAID/WA also provides limited technical assistance and service delivery to non-USAID presence countries. Finally, USAID/WA provides significant support for Global Fund To Fight AIDS, Tuberculosis and Malaria (GFATM) activities in the region. III. STATEMENT OF WORK The assessment team will conduct a programmatic, technical, managerial, and organizational review of USAID/WA’s SO5 activities implemented to date. It will identify results and lessons learned, and make recommendations on activities to be continued, modified, or enhanced, in light of USAID’s new Strategic Framework for Africa and USAID/WA’s draft strategy under the Framework, as well as OGAC’s HIV/AIDS policy and, if available, the results of its ongoing assessment of regional programs, including the USAID/WA HIV/AIDS program. The team will answer four overarching questions: 1. How has the USAID/WA regional health program been implemented over the last three years and what are the results to date? 2. What lessons can be learned from the implementation process and results, and what are the implications for a regional approach to health programming under the new agency strategy on fragile and transformational development states, and PEPFAR? 68 3. How should the USAID/WA health strategy and portfolio respond to substantially reduced budget levels for FY2006-2007 and a changing implementation and policy environment, both in West Africa and Washington? 4. What can USAID/WA do to strengthen the absorptive capacity of its regional partners, especially the IGO, regional NGOs and NGO networks to ensure program sustainability? The assessment will review activities that have been implemented to date, and identify successes, gaps, and constraints in the implementation of program activities. In addition, the assessment will determine which program results have had significant progress, and which results are lagging. The assessment team will determine the extent to which the planned results in the USAID/WA SO5 Performance Management Plan (PMP) have been achieved to date. It will highlight the main programmatic, technical, managerial and organizational issues arising during the first three years of the USAID/WA implementation strategy, and identify program results that are reasonably attributable to USAID efforts while acknowledging the need for and extent of donor collaboration between USAID and other regional partners. The team will also review the indicators included in the PMP to ensure that these are the most appropriate measures to demonstrate USAID/WA’s achievements. Based on this analysis, the team will identify lessons learned that will inform future program strategy and implementation, particularly USAID/WA’s role in the new Agency strategy for fragile and transformational development states, and program priorities given increased responsibilities to cover additional NPCs and support bilateral missions, particularly in the light of decreased budget levels and reductions in Health Team staff. Issues that will be addressed by the assessment team in response to each of these questions are outlined below: 1) How has the USAID/WA program been implemented over the last three years and what are the results to date? In answering this question, the team will review the programmatic, organizational, technical, and managerial aspects of activities implemented in each portion of the results package for all technical domains (IR1, IR2, IR3 and IR4). These activities are implemented primarily through the two AWARE projects (RH and HIV), regional partners including WAHO, CERPOD, and other regional organizations/networks, with additional implementation by 9 Field Support partners. The team will also determine the extent to which results outlined in the SO5 PMP have been achieved through program activities implemented by these institutions, by addressing the following issues: • Regional Advances in FP/RH, STI/HIV/AIDS and child survival approaches; • Capacity development of regional institutions and networks to provide leadership and technical assistance; • Regional policy change through USAID/WA’s activities; and • Results from selected health sector reform activities. 1a. Regional Advances in FP/RH, STI/HIV/AIDS and child survival approaches In addressing this IR area, the assessment team will: • Identify USAID/WA supported activities that have been implemented through AWARE (RH and HIV/AIDS) and other partners over the last two and on half years to improve FP/RH, STI, HIV/AIDS, CS and the overall health sector, and determine the extent to which these activities are responsive to the ECOWAS and USG’s regional agenda; 69 • Determine whether the current funding distribution across the USAID/WA health program areas is the optimal use of funds to meet the regional agenda; (will be a moot question for earmarked funds) • Determine the effectiveness of the USAID/WA health portfolio management at the Mission, and CA management levels ; • Assess the effectiveness of processes for communicating with partners, exchanging information, prioritizing issues, identifying and resolving problems, etc. (e.g. collaborative/joint decision making) • Identify and review the actual results of these activities, and compare them with the planned targets outlined in the SO5 PMP; • Assess the effectiveness of efforts to integrate Local Regional Partner and Field Support inputs into the overall program • Conduct a comprehensive assessment of the results, to determine successes, gaps, and constraints in the implementation of USAID/WA activities; • Review and report on progress made by USAID/WA to integrate its interventions with the Global Fund in HIV/AIDS, TB and malaria programs, with the view to improving better utilization of Global Fund resources; and • Based on current experience, lessons learned to date, and existing and expected changes in the implementation context, including resource levels, make recommendations as to which program activities should be continued, changed, eliminated or expanded in the remaining strategy period. 