Health PAD 2016_2021.pdf

Health Project 2016-2021 Project Appraisal Document (PAD)

Procurement sensitive (USG Only)

August 6, 2015

Procurement Sensitive

USAID/Senegal 2016-2021 Health PAD 1

Table of Contents

List of Acronyms I. Executive Summary II. Relationship to Mission CDCS, Results Framework and Other Mission Projects III. Relationship to Partner Country and Other Donor Projects

A. Relationship to Partner Country B. Relationship to Other Donors Projects

IV. Project Description A. Background and Problem Statement B. Project Description

V. Implementation Mechanisms, Participating Institutions and Management Plan A. Implementation Mechanisms and Procurement Plan B. Participating Institutions and Local Actors C. Management Plan

Annexes

Annex A: CDCS DO2 Results Framework – Current and Proposed Annex B: Donor Analysis and Mapping Annex C: Executive Summary: Mid-Term Evaluation of USAID Senegal Health Program Annex D: Expanded Project Description Annex E: Institutional Analysis Annex F: Executive Summary Gender Assessment Annex G: Key Child and Maternal Indicators by Region Annex H: List of MNCH/Family Planning High-Impact Interventions and Priority Services Annex I: Sustainability Analysis Annex J: Acquisition and Assistance Strategy Annex K: Draft Health Team Structure (2016-2021) Annex L: Financial Plan: Estimated Project Cost and Health PAD Budget Summary Annex M: Environmental Analysis: Initial Environmental Examination (IEE) Annex N: Health Project Logical Framework Annex O: CDCS Indicators and Targets Annex P: Technical Orientations Annex Q: Policy Agenda Annex R: Waiver of Manufacture and Source Requirements

USAID/Senegal 2016-2021 Health PAD 2

List of Acronyms

A&A Acquisition and Assistance Strategy AIDS Acquired immune deficiency syndrome AMTSL Active management of the third stage of labor ARI Acute respiratory infection ARV Anti-retroviral BCC Behavior change communication CDCS Country Development Cooperation Strategy C-DHS Continuous Demographic Health Survey CHW Community health workers CSW Commercial sex workers DRG Democracy, Human Rights and Governance DCA Development Credit Authority DHS Demographic Health Survey DRG Democracy, Human Rights and Governance DO Development objective ELMIS Electronic Logistics Management Information System EPCMD Ending Preventable Child & Maternal Deaths FARA Fixed-amount reimbursement agreement FGM Female genital mutilation FTF Feed the Future G2G Government-to-government GBV Gender-based violence GOS Government of Senegal HMIS Health Management Information System HIV Human immunodeficiency virus HPN Health, Population, and Nutrition Office HR Human Resources HRH Human resources for health HRIS Human resources information system HSS Health systems strengthening ICT Information and Communication Technologies iHRIS Open source health workforce information system IP Implementing partner IR Intermediate Result IRS Indoor Residual Spraying KMC Kangaroo Mother Care M&E Monitoring and evaluation MARP Most at-risk population MCH Maternal and child health MCPR Modern contraceptive prevalence rate MHO Mutuelle Health Organization MNCH Maternal, newborn and child health MOE Ministry of Education MOH Ministry of Health MSM Men who have sex with men NTD Neglected Tropical Diseases

USAID/Senegal 2016-2021 Health PAD 3

PBF Performance-based financing PMP Performance monitoring plan PMTCT Prevention of mother-to-child transmission of HIV PNDS National Health Development Plan PNLP National Malaria Control Program PNSSC National Community Health Strategy PPH Post-partum hemorrhage RH Reproductive health SBCC Social and behavior change communication SP Sulfadoxine-pyrimethamine STI Sexually-transmitted infection Sub-IR Sub-Intermediate Result TFR Total fertility rate TWG Technical working group VCT Voluntary counseling and testing WASH Water, sanitation, and hygiene

USAID/Senegal 2016-2021 Health PAD 4

Figure 1: Project Purpose: Improved Health Status of the Senegalese Population Coverage: 7 regions with a package of priority, high-impact reproductive, maternal, neonatal, and child health (RMNCH) services; 7 regions with targeted direct funding to maintain and increase gains in RMNCH; and national coverage for malaria, family planning and select health system strengthening activities.

Priority Populations Children under 5 Women of reproductive age (15-49) Young adolescent girls (10-14) Youth (10-24) Most At-Risk Populations for HIV

Methods Provision of high-impact RMNCH services Strategic use of direct funding to Ministry of Health at central level and in 7 regions Emphasis on individuals and communities Social and behavior change activities addressing gender, youth issues, service demand, and community health financing Strengthening of select national health systems Impact/Expected Results Access to quality, priority health services increased for targeted populations Performance of health systems strengthened Positive health behaviors adopted Communities more able to meet health needs

I. Executive Summary

Despite serious health constraints, Senegal has achieved notable results over the last two decades, largely due to improved health interventions. Between 1997 and 2014, there has been a 61% decrease in under-five child mortality1 (U5MR), among the fastest reductions in sub-Saharan Africa, and Senegal is on track to meet MDG 4, a two-thirds reduction in child mortality between 1990 and 2015. Most recently, Senegal successfully avoided widespread cases of Ebola virus with only one imported case detected, although neighboring countries have experienced serious outbreaks.