1b. Capacity development of regional institutions and networks to provide leadership and technical assistance Capacity building of institutions in the West Africa region is a central element in USAID/WA’s health portfolio. This is captured in result 3 of SO5 which is, “increased capacity of regional institutions and networks.” To what extent have the capacity building activities of USAID/WA resulted in regional organizational change and adoption of sustainable approaches in implementation, management, monitoring and evaluation of health programs? The Team should note that a significant portion of activities under initial plans was to have Centers for Disease Control (CDC) under an IAA with USAID/WA implement a large portion of this activity but the emergence of PEPFAR and its tremendous demands led to CDC pulling out. In response to this question, the assessment team will: • Determine the extent to which USAID/WA’s capacity building activities with selected international donors, institutions and networks are contributing to make the needed technical assistance in the various technical areas more available in the sub-region; • Determine the extent to which USAID/WA capacity building activities have resulted in an increased ability of regional and selected national organizations to implement and support activities to strengthen health systems; • Determine the effectiveness of the process used by USAID/WA in identifying partners, particularly African institutions, and the successes, constraints, and gaps in working with these partners towards the achievement of SO5 results; • Determine the impact of the withdrawal of the Centers for Disease Control and Prevention (CDC) from the Capacity Building Inter-Agency Agreement between USAID and CDC, on the capacity building activities of USAID/WA; • Make recommendations based on lessons learned in USAID/WA’s capacity building efforts on what capacity building activities should be continued, changed, eliminated or expanded in the remaining strategy period. 1c. Policy Change and Development 70 An improved policy environment is a stated outcome of USAID/WA’s regional strategy. This is expected to be achieved through increased advocacy by stakeholders in the West Africa region. The assessment team will determine USAID/WA’s progress towards this result, by determining the success of the regional health program in supporting the creation of an enabling policy environment that allows the Reproductive Health, STI/HIV/AIDS, Child Survival, and Infectious Diseases agenda in the West Africa Region to move forward. Specifically the team will: • Determine if the international and regional institutions and networks that have partnered with USAID/WA/SO5 demonstrate concrete (and documented) contributions to improving the policy environment and/or the quality and quantity of service provision in the above areas; • Determine the extent to which advocacy plans are being developed and implemented in the region, as well as the number of countries that have adopted international/regional agreements supported by USAID/WA; and • Determine the extent to which countries in the region are actually implementing specific international agreements. 1d. Health Sector Reform While this aspect of the program has been rolled into the other three IRs, for the purpose of this assessment the team will review activities that were implemented under this IR and identify successes and gaps, and determine how these activities can be better integrated into the other 3 IRs. The team will focus on activities that include community financing schemes, health care management systems, commodity security plans, and other health system reforms. 2. What lessons can be learned from the USAID/WA implementation process and results, and what are the implications for a regional approach to health programming under the new Agency strategy with a focus on fragile and transformational development states, and the President’s Emergency Plan for AIDS Relief? 2a. The Value of a Regional Approach to Health Programming In general, a regional approach to health programming can complement, support, and strengthen country programs. It can provide added value by strengthening regional institutions, networks, structures, and systems to provide support to country agendas. Regional approaches can also help countries develop and implement policy and share information and other resources. In view of this, to what extent has the USAID/WA program contributed to advancing regional health agendas and strengthened sustainable health networks and institutions in the West African region through the approach of building on the political mandate of regional institutions such as ECOWAS? In addressing this issue, the assessment team will: • Determine USAID/WA’s contribution to bilateral mission activities, non-presence country activities, and regional health agendas; • Determine USAID/WA’s contribution to the 2-7-10 goals of the President’s Emergency Plan for AIDS Relief, as well as the expanded mandate of the Office of the Global AIDS Coordinator (OGAC) which encompasses all USG HIV/AIDS programs. • Identify the key factors and elements of USAID/WA's regional strategy that have added value to USAID’s investments in the region and to investments by other donors, multilateral organizations (e.g., UNFPA, WHO), and global partnerships (e.g., GFATM); • Determine USAID/WA’s comparative advantage to implement the USAID Africa Bureau strategy. 71 • Determine USAID/WA/SO5’s strengths and weaknesses in terms of SO5 management, coordination and communication with regional and international partners and USAID/Washington • Does a regional program contribute to improved access, coverage, quality and sustainability of service delivery? If so, how? IV. METHODOLOGY The assessment will by conducted by a six-member team to be identified by USAID and its regional stakeholder partners. Data will be collected through primary and secondary sources. This will include (1) In-depth interviews with key informants, (2) identification and review of relevant documents. The team will make field visits to selected countries in the region. Country visits will be used principally to answer assessment questions that cannot reasonably be answered in any other way. The benefit of country visits is that they enable the assessment team to verify and better understand information in reports, and to hear the views of local program partners. USAID/WA will also arrange for representatives of selected partner organizations to visit Accra, Ghana, where they will meet and be interviewed by the team members. Pre-Field Visit Technical Support Because the team will be spending a limited time in the field (approximately 2 weeks), prior to their visit USAID/WA will provide technical support to its partners through the Africa’s Health in 2010 Project. The support will help the partners identify and assemble relevant data on program activities and results, so they are easily accessible to the assessment team when they arrive. This will allow the team to use its time in the field most efficiently. In-Depth Interviews with Key Informants The assessment team will conduct qualitative in-depth interviews with key stakeholders and partners. The team will develop a structured interview guide that will be used to guide the interview process. The interviews should be loosely structured, but following the list of questions in the guide. The interviewer should probe for information and takes notes as necessary. Interviews will be conducted through face-to-face contact or by telephone. Whenever possible, the assessment team should conduct face-to-face interviews with informants. This will involve traveling to at least the two African inter-governmental partner institutions in Burkina Faso (WAHO: definite) and Mali (CERPOD: probable). The assessment team also is expected to interview USAID Mission PHN staff. Some respondents from other countries may travel to Ghana where they could meet with the team for interviews. In order to obtain the perspectives of beneficiary institutions, the team should interview some of the technical leadership institutions and networks that have been supported though the capacity building activities of the two AWARE projects (a list of these, and contacts at each, will be provided). Additional interviews may be included per consultations between USAID/WA and the assessment team. Implementing Field Support partners with limited Field presence will also be interviewed. Identification and review of relevant documents USAID/WA and its partners will work with the consultants to make background materials available for review and content analysis by the consultants. Prior to field work, consultants will be given as many relevant background materials as possible. The team is also expected to collect and annotate additional documents and materials, which it will make available to USAID/WA/SO5 for future use. The team will review all available materials prior to conducting key informant interviews and as necessary throughout the course of the assessment. Documents may include but are not limited to the following: 72 1. USAID/WA, September 12, 2004, "Performance Management Plan: SO5 Increased Adoption of Sustainable RH, STI/HIV/AIDS, and Child Survival Policies and Approaches in West Africa." 2. USAID, 2000, "Strategic Plan FY2001-2008 for the West Africa Regional Program (USAID/WA)." 3. USAID, 2005, "West Africa Regional Program: Regional Strategy Statement 2006-2010 - (DRAFT not for circulation)." 4. USAID, 2003, "West Africa Regional Health Program: HIV/AIDS Strategy." 