Although it currently ranks 163 out of 187 countries on the Human Development Index,2 Senegal is classified as lower middle income (LMIC),3 and is a stable, democratic country. Over 40% of its estimated 13.5 million people live in urban areas;4 the proportion living below the poverty line is 57% in rural areas and 26% in the capital, Dakar.5 Approximately 30% of the population lives on less than $1 USD per day, and average life expectancy is 64 years.6 With an annual growth rate of 2.7%,1 the population is projected to increase to approximately 19 million by 2025,6 challenging Senegal’s attempts to provide quality health, education, and other services for the well-being of its people and environment.

In comparison to other countries in West Africa, Senegal has a lower level of child mortality.7 However, Senegal’s overall performance masks wide disparities, both regionally and among urban and rural populations. The mortality rate for children under 5 years of age (U5MR) is 44 in urban areas versus 77 in rural areas, per 1,000 live births.1 Senegal’s elevated infant rate, 33 per 1,000 live births,1 and maternal mortality ratio, 392 per 100,000 live births,8 are largely due to inadequate access to quality health services, including insufficient emphasis on disease prevention.

Fertility has slowly and consistently decreased but remains high, at 5.0 children per woman.1 Only about 20% of married women of reproductive age use modern methods of contraception, and the unmet need for family planning is high at 25%1.

Malnutrition, a significant contributor to child mortality, remains a persistent problem with 19% of children classified as stunted.1 Adult HIV prevalence is low, estimated at 0.7% for 15 to 49 years of age, with 56,000 adults and 5,000 children estimated to be living with the disease.8 Despite the low prevalence in the general population, key populations have high rates of HIV infection, including commercial sex workers (CSW) estimated at 18%9 and men who have sex with men (MSM) at 22%.10 Like other countries in the sub-region, Senegal has confronted a confirmed case of Ebola as part of the

USAID/Senegal 2016-2021 Health PAD 5

2014 outbreak, and—while effectively containing any further spread—significant gaps in pandemic preparedness exist.

The USAID/Senegal Health Project is a robust and strategic response to these challenges, designed to improve health status in regions most in-need while providing targeted assistance to higher-performing regions in terms of maternal and neonatal mortality. Project activities align with USAID/Senegal’s Country Development Cooperation Strategy (CDCS) and address Senegal’s socioeconomic and cultural contexts, as well as core contributors to the national disease burden. The Project’s development objective (DO2) is to improve the health status of the Senegalese population, as USAID/Senegal’s development hypothesis states:

If strategic investments are made to strengthen the performance of the health system, increase access to high quality priority health services and products, and increase commitment of individuals and communities in the management of their own health and health services, then the health status of women, children, and other vulnerable populations will be improved.

The Project will build on USAID’s legacy of programming in the health sector over the last several decades and will be implemented through complementary activities and implementing mechanisms detailed in this Project Appraisal Document (PAD). One of the key findings from the 2014 midterm evaluation highlighted the need to improve collaboration at the community level between service delivery and behavior change communication efforts.11 The report also suggests that USAID define an essential package of services in an integrated continuum of care approach that will enable future programs to more closely integrate community- and facility-based services. As a result, support for integrated service delivery under this new Project will include community health, in addition to behavior change communications activities, that are currently implemented under separate mechanisms.

In addition, as USAID Senegal seeks to strengthen local systems across all development sectors, this Project focuses more robustly on deepening the engagement of individuals and local communities in the governance and financing of health services and community management of health. Interventions will directly support civil society to ensure accountability of service providers and raise community awareness about the importance of taking ownership of and responsibility for their own health. The new Project will also maintain an emphasis on health systems strengthening to sustain and further enhance improvements in the management of human resources for health, data for decision-making, commodities management, and health care financing.

A large direct government financing component to the Ministry of Health and Social Action (MOH) builds on the significant progress made in Government-to-Government (G2G) programming and indicates a major shift towards increased government ownership and stewardship, enhancing sustainability. The new Project will build on this approach by consolidating G2G assistance at the central level, while still targeting specific regions for tailored direct financing. The Project will continue close collaboration with USAID development activities in other sectors such as Food Security (Feed the Future), Education (Equitable Access to Education in Southern Senegal) and the Governance and Democracy (a new project is currently under design).

The Project interventions will strengthen regional and national capacity to provide sustainable, quality health services. Key areas of intervention include the delivery of a basic package of high-impact Reproductive, Maternal, Neonatal, and Child Health (RMNCH) services, the planning and management of human resources (HR) and pharmaceutical and equipment supply chain and logistics, and the

USAID/Senegal 2016-2021 Health PAD 6 management of data and health management information systems (HMIS). These interventions will advance the GOS and Agency goals to end preventable child and maternal mortality. The Project will advance Senegal’s goal of universal health coverage (UHC), expand access to health services, and reduce future disease burden, while increasing Senegal’s preparedness to combat emerging pandemic diseases.