5. WAHO, 2005, “Communication Strategy: FY2005-2010” 6. WAHO, 2003, “Five-Year Strategic Plan of the West African Health Organization (WAHO): FY2003-2007” 7. AWARE-RH and HIV Annual Reports (FY2004 and 2005) 8. AWARE-RH and HIV Work Plans (FY2006) 9. WAHO Annual Report 2004, 2005 10. Office of the Global AIDS Coordinator, “U.S. Five-Year Global HIV/AIDS Strategy” 11. Office of the Global AIDS Coordinator, “First Annual Report to Congress” 12. CERPOD Annual Report 2004, 2005 13. Terms of Reference and if possible, report of Regional HIV/AIDS Program Review V. LEVEL OF EFFORT An independent assessment team will be identified to conduct the evaluation (See Section X, Personnel). The performance period for the actual assessment will begin o/a March 15 with preparation and will end on June 15, 2006 with the submission of the final report. The following table estimates overall level of effort (LOE) expected during that performance period. The SO5 team and the team leader will identify and select the evaluation team, and then will determine the final schedule for the evaluation. The LOE of each Team Consultant may vary based on responsibilities assigned to each member. Throughout the evaluation, the team will coordinate with the USAID/WA program office and with the Africa Bureau and Global Health technical staff, and relevant technical contractors and cooperating agencies. Task/Deliverable LOE Team Leader LOE (x2) US-based/ Team Consultants LOE (x3) Field/Team Consultants 1. Preparation: - Prepare individual scopes of work - Conduct team building exercises to determine division of labor, team roles and responsibilities, 7 days (in DC) 3 days 2 days 73 Task/Deliverable LOE Team Leader LOE (x2) US-based/ Team Consultants LOE (x3) Field/Team Consultants methodology (Washington and electronically with field) - Develop interview instruments - Review background documents 2. Preparation: Advance in Ghana 3 days 3. Site Visit as team (17 days on site country, team members arrive on April 23, to start work on April 24, departure date May 9), during which: - Meet with USAID/WA SO5 team and Program Office - Finalization of interview instrument - Information and data collection. Includes: interviews with key informants (including partners, PHN officers, and Embassy contacts) in Benin, Burkina Faso, Ghana, Mali, Togo, and telephone interviews and electronic communication with others outside these countries. - Draft assessment report in country - Debrief with SO5 team - Debrief with senior mission staff (May 8) - Initial draft submitted to USAID/WA 17 days 17 days 17 days 4. Follow-up: (In DC and by electronic communication) - Finalize draft (initial comments from USAID/WA; editorial and final comments put into draft) - Submit draft to USAID for review, request for return comments within 10 days - Prepare final evaluation report - Prep for and briefings for Washington Staff 7 days 4 days 2 days Total # days, not to exceed 34 days 24 days 21 days VI. DELIVERABLES A. Draft Questionnaire The team will develop a draft questionnaire that will include questions that will guide the review of documents, and the in-depth interview of key informants. The questions will be reviewed by USAID prior to use by the team. B. Debriefing Meetings The assessment team will conduct debriefings for the SO5 team and senior mission staff. This will include the preparation and delivery of a PowerPoint presentation which summarizes the team’s principal findings, including lessons learned from the USAID/WA implementation and results. C. Draft Report Prior to their departure, the assessment team will provide the Program Office and SO5 team with a draft report that includes all the components of the final assessment report. Each of the SO5 team members 74 should receive a hard copy of the report and the team should also provide at least one electronic copy of the report in Word format. USAID will provide comments on the draft report to the assessment team leader within 10 working days of receiving the report. D. Final Assessment Report The team leader is then required to submit a final report within 10 working days after USAID provides feedback on the draft report. The final report is to be submitted to the USAID/WA/SO5 team both in hard copy (10 copies) via express mail and in electronic form. At a minimum, the final assessment report should include the following: Evaluation Objective, scope and methodology used; important findings (empirical information collected by the team); lessons learned (implications for future designs and for others to incorporate into similar programs); conclusions (the team’s interpretations and judgments based on the findings); and recommendations (proposed actions for management and the SO5 technical team based on the conclusions). VII. TEAM COMPOSITION A six-member assessment team is requested. Three will be from USAID/Washington (either staff or consultants) and three from the West Africa region. The team should have the following skills mix: 1. Public health expertise in reproductive health/family planning and HIV/AIDS, and preferably in others, including: • Maternal and Child Health • Nutrition • Health care financing, logistics, and drug management • HIV/AIDS /STI and Infectious Diseases, particularly malaria 2. Organizational development and institutional capacity building expertise 3. Understanding and hands-on knowledge of USAID 4. Knowledge and experience with the President’s