Increasing support to improve community level health services and strengthening local community and governance structures will build, finance, and sustain improved services. USAID will leverage its investments to increase GOS health sector contributions, currently estimated at four percent of total expenditures.1 Key results by the end of the project period include:

● Reduced Maternal Mortality Ratio (per 100,000) from 392 to 211;

● Reduced Under Five Mortality Rate (per 1000 live births) from 54 to 33;

● Reduced Newborn Mortality Rate (per 1,000) from 19 to 12;

● Reduced Prevalence of Under Five Stunting from 18% to 10%;

● Reduced Total Fertility Rate from 5.0 to 3;

● Percent increase in GOS budget allocations for health from 11% to 15%.

The Project’s anticipated level of funding for the five-year implementation period (FY 2016-FY 2021) is $300 million and fully supports the Mission’s CDCS.

II. Relationship to Mission CDCS, Results Framework and Other Mission Projects

This Project supports the CDCS’ second Development Objective (DO2), Improved Health Status of the Senegalese Population. To achieve this DO, USAID Senegal will continue to support Senegal’s progressive health reform program based on UHC, decentralization of the health system, and greater inclusion of the private sector in providing health services and generating new revenue streams. This PAD changes the CDCS Results Framework (Annex A) to reinforce USAID’s commitment to strengthening the private sector, supporting decentralized structures and local communities, and providing more focused health systems strengthening and governance support. All activities will contribute to broad improvements in RMNCH as Senegal has been named one of 24 USAID priority countries for ending preventable child and maternal deaths (EPCMD).

Intermediate Result (IR) 1 places a new focus on strengthening the quality and availability of private sector health care services. IR 1 activities will consolidate interventions that support service delivery at the community and facility level, as well as access to health products—reinforcing an integrated, holistic approach to programming, as recommended in the 2014 performance evaluation of the health portfolio.

The new IR 2 maintains the focus on increasing demand for health services through encouraging the adoption of healthy behaviors but adds a critical component to increase individuals’ and communities’ commitment to managing decentralized health services. This addition reflects USAID’s emphasis on sustainability and governance in the health sector. The additional Sub-IR focuses on increasing community involvement in health systems management. Specific changes under IR 3 include a more robust focus on improving overall health system performance through targeted interventions to reinforce/strengthen information and data use, human resources, commodities management, and

1 Institutional Analysis, Annex E. Note: 4% is a calculation based on the actual GOS health budget (money actually received from MOF not money promised at beginning of year) divided by the actual GOS national budget. It does not include donor contributions, the contributions of the population (receipts paid at health service delivery point), or locally levied taxes or FECL (funds that are allocated for infrastructure construction).

USAID/Senegal 2016-2021 Health PAD 7 health care financing. This IR now includes four Sub-IRs that outline USAID’s support in these key areas for strengthening the health sector’s performance through more deliberate and focused activities.

Cross-Sector Mission Collaboration: The Project’s focus on governance and deepening the engagement of local communities aligns with USAID Senegal’s multisectoral emphasis on strengthening local systems.

The Project will participate in and contribute to the Democracy, Human Rights and Governance (DRG) Local Governance Project currently in the design process which will likely work in three southern regions. In addition, given the complexity of the Health Project’s work at the community level with local collectives, health committees, health insurance organizations and other community organizations, the Health Project will directly manage and implement targeted local health governance activities in select focus regions.

The Project reflects other important synergies between DO2 and DO3 activities. For example, the Project will continue to provide $1.5-3 million annually to support nutrition activities in the Mission’s Feed the Future Project (FTF). By strengthening RMNCH services and referral mechanisms for a continuum of care between the community and the health facility, the Project further improves the nutritional status of mothers and children. In collaboration with the DO3 Equitable Access to Education Activity with young adolescents in the southern regions, the Project will support the Ministry of Education (MOE) with the development and introduction of a RH curriculum for secondary schools.

Adolescents will also benefit from the Project’s support of improved youth-friendly health services at the post and health center levels in three overlapping regions. DO3 WASH activities will be supported by assisting the MOE with further implementation of their elementary school-level WASH curriculum.

Beyond these areas, the Project will continue to support cross-sector mission collaboration and seek opportunities for further synergies.

III. Relationship to Partner Country and Other Donor Projects

A. Relationship to Partner Country

The GOS health policy outlined in the National Health Development Plan 2009-2018 (PNDS) highlights key priorities for strategic investment. The Project’s investments in family planning, MCH, nutrition, malaria and HIV directly respond to GOS strategic health objectives as described in the PNDS, which are to:

• Reduce maternal and child mortality;

• Increase the performance of the health sector in disease prevention and control;

• Sustainably strengthen the health system;

• Improve the governance of the health sector.12

USAID Senegal will continue to contribute to community health and directly support the objectives of the MOH’s National Community Health Strategy (PNSSC) 2014-2018, including expanding coverage, improving service quality and availability, and strengthening community and local government participation in health.13

While the proposed Project continues to advance USAID’s long-term goals and objectives for the health sector, it includes “scaling up” evidence-based, high-impact health solutions, innovative approaches, and technologies to address key drivers of focus diseases, as well as a more strategic and targeted focus on youth, gender issues, the role of the private sector, and the use of direct government financing.