Emergency Plan for AIDS Relief 5. Knowledge of ECOWAS/WAHO visions and experience developing and implementing international health programs in West Africa 6. Monitoring and evaluation of health programs including data management and analysis 7. Financial/grants management expertise Each team member should have at minimum: • An advanced degree in health sciences, an MPH or commensurate experience • Eight or more years’ experience working in health, with experience in West Africa highly desirable • Bilingual French-English skills In addition, the team leader must have excellent team coordination and English language skills (both written and verbal) as s/he will have the overall responsibility for the final report. VIII. RELATIONSHIPS AND RESPONSIBILITIES 1. Overall Guidance: The USAID Program Office and SO5 Team will provide overall direction to the assessment team. 75 2. USAID/WA Contact: The USAID/WA Program Office, assisted by the Health Team Leader (or Acting Team Leader) will be the official contact for the assessment team pre-assessment, while in country, and post assessment. 3. Responsibilities: • USAID/WA/SO5 will be responsible for obtaining country clearances for travel. • USAID/WA/SO5 will be responsible for coordinating and facilitating initial assessment-related field trips, interviews, and meetings. • USAID/WA/SO5 will assist the assessment team with all logistical arrangements and subsequent arrangements as needed. • The Agency section covering each team member’s participation will be responsible for all costs incurred in carrying out this review. The proposed cost may include, but not be limited to: (1) international and regional travel; (2) lodging; (3) M&IE; (4) in-country transportation; and (5) other office supplies and logistical support services (i.e., paper, communication costs, and teleconferencing cost, if needed, due to current travel restrictions). Ideally, each team member should have a personal laptop computer. • As there is no single Agency funding everyone on the team USAID/WA will take the responsibility of providing a greater amount of back stop assistance than is indicated above. 76 Appendix B: References Action for West Africa Region, Monitor, Volume 1, Issues 1-2, 2005 and Volume 2, Issue 1, 2006 Action for West Africa Region, Reproductive Health (Engender Health and Partners), Annual Reports, FY2004 and 2005 Action for West Africa Region, Reproductive Health (Engender Health and Partners), “Avoiding Preventable Child Mortality in West Africa.” 2006 Action for West Africa Region, Reproductive Health (Engender Health and Partners), “Contraceptive Commodities.” 2006 Action for West Africa Region, Reproductive Health (Engender Health and Partners), “Description of AWARE-RH Promising and Best Practices.” 2006 Action for West Africa Region, Reproductive Health (Engender Health and Partners), “Institutional Capacity Development, Strategic Plan, 2003-2005.” June 2005 Action for West Africa Region, Reproductive Health (Engender Health and Partners), “Key Performance Indicators for FY and Targets for FY06.” 2006 Action for West Africa Region, Reproductive Health (Engender Health and Partners), “Policy Environment for Addressing Reproductive Health and Family Planning in the West Africa Regional,” Paper prepared for the Policy Advisory Meeting on Reproductive Health and Child Survival.” Accra Ghana, June 12-15, 2004 Action for West Africa Region, Reproductive Health (Engender Health and Partners), “Indicators and Results, October 1, 2003 – April 30, 2006.” April 2006 Action for West Africa Region, Reproductive Health (Engender Health and Partners), “Plan of Action for the Integration and Capacity Development of the Institutions and Networks collaborating with AWARE-RH.” March 2004 Action for West Africa Region, Reproductive Health (Engender Health and Partners), Power Point Presentation: “Mid-Term Assessment of the Aware-RH Project.” May 2006 Action for West Africa Region, Reproductive Health (Engender Health and Partners), “Profile of AWARE-RH Collaborating Technical Learning Institutions and Networks, April 2005 Action for West Africa Region, Reproductive Health (Engender Health and Partners), “Situation Analysis of Policies and Strategies for Reproductive Health in the West Africa Region.” December, 2004 Action for West Africa Region, Reproductive Health (Engender Health and Partners), “Supporting Advocacy for Maternal and Neonatal Health in Burkina Faso.” 2006 Action for West Africa Region, Reproductive Health, (Engender Health and Partners) Workplan, 2006 Action for West Africa Region, HIV/AIDS, (Family Health and Partners), Annual Reports, FY2004 and 2005 Action for West Africa Region, HIV/AIDS, (Family Health and Partners), “ Building the Capacity of Regional and Institutions and Networks.” 2006 Action for West Africa Region, HIV/AIDS (Family Health and Partners), “Description of AWARE-RH Promising and Best Practices.” 