USAID/Senegal 2016-2021 Health PAD 8

B. Relationship to Other Donors Projects

In Senegal, multilateral and bilateral donors, foundations and other non-profit organizations account for approximately 19% of health sector financing.14 USAID is the largest health donor, leads several donor coordination groups and is an active member of the Country Coordinating Mechanism for The Global Fund. In terms of scope and funding levels, the most significant donors in the health sector are:

● The Global Fund, which provides funding for malaria, HIV/AIDS and TB programs and some support for health systems strengthening (HSS);

● The World Bank, which supports a health financing, policy reform and nutrition project;

● At the UN level, UNFPA, UNICEF, and WHO, who provide important technical support for areas including immunization, RH, WASH, nutrition and MCH;

● GAVI, which provides support for immunization and HSS;

● Other bilateral donors including Germany, Japan, France, Luxembourg, Canada, and Belgium.

As part of PAD development, USAID consulted extensively with these stakeholders and incorporated their feedback into the design process. As development partners revise and update their strategic plans in Senegal, USAID will continue to coordinate closely with donors and the GOS to maximize the benefit of donor health resources. Table 1 gives an overview of the donor assistance and the convergence of USAID projects by region while Annex B presents a more detailed donor analysis.

Table 1: Donor Assistance and Convergence of USAID Projects by Region

Region Population1 Other Donors2 Overlap with other USAID Programs3

Level of Support by the Project

Dakar 3,139,325 SpC, WB, WHO, UNICEF, GFATM, GAVI, Gates

Consolidated

Diourbel 1,499,867 CTB, WB, WHO, UNICEF, GFATM, GAVI

Concentrated

Fatick 714,674 ADB, WB, CTB, MI, WHO, UNICEF, GFATM, GAVI

Consolidated

Kaffrine 567,763 ADB, CTB, WB, WHO, UNICEF, GFATM, GAVI

Consolidated

Kaolack 962,019 ADB, CTB, MI, WB, WHO, UNICEF, GFATM, GAVI

Consolidated

Kedougou 151,715 JICA, WB, MI, WHO, UNICEF, GFATM, GAVI

FTF Concentrated

Kolda 662,666 SpC, WB, MI, WHO, UNICEF, GFATM, GAVI

DRG, Ed, FTF Concentrated

Louga 874,955 AFD, LuxDev, WB, WHO, UNFPA, UNICEF, GFATM, GAVI

Consolidated

Matam 563,058 ADB, LuxDev, JICA, WB, WHO, UNFPA, UNICEF, GFATM, GAVI

FTF Concentrated

Saint Louis 909,848 SpC, LuxDev, WB, WHO, UNFPA, UNICEF, GFATM, GAVI

FTF Concentrated

Sedhiou 453,264 SpC, WB, WHO, UNICEF, GFATM, GAVI

FTF, DG, Ed Concentrated

USAID/Senegal 2016-2021 Health PAD 9

Tambacounda 681,587 ADB, JICA, WB, WHO, UNFPA, UNICEF, GFATM, GAVI

FTF Concentrated

Thies 1,789,923 CTB, MI, WB, WHO, UNICEF, GFATM, GAVI

Consolidated

Ziguinchor 549,448 WB, WHO, UNICEF, GFATM, GAVI DRG, Ed Consolidated National 4/5 Central Support

1. Data sources: 2013 Senegal National Census Report, C/DHS 2013 2012 Health Systems Strengthening Donor Map for Senegal, SNIS 2012

2. ADB = Africa Development Bank; AFD = French Development Agency; CTB = Belgian Technical Cooperation; SpC = Spanish Cooperation; LuxDev = Luxembourg Development Agency; JICA = Japanese International Cooperation Agency; WB = World Bank; MI = Micronutrients Initiative; GFATM = Global Fund to Fight AIDS, Tuberculosis and Malaria; GAVI = GAVI Alliance; most multilateral donors work in all regions; please note that Donors may not be present in all districts within the region.

3. DRG = Democracy, Human Rights & Governance; FTF = Feed the Future

4. The World Bank supports UHC on a nationwide basis.

5. UNICEF provides national support to child survival, PMTCT and pediatric HIV.

As a member of the Harmonization for Health in Africa (HHA) initiative, USAID/Senegal has aligned its interventions according to the classification system developed by HHA donors. This alignment is summarized in Table 2, below.

Table 2: Harmonization for Health in Africa Criteria by Donor

HHA Objective Donor Health Financing World Bank, USAID, CTB, LuxDev Human Resources for Health USAID, JICA, UNICEF, UNFPA, WHO, Gates

Foundation, AFD Pharmaceuticals and Supply Chains Global Fund, UNFPA, USAID, GAVI, UNICEf, WHO

Governance and Service Delivery World Bank, AFD, USAID, LuxDev, JICA, UNICEF, UNFPA, Gates Foundation, GAVI, Global Fund, WHO

Infrastructure ADB, AFD, Lux Dev, Global Fund, World Bank, GAVI, USAID*

Information and Communication Technologies CTB, USAID, Gates Foundation, UNFPA, UNICEF

Health Sector Program Assistance LuxDev, European Union, World Bank, Canada

*USAID only supports renovation and rehabilitation

Beyond this strategic alignment, USAID will ensure that alignment exists at the operational level via the exercise of its advocacy role in donor coordination. Building on its successful and focused coordination of the RMNCH donor’s working group, USAID will continue to encourage the WHO-led broader health donor working group to adopt key best practices, including a work plan, revision of the group’s terms of reference, a chosen set of high-level policy goals behind which each donor is engaged, and the establishment of a direct feedback mechanism between the working group and the minister herself.

USAID’s leadership in these conversations is crucial: as the largest donor in the health sector, a key innovator routinely introducing new practices and policies, and in very good standing with the MOH, USAID/Senegal 2016-2021 Health PAD 10

USAID is looked to by the other donors to provide a vision for engagement in the sector. This will require strategic coordination with WHO, whose role as the primary technical assistance provider to the Ministry is widely accepted but whose de facto leadership capacities are limited by its staffing and mission.

IV. Project Description

This section is based on stakeholder consultations with MOH counterparts, healthcare service providers at the regional and district level, AID/W technical health teams, implementing partners (IPs), and donors. The results of the recent Continuous DHS (C-DHS), Service Provision Assessment (SPA), the Mid- Term Evaluation of USAID Senegal Health Program (Annex C), and various analyses found in the Annex inform the Project. The Expanded Project Description (Annex D) provides a detailed illustrative description of Project approaches.

A. Background and Problem Statement

1. Problem Statement

Due to limited access to quality health services, suboptimal engagement by individuals and communities in the management of their health and health services, and an underperforming health system, Senegal’s population continues to suffer from high rates of infectious disease and preventable child and maternal deaths. This section summarizes these challenges and their major technical issues.

2. Major Challenges

Limited access to quality health services: Despite a network of primary care and community health services, significant weaknesses affect service quality and health facilities show uneven uptake of high-impact interventions to reduce maternal and newborn mortality. The PNDS estimates that the scale up of just four affordable, high-impact interventions (breastfeeding, warming, cord care, and Kangaroo Mother Care) could avert 57% of newborn deaths. Long wait times to see a provider, lack of private spaces for confidential counseling, and stock-outs of essential medications lead beneficiaries to delay seeking care. As a result of limited staff and insufficient capacity building in health financing and administration, regional and district-level management and governance remain challenging.

Geographical access creates barriers to utilizing health services for many Senegalese, and even where services are accessible, their use is low as the quality may be poor or unresponsive to their needs.

The private sector is increasingly expanding its products and services, especially for those in urban areas and able to pay, yet service quality varies widely and is largely unregulated. The private sector also offers opportunities for the expansion of RMNCH health services and increased access to affordable, life-saving products. The number of private providers has more than tripled over the past decade, a trend expected to increase as health insurance and mutuelles, (community-based health insurance providers) reimburse for services and pharmaceuticals and as people begin to demand quality, convenient care with high customer service standards. Such an expansion of private provider services will be contingent on the successful roll out of UHC. Although this means that scarce government resources can then serve those less able to pay, the GOS needs to improve private sector oversight to ensure quality of care.

Government regulations and procedures for inspecting and certifying private sector providers must be updated to ensure that national quality standards are met. In addition, for-profit and not-for-profit

USAID/Senegal 2016-2021 Health PAD 11 service providers have only just begun to be included in national public health programs and remain outside efforts towards UHC.

Suboptimal engagement affects demand for health services: In general, community oversight in the management and monitoring of health facilities and the health system is weak, and there is an inability to hold health systems and local governments accountable for providing quality services. Traditionally, Senegal’s civil society is not highly engaged in local governance (see Institutional Analysis, Annex E).

Significant gender inequalities and gender-biased norms also contribute to women’s lack of engagement in local governance (see Executive Summary Gender Assessment, Annex F). Effective, efficient, and transparent health sector management by local governments is also challenged because government staff do not understand basic technical issues on the underlying causes of maternal, neonatal, and child mortality, are not involved in localized behavior change communication (BCC) activities, and do not partner or engage with civil society organizations, NGOs, or other community groups. Local government and civil society’s ability to effectively and routinely monitor all aspects of local health services (e.g. to verify performance-based financing) is hampered by this lack of capacity. These factors have contributed to slow implementation of health system reform and the scale up of high-impact interventions.

According to the GOS’s decentralization plan, by 2016 health sector services, administration, and oversight will be provided at peripheral levels with delegated authority granted to carry out services, execute budgets, manage and contract health staff, and procure commodities and equipment. Under the new decentralized system, local authorities will play a more prominent role in managing, overseeing, and raising funds for health services as well as in planning and managing those services. A Government of Senegal review of public sector expenditures from 2009-2012 found that localities provided an additional 3.8% for health expenses on top of the 58.6% provided by the GOS, with an additional 19.6% paid by external partners and 18% by citizens’ out of pocket expenses.14 In order to reach Senegal’s health goals, local revenues for health will need to be raised and local financing expanded. Many locally elected officials and health committee members have a limited understanding of their roles and responsibilities as they relate to the current health system or to decentralization. There is an urgent need to strengthen the financial and administrative capacity of the community and local government for them to effectively manage decentralized health services, and encourage to civil society to work alongside government in the management of local resources for community health needs.