2006 77 Action for West Africa Region, HIV/AIDS, (Family Health and Partners), Power Point Presentation: “Overview of the Aware-HIV/AIDS Project.” May 2006 Action for West Africa Region, HIV/AIDS (Family Health and Partners), Workplan, 2006 “Assessment of the Contribution of Regional Programs to the President’s Emergency Plan for AIDS Relief,” Submitted to the Office of the U. S. Global AIDS Coordinator, March 31, 2006 (Draft, not for circulation) “Assessment of International Approaches to Regional Operations,” by Judith Justice for the Global AIDS Program, Centers for Disease Control and Prevention. Atlanta, 2002 Completed Questionnaires for the Mid-term Assessment of the USAID/West Africa Regional Health Strategic Objective 5, April 2005, including: Bilateral Programs: Action for West Africa Region, Reproductive Health, Engender Health Action for West Africa Region, HIV/AIDS, Family Health International Center of Studies and Research on Population for Development West Africa Field Support or Other Programs ACCESS, John Hopkins Program for International Education in Obstetrics and Gynecology (Prime) DELIVER, John Snow, Inc, and PATH, Grown Agents Consultancy, Manoff, Boston University, SSDS, Synaxis, and George Washington University Malaria Action Coalition, West Africa Program, Centers for Disease Control, ACCESS, World Health Organization/AFRO, RPMplus Hope for African Children Initiative Policy and the Policy Development Project, The Futures Group and Center for Development and Population Activities MEASURE/Evaluation MEASURE/Macro DHS+ NETMARK Africa Regional Malaria Program Rational Pharmaceutical Management Plus Cameroon Baptist Convention Health Board, AIDS Control and Prevention Program, Prevention of Mother-to-Child Transmission of HIV, Quarterly Report, March 2006 Center of Studies and Research on Population for Development, Annual Report 2004 and 2005 Office of the Global AIDS Coordinator, “U.S. Five-Year Global HIV/AIDS Strategy,” 2005 Office of the Global AIDS Coordinator, “First Annual Report to Congress.” 2005 “Knowledge Utilization and the Process of Policy Formation: Toward a Framework for Africa” by Robert W. Porter with Irvin Hicks, Porter, Novelli, and Associates for USAID, Bureau of Africa, Office of Sustainable Development, Washington, DC, January 1995 USAID/Bureau of Africa, Office of Sustainable Development, Strategic Plan, FY1998–2003, Washington, D.C., 2000 USAID/West Africa, "Performance Management Plan: SO5 Increased Adoption of Sustainable RH, STI/HIV/AIDS, and Child Survival Policies and Approaches in West Africa," September 12, 2004 USAID/West Africa, Health Budget Breakdown, FY2005-2006, April 2006 USAID/West Africa, “Health Budget Allocations, FY2004-2006, April 2006 78 USAID/West Africa, “Health Program Geographic Matrix, April 2006 USAID/West Africa, “Health Program: Program Achievements, Regional Functions, Future Directions and Challenges.” April 2006 USAID/West Africa, “Performance Management Plan: S05 – Increased Adoption of Sustainable RH, STI/HIV/AIDS, and Child Survival Policies and Approaches in West Africa.” September 14, 2004 USAID/West Africa, Power Point, “ Debrief for the Office of the AIDS Coordinator’s Review of the Regional HIV/AIDS Program.” February 21, 2006. USAID/West Africa, Power Point, “Debrief for the Mid-term Assessment Team for the Regional Health Program.” April 2006 USAID/West Africa, “OGAC Regional HIV/AIDS Platform Review: USAID/West Africa Perspective on Overarching Questions.” February 2006. USAID/West Africa, “Strategic Objective 05 (Health), Cross-Sectoral Efforts.” April 2006 USAID/West Africa, “Strategic Framework for the Health Strategic Objective.” 2003 USAID/West Africa, "Strategic Plan FY2001-2008 for the West Africa Regional Program.” 2000 USAID/West Africa, "West Africa Regional Program: Regional Strategy Statement 2006-2010.” 2005 (DRAFT not for circulation). USAID/West Africa, "West Africa Regional Health Program: HIV/AIDS Strategy. " 2003 West Africa Health Organization, “Communication Strategy: FY2005-2010.” 2005 West Africa Health Organization, “Five-Year Strategic Plan of the West African Health Organization: FY2003- 2007.” 2003 West African Health Organization, Annual Reports, 2004 and 2005 World Health Organization, Regional Institute of Public Health (Benin), “Briefing Paper-History and Mission.” May 2006 79 Appendix C: List of Informants The mid-term assessment team gathered information through a series of interviews and site visits. This Annex provides a list of individuals who provided the mid-term assessment team with information via meetings, briefings during site visits, telephone interviews and electronic correspondence. USAID/West Africa Jatinder K. Cheema Mission Director Felix Awantang Mission Deputy Director Jamie Browder Senior Regional HIV/AIDS Advisor Kristin Cooney Senior Regional Reproductive Health/Child Survival Advisor Sosthene Bucyana Senior Regional HIV/AIDS Specialist Seydou Doumbia Senior Regional RH/CS/IS Specialist Letitia Sam Senior Regional Capacity Building Specialist Ariane Kwantreng Administrative Assistant, USAID/WA Gregory Vaut Regional Alliance Builder USAID/Washington Hope Sukin Team Leader, Health, Bureau for Africa Alan Bornbusch West Africa, Country Team Leader, Bureau for Global Health Janean Martin AIDS Liaison, Office of HIV/AIDS, Bureau for Global Health Roxana Rogers Deputy Director, Office of HIV/AIDS, Bureau for Africa Michelle Wu Field Support Coordinator, Office of HIV/AIDS, Bureau for Africa Gordon Bertolin Acting Director, Bureau for Africa/West Africa Crystal Garrett Desk Officer, Bureau for Africa/West Africa AWARE-RH Isaiah Ndong Project Director Jeanne Rideout Deputy Project Director Alex Kwasi Nazzar Monitoring and Evaluation Specialist Adama Kone Child Survival Specialist Fatimata Diabate Sambou Senior Reproductive Health Advisor Jean Affo Technical Advisor for Social Marketing Simon Nchifor Anyam Family Planning Advisor Badara Seye Policy and Advocacy Senior Advisor Carmen Coles Advocacy Advisor Fara Mbodj Institutional Strategy Technical Advisor Mohamed Oubnichou Health Sector Reform Senior Advisor Mamadou Ba Institutional Capacity Development Senior Advisor Abdoulaye Ba Mutual Health Organization Officer Antoine Ndiaye Commodity Security Specialist Tiamiyou Radji Regional Information Technology Specialist Mary O. Anim Administrative Assistant Koffi Agbedo Komassi Operations Manager 80 Stephane Ayivi Accounts Officer Eugenia Oppong-Aidoo Secretary/Receptionist AWARE-HIV Fatimata Sy Director Claudes Kamenga Deputy Director Martin Laourou Advocacy and Policy Marie-Louise Baleng Behavior Change, Social Marketing and Ambassador’s Fund Dipoko Embola Degrando Technical Officer - Cross Border Interventions Sophie Cowppli-Bony Program Officer-WAAF Abo Kouame Technical Officer Mamadou Alpha Bah Senior Capacity Officer Assole Dabire Associate Director, Finance and Administration Agnes Cash-Abbey Senior Technical Officer Gilles Bokpe Regional Economic Advisor Angela Bannerman Monitoring and Evaluation Officer Harvey De Hardt-Kaffils Communication and Marketing Officer Bernardin Gatete Program Officer Jane Owiredu Yeboah Senior Finance Assistant Patience D. Bledu Senior Administrative Assistant Boukari Conombo Finance Officer Patrick Addai Accountant Joseph Ofosu IT Victoria Y. Mawugbe Administrative Assistant Caroline Briandt-Coker Administrative Assistant Evelyn Ngarnaye Administrative Assistant Karen Maryse Radji Bilingual Receptionist Samuel Hokey Office Assistant Benin Justin Koffi Executive Secretary, World Bank Corridor Program Ines Adingni Team Leader, World Bank Corridor Program Khaled Bessaoud Director, WHO Regional Institute of Public Health (IRSP) Michel Kouakou Administrator, Institut Régional de la Santé Publique M. Auguste Sagbohan Economic Planner, Ministry of Health Hon. Bani Leon Bio Bigou Parliamentarian Jim Malstar Resident Representative, Population Services International Heather Robinson Reproductive Health Advisor, Population Services International 81 Don Dickerson Deputy Director, Health Office, USAID/Benin Burkina Faso Kabba Joiner Director General, West Africa Health Organization (WAHO) Albert K. Ouedraogo Program Officer, WAHO Ismail Thiam Program Officer, Nutrition and Child Survival,WAHO Doulaye Sacko Coordinator Vision 2020, WAHO Ibnou Deme Program Officer Transmissible Diseases, WAHO Sansan Stanislas Kambou Program Officer, WAHO Galandou Gorre-N’diaye Human Resource Operations Manager, WAHO Moctar Traore Program Officer, Information Dissemination Publication, WAHO Pierre Thomas Hien Internal Auditor, WAHO Prof. Angela Okolo Program Officer, Maternal & Prenatal Health, WAHO Salifou Zouma DPTA, WAHO Stephen Nartey DAF, WAHO Cameroon Daniel Agoons Special Projects Coordinator, US Embassy/Cameroon Charlotte Chendjou Administrative Officer, Care and Health Program (CHP) Martin Fetue Tokam Program Officer, CHP Medang Raphael Senior Program Officer, CHP Boupda Kuate Aubin Alexis Executive Manager, CHP Theresa Gruber-Tapsoba Director, Cameroon Association for Social Marketing (ACMS) Maurice Kwite Program Manager, ACMS Prof. Tih Pius Muffih Director, Cameroon Baptist Convention Health Board (CBCHB) Charles Moses M&E and PMTCT Specialist, CBCHB Forgivei Gideon CIACP Supervisor, CBCHB Joseph Nkusai Administrator, CBCHB Eveline Mboh AWARE Coordinator, CBCHB Vilma Karawa ACP Secretary, CBCHB Lauretta Kometa Yonefab Coordinator S. W. P, CBCHB Fonymy Silvia ACP Staff, CBCHB Irene Ndong Accounts Clerk HSC, CBCHB Dorcas Waindim M & E Officer, CBCHB Alexander Wrytter CMO, BHM, CBCHB Monju Johnson Accountant, AWARE-Support Activities, CBCHB Paul Agho ACP Staff, CBCHB Bih Malise FUL ACP Staff, CBCHB Hezier Nana Director, SAILD (Service d’Appui aux Initiatives Locales 82 de Développement Tatia Goum Patricia Animatrice, SAILD Stephen Ngenchi Supervisor, SAILD Ngamngne Louise Angeline Animatrice, SAILD Yanguet Harriette President, BINUM, Bameka Mutual Health Organization (MHO) Fossi Sylveste President, Bameka MHO Menzening Adamou Participant, Bameka MHO Fandie Simeon Participant, Bameka MHO Tchiasseu Yeannette Participant, Bameka MHO Rose Nana Participant, Bameka MHO Fogaung Christophe Mutuelle, Secretary-General, Bameka MHO Yimning Ng. Pulcherie Mutuelle, Vice President, Bameka Magotsing Martin CAMB Member, Bameka MHO Mameke Sejfare CAMB Member, Bameka MHO Djoussi Edithe Lucienne CAMB Member, Bameka Djnissi Rose CAMB Member, Bameka Tounam Pauline CAMB Member, Bameka Fotsing Jacob CAMB Member, Bameka Dr. Djibrilla Kaou Director, Family Health, Ministry of Public Health Dr. Nicole Eteki Chief, Service of Maternal Health, Ministry of Public Health Dr. Inoussa Nsangou Deputy Director, Reproductive Health, Ministry of Public Health Ghana Amey Kouwonou Regional HIV/AIDS Advisor, UNHCR Gifty Akosua Baka Society of Women Against AIDS in Africa Khonde Nzambi National Coordinator, WAPCAS Mali Baba Traore Chief