The GOS’ expansion of UHC requires approaches to ensure adequate health financing and program sustainability. USAID is advancing the expansion of mutuelles that currently cover only 6% of the population; President Macky Sall has targeted coverage at 75% by 2017. Broad community support, participation and oversight will be important for the uptake and success of UHC.

Underperforming health system: The health system’s most acute weaknesses include health care financing, underfunded capital improvements including equipment, and inadequate numbers of qualified health providers and administrators. Further, the geographic distribution health providers does not target areas of greatest need; as noted in the Institutional Analysis, this is linked to a lack of regional level control over hiring and assignment of health staff and few incentives to serve in difficult areas.

Curricula at both private and public training institutions for new health workers often neither addresses the latest policies and technologies nor includes the skills required for managing services within the public health system, including administration and management, use and interpretation of health data, and working with communities and local authorities. The three year health data strike that ended in 2013 decimated an already weak health information system. Even today, availability of timely, accurate, and targeted data for decision-making remains a challenge. Systemic weaknesses in health finance, USAID/Senegal 2016-2021 Health PAD 12 human resource management, commodity management, and information and data use continue to slow progress in improving services and reaching UHC.

3. Major Issues

Reproductive Health and Family Planning: Fertility has slowly and consistently decreased but remains high, with a total fertility rate (TFR) of 5.0 children per woman. According to the C-DHS, while women’s knowledge about any method of contraception is high (90%), only 20% of women of reproductive age use modern methods of contraception. Already, 18% of women aged 15-19 are mothers or currently pregnant and 25% of women have an unmet need for family planning. Substantial disparities are evident in contraceptive use among married women in urban (29% MCPR) and rural (13% MCPR) areas, and nationwide there is limited access to all methods of contraceptives, especially long-lasting methods and particularly in rural areas. Still, Senegal has made tremendous progress to increase the modern contraceptive prevalence rate (MCPR), achieving a jump from 12% in 2010 to 20% 2014, providing hope that the GOS may be on track to achieve its goal of 27% MCPR by the end of 2015.

As explained in the Gender Assessment, Senegal’s high fertility rate can be attributed to many factors, including women and girls’ low status and limited decision-making power, early sexual debut, early marriage, low contraceptive use, and poor birth spacing. Reproductive health (RH) interventions have focused almost exclusively on women and have not engaged men enough in the importance of sharing responsibility.15 Additionally, social and religious norms give high value to large family size. Because the under-five mortality rate is over two times greater for births spaced less than two years apart, compared with births spaced by 36 months or more, by enabling women and couples to practice healthy timing and spacing of pregnancies, family planning could reduce maternal deaths by an estimated 30% and child deaths by 25%. In Senegal, 56% of children born in the five years preceding the most recent C-DHS survey fall into this category of avoidable high mortality risk, yet historically there have been few consistent political advocates for family planning.

HIV: Senegal has a concentrated HIV epidemic with low prevalence (0.7%) in the general population. Key populations of interest include CSWs (at 18% prevalence) and MSM (at 22%), along with other vulnerable groups, including women and youth. HIV rates are highest in the southern and southeastern regions where borders are porous; HIV prevalence is higher in neighboring countries.16 Emerging trends show between 7% and 11% of youth have multiple partners, but only 52% report using a condom;

stigma and discrimination pose a significant barrier to HIV testing and treatment.17 While most health facilities offer HIV counseling and testing, very few have ARV prophylaxis or a private space for counseling services. Private spaces are also critical to offer confidential couples counseling for PMTCT, treating sexually transmitted infections (STIs), and responding appropriately to situations involving GBV.

Maternal, Newborn, and Child Health: High rates of preventable maternal and neonatal deaths remain a major public health challenge for Senegal. The primary causes of maternal mortality are postpartum hemorrhage (PPH) and pre-eclampsia or eclampsia, accounting for more than 50% of maternal deaths and a maternal mortality ratio of 392 deaths per 100,000 live births, with considerable variation by region. Lack of access to skilled providers, whose geographic distribution is highly inequitable,18 and a weak emergency referral service are contributing factors. Most maternal deaths happen during labor, childbirth, and the immediate postpartum period due to obstetric hemorrhage and are easily preventable, indicating deep inequities within the health system.15 Although health services are improving, problems with service delivery include long distances to health facilities; lack of affordable transportation, skilled attendants, equipment, medications, or treatments; poor infrastructure; and

USAID/Senegal 2016-2021 Health PAD 13 health personnel’s low capacity, absenteeism, and negative attitudes. These issues are ongoing and influence whether women seek prompt maternal health care.19 On the demand side, most pregnant women wait until their second trimester or the beginning of their third before visiting a health facility, and many health facilities find it difficult for their pregnant clients to fulfill the MOH minimum of four prenatal consultations.

Key drivers of newborn deaths include prematurity, asphyxia, and sepsis, resulting in an infant mortality rate of 33 per 1,000 live births. As with maternal mortality, newborn deaths vary significantly by region, with the highest rates in the regions of Diourbel (43/1000), Louga (40/1000), Matam (39/1000), and St.