Department, Center for Studies and Research on Population for Development (CERPOD) Reffing Dabo Specialist in Policies and Strategies for Population, CERPOD Andre Zombre Financial and Administrative Manager, CERPOD Diarra Fadema Change de Banque de donnees et documentation, CERPOD Amadou Diarra Dream/Couite Sahelien les Pesticides, CERPOD Khassoum Dieye Dream/GRN, CERPOD Coulibaly Aguibou Chief UCID, CERPOD Dr. Dmadou Mustapha Director General INSAH, CERPOD Akpene Dzikum Accountant, CERPOD Modigo Maiga PDI Toumani Sidibe CREDOS 83 Christine Sow Health Team Leader, USAID/Mali Togo Jack Diffily Deputy Chief of Mission US Embassy/Togo Rona Rathod Political/Economics Officer, US Embassy/Togo Manya Andrews Country Representative, PSI K. D. John Agbodjavou Senior Technical Advisor, JHPIEGO Amoutou Amegonona Monitoring and Evaluation Specialist, JHPIEGO 84 Appendix D. Socio-Economic and Health Indicators Country Population (mid-2004) millions Average annual Populati on growth rate % per year Under 5 mortality Rate per 1,000 live births 2003 Fertility Rate Physicians per 100,000 (1990-2000) Maternal Mortality Rate Per 100,000 live births 2000 Dependency Rate % of Population age <15 Child Malnutrition Under￾weight for age % of Children < 5 (1995-2003)* Adult HIV Prevalence (2003) % of population aged 15-49 Access to Contraceptives % of Married women 15-49 All Modern West Africa 263 2.8 5.8 44 4.3 14 8 Benin 7.3 2.7 154 5.6 6 850 46 23 1.9 19 7 Burkina Faso 13.6 2.6 207 6.2 4 1000 46 34 1.8 14 9 Cape Verde 0.5 2.3 4.0 42 53 46 Côte d’Ivoire 16.9 2.0 192 5.2 9 690 43 21 7.0 15 7 Gambia 1.5 2.9 123 5.6 4 540 45 17 1.2 10 9 Ghana 21.4 2.2 95 4.4 9 540 40 25 2.2 25 19 Guinea 9.2 2.7 160 6.0 9 740 45 23 3.2 6 4 Guin-Bissau 1.5 3.0 204 7.1 17 1100 47 25 8 4 Liberia 3.5 2.9 6.8 47 5.9 Mali 13.4 3.3 220 7.0 4 1200 49 33 1.9 8 6 Mauritania 3.0 2.7 183 5.9 14 1000 43 32 0.6 8 5 Niger 12.4 3.5 262 8.0 3 1600 50 40 1.2 14 4 Nigeria 137.3 2.9 198 5.7 27 800 44 29 5.4 12 8 Senegal 10.9 2.6 137 5.1 8 690 44 23 0.8 11 8 Sierra Leone 5.2 2.1 284 6.5 7 2000 44 27 4 4 Togo 5.6 2.7 140 5.5 6 570 46 25 4.1 26 9 Cent. Africa 107 2.8 6.4 47 5.0 25 5 Cameroon 16.1 2.2 166 4.9 7 730 43 21 6.9 26 8 Gabon 1.4 2.1 91 4.3 29 420 42 12 8.1 33 12 Chad 9.5 3.2 200 6.8 3 1100 48 28 4.8 8 2 ST & P 0.2 2.8 118 4.3 47 41 13 29 27 Eq Guinea 0.5 2.6 146 5.9 25 880 44 19 Sources: UN Human Development Report 2005, PRB Fiche de Données sur la Population Mondiale 2004 * Statistic for latest year available within range 85 Expenditures on Education 2000-2002* Expenditures on Health 2002 Country GDP per capita $US 2002 Adult Literacy Rate Safe water % of population with sustainable access 2002 Improved Sanitation % of population with sustainable access 2002 Human Development index Rank with 177 countries 2005 Poverty Levels 1990-2003* % of Population living on <$1 <$2 per day % of GDP % of Total Government Expenditure s Public spending % of GDP GDP Per capita spending $US West Africa 1070 Benin 1060 34 68 32 162 3.3 2.1 44 Burkina Faso 1090 13 51 12 175 45 81 2.0 38 Cape Verde 4920 Côte d’Ivoire 1450 48 84 40 163 11 38 4.6 21.5 1.4 107 Gambia 1660 38 82 53 155 59 83 2.8 8.9 3.3 83 Ghana 2080 54 79 58 138 45 79 2.3 73 Guinea 2060 41 51 13 156 59 83 1.8 25.6 0.9 105 Guin-Bissau 680 40 59 34 172 3.0 38 Liberia Mali 860 19 48 45 174 72 91 2.3 33 Mauritania 1790 51 66 42 152 26 63 2.9 54 Niger 800 14 46 12 177 61 85 2.3 2.0 27 Nigeria 800 67 60 38 158 70 91 1.2 43 Senegal 1540 39 72 52 157 26 68 3.6 2.3 62 Sierra Leone 500 30 57 39 176 57 75 3.7 1.7 27 Togo 1450 53 51 34 143 2.6 13.6 1.1 163 Cent Africa 1130 Cameroon 1910 68 63 48 148 17 51 3.8 17.3 1.2 68 Gabon 5530 71 87 36 123 3.9 1.8 248 Chad 1010 26 34 8 173 2.7 47 ST & P 83 79 24 126 9.7 108 Eq Guinea 9110 84 44 53 121 0.6 1.6 1.3 139 Sources: UN Human Development Report 2005, PRB Fiche de Données sur la Population Mondiale 2004 * Statistic for latest year available within range 86 Appendix E. USAID/WA Health Program Geographic Matrix USAID Type of State GFATM Country US Embassy Bilateral Presence Limited or Non Presence (USAID/WA or USAID staff) PEPFAR Focus Transformational Development Fragile Strategic ECOWAS CILSS HIV TB Malaria AI Infection Confirmed Benin X X X X X X X Burkina Faso X (USAID/WA Education PSC for MCA project) X X X X X X X Cameroon X X X X X X X Cape Verde X X X X X Chad X (USAID/WA PSC for Conflict Initiative) X X X X Côte D’Ivoire X (USAID/WA PSC coordinates USAID PEPFAR portfolio) X X X X X Confirmation expected Equatorial Guinea Handled by Cameroon (USAID/WA PSC to be contracted) X X Gabon X X To be determined (higher income country) X X The Gambia X X X X X X X X Ghana X X X X X X X Guinea X X X X X X X Guinea Bissau Handled by Senegal X X X X X X X Liberia X X X X X X X X Mali X X X X X X X X Mauritania X X X X X X X Niger X (USAID/WA PSC to coordinate USAID portfolio to be contracted) X X X X X X X 87 Nigeria X X (USAID/WA PSC coordinates with ECOWAS) X X X X X X X X Sao Tome & Principe Handled by Gabon X X X X Senegal X X X X X X X Sierra Leone X (USAID Office but no Mission-twins with USAID/ Guinea) X X X X X Togo X X X X X X X X 88 U.S. Agency for International Development 1300 Pennsylvania Avenue, NW Washington, DC 20523 Tel: (202) 712-0000 Fax: (202) 216-3524 www.usaid.gov