Louis (39/1000). Rural providers’ knowledge and skills demonstrate key gaps about the signs of neonatal asphyxia and the procedures for the Active Management of the Third Stage of Labor (AMTSL).

Up to 45 percent of stillbirths and early neonatal deaths are preventable and directly related to the quality of care during childbirth.19 In line with the global Every Newborn Action Plan, the GOS is focused on preventing preterm births, low birth-weight, neonatal infections, and asphyxia. Prioritized high-impact interventions in the MOH’s essential newborn care package include breastfeeding, warming, cord care and Kangaroo Mother Care (KMC). Although these interventions could prevent up to 57% of newborn deaths, there is still uneven application across health facilities.

The primary causes for under-five mortality are acute respiratory infections (ARI) (18 percent) and diarrhea (13 percent), as deaths from malaria have declined substantially in the past decade.20 Prioritized interventions include prevention of pneumonia with pneumococcal and Hib vaccine, improved case management, treatment of diarrhea with ORS/Zinc and rotavirus vaccine, routine immunizations, malaria prevention and treatment, and care for acute malnutrition. Although under-five mortality has decreased from 121 to 54 per 1,000 live births, as with other indicators, progress varies considerably by region. Some of the highest rates of under-five mortality are found in the southern regions of the country, at approximately 100 deaths per 1,000 live births. These geographical differences need to be further investigated, particularly as neonatal mortality rates vary between urban (15 per 1,000 live births) and rural areas (25 per 1,000 live births), and under-five mortality is 75% higher in rural (77 per 1,000 live births) versus urban settings (44 per 1,000 live births).

Nutrition: In Senegal, food insecurity and undernutrition remain critical challenges exacerbated by a lack of dietary diversity and yearly “hunger seasons.” Approximately 19 percent of the population is food insecure,21 and undernutrition is a contributing factor to the high under-five mortality rate, responsible for 31 percent of all child deaths.22 It is also an underlying cause of child disability, with 19 percent of children under-five classified as stunted and 6% percent classified as wasted. Although almost all infants under six months are breastfed, only about 33 percent are breastfed exclusively. Regional variations in stunting mirror those of food insecurity, with 23 percent of all children under-five stunted in rural areas and 12 percent in urban areas. Regional disparities in under-nutrition exist, and as with mortality, the prevalence of stunting is worse in the South region (30%), which includes the conflict affected Casamance, than in other areas of the country. Still, the prevalence of stunting in Senegal is lower than the West African regional average, and child rates of stunting, wasting, and being underweight have decreased between 2010 and 2013.

“Hidden hunger” in the form of micronutrient deficiencies is prevalent. Anemia affects 60 percent of children under-five,1 61 percent of pregnant women, and 54 percent of women of reproductive age.8 Early micronutrient deficiencies critically impact young children’s growth and development and maternal anemia is associated with low birth weight and accompanying neonatal complications. Among women who were pregnant in the last five years, had at least one ANC visit, and took at least one iron-

USAID/Senegal 2016-2021 Health PAD 14 folic acid tablet, only 42 percent received and took the ideal minimum number of iron tablets, less than 50 percent received a postpartum dose of vitamin A and only 25 percent took a deworming tablet during their third trimester.

Malaria: The percent of children under five years old with malaria parasites in their blood decreased from six percent in 2008 to 1.2% in 2014, demonstrating significant progress in the malaria prevention program. In most of Senegal, less than 0.5 percent of children under five had parasites in their blood in 2014, compared to 5.9% in the southeast where transmission is higher. More than 76 percent of households have at least one mosquito net, but only 38 percent of pregnant women and 43 percent of children under-five slept under an insecticide-treated net the night preceding the survey, and only 43 percent of pregnant women reported taking at least two doses of sulfadoxine-pyrimethamine (SP) as intermittent preventive treatment. The National Malaria Control Program (PNLP) has set a target of pre-elimination by 2018, and reaching this goal will require targeted approaches to specific geographic areas and new interventions aimed at eliminating local transmission. Among these approaches are seasonal malaria chemoprevention (SMC), in which children under ten years receive malaria treatment monthly during peak malaria season, and active community-based malaria management, in which trained health workers visit every home in their community weekly during malaria season to offer diagnosis and treatment, particularly in the southeast. In the north, all diagnosed cases are investigated and their household members tested for malaria. As malaria decreases, surveillance will become increasingly important.

Youth and Urbanization: As the 2013 National Census Report indicates, Senegal’s estimated population of 13.5 million is growing at a rate of 2.5 percent per year, and youth (individuals less than 18 years of age) represent 50 percent of the total population. One-third of adults live in urban slums while Dakar residents comprise nearly 25 percent of the nation’s total population. Urban public health services are struggling to keep pace with health needs while the level and quality of youth-friendly services varies by region and between centers, posts, and health huts. Youth centers are reported to be low functioning and neglected, as many face challenges to self-sustain or to hire and pay for trained health care professionals. In addition, few facilities have youth-friendly spaces where young people can access health information and care, especially around sexual health issues. The lack of youth-friendly services means young people’s sexual health needs for information and support remain unaddressed.

Gender: Increased education levels and wealth status for women and girls reduce fertility and positively impact maternal, newborn, and child mortality rates. This indicates the need to address women's and girls’ access to school, employment, and health in a multi-sectoral way. Although more girls attend primary school than boys, with a gender parity index of 1.03, at the secondary school level, the index drops to 0.99, with more boys in school than girls. The 2013 Senegal National Census Report indicates that the national illiteracy rate is 55 percent, and 62 percent of women are illiterate compared to 46 percent of men.4 As noted in the Gender Analysis (Annex F), more than 20 percent of females have experienced the harmful traditional practice of female genital mutilation (FGM), a reality that has major implications for reproductive and neonatal health. FGM is particularly prominent in the southern and northern regions where almost 100 percent of females have experienced some form of FGM.

Sociocultural norms support early marriage and approximately one in four females aged 15-19 are married. Childbearing is complicated by strict gender norms that inhibit women’s independent health decision-making, religious beliefs that discourage family size limitation, and harmful traditional practices correlated with an increased risk of morbidity and mortality for both mother and newborn. Women’s ability to negotiate for resources to access services, purchase commodities, or address their own or their

USAID/Senegal 2016-2021 Health PAD 15 family’s health needs is also limited, as men remain the principal decision-makers and gatekeepers for health services. Actively involving men in all components of future programming will be part of the overall gender transformative approach.

Climate Change: Local changes in temperature and rainfall have already altered distribution of some water-borne illnesses and disease vectors and reduced food production for some vulnerable populations.23 Temperature is a significant driver of development rates of vectors and parasites as well as biting rates for insects. Flooding provides breeding sites for vectors and leads to disease outbreaks, as well. Climate change is also expected to affect the geographic range and incidence of malaria, particularly along the current edges of its distribution, creating unpredictable patterns of increasing and decreasing incidence.24

Climate change has already reduced productivity of many rain-fed crops grown in Africa such as maize, sorghum, rice, and groundnuts.25 In addition, crops grown in hotter temperatures generally have reduced nutritional value,26 and malnutrition contributes to increased mortality from diarrhea and malaria,27 to name a few. Rural populations that rely on subsistence farming in low rainfall areas are at high risk of undernutrition and water-related diseases if drought occurs.28

Global Health Security: The outbreak of Ebola in West Africa has highlighted the need for strong surveillance and response systems and raised the priority of monitoring zoonotic diseases to prevent their spread within the human population. Major gaps exist in Senegal’s Global Health Security preparedness: limited effective, rapid, or responsive biosurveillance data reporting capabilities, a lack of intersectoral One Health Platforms for zoonotics, nonadherence to International Health Regulations reforms including at Senegal’s borders, and poor commodity management systems. Preventing the resurgence of diseases like Ebola or the emergence of new pandemic threats will require targeting and strengthening these systems as well as ensuring that the underlying health system is resilient and responsive to emerging diseases and unexpected health events.

Change in Disease Profile: The MOH is keenly aware that the country faces a complex epidemiological and demographic transition in the years to come, with increasing levels of preventable chronic diseases in the general population such as hypertension, Type II diabetes, and cervical and breast cancer. This transition will take place while the country is still battling undernutrition and communicable diseases.

Senegal’s health system must increase its capacity to address emerging and existing infectious diseases while also providing services to treat the growing chronic disease burden. Measuring the impact of this epidemiological transition as well as preventing both chronic diseases and the current leading causes of mortality for women and children will be a key challenge for the MOH during the 2016 -2021 period.

B. Project Description

1. Geographic Focus

Historically, USAID has provided technical assistance, training, and commodities and equipment in every region of the country. As the capacity of local health providers, the rates of maternal mortality, and the indicators for under-five child health have improved in specific higher-performing regions, USAID has the opportunity to provide targeted investments in these parts of the country, referred to as regions of consolidation, to ensure continued gains. Regions of consolidation encompass Dakar, Fatick, Kaffrine, Kaolack, Louga, Thies, and Ziguinchor. In lower-performing regions, USAID has an opportunity to concentrate its investments to significantly impact the key drivers of child and maternal mortality (Key

USAID/Senegal 2016-2021 Health PAD 16

Child and Maternal Indicators by Region, Annex G). These regions of concentration include Diourbel, Kedougou, Kolda, Matam, St. Louis, Sediou, and Tambacounda (Figure 2).

Figure 2: Map of Priority Regions

Based on the category of consolidated or concentrated, the Project will implement key program areas with different levels of emphasis. Activities in family planning and malaria will be implemented nationwide, although the modality will vary between the regions of concentration and regions of consolidation. This is due to the fact that--while recent efforts in family planning are showing results--overall MCPR remains low, and that major, nationwide efforts are still needed if the US wants to aid Senegal in reaching pre-elimination status for malaria. By contrast, HIV activities will target key populations in hotspot areas throughout the country, and private sector activities will focus on larger urban areas. The following section further explains the geographic focus of the program areas according to national level and regions of concentration and consolidation with an estimated approximate overall level of effort (LOE).

National Level (30% LOE): USAID will continue to provide strong support and TA to the MOH at the national level, where the Project will continue to second staff. All program areas will further develop and refine national policies, guidelines, and standards and participate in technical working groups